Scientific Letter
Routine tooth brushing in the intensive care unit: A potential risk factor for oral flora bacteremia in immunocompromised patients
Cepillado de dientes rutinario en la UCI, un factor de riesgo potencial para la bacteremia de la flora bucal en pacientes inmunocomprometidos
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Torrents, R. Ferrer, A. Artigas, A. Rodriguez, I. Martin-Loeches" "autores" => array:6 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "de Haro" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Torrents" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Ferrer" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Artigas" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Rodriguez" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Martin-Loeches" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572717300127?idApp=WMIE" "url" => "/21735727/0000004100000001/v1_201703040056/S2173572717300127/v1_201703040056/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572717300103" "issn" => "21735727" "doi" => "10.1016/j.medine.2017.02.007" "estado" => "S300" "fechaPublicacion" => "2017-01-01" "aid" => "1013" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Med Intensiva. 2017;41:44-52" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2280 "formatos" => array:3 [ "EPUB" => 165 "HTML" => 1069 "PDF" => 1046 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Microcirculatory monitoring in septic patients: Where do we stand?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "52" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorizando la microcirculación en el paciente séptico: ¿en qué punto estamos?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 560 "Ancho" => 1500 "Tamanyo" => 160214 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cytocam-Incident Dark Field (IDF) images of sublingual microcirculation. <span class="elsevierStyleItalic">Image A</span>: early phase septic shock patient. A decrease of vessel density and of perfused vessels, and an increase of non-perfused/under-perfused vessels can be observed. Although not appreciable in static images, heterogeneity of microvascular blood flow velocity between coexisting areas is also present (normal or high microvascular blood flow vessels in close vicinity to non-perfused or low microvascular blood flow vessels). <span class="elsevierStyleItalic">Image B</span>: healthy volunteer. A normal vessel density and proportion of perfused vessels can be observed. Although not appreciable in static images, microvascular blood flow velocity is normal and homogeneous overall the studied areas. (<span class="elsevierStyleItalic">Images courtesy of Braedius Medical and Prof. D. Payen, H. Lariboisiere</span>).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Gruartmoner, J. Mesquida, C. Ince" "autores" => array:3 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Gruartmoner" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Mesquida" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Ince" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572717300103?idApp=WMIE" "url" => "/21735727/0000004100000001/v1_201703040056/S2173572717300103/v1_201703040056/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Routine tooth brushing in the intensive care unit: A potential risk factor for oral flora bacteremia in immunocompromised patients" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "53" "paginaFinal" => "55" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Lecomte, E. Begot, O. Barraud, M. Matt, B. François" "autores" => array:5 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Lecomte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Begot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Barraud" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Matt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "B." "apellidos" => "François" "email" => array:1 [ 0 => "b.francois@unilim.fr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Intensive Care Unit, CHU Dupuytren, 2 avenue Martin Luther King, 87042 Limoges, France" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Microbiology Department, CHU Dupuytren, 2 avenue Martin Luther King, 87042 Limoges, France" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Internal Medicine Department, CHU Dupuytren, 2 avenue Martin Luther King, 87042 Limoges, France" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cepillado de dientes rutinario en la UCI, un factor de riesgo potencial para la bacteremia de la flora bucal en pacientes inmunocomprometidos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 458 "Ancho" => 900 "Tamanyo" => 28389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A single-use suction toothbrush. This is a toothbrush that was tested in our unit. These toothbrushes are supposed to be more efficient removing dental plaque while being less traumatic. It sucks out debris and secretions very easily. The small sponge on the back enables cleaning and freshening up the mouth.