Vous êtes sur la page 1sur 8

THE EFFECTIVENESS OF ANTISEPTIC ADMINISTRATION ON ORAL HYGIENE TO

PREVENT VENTILATOR-ASSOCIATED PNEUMONIA (VAP) IN INDONESIA

Anis Laela Megasari1* Umi Margi Rahayu 2


Poltekkes Kemenkes Semarang, Semarang, Indonesia

*correspondent author: anislaela333@gmail.com

ABSTRACT

Background Many diseases are emerging in the community, not a few of them cause the patient to
require intensive care. Intensive care is closely linked to invasive devices, such as the installation of
mechanical ventilation. The use of mechanical ventilation for more than 48 hours may lead to
infection of Ventilator Associated Pneumonia (VAP). The increased of VAP impact is directly
proportional to colonization of pathogenic organisms. For that reason, it needs an intervention that can
prevent the emergence of colonization pathogen organism. Oral hygiene is usually combined with
antiseptic. The goal is to maximize the oral hygiene, but in Indonesia there is no standard rule about
the most effective antibacterial to prevent VAP. There are always many different types of available
antiseptic during oral hygiene. Therefore, it is necessary to study the literature about the most
effective types of antiseptic as a material for oral hygiene in patients on ventilator apparatus. If all
hospitals in Indonesia use the safest and most effective antiseptic type, it is expected that the
incidence of VAP in Indonesia decreases.
Methods Methods The references of articles were indexed in the MEDLINE data base, Proquest
Research Library, and Google Scholar. After analysis of various literatures were got four reference
research about various antiseptic used in oral hygiene to prevent VAP.
.
Result To determine which is the safest and most effective type of antiseptic as an oral hygiene
ingredient in patients who using ventilators

Conclusion VAP events have a lot of impact for the sufferer. Therefore it is necessary to prevent the
occurrence of VAP. One of the prevention that many done with oral hygiene. According to various
research oral hygiene is the best way to prevent VAP as well as hospitals in Indonesia. But in reality
the prevalence of VAP is still a lot. This occurs due to the use of antiseptic is still diverse. Therefore, it
is important for every hospital in Indonesia to choose the safest and most effective antiseptic as
ingredient for oral hygiene.

Keywords: Ventilator Associated Pneumonia (VAP), oral hygiene, antiseptic.


INTRODUCTION

condition Many diseases are emerging in the community, not a few of them cause an intensive
care. Critical patients are people who come to the hospital with actual or potential health problems
that cause pathophysiological changes and have the physiological effect of one organ or other organ
that can prevent life and cause death. Intensive care is usually carried out in a special room called
Intensive Care Unit (ICU). ICU is a hospital room which provide service to patients with life-
threatening circumstances and requires comprehensive and full-time services. One of the most
frequent treatments in ICU rooms is therapy with invasive procedures such as mechanical ventilation.

Reliable mechanical ventilation is necessary to critical patients. The main purpose of


mechanical ventilator use is to normalize arterial blood gas and acid-base balance by providing
adequate ventilation and oxygenation. Mechanical ventilation is divided into 2: non-invasive
mechanical ventilation and invasive mechanical ventilation. In practice, the installation of non-
invasive mechanical ventilation is rarely used because the oxygen that enters the lungs is inadequate.
Unlike non invasive mechanical ventilation, the use of invasive mechanical ventilation is typically
used because it uses the Endo Trachea Tube (ETT) tube so that the oxygen enters the lungs totally.
However, invasive mechanical ventilation has a deficiency: the ETT tube that enters the
oropharyngeal will light up the host defense system so that it can cause local trauma and
inflammation. The consequence of this condition is the possibility of aspiration of nosocomial
pathogens from oropharyngeal around the cuff. This nosocomial pathogen will eventually develop
become an infection.

Infections that occur during hospital treatment are often referred to as Healtcare Associated
Infection (HAIs). As can occur due to the transmission of pathogenic pathogenic microbes that are
sourced from the hospital environment and its equipment . Currently HAIs is a major problem that can
be a direct or indirect cause of patient death. problem HAIs increased incidence in the hospital at this
time to be a chore for the world, not least Indonesia. One type of HAIs found in many hospitals is
Ventilator Associated Pneumonia (VAP). Center for Disease and Prevention, said 157,000 patients in
the ICU experienced VAP.

