Assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 - A Systematic Review

Assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 - A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 - A Systematic Review Samah Kamal Abuzaid, Suha Mohamed Awad, Raneen Mohamed Awad, Tarig T G.E.E Mahmoud, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8203437/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background. Patient under mechanical ventilator for longer than 48 hours are susceptible to the nosocomial infection known as ventilator-associated pneumonia (VAP). This systematic review assessed the impact of endotracheal cuff pressure optimization and good oral hygiene habits on the prevalence of VAP in intensive care units in Africa and Middle East during 2019–2024. Methods. A team of three members implemented a systematic review during the period of January 2019 to September 2024 in accordance with PRISMA guidelines. Their working language was English; they agreed on their research question and inclusion and exclusion criteria. They set the keywords and embarked on search of articles relevant to their research question through PUBMED as a database engine. They retrieved an initial sample of 2349 published articles and included in their study 4 articles fulfilling inclusion criteria. The data were summarized in tabular form for qualitative assessment and graphically as a forest plot to assess the quality and risk of bias across the retrieved publications. Results. The team retrieved an initial sample of 2349 articles related to their research question. They removed 736 articles, which were duplicated. The team screened 1613 articles. After applying their inclusion criteria, they ended by included in their systematic review a final sample of 4 articles which fulfil their inclusion criteria. The findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. The prevalence of VAP in patients in emergency, surgery and reintubation was estimated to be 19.7%. VAP developed in patients under mechanical ventilator in 3 to 18 days with mean duration of 7.50 days ± 5.07. The use of povidone-iodine in providing oral health care to patients under ventilator reduced the length of stay in ICU and consequently the mortality rate. Conclusion. In intensive care units, throughout Africa and Middle East, oral cleanliness and cuff pressure optimization are still underutilized. The adoption of evidence-based VAP prevention measures should be top priority policy to be implemented in health care services including ongoing staff training. Cuff pressure optimization Intensive care unit Infection prevention Oral hygiene Ventilator assisted pneumonia Figures Figure 1 Figure 2 Background Ventilator associated pneumonia is a nosocomial infection, which occurs in intensive care units in patients intubated and under mechanical ventilation for over 48 hours. Clinical signs in affected patients include fever, respiratory distress, and purulent tracheal secretions 1 . Globally, VAP incidence was reported to vary from 5.0% to 65.0% based on different diagnostic criteria. In the USA, 2.0 to 11.9 cases/1000 ventilators days was recorded it raised up to 116/1000 ventilator in Southeast Asia, however in western China an incidence of 1.64/1000 days was published 2 – 5 . In the literature 6 – 8 , a worldwide variation of the costs associated to VAP was reported. In the USA, Stone PW 7 pointed out that VAP ranked second among the health care associated infections (HAIs) with an annual average of 250,205 infection cases and 35,967 deaths cases/year, which led to a mean hospital cost of US $ 9966. While the cost analysis of Cabrera-Tejada GG et al 8 revealed that patients with VAP had a significantly extended stay in the critical care units (CCUs) compared to their counterparts without VAP, with respective durations of 26.20 ± 18.77 days and 12.78 ± 12.33 days ( p < 0.001). In contrast, the duration of the stay in medical services was not significantly different ( p = 5.04) between the VAP (13.20 ± 18.73 days) and non-VAP groups (13.06 ± 27.39 days). VAP prolongs hospital stays, increases morbidity and mortality, and had a significant financial burden on healthcare systems. Between 15% and 50% of patients with VAP may die. A key factor contributing to the development of VAP is the introduction of bacterial organisms in the lower respiratory tract via an endotracheal tube, which increases the risk of pulmonary infections. Six key strategies for patients on mechanical ventilation were recommended (i) avoiding intubation, when possible, (ii) minimizing the duration of mechanical ventilation, (iii) provide regular oral care, (iv) elevating the head of the bed, (iv) maintaining ventilator circuits, and (vi) properly selecting and managing endotracheal tubes. The cost remains significant, emphasising the need for effective preventive measures. Therefore, reducing the incidence of VAP can reduce the use of antimicrobials, and thereby decreases the development and spread of antimicrobial resistance in intensive care units (ICU) 9 , 10 . Oral health in patients requiring critical care is vital because it can affect the health and clinical outcomes of these individuals. Oral epithelium cells are easily damaged in ICU patients due to poor circulation, lack of fluid and food intake, and toxicity of administered drugs. Oral microflora in ICU patients differs with healthy individuals; since it contains organisms that may rapidly cause pneumonia. Within 48 hours after admission, the microflora changes from Gram-positive streptococci to Gram-negative pathogens, most of which cause ventilator-associated pneumonia (VAP). Guarantying oral hygiene and care is one of the main responsibilities of health care providers. It is an essential component of ICU nursing care. Dental plaque, a main cause of VAP in ICUs, can be removed through toothbrush and antimicrobial agents like mouthwash. VAP can be prevented by use of antibacterial chemical solutions; the most conventional of these solutions is chlorhexidine mouthwash. Chlorhexidine is a broad-spectrum antibiotic, widely used by healthy people to prevent dental plaque formation and prevent or treat gingivitis, yet, the Centres for Disease Control and Prevention (CDC) has not approved it due the