EFFECTIVENESS OF ANTISEPTICAL FOR ORAL HYGIENE TO PREVENTION

OF VENTILATOR-ASSOCIATED PNEUMONIA (VAP) IN INDONESIA

THE EFFECTIVENESS OF ANTISEPTIC ADMINISTRATION ON ORAL HYGIENE TO
PREVENT VENTILATOR-ASSOCIATED PNEUMONIA (VAP) IN INDONESIA

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). There is no accurate
data about VAP incidence in Indonesia. There are only VAP data sourced from the hospital.
VAP prevalent in one of hospitals in Indonesia from year to year has increased, for example
in ICU Dr. Kariadi Semarang amounted to 36.8%, and then in 2014 increased to 42%. 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.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 The references of articles are 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. This article is
intended to determine the effectiveness of various antiseptics that are frequently used in
Indonesia.
Result After analysis of various literatures were got four reference research about various
antiseptic used in oral hygiene to prevent VAP To determine which is the safest and most
effective type of antiseptic as an oral hygiene ingredient in patients who using ventilators.

Conclusion This article aims to determine the effectiveness of various antiseptics that are
frequently used in Indonesia. Lately a lot happening around the world, especially in
developing countries including Indonesia. One of the many HAIs found in Indonesia is VAP.
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

Mdevelopment of age that uncontrolled 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. According to the Decree of the Health
Minister of the Republic of Indonesia Number 1778/ MENKES/SK/XII/2010 concerning
Guidelines for the Implementation of ICU Services in hospitals, ICU rooms have a function
to observe patient condition and treatment of certain therapies. 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 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. Hbecomes cause HAIs
increased incidence in the hospital at this time to be a chore for the world, not least Indonesia.
The Health Ministry even issued Permenkes 1691 in 2011 chapters 7 which reads "Every
Hospital is obliged to comply with Patient Safety Standard" in which contains about HAIs.
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 . VAP appears owing to
bacterial colonization in the lung. Based on the onset or flow of exposure to the causes of
VAP are divided into two groups: early onset and late onset. 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
300-450, and avoiding large gastric volume. However, this non-pharmacological prevention is
still not effective in preventing VAP, therefore to maximize the intervention is also done
pharmacological way . 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, SDD is not currently recommended for routine use. 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. Centers of Control and Prevention Disease recommends the development and
implementation of a comprehensive oral hygiene program in the prevention of VAP.
 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
The literature search strategy in this article uses medical literature and nursing, especially the
literature on acute nursing, mechanical ventilation, VAP, oral hygiene, and antiseptic. The
literature search is intended to answer questions and goals of the author. Published articles
from 2007 to 2016 in English and Indonesian are indexed in the MEDLINE database,
Proquest Research Library, and Google Scholar. The articles used must meet the inclusion
criteria (journals on antiseptic effects on VAP, keyword-related journals, and research design
are minimal quasi experimental).

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 Result

variables
Jena, Sritam et 50 Suction above cuff Ventilator Associated -The analysis test
al (2016) endotracheal tube Pneumonia (VAP) results showed the
(SACETT) 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 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 has a strong but
statistical test results 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. Berry AM, Davidson PM, Masters J, Rolls K. Systematic Literature Review of Oral
Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation.
American Journal of Critical Care. 2007;16(6).
9. 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).
10. 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).