Innumerable studies have shown predictors of VAP mortality in different countries that show
mixed results. In America VAP is the second cause (25%) infection in hospitals . VAP incidence rate
in Japan ranges from 20-30%. There is no accurate data on VAP incidence nationally for Indonesia
.VAP prevalence in ICU for RSUP Dr. Kariadi Semarang by 36.8%, then in 2014 increased to 42%, of
which 86.8% was declared dead . In addition to the etiology, there are two risk factors caused by VAP
are endogenous factors and exogenous factors. Both of these factors can improve the incidence of
VAP. The emergence of VAP can be the cause of longtime in heal process and the extent of the patient,
the cost of treatment will also increase so that it will affect the economic status and the familys
welfare, and increase rate of patient morbidity and mortality in ICU.

The increasing of VAP is directly proportional to the colonization of pathogenic organisms.


Therefore, it is necessary to have an intervention that can change the progress of colonization of
pathogenic organisms. In general, prevention of VAP is divided into two, namely prevention of
pharmacology and nonparametric. Non pharmacological methods include washing hands before and
after contact with patients, oral intubation, higher head position 30 0-450, and avoiding large gastric
volume . Pharmacology prevention that can be done include selective decontamination by using
antibiotics in the digestive tract (Selective decontamination or the digestive tract/ SDD) and
oropharyngeal decontamination (oropharyngeal decontamination/ OD) by using antiseptic.
Empirically SDD has been shown to reduce VAP, but since SDD user has a negative impact. OD
administration with antiseptics is now widely proposed as an intervention to prevent VAP.

OD is an action to maintain oral hygiene where this intervention is an integral part of


treatment in ICU rooms. The susceptibility of ICU patients with an infection, especially with the use
of mechanical ventilation, becomes a problem that must be addressed to prevent complications.
According to some research, oral hygiene is a major intervention that can be made to prevent VAP.
Currently, the use of antibacterial for oral hygiene in Indonesian hospitals is still diverse. There is no
standard rule regarding the most effective antiseptic sequence to break the chain of colonization
development of microorganisms so that when nurses perform antiseptic oral hygiene that is used
diversity in accordance with their reference. Therefore there is a need for a universal rule that explains
what antiseptic sequence is recommended for oral hygiene because there is a relationship between the
antiseptic types of VAP events. The goal is that in conducting preventing strategy of VAP, nurse can
contribute maximally.

METHODS

Identification and analysis of the problem was performed by collecting information from
national and international scientific and health journals related to the management of VAP, oral
hygiene, and antiseptic, such as MEDLINE data base, Proquest Research Library, and Google Scholar
as well as from relevant textbooks from 2007 2016.

RESULT
Here were effect size and significance from some researches that were conducted about
antiseptic type for oral hygiene that was often done at the Indonesian Hospital to prevent VAP. Table 1
effect size and significant some researches in Indonesia about antibiotic to prevent VAP.
Researchers Sample Independent Dependent variable value Result
variables
Jena, Sritam et 50 Suction above cuff Ventilator AssociatedP= 0.78
al (2016) endotracheal tube Pneumonia (VAP) The analysis test
(SACETT) results showed the
significance value p
0.78 it means that not
significant.
-The effect size of
SACCETT utilization
is 0.1, that indicate
SACCETT utilization
has low effect size
-Research method
used experimental
design
Amat. T, Mona 15 Oral hygiene by Minimize incidence The analysis test
S., Siti. H., using hexadol of Ventilator results showed the
Galih. W., gargle Associated significance value p
(2015) Pneumonia (VAP) 0.03 it means that
significant
-The effect size of
hexadol gargle
utilization is 0.9, that
indicate hexadol gargle
utilization has high
effect size
-This research used
pre-eksperimental
design