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Intensive care unit (ICU) patients are fragile and highly subject to infections. Respiratory infections and especially ventilator-associated pneumonia (VAP) are the most frequent infectious complications in critically ill patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Among the main measures to decrease VAP incidence, dental care is recommended in the prevention bundles.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Aside from mouthwash with chlorhexidine, tooth brushing is widely used for VAP prevention in routine nursing practice even if its interest has not been fully demonstrated. It is well known that tooth brushing can cause transient bacteremia that are harmless for healthy individuals but can cause serious problems in critically ill patients.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 38-year old woman was admitted in the ICU with acute respiratory failure. Her main medical history was a mixed connective tissue disease (Sjögren's syndrome) associated to natural killer (NK) cell deficiency. The Sjögren's syndrome had been diagnosed seven years earlier because of strong clinical symptoms associated to positive anti-Ro, anti-La and anti-ribonucleoprotein (RNP) antibodies. The patient had then discontinued medical follow-up as she did not tolerate the treatments.</p><p id="par0020" class="elsevierStylePara elsevierViewall">At admission in the Emergency Department (ED) for serious dyspnea, she presented with acute respiratory failure and anasarca associated to a left ventricular dysfunction. An acute renal failure was biologically evidenced. The patient was directly transferred to the ICU where she was intubated and mechanically ventilated. Diagnostic assessment disclosed a type II cryoglobulinemia with consumption of the complement components and positive anti-Ro and anti-La antibodies. Renal biopsy showed a membranoproliferative glomerulonephritis associated to vascular lesions. An immunosuppressive treatment was started due to the renal cryoglobulinemic vasculitis: high dose corticotherapy including 3 boluses of methylprednisolone (1<span class="elsevierStyleHsp" style=""></span>g) then replaced by prednisolone (0.5<span class="elsevierStyleHsp" style=""></span>mg/kg) associated to weekly infusion of rituximab (375<span class="elsevierStyleHsp" style=""></span>g/m<span class="elsevierStyleSup">2</span>) during four weeks.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The infectious complete checking performed at admission in the ICU (blood cultures, pleural fluid, and urine culture) resulted negative. During the first week of hospitalization, the patient received oral care with chlorhexidine three times a day and tooth brushing with a single-use device newly tested in the unit at that period. It was a single-use untreated suction toothbrush (Toothette<span class="elsevierStyleSup">®</span>, Sage Products, Cary, IL) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Of note, dental hygiene was strictly normal without any dental or periodontal lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At D2, because of a 39<span class="elsevierStyleHsp" style=""></span>°C fever, a distal protected aspirate was performed. The cultures grew positive to methicillin susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MSSA) [10<span class="elsevierStyleSup">4</span><span class="elsevierStyleHsp" style=""></span>CFU/ml] and <span class="elsevierStyleItalic">Streptococcus pyogenes</span> [10<span class="elsevierStyleSup">3</span><span class="elsevierStyleHsp" style=""></span>CFU/ml]. As radiography showed no infection, it was considered as a bronchial colonization and no antibiotic therapy was started. The blood cultures performed on D2 grew positive to <span class="elsevierStyleItalic">Parvimonas micra</span>. In the meantime, an antibiotic treatment with amoxicillin was started. Other blood cultures performed on D6 because of a hectic fever were positive to <span class="elsevierStyleItalic">Veillonella parvula</span>. The antibiotic therapy with amoxicillin lasted 10 days in total. Both bacteremic episodes had no clinical consequences and transesophageal echocardiography (TEE) ruled out endocarditis. Following both bacteremias, tooth brushing was discontinued on D7 until discharge on D43. Mouthwashing with chlorhexidine was maintained. No other bacteremia occurred during the hospitalization (seven blood cultures performed between D7 and discharge).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mouth has a rich saprophytic flora mainly composed by <span class="elsevierStyleItalic">Streptococcus viridans, Neisseria sp., Haemophilus sp.