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Because of etiological, therapeutic and prognostic implications, HAP has been classified, according to the time elapsed since hospital admission until its onset, as early which develops within four days of hospital admission or late which develops at least five days after hospital admission.

Similar to HAP, VAP is classified as early which develops within four days of intubation and institution of MV or late which develops at least five days after intubation and institution of MV. Nosocomial pneumonia is the second most common hospital infection and the most common cause of death among hospital-acquired infections. In addition to these factors, in a hospital environment there is a greater possibility of treating patients who are immunocompromised due to diseases or medications and who therefore present reduced salivary flow due to procedures such as drug-induced dehydration to increase respiratory and cardiac function , reduced cough reflex and decreased hygiene ability, factors that increase the risk of developing other diseases.

Evidence has correlated microbial colonization of the oropharynx and of the dental plaque with VAP. The mouth is continuously colonized, presenting approximately half of the microbiota observed in the human body; in addition, bacterial plaque serves as a permanent reservoir of microorganisms, which might lead to remote infections. In healthy adults, the organism that predominates in the oral cavity is Streptococcus viridans ; however, in critical patients the oral flora changes and becomes predominantly composed of gram-negative organisms, thus becoming a more aggressive flora.

This flora can comprise Staphylococcus aureus, Streptococcus pneumoniae, Acinetobacter baumannii, Haemophilus influenza and Pseudomonas aeruginosa. The level of oral hygiene is related to the number of bacterial species present in the mouth. Salivary flow is also reduced due to the use of some medications, which contributes to increase the formation of the biofilm and, therefore, its complexity, favoring the oral colonization by respiratory pathogens. The main entry point for microorganisms to reach the lower respiratory tract consists in the aspiration of oropharyngeal secretion and, in cases of patients on ventilatory support, in the aspiration of secretion that accumulates above the tube cuff.

The access of pathogens through the bloodstream, via catheters or bacterial translocation from the intestinal tract, should also be considered. Salivary enzymes and local immunoglobulins act as a defense barrier against these bacteria; however, in addition to the factors mentioned above and to the age of the patients, other factors-such as smoking, alcohol consumption, antibiotic therapy, hospitalization, nutritional state and poor oral hygiene-can increase or reduce the oral microbial flora, facilitating the formation of an oral biofilm.

These bacteria are also found in saliva and can be easily aspirated from the oropharynx to the lungs, which might lead to pneumonia. Colonization of the oropharynx with gram-negative bacilli in patients on mechanical ventilation occurs h after the patient is admitted to the ICU. In vitro studies carried out in the s and s showed that P.

It has long been known that pulmonary anaerobic infections can occur through the aspiration of salivary secretion, especially in patients with periodontal disease; however, only recently has colonization by oral and dental bacteria been implicated as the main source of bacteria involved in the etiology of VAP.

This evaluation suggested that it was likely that the dorsum of the tongue acted as a reservoir of bacteria that are pathogenic for the respiratory tract and involved in VAP. Periodontal diseases are multifactorial diseases of infectious etiology and inflammatory nature; they are considered the second major cause of oral pathology in the world population.

The development of VAP is primarily caused by the aspiration of oropharyngeal secretions, of the condensate formed in the ventilator circuit or of gastric contents colonized with pathogenic bacteria. Therefore, the onset of bacterial pneumonia can depend on the colonization of the oral cavity and the oropharynx with potential respiratory pathogens, on the aspiration of these pathogens to the lower airways or on the failure of the host defense mechanisms.

The American Centers for Disease Control and Prevention postulated mechanisms that lead to nosocomial pneumonia. Three possible mechanisms might explain the association between oral biofilm and respiratory infections.

Poor oral hygiene can contribute to increase the concentration of pathogens in the saliva; these pathogens can be aspirated to the lung in a sufficient amount to compromise the immune defenses.

Prevention of nosocomial pneumonia: importance of oral hygiene and control of the oral biofilm. According to the Brazilian Guidelines for Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia of , 11 the risk factors for nosocomial pneumonia can be classified as modifiable and non-modifiable. Non-modifiable risk factors include advanced age, greater disease severity score at the time of hospital admission, COPD, neurological disease, trauma and surgery.

Some of the modifiable factors can be changed using relatively simple measures, such as washing and disinfecting the hands; implementing protocols to reduce inadequate prescription of antimicrobials; and maintaining a microbiological vigilance, with periodical information to health professionals regarding the prevalence and resistance of the oral microbiota. Initiative such as the implementation of protocols for sedation and ventilatory weaning, as well as the early removal of invasive devices, can reduce the prevalence of nosocomial respiratory infections.

Various studies have evaluated the efficacy of oral decontamination for the prevention of nosocomial pneumonia. Nevertheless, it is clear that all preventive methods have proven effective in reducing the oral colonization of respiratory pathogens or the incidence of these pathogens in the oral cavity.

Essentially, dental plaque and associated microorganisms can be removed in two ways: through mechanical interventions or pharmacological interventions. There is significant reduction in the levels of VAP in patients decontaminated with systemic antibiotics; however, this type of intervention is limited due to bacterial resistance.

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Some features of this site may not work without it. Buscar DSpace. However, before the procedure, a total colonoscopy was performed because of the history of polyps. This elderly patient was hospitalized for colonoscopy. At admission, he presented with fever, right iliac fossa tenderness, and a biological inflammatory syndrome. A CT-scan was performed. It showed a recurrent acute appendicitis without mass, with a 2cm abscess on the tip of the appendix. An appendectomy was performed in this case.

Laparoscopic appendectomy for appendicitis with peritonitis. This is the case of a year-old male patient who presented with abdominal pain and fever at The work-up demonstrated important inflammation with leukocytes at 16, and CRP levels at CT-scan confirmed an acute appendicitis with an appendicolith at the base. The appendix is probably perforated as the CT-scan also demonstrated a pneumoperitoneum.

Laparoscopic appendectomy is decided upon.