Rondhianto, 20 Chlorhexidine staphylococcus The analysis test


Iis R., Aridha 0.2% with NaCl aureus Colonization results of
S.A (2012) 0.9% as oral chlorhexidine
decontamination 0,2%showed the
significance value p
0.006 it means that
significant.
-The analysis test
results of NaCl 0.9%
showed the
significance value p
0.006 it means that
significant
-The study was quasy
experimental which
non equivalent control
group design
Fitri H.P., Jati 30 Oral hygiene by Total bacteria on -The analysis test
L.P., Ery L using Ventilator Associated results of
Chlorhexidine and Pneumonia (VAP) chlorhexidine showed
Providone iodine the significance value
p 0.004 it means that
significant.
-The effect size of
chlorhexidine
utilization is 0.6, that
indicate chlorhexidine
utilization has high
effect size.
-The analysis test
results of Providone
iodine showed the
significance value p
0.75, it means that
not significant.
-The effect size of
Providone iodine
utilization is 0.2, that
indicate Providone
iodine utilization has
medium effect size.
-this study use
eksperimental design
Basically the application of oral hygiene using antiseptic in patients with mechanical
ventilation has been made, but the antiseptic that used is different. Commonly antiseptics that used in
oral hygiene to prevent VAP in Indonesia are Chlorhexidine 0.2%, providone iodine 1%, hexagon
gargle, NaCl 0.9%, and listerine. The use of such antiseptics can be combined with the use of suction
to maximize the results that wish to be achieved achieved. Based on the table above can be seen that
chlorhexidine 0.2% is the most effective antiseptic of other antibacterial. This is also accordance with
research conducted abroad. It is research conducted by Tantipong Tantipong H et.al (2008), stated that
chlorhexidine 0.2% is an effective antiseptic for lowering inside VAP. Chlorhexidine may cause 52%
reduction in VAP as a whole and 71% lower than incubated patients. Although chlorhexidine 0.2% is
capable considered by preventing VAP. However, until now VAP events are still found widely.

DISCUSSION

VAP is described as nosocomial pneumonia that occurs after 48 hours to patients with
mechanical ventilation through either the endotracheal tube or the tracheostomy pipe. VAP appears
fitting to bacterial colonization in the lung. The three main causes of VAP in most cases are gram
negative bacteria, and gram-positive bacteria, those are Pseudomonas aeruginosa and Staphylococcus
aureus. Pseudomonas aluminous and Staphylococcus aureus bacteria are resistant to some antibiotics
and can cause high mortality .

The pathogenesis of VAP due to risk factors is divided into two processes, namely the
occurrence of colonization of pathogenic microorganisms in the aeromedicine tract and respiratory
and also contaminated aspiration on the upper and lower airway. Most of the VAP are caused by
aspiration of pathogenic bacteria colonizing on the surface of the oropharyngeal mucosa, where
intubation will facilitate the entry of germs and cause contamination around the end of the
endotracheal tube with the patient in the supine position. In addition, VAP can also occur due to
gastric macrosporangium. Optical fiber bronchoscopy, mucus sucking up the trachea and manual
ventilation can contaminate pathogens into the lower respiratory tract.

Prevention of VAP is done to avoid further complications. Nowadays oral hygiene is a major
intervention to prevent VAP. One of the most important things of oral hygiene to prevent VAP is the
antiseptic used. Recently, there are many researches on the effectiveness of antiseptic types to prevent
VAP. The results showed that chlorhexidine 0.2% was operative in VAP prevention with medium
effect size. At first chlorhexidine 0.2% is used extensively as an antiseptic in dentistry. Chlorhexidine
0.2% is bacteriostatic for gram negative bacteria. Therefore some researchers use chlorhexidine 0.2%
in preventing VAP because one of the bacteria that often cause VAP is gram-negative bacteria. The
therapeutic index of this drug is very sharp with a fairly low toxicity. Chlorhexidine 0.2% at
physiological pH can find bacteria in the oral surface, due to the interaction between positive charges
and molecules. Chlorhexidine 0.2% has a good bond with soft tissue and hard on the mouth causing
chlorhexidine 0.2% effect last long. The number of bacteria in the saliva is slowly reduced to between
10-20% reported at the initial amount before use and lasts for 7 to 12 hours. Chlorhexidine 0.2% has
side effects such as causing bad breath and high concentrations can harm organs .

Providence iodine1% is one of antiseptics that commonly used in VAP prevention in


Indonesia. According to research conducted providence iodine effect in prevention of VAP if assessed
clinically is significant because it has mild effect size, but if judged by statistics the result is not
meaningful. Povidone Iodine is iodine that acts as an antiseptic. In addition to mouthwash used after
brushing, povidone iodine gargle is utilized to treat oral and throat infections, such as gingivitis and
thrush. According to Joel Chua's research on oral hygiene, by using providence iodine in preventing
VAP does indeed decrease the number of bacteria but when proven statistically obtained results that
are not significant. Therefore it is necessary in order to review this antiseptic .

Some hospitals in Indonesia also use NaCl 0.9% antiseptic for VAP prevention. NaCl 0.9% is
a crystalloid liquid which is isotonic, physiological, non toxic and does not cause hypersensitivity
reactions so it is safe to be used. Chloride content in NaCl 0.9%can reduce the growth of
microorganisms, but if chloride is determined by high doses in water it can cause side effects that
interfere with osmoregulation that organism retains proper concentration of solute in body fluids. The
results showed that there are some respondents who pre-post results against the number of bacteria
that are not unusual in giving this antiseptic. This is because NaCl 0.9% is an isotonic fluid and it is a
medium of bacterial transport. So when patients eat or drink bacteria can survive in a NaCl
0.9%environment.

