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
Leído
10622
Vecesse ha leído el artículo
3293
Total PDF
7329
Total HTML
Compartir estadísticas
array:23 [ "pii" => "S0210569116000589" "issn" => "02105691" "doi" => "10.1016/j.medin.2016.02.006" "estado" => "S300" "fechaPublicacion" => "2017-01-01" "aid" => "901" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2017;41:53-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3022 "formatos" => array:3 [ "EPUB" => 163 "HTML" => 1963 "PDF" => 896 ] ] "itemSiguiente" => array:18 [ "pii" => "S0210569116301334" "issn" => "02105691" "doi" => "10.1016/j.medin.2016.06.005" "estado" => "S300" "fechaPublicacion" => "2017-01-01" "aid" => "949" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Med Intensiva. 2017;41:55-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2090 "formatos" => array:3 [ "EPUB" => 156 "HTML" => 1153 "PDF" => 781 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Toward a personalized response approach in sepsis 4.0" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "55" "paginaFinal" => "56" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hacia una estrategia de respuesta personalizada en sepsis 4.0" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 779 "Ancho" => 1622 "Tamanyo" => 45466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Odds ratio for mortality in patients included in the study. <span class="elsevierStyleItalic">Abbreviation</span>: OR, odds ratio.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. de Haro, E. 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/S0210569116301334?idApp=WMIE" "url" => "/02105691/0000004100000001/v3_201702170036/S0210569116301334/v3_201702170036/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0210569116302650" "issn" => "02105691" "doi" => "10.1016/j.medin.2016.11.011" "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" => 7017 "formatos" => array:3 [ "EPUB" => 190 "HTML" => 4723 "PDF" => 2104 ] ] "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" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1804 "Ancho" => 2434 "Tamanyo" => 183671 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Different StO<span class="elsevierStyleInf">2</span> patterns in response to a vascular occlusion test (VOT) in healthy subjects and septic shock. Figure A shows a normal StO<span class="elsevierStyleInf">2</span> response to a VOT, whereas figure B shows an altered response in a septic shock patient. Note that, independently of the baseline absolute StO<span class="elsevierStyleInf">2</span> value, the response to ischemia is different. The DeO<span class="elsevierStyleInf">2</span> slope is slower, and a longer period in order to reach a predetermined ischemic threshold (i.e. 40%)<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a> is needed. The vascular reactivity is also impaired, leading to a slower StO<span class="elsevierStyleInf">2</span> recovery rate (ReO<span class="elsevierStyleInf">2</span>), and a blunted hyperemic response before returning to baseline StO<span class="elsevierStyleInf">2</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/S0210569116302650?idApp=WMIE" "url" => "/02105691/0000004100000001/v3_201702170036/S0210569116302650/v3_201702170036/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" => "xack268847" "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] <a 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</a> [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. Yusuf" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/sj.ebd.6400956" "Revista" => array:6 [ "tituloSerie" => "Evid Based Dent" "fecha" => "2013" "volumen" => "14" "paginaInicial" => "89" "paginaFinal" => "90" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24071681" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral care reduces incidence of ventilator-associated pneumonia in ICU populations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Mori" 1 => "H. Hirasawa" 2 => "S. Oda" 3 => "H. Shiga" 4 => "K. Matsuda" 5 => "M. Nakamura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-005-0014-4" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2006" "volumen" => "32" "paginaInicial" => "230" "paginaFinal" => "236" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16435104" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral care practices in intensive care units: a survey of 59 European ICUs" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Rello" 1 => "D. Koulenti" 2 => "S. Blot" 3 => "R. Sierra" 4 => "E. Diaz" 5 => "J.J. De Waele" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-007-0605-3" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2007" "volumen" => "33" "paginaInicial" => "1066" "paginaFinal" => "1070" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17384927" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tooth brushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W. Alhazzani" 1 => "O. Smith" 2 => "J. Muscedere" 3 => "J. Medd" 4 => "D. Cook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/CCM.0b013e3182742d45" "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "2013" "volumen" => "41" "paginaInicial" => "646" "paginaFinal" => "655" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23263588" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilator-associated pneumonia with or without tooth brushing: a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Lorente" 1 => "M. Lecuona" 2 => "A. Jiménez" 3 => "S. Palmero" 4 => "E. Pastor" 5 => "N. Lafuente" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10096-012-1605-y" "Revista" => array:6 [ "tituloSerie" => "Eur J Clin Microbiol Infect Dis" "fecha" => "2012" "volumen" => "31" "paginaInicial" => "2621" "paginaFinal" => "2629" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22422274" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized trial of dental brushing for preventing ventilator-associated pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Pobo" 1 => "T. Lisboa" 2 => "A. Rodriguez" 3 => "R. Sole" 4 => "M. Magret" 5 => "S. Trefler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-0706" "Revista" => array:7 [ "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" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109707003361" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 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" => "xack268847" "titulo" => "Acknowledgment" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We thank Sarah Demai who provided medical writing services.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004100000001/v3_201702170036/S0210569116000589/v3_201702170036/en/main.assets" "Apartado" => array:4 [ "identificador" => "19505" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas Científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004100000001/v3_201702170036/S0210569116000589/v3_201702170036/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569116000589?idApp=WMIE" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 7 | 19 |
| 2024 Octubre | 113 | 57 | 170 |
| 2024 Septiembre | 130 | 30 | 160 |
| 2024 Agosto | 139 | 48 | 187 |
| 2024 Julio | 97 | 27 | 124 |
| 2024 Junio | 164 | 88 | 252 |
| 2024 Mayo | 103 | 38 | 141 |
| 2024 Abril | 124 | 40 | 164 |
| 2024 Marzo | 116 | 48 | 164 |
| 2024 Febrero | 95 | 38 | 133 |
| 2024 Enero | 129 | 34 | 163 |
| 2023 Diciembre | 143 | 31 | 174 |
| 2023 Noviembre | 141 | 54 | 195 |
| 2023 Octubre | 209 | 39 | 248 |
| 2023 Septiembre | 155 | 40 | 195 |
| 2023 Agosto | 70 | 10 | 80 |
| 2023 Julio | 79 | 33 | 112 |
| 2023 Junio | 84 | 19 | 103 |
| 2023 Mayo | 93 | 38 | 131 |
| 2023 Abril | 104 | 22 | 126 |
| 2023 Marzo | 112 | 30 | 142 |
| 2023 Febrero | 159 | 35 | 194 |
| 2023 Enero | 142 | 29 | 171 |
| 2022 Diciembre | 121 | 40 | 161 |
| 2022 Noviembre | 136 | 46 | 182 |
| 2022 Octubre | 102 | 32 | 134 |
| 2022 Septiembre | 89 | 47 | 136 |
| 2022 Agosto | 84 | 37 | 121 |
| 2022 Julio | 74 | 50 | 124 |
| 2022 Junio | 95 | 45 | 140 |
| 2022 Mayo | 86 | 48 | 134 |
| 2022 Abril | 108 | 45 | 153 |
| 2022 Marzo | 108 | 68 | 176 |
| 2022 Febrero | 92 | 42 | 134 |
| 2022 Enero | 100 | 45 | 145 |
| 2021 Diciembre | 92 | 56 | 148 |
| 2021 Noviembre | 81 | 50 | 131 |
| 2021 Octubre | 99 | 81 | 180 |
| 2021 Septiembre | 47 | 54 | 101 |
| 2021 Agosto | 52 | 52 | 104 |
| 2021 Julio | 50 | 41 | 91 |
| 2021 Junio | 59 | 35 | 94 |
| 2021 Mayo | 54 | 77 | 131 |
| 2021 Abril | 137 | 143 | 280 |
| 2021 Marzo | 89 | 57 | 146 |
| 2021 Febrero | 86 | 43 | 129 |
| 2021 Enero | 74 | 38 | 112 |
| 2020 Diciembre | 95 | 34 | 129 |
| 2020 Noviembre | 56 | 26 | 82 |
| 2020 Octubre | 47 | 39 | 86 |
| 2020 Septiembre | 41 | 29 | 70 |
| 2020 Agosto | 48 | 27 | 75 |
| 2020 Julio | 35 | 40 | 75 |
| 2020 Junio | 51 | 22 | 73 |
| 2020 Mayo | 40 | 14 | 54 |
| 2020 Abril | 55 | 34 | 89 |
| 2020 Marzo | 44 | 13 | 57 |
| 2020 Febrero | 107 | 40 | 147 |
| 2020 Enero | 50 | 30 | 80 |
| 2019 Diciembre | 75 | 33 | 108 |
| 2019 Noviembre | 56 | 26 | 82 |
| 2019 Octubre | 88 | 41 | 129 |
| 2019 Septiembre | 75 | 45 | 120 |
| 2019 Agosto | 107 | 43 | 150 |
| 2019 Julio | 72 | 22 | 94 |
| 2019 Junio | 71 | 17 | 88 |
| 2019 Mayo | 74 | 41 | 115 |
| 2019 Abril | 54 | 19 | 73 |
| 2019 Marzo | 41 | 36 | 77 |
| 2019 Febrero | 48 | 40 | 88 |
| 2019 Enero | 56 | 30 | 86 |
| 2018 Diciembre | 97 | 50 | 147 |
| 2018 Noviembre | 143 | 84 | 227 |
| 2018 Octubre | 136 | 26 | 162 |
| 2018 Septiembre | 59 | 27 | 86 |
| 2018 Agosto | 37 | 15 | 52 |
| 2018 Julio | 35 | 20 | 55 |
| 2018 Junio | 41 | 20 | 61 |
| 2018 Mayo | 20 | 12 | 32 |
| 2018 Abril | 45 | 28 | 73 |
| 2018 Marzo | 39 | 9 | 48 |
| 2018 Febrero | 23 | 6 | 29 |
| 2018 Enero | 53 | 20 | 73 |
| 2017 Diciembre | 32 | 10 | 42 |
| 2017 Noviembre | 28 | 12 | 40 |
| 2017 Octubre | 37 | 10 | 47 |
| 2017 Septiembre | 24 | 11 | 35 |
| 2017 Agosto | 39 | 17 | 56 |
| 2017 Julio | 23 | 17 | 40 |
| 2017 Junio | 27 | 20 | 47 |
| 2017 Mayo | 29 | 20 | 49 |
| 2017 Abril | 42 | 7 | 49 |
| 2017 Febrero | 6 | 2 | 8 |
| 2017 Enero | 0 | 2 | 2 |
Mostrar todo