absence of evidence of its efficacy 9 , 11 . The tracheal cuff is essential in preventing ventilator-associated pneumonia (VAP) by maintaining an airtight seal to block aspiration of contaminated secretions. The percentage of time cuff pressure (Pcuff) recommended to ensure effective ventilation and mucosal protection ranged from 25 to 30 cm H 2 O 2 . Maintaining the tracheal cuff pressure at this optimal level is of critical importance. However, regulation of tracheal cuff pressure using a pneumatic device was superior to manual assessment in preventing VAP in patients with severe trauma 12 . This systematic review assessed the impact of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019–2024. Methods Search Strategy This systematic review covered the period from January 2019 to December 2024 inclusive. It was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines The search of all relevant articles published during the period of study was performed through the database engine PUBMED. The working language adopted by the researchers was English. Their search combined Boolean logic operators “OR, and “AND” and They used predefined keywords which were “ventilator-associated pneumonia", “prevalence or incidence of ventilator associated pneumonia", “Trends and factors associated to ventilator-associated pneumonia”. “Challenges of ventilator-associated to pneumonia”, “oral hygiene and cuff pressure optimization”, “Ventilator-associated pneumonia and oral hygiene”, “Ventilator-associated pneumonia and oral care”, “Ventilator-associated pneumonia, pathobiological heterogeneity and diagnostic challenges”, risk factors for ventilator associated pneumonia”, "oral care", ‘‘mouthwash’’ OR ‘‘chlorhexidine’’,, ‘‘tooth brushing’’ "cuff pressure" ,"endotracheal cuff pressure", "subglottic secretion drainage". Selection and Eligibility Criteria A team of three members adopted the inclusion and exclusion criteria for the publications to be included in their systematic review. The inclusion criteria encompassed all the papers related to their research question published in English language on Africa and Middle East between January 2019 and December 2024. Their inclusion criteria were published articles on adult patients critically ill, intubated, and admitted in intensive care units (ICUs) for VAP. They also restricted their selection on management of VAP, oral care and/or cuff pressure optimization, outcomes and prevention. Data Extraction and Synthesis The search of published papers was performed by a team of three members. Each of them firstly used a standardized data extraction developed in MS Excel to record the following information authors, journal name. year of publication, page numbers, article title, study design, study setting, study population, sample size, statistical tests, main findings and conclusions of the authors. A member of research team merged the three Excel files into a master data file which was shared with the two other members of the team. Independently, these two members of the team search for duplicate papers in the master file and they remove all the duplicates. The two members produced a second master file, which was handled to the third member who screened this master file to ensure that all the duplicates were removed, all the articles retained fulfil their inclusion criteria. After the team members agreed on the master file from which all the duplicates were removed, and which fulfilled their inclusion criteria. The three members worked online and completed their PRISMA Follow Diagram. The clean master file was sorted by study design, and the retrieved papers were shared proportionally to the number of research team and the study designs (cross-sectional, case control, cohort, randomized clinical trial). Each of the team members used a standardized data abstraction developed in MS Excel to record the following variables, author et al year, mean, 95% confidence intervals (lower and upper limits), sample size and inverse variance. Any of these variables except the authors and year of publication were computed by the team members as below. The Inverse variance was computed as 1/SEM or 1 /SE(p) where SEM = standard error for mean = SD/√n and SE(p) = standard error for a proportion = √(pq/n). The Sample size was the number of study participants mentioned by the authors in the concerned article. The 95% confidence intervals if not provided were computed for mean as mean± (1.96x SEM) and for proportion as mean/pooled proportion ± (1.96 x SE(p)). Risk of Bias and Quality Assessment The data recorded by the research team were copied and pasted in forest plot generator developed Bailey, T.M. (2009) developed in MS Excel workbook and downloadable from URL ttp:// www.cardiff.ac.uk/psych/home2/mat/ . It is free for use by any research to interpret and assess the risk of bias related to various articles and to assess the quality of various articles. Clinical trial number: not applicable. Results The team of three members retrieved an initial sample of 2349 articles related to their research question. They removed 736 articles, which were duplicated. The team screened 1613 articles. Finally, after applying their inclusion criteria, they ended up by including in their systematic review a final sample of 4 articles which fulfil their inclusion criteria. Figure 1 described the framework used by the researchers. Figure 1 : PRISMA flow diagram of the assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 by Samah K. Abuzaid, Suha M. Awad, Raneen M. Awad. Table 1 summarized the four articles (cross-sectional, cohort, radomized control experimental and systematic review and meta-analysis) included in this systematic review. The findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. The prevalence of VAP in patients in emergency, surgery and reintubation was estimated to be 19.7%. VAP developed in patients under mechanical ventilator in 3 to 18 days with mean duration of 7.50 days±5.07. The use of povidone-iodine in providing oral health care to patients under ventilator reduced the length of stay in ICU and consequently the mortality rate. Table 1 : Summary results of findings of studies included in this systematic review (n=4) Authors Title Study Design Main Findings Nasrolahzadeh et