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* From the Departments of Anesthesiology, and
Microbiology, University of Occupational and Environmental Health School of Medicine, Fukuoka, Japan.
Address correspondence to: Dr. Kouichiro Minami, Department of Anesthesiology, University of Occupational and Environmental Health School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, Fukuoka 807-8555, Japan. Phone: +81-93-691-7265; Fax: +81-93-601-2910; E-mail: kminami{at}med.uoeh-u.ac.jp
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Abstract |
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Methods: In the gargling group, patients gargled with 25 mL of povidone-iodine (2.5 mg·mL–1). In the control group, patients gargled with 25 mL of tap water. Before tracheal intubation, microorganisms were obtained from the posterior wall of the patient’s pharynx using sterile cotton swabs. After anesthesia, all patients were extubated and bacteria contaminating the tip of the tracheal tube were sampled and cultured.
Results: Before orotracheal intubation, all 19 patients who gargled with tap water (control group) had bacterial colonization on the posterior walls of the pharynx. This group included five patients who had methicillin-resistant staphylococcus aureus (MRSA) in their nasal cavity preoperatively and MRSA was also detected in the pharynx of four patients. Bacterial colonization was observed in all 19 patients who gargled with povidone-iodine (gargling group) and four patients carried MRSA in their nasal cavity, although no MRSA was detected in the pharynx. In the control group, all the patients had bacterial colonization at the tip of the tube after extubation. Additionally, MRSA was detected in two of the four patients. In the gargling group, povidone-iodine eradicated general bacteria and MRSA colonies in the pharynx before intubation and at the tip of the tube after extubation.
Conclusion: Gargling with povidone-iodine before oral intubation reduces the transport of bacteria into the trachea.
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Introduction |
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Methicillin-resistant staphylococcus aureus (MRSA) is a nosocomial pathogen that has become of great concern in hospitals worldwide.1–6 Up to 40% of the normal population carry S. aureus in the anterior nares, and this rate is often increased in hospitalized patients and their attendants.1 Moreover, epidemiologic studies have shown that gram-negative bacteria account for most NP in intubated patients, but S. aureus may also play a role in polymicrobial infections.9 The increasing incidence of MRSA has been associated with hospital outbreaks leading to considerable morbidity and the disruption of hospital services.
The efficacy of povidone-iodine for disinfection is known.12–14 Shiraishi et al. (2002) reported that gargling with povidone-iodine had the highest disinfection rate and the highest reduction in the oral bacterial count.12 Kawana et al. (2002) reported that gargling with povidone-iodine was useful for preventing nosocomial and opportunistic infections due to MRSA.13 Nagatake et al. (2002) showed that povidone-iodine gargling reduced infections with Pseudomonas aeruginosa, S. aureus including MRSA, and Haemophilus influenzae by about 50%.14 Therefore, gargling with povidone-iodine appears to be a simple, effective way to disinfect the upper respiratory tract.
In this study, we investigated whether preoperative gargling with povidone-iodine can reduce the transport of bacteria from the pharynx into the trachea with endotracheal intubation.
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Methods |
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None of the patients received sedative drugs pre-operatively. In the gargling group, patients gargled with 25 mL of povidone-iodine (2.5 mg·mL–1) for one minute, twice. In the control group, patients gargled with 25 mL of tap water for one minute, twice. After preoxygenation, general anesthesia was induced with 1.5 mg·kg–1 propofol and 0.1 mg fentanyl intravenously, and maintained with 1.5 to 2% sevoflurane in 5 L·min–1 oxygen. Before tracheal intubation, microorganisms were obtained from the posterior wall of the patient’s pharynx using sterile cotton swabs. Vecuronium (1 mg·kg–1 iv) was used to facilitate intubation. Endotracheal tubes with inner diameters of 7.5 and 8.0 mm with a low-pressure cuff (SheridanTM; Kendall Healthcare Products Co., Inc., Mansfield, MA, USA) were inserted orally. The endotracheal tubes were lubricated with 1 mL 10% xylocaine to avoid sore throat. Wearing sterile gloves, a single skilled anesthesiologist blinded to group assignment performed all intubations with an autoclaved curved laryngoscope. Patients in whom more than two attempts at passage of the endotracheal tube were required were excluded from the study. The cuff was inflated to the point of obtaining a seal in the presence of positive airway pressure. After emergence from general anesthesia, saliva was aspirated before tracheal extubation. The mouth of the patient was kept open with a laryngoscope to prevent the tube tip from touching the tongue and all patients were extubated gently. Patients in whom extubation provoked bucking or coughing were excluded from this study. Then, the tip of the tracheal tube was sampled using sterile cotton swabs. All the equipments including the endotracheal tube, the laryngoscope and suction tube was manipulated in a sterile fashion.