</span> and anaerobes from the salivary flora. In ICU patients this flora is modified and patients are often colonized especially by aerobic Gram negative bacilli and <span class="elsevierStyleItalic">S. aureus</span>. Dental plaque is then a breeding ground for potential virulent germs. <span class="elsevierStyleItalic">Parvimonas micra</span> also called <span class="elsevierStyleItalic">Micromonas micros</span> is an anaerobic Gram positive coccus belonging to oral and intestinal commensal florae. It often causes periodontal and bone and joint infections. <span class="elsevierStyleItalic">Veillonella parvula</span> is an anaerobic Gram negative coccus from the oral, intestinal and vaginal florae and is responsible for dental plaque especially when associated to <span class="elsevierStyleItalic">Streptococcus mutans</span>. It can also cause extremely rare infections such as osteomyelitis, endocarditis, meningitis and cerebral and pulmonary abscesses.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Oral care is provided to all ICU patients whether intubated or not. It is widely admitted as an essential measure of VAP prevention.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> However, there is no consensus on how the care should be provided. It is usually done with gauze or other devices such as cotton swabs soaked with antiseptic solution such as chlorhexidine and performed every 6–8<span class="elsevierStyleHsp" style=""></span>h. The role of tooth brushing is not clear and the studies have diverging results. Rello et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> suggested its efficacy showing a tendency for VAP decrease. On the opposite, more studies<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5–7</span></a> showed neither significant decrease of the risk of VAP, nor a decrease of morbidity–mortality or length of stay for the patients receiving tooth brushing. Tooth brushing can cause bacteremia even in healthy individuals.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The gingiva being highly vascularized, the irritation induced by the toothbrush can enable bacteria to go to the systemic circulation. In healthy individuals, bacteremias can be qualified as transient. They occur frequently and have no infectious and clinical consequences as the bacteria are rapidly eliminated. On another hand, immunocompromised patients and especially intubated and mechanically ventilated ICU patients are at high risk of infections. In particular, septicemia could result in complications such as endocarditis, spondyloscitis or visceral abscesses.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Oral care in healthy individuals is based on tooth brushing. Since oral care proved its efficacy in VAP prevention, it could seem right to brush the teeth of ICU patients as well. Nevertheless, most studies do not prove the superiority of the association of tooth brushing and mouthwashing with chlorhexidine compared to mouthwashing alone. Despite the lack of evidence, tooth brushing remains a common practice which tends to increase with the introduction of new devices such as single-use suction toothbrushes. These toothbrushes are supposed to be more efficient on removing dental plaque and sucking out debris and secretions while being less traumatic.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This case report confirms that tooth brushing can cause bacteremias that are transient and harmless in healthy individuals, but can result in infections in immunocompromised patients. Since it is increasingly used in the ICU despite this risk, the benefit–risk ratio of tooth brushing associated to conventional oral care with chlorhexidine in the prevention of VAP must be carefully reconsidered.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contribution</span><p id="par0060" class="elsevierStylePara elsevierViewall">ML, BF (1) acquisition and interpretation of data and (2) article drafting; EB, OB, MM (1) acquisition of data and (2) article revision. All authors read and approved the final manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Ethical approval</span><p id="par0070" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Ethical approval" ] 3 => array:2 [ "identificador" => "xack271160" "titulo" => "Acknowledgment" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 458 "Ancho" => 900 "Tamanyo" => 28389 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A single-use suction toothbrush. This is a toothbrush that was tested in our unit. These toothbrushes are supposed to be more efficient removing dental plaque while being less traumatic. It sucks out debris and secretions very easily. The small sponge on the back enables cleaning and freshening up the mouth.