Apart from some antiseptic above, another antiseptic used is hexagon Gargle. For the
application of this antiseptic in the VAP prevention in hospitals is not as much as antiseptic before, but
there are some who are used. The advantage of this antiseptic is the fact that it can bind the mucosal
protein of the mouth so that it can prolong the effects of anti-bacteria. Protein bonds can inhibit
metabolism of microorganisms present in dental plaque. In accordance with the effect size calculation
shows that hexagon gargle 0.2%. has a strong strength, but statistic test results show that
chlorhexidine are still significant, namely 0.2%.

CONCLUSION

Chlorhexidine 0.2% is an antiseptic recommended for use in Indonesia, because according to


some researchers in Indonesia shows significant results on statistical tests. However, there are some
things to consider when giving this antiseptic for example concentrations should not be given in large
quantities, should not be used in the long term because it has some effects, control elevated risk
factors for VAP to obtain maximum results. Maybe the government can use this antiseptic for oral
hygiene to prevent VAP. The research result of Providone iodine 1% showed that there decreases in
the number of bacteria but statistically and the effect size calculation is not significant. Therefore for
nurses who are still using this antiseptic to prevent the occurrence of VAP requires are evidence-
based.

The research results of NaCl 0.9% indicate that this antiseptic is capable of killing bacteria,
but can also become a bacterial transport medium so the exceptional consideration is required if the
nurse wishes to use this antiseptic in VAP prevention. Although charcoal was used, the research
results showed that hexagon gargle was able to kill bacterial microorganisms in the mouth.

Several researches that have been conducted in Indonesia regarding the kind of antiseptic that is
effective for VAP prevention, it is seen that each antiseptic have its own effectiveness. Just as research
did abroad, Chlorhexidine 0.2% is the recommended antiseptic in VAP prevention.

Although there has been a lot of researches on the kinds of antiseptic effect for VAP
prevention. But the incidence of VAP to date is still found widely. This can be occurring because
many things one of them is the absence of standard rules that require nurses to use what kind of
antiseptic in VAP prevention. With the standard rule of antiseptic what is most effective in preventing
VAP, it is expected that all hospitals in Indonesia use the same colorless so it is expected that the VAP
incidence rate will decrease.

REFERENCES
1. Rab T. Agenda Gawat Darurat (Critcal Care). Bandung2007: PT Alumni.
2. Depkes RI. Riset Kesehatan Dasar Tahun 2012. Penelitian dan Pengembangan Kesehatan
Departemen Kesehatan RI. Badan Litbangkes RI 20122012
3. Darmadi. Infeksi Nosokomial: Problematika Dan Pengendaliannya. Jakarta: Penerbit Salemba
Medika; 2008. 2-4 p. p.
4. Sedwick MB, Lance-Smith, M., Reeder, S. J., & Nardi, J., . Using Evidence-Based Pracrice to
Prevent Associated Pneumonia. Crit Care Nurse. 2012;32.
5. Widyaningsih R, & Buntaran, L.,. Pola Kuman Penyebab Ventilator Associated Pneumonia
(VAP) dan Sensitivitas Terhadap Antibiotik di RSAB Harapan Kita. Sari Pediatri. 2012;3(6).
6. Rahmawati. Angka Kejadian Pneumonia Pada Pasien Sepsis di ICU RSUP Dr. Kariadi
Semarang Medika Muda UNDIP Semarang. 2014;3(1).
7. Chlebicki MP SN. Topical chlorhexidine for prevention of ventilator- associated pneumonia: A
meta-analysis. Crit Care Med. 2007;35:595-602.
8. Rodhianto IR, Aridha S.A, . Perbedaan Penggunaan Clorhexidine 0,2% dengan NaCl 0,9%
sebagai Dekontaminasi Oral terhadap Kolonisasi Staphylococcus aureus pada pasien post
operasi General Anastesi di Ruang Mawar RSUD dr. Abdoer Rahem Kabupaten Situbondo.
2015;7(1).
9. Fitri H.D. JLP, Ery. L, . Perbedaan Jumlah Bakteri Trakhea pada Tindakan Oral Hygiene
Menggunakan Chlorhexidine dn Providone Iodine pada Penderita dengan Ventilasi Mekanik.
2012;IV(2).

Vous aimerez peut-être aussi