The microorganisms obtained by swabbing were suspended in 1 mL of phosphate buffered saline by vortexing for 20 sec; 100 µL of these suspensions were then inoculated onto nutrient agar plates (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan). After a two-day incubation at 37°C, the number of colony forming units (CFUs) was counted to give the overall number of bacteria. Based on the number of colonies, the patients were classified into four levels of bacteria carriage: level 1 (0 to 9 CFUs); level 2 (10 to 99 CFUs); level 3 (100 to 999 CFUs); level 4 (over 1000 CFUs). The bacteria were replicated onto both yolk salt agar (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan) and MRSA screening agar (Nippon Becton Dickinson Co., Ltd., Tokyo, Japan); the latter contained 6 µg of oxacillin per litre and 4% NaCl. These plates were incubated overnight at 37°C, and methicillin-resistant lipase-producing colonies were presumptively identified as MRSA. MRSA was confirmed by gram staining, an agglutination test for protein A and clumping factor (Staphylo LA; Denka Seiken, Tokyo, Japan), and amplification of the mecA gene by polymerase chain reaction.15
Statistics
All results are expressed as mean ± standard deviation. The following statistical tests were used: for comparison of patient characteristics including age, body weight, and duration of anesthesia and surgery, a Student t test was performed. The Mann-Whitney U test was used for multiple paired comparisons. A P value < 0.05 was considered statistically significant.
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).
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). MRSA in the pharynx was isolated in four (21%) of the five patients who had MRSA in the nasal cavity preoperatively.
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Next, we studied the bacterial contamination of the tip of the tube after extubation. In the control group, four patients (21.1%) had level 3 colonization and one patient (5.1%) had level 4 (Table II
). MRSA was detected in two patients (10.5%). In the gargling group, colonization was level 1 or 2 in all patients and no MRSA was detected at the tip of the tube (Table II). Gargling with povidone-iodine reduced the number of bacteria at the tip of the tube more than in the control group (Table II).
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Discussion |
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Continuous subglottic aspiration could reduce the incidence of pneumonia associated with mechanical ventilation since oropharyngeal secretions available for aspiration would be limited.9,18 During general anesthesia, endotracheal intubation prevents aspiration, although pooled secretions above of the endotracheal tube cuff facilitate bacterial overgrowth and aspiration after extubation.18 In this study, we sampled the endotracheal tube since we focused on the possibility of micro aspiration of potentially pathogenic microorganisms from the oropharynx just after extubation.
Further, the gargling group had fewer bacteria at the tip of the tracheal tube than the control group. The number of bacteria at the tip of the tube was proportional to the number in the pharynx. These results suggest that gargling with povidone-iodine reduces bacterial transport from the pharynx by reducing the number of bacteria in the pharynx. This is the first report of the efficacy of gargling in reducing bacterial transport into the trachea. We speculate that a decrease in the number of bacteria in the pharynx before general anesthesia may reduce upper airway infection due to general anesthesia, but we did not compare the rate of pneumonia after anesthesia between the two groups in this study. We identified MRSA since MRSA is a nosocomial pathogen of great concern in hospitals worldwide. Identification of other pathological microorganisms in the pharynx and the trachea will be necessary to evaluate the efficacy of gargling with povidone-iodine. Further studies will be necessary to answer these questions. For prevention of NP, it has been reported that selective digestive decontamination (SDD) would prevent infection by eradicating and preventing carriage of potentially pathogenic aerobic microorganisms from the oropharynx.19,20 Although this technique reduces the frequency of NP, SDD is not routinely recommended because of cost and risk of increasing bacterial resistance and drug toxicity.