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[in French] <span class="elsevierStyleInterRef" id="intr0005" href="http://www.sfar.org/article/134/risques-et-maitrise-des-infections-nosocomiales-en-reanimation">http://www.sfar.org/article/134/risques-et-maitrise-des-infections-nosocomiales-en-reanimation</span> [Accessed 05.05.15]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The risk for and approaches to control of nosocomial infections in ICUs: guideline from the SRLF/SFAR Task Force on nosocomial infections in ICUs" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Brun-Buisson" 1 => "G. Bonmarchand" 2 => "J. Carlet" 3 => "J. Chastre" 4 => "A. Durocher" 5 => "J.Y. Fagon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2010" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tooth brushing may reduce ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H. 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Trefler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-0706" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2009" "volumen" => "136" "paginaInicial" => "433" "paginaFinal" => "439" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19482956" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence, intensity and nature of bacteraemia after toothbrushing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.S. Lucas" 1 => "G. Gafan" 2 => "S. Dewhurst" 3 => "G.J. Roberts" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jdent.2008.03.005" "Revista" => array:6 [ "tituloSerie" => "J Dent" "fecha" => "2008" "volumen" => "36" "paginaInicial" => "481" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18448227" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack271160" "titulo" => "Acknowledgment" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We thank Sarah Demai who provided medical writing services.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004100000001/v1_201703040056/S2173572717300115/v1_201703040056/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004100000001/v1_201703040056/S2173572717300115/v1_201703040056/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572717300115?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 91 | 37 | 128 |
| 2024 September | 126 | 24 | 150 |
| 2024 August | 122 | 39 | 161 |
| 2024 July | 85 | 27 | 112 |
| 2024 June | 117 | 45 | 162 |
| 2024 May | 93 | 34 | 127 |
| 2024 April | 78 | 39 | 117 |
| 2024 March | 85 | 32 | 117 |
| 2024 February | 98 | 43 | 141 |
| 2024 January | 122 | 45 | 167 |
| 2023 December | 118 | 53 | 171 |
| 2023 November | 108 | 47 | 155 |
| 2023 October | 103 | 26 | 129 |
| 2023 September | 117 | 43 | 160 |
| 2023 August | 72 | 13 | 85 |
| 2023 July | 79 | 25 | 104 |
| 2023 June | 80 | 15 | 95 |
| 2023 May | 86 | 31 | 117 |
| 2023 April | 98 | 22 | 120 |
| 2023 March | 87 | 46 | 133 |
| 2023 February | 88 | 28 | 116 |
| 2023 January | 96 | 26 | 122 |
| 2022 December | 113 | 35 | 148 |
| 2022 November | 130 | 44 | 174 |
| 2022 October | 109 | 49 | 158 |
| 2022 September | 95 | 34 | 129 |
| 2022 August | 106 | 47 | 153 |
| 2022 July | 118 | 43 | 161 |
| 2022 June | 70 | 22 | 92 |
| 2022 May | 80 | 43 | 123 |
| 2022 April | 87 | 38 | 125 |
| 2022 March | 87 | 51 | 138 |
| 2022 February | 92 | 44 | 136 |
| 2022 January | 94 | 32 | 126 |
| 2021 December | 89 | 57 | 146 |
| 2021 November | 116 | 45 | 161 |
| 2021 October | 83 | 77 | 160 |
| 2021 September | 74 | 36 | 110 |
| 2021 August | 79 | 43 | 122 |
| 2021 July | 50 | 24 | 74 |
| 2021 June | 69 | 39 | 108 |
| 2021 May | 106 | 58 | 164 |
| 2021 April | 242 | 77 | 319 |
| 2021 March | 147 | 32 | 179 |
| 2021 February | 81 | 31 | 112 |
| 2021 January | 87 | 29 | 116 |
| 2020 December | 89 | 20 | 109 |
| 2020 November | 66 | 22 | 88 |
| 2020 October | 66 | 26 | 92 |
| 2020 September | 68 | 17 | 85 |
| 2020 August | 45 | 12 | 57 |
| 2020 July | 55 | 16 | 71 |
| 2020 June | 66 | 9 | 75 |
| 2020 May | 38 | 27 | 65 |
| 2020 April | 56 | 33 | 89 |
| 2020 March | 22 | 16 | 38 |
| 2020 February | 78 | 62 | 140 |
| 2020 January | 52 | 28 | 80 |
| 2019 December | 48 | 27 | 75 |
| 2019 November | 67 | 38 | 105 |
| 2019 October | 44 | 26 | 70 |
| 2019 September | 50 | 29 | 79 |
| 2019 August | 40 | 16 | 56 |
| 2019 July | 45 | 23 | 68 |
| 2019 June | 19 | 10 | 29 |
| 2019 May | 44 | 25 | 69 |
| 2019 April | 19 | 16 | 35 |
| 2019 March | 17 | 23 | 40 |
| 2019 February | 24 | 23 | 47 |
| 2019 January | 22 | 37 | 59 |
| 2018 December | 41 | 39 | 80 |
| 2018 November | 37 | 75 | 112 |
| 2018 October | 30 | 15 | 45 |
| 2018 September | 14 | 6 | 20 |
| 2018 August | 11 | 12 | 23 |
| 2018 July | 13 | 7 | 20 |
| 2018 June | 16 | 9 | 25 |
| 2018 May | 12 | 3 | 15 |
| 2018 April | 16 | 4 | 20 |
| 2018 March | 19 | 3 | 22 |
| 2018 February | 17 | 4 | 21 |
| 2018 January | 20 | 12 | 32 |
| 2017 December | 20 | 2 | 22 |
| 2017 November | 18 | 5 | 23 |
| 2017 October | 22 | 5 | 27 |
| 2017 September | 21 | 7 | 28 |
| 2017 August | 14 | 7 | 21 |
| 2017 July | 14 | 9 | 23 |
| 2017 June | 21 | 7 | 28 |
| 2017 May | 12 | 18 | 30 |
| 2017 April | 20 | 0 | 20 |
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