We showed that oral gargling with povidone-iodine is a simple, effective maneuver for disinfecting the upper respiratory tract prior to anesthesia and surgery. However, povidone-iodine can cause cytotoxic reactions.21 Prolonged exposure to povidone-iodine solution may cause irritation or severe skin reactions.22 The safety of povidone-iodine preparations applied to the nasal mucosa and other mucous membranes has been well described.12–14,16 We used a single application of povidone-iodine before anesthesia and observed no adverse event. Nevertheless, care should be taken when using povidone-iodine solution, especially with regard to allergic reactions.
In conclusion, we demonstrated that gargling with povidone-iodine reduced the number of microorganisms in the pharynx and bacterial transport into the trachea. Povidone-iodine gargling may reduce the risk of infectious complications associated with endotracheal intubation.
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Footnotes |
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2 Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study; EPIC International Advisory Committee. JAMA 1995; 274: 639–44.[Abstract]
3 Vincent JL. Nosocomial infections in adult intensive-care units. Lancet 2003; 361: 2068–77.[Medline]
4 Hoffken G, Niederman MS. Nosocomial pneumonia. The importance of a de-escalating strategy for antibiotic treatment of pneumonia in the ICU. Chest 2002; 122: 2183–96.
5 Appelgren P, Hellstrom I, Weitzberg E, Soderlund V, Bindslev L, Ransjo U. Risk factors for nosocomial intensive care infection: a long-term prospective analysis. Acta Anaesthesiol Scand 2001; 45: 710–9.[Medline]
6 Tejada Artigas A, Bello Dronda S, Chacon Valles E, et al. Risk factors for nosocomial pneumonia in critically ill trauma patients. Crit Care Med 2001; 29: 304–9.[Medline]
7 Levine SA, Niederman MS. The impact of tracheal intubation on host defenses and risks for nosocomial pneumonia. Clin Chest Med 1991; 12: 523–43.[Medline]
8 Kotani N, Lin CY, Wang JS, et al. Loss of alveolar macrophages during anesthesia and operation in humans. Anesth Analg 1995; 81: 1255–62.[Abstract]
9 Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest 2002; 121: 858–62.
10 Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 1995; 122: 179–86.
11 Dennesen P, van der Ven A, Vlasveld M, et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit Care Med 2003; 31: 781–6.[Medline]
12 Shiraishi T, Nakagawa Y. Evaluation of the bactericidal activity of povidone-iodine and commercially available gargle preparations. Dermatology 2002; 204(Suppl 1): 37–41.
13 Kawana R, Nagasawa S, Endo T, Fukuroi Y, Takahashi Y. Strategy of control of nosocomial infections: application of disinfectants such as povidone-iodine. Dermatology 2002; 204(Suppl 1): 28–31.
14 Nagatake T, Ahmed K, Oishi K. Prevention of respiratory infections by povidone-iodine gargle. Dermatology 2002; 204(Suppl 1): 32–6.
15 Murakami K, Minamide W, Wada K, Nakamura E, Teraoka H, Watanabe S. Identification of methicillin-resistant strains of staphylococci by polymerase chain reaction. J Clin Microbiol 1991; 29: 2240–4.
16 Reimer K, Wichelhaus TA, Schafer V, et al. Antimicrobial effectiveness of povidone-iodine and consequences for new application areas. Dermatology 2002; 204(Suppl 1): 114–20.
17 Fuursted K, Hjort A, Knudsen L. Evaluation of bactericidal activity and lag of regrowth (postantibiotic effect) of five antiseptics on nine bacterial pathogens. J Antimicrob Chemother 1997; 40: 221–6.
18 Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 1999; 116: 1339–46.
19 Selective Decontamination of the Digestive Tract Trialists Collaborative Group. Meta-analysis of randomised controlled trials of selective decontamination of the digestive tract. BMJ 1993; 307: 525–32.
20 Vandenbroucke-Grauls CM, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991; 338: 859–62.[Medline]
21 Niedner R. Cytotoxicity and sensitization of povidone-iodine and other frequently used anti-infective agents. Dermatology 1997; 195(Suppl 2): 89–92.
22 Kozuka T. Patch testing to exclude allergic contact dermatitis caused by povidone-iodine. Dermatology 2002; 204(Suppl 1): 96–8.
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