al. 2023 Evaluation of ventilator-associated pneumonia care practice in the intensive care units of a comprehensive specialized hospital in Northwest Ethiopia: a 1.5-year prospective observational study Observational cross sectional The findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. Furthermore, certain measures—such as maintaining endotracheal tube cuff pressure within the recommended range of 20–25 cmH₂O and the use of subglottic suction endotracheal tubes—were considered not applicable in this setting. Elsheikh et al. 2024 Incidence and predictors of ventilator-associated pneumonia using a competing risk analysis: a single-center prospective cohort study in Egypt Prospective cohort study 19.7% of patients developed VAP, emergency surgery, reintubation, and increased duration of MV were independent risk factors for VAP development Akbiyik A et al 2020 The effect of oropharyngeal aspiration before position change on reducing the incidence of ventilator- associated pneumonia Randomized controlled experimental The mean duration of VAP development was 7.50±5.07 days of mechanical ventilation (min 3 days; max 18 days). Emami Z.A 2023 Effect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis Systematic Review and Meta-Analysis The present systematic review and meta-analysis assessed the effect of oral care with PI in preventing VAP, improving the length of ICU stay, and on the mortality rate among mechanically ventilated ICU patients The quality assessment for reliability and bias was performed through a forest plot (figure 2). All the for articles included in the research was contributing positive to address the research as all of them are their box located on the right the vertical axis which the horizontal axis of effect of size. All the four articles reliable. The study of Akbiyik A et al 2020, had an effect size between 10%-15% with two equal whiskers (tails) of size indicating a large variability of the data used by the authors. Furthermore, the tail left cross on the left the vertical 0 axis. The remaining three articles were not only reliable with an effect size ranging 20% to about 30%, by they were accurate as their respective tails were short indicating low variability in the data collected. Discussion Ventilator associated pneumonia (VAP) constitute nearly 9% to 40% of intensive care unit acquired infections, one of the etiological factors of VAP is endotracheal tube, which act as a conductor of microorganisms of the oropharynx and lower respiratory tract, as well as oral cavity microbiota which plays an important role in development of VAP Lacerda Vidal CF et al 13 . This systematic review found a prevalence of 19.7% which is in the range of published VAP global prevalence in patients in emergency, surgery and reintubation as reported elsewhere in the litterature 2 – 5 varying from 5.0% to 65.0% according to various diagnostic criteria. The findings of this systematic review highlighted that both oral hygiene practices and optimization of cuff pressure play a crucial role in reducing the burden of ventilator-associated pneumonia (VAP) among critically ill patients in Africa and Middle East. Elsheikh M et al 14 revealed that 20% of mechanically ventilated patients developed VAP with an incidence rate of 17.1%; they hypothesized that the risk of VAP increased due to reintubation which allowed the aspiration of either oropharyngeal secretion or gastric content into lower respiratory tract. Various authors 9 , 11 also highlighted the importance of oral hygene in occurrence of VAP. In this systematic review Singh P et al 15 pointed out that the compulsory tooth brushing decreases the number of VAP patients, as well as the length of ICU stay and ventilator time as stated by various authors 9 , 11 . In this systematic review Akbiyik A et al 16 revealed that the effect of oral care with povidone-iodine in preventing VAP, reducing the length of ICU stay, as well as the mortality rate among mechanically ventilated ICU patients. Authors 9 , 10 also pointed out the benefits of the use of chloroxidine in oral health care to prevent VAP in ICUs. In this review Akbiyik A et al 16 regarding cuff pressure optimization found a significant reduction ( p = 0.005) in VAP when performing oropharyngeal aspiration before changing the patient position. Marjanovic N et al 12 confirmed also this crucial importance of tracheal cuff pressure in preventing VAP in patients with severe trauma. In the Overall, this review indicates that effective VAP prevention requires a combination of evidence-based oral care and Precise cuff pressure management. Conclusions The variation in implementation of oral hygiene and cuff pressure optimization practices across Africa and Middle East highlights the need for a specific guidelines and continuous education of ICU staff. Although most studies demonstrated positive impacts on reducing VAP incidence and hospital stay, the lack of uniform methodologies and limited regional data remain key of challenges. Therefore, future regional research based multi-country hospital based trials is required to develop standardized strategies to issues guidelines and protocols for VAP management. Abbreviations CDC Centres for Disease Control and Prevention HAIs Health Care Associated Infections ICU Intensive Care Unit Pcuff Percentage of time Cuff Pressure PI Povidone-Iodine PRISMA Preferred Reporting Items for Systematic Review and Meta-Analysis VAP Ventilator Associated Pneumonia Declarations Authors’ contributions SKA : Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript. SMA : Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript RMA : Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript TR : Review the manuscript and proofread the final manuscript prior its submission. SGEM : Review the manuscript and proofread the final manuscript prior its submission. MN : Supervised the research proposal and its Implementation, read the manuscript and proof read the final manuscript prior its submission Ethics approval and consent to participate Not applicable, it was a systematic review which proposal was approved by the Review Committee of the Faculty of Medical Laboratory Sciences. Consent for publication Not applicable. Availability of data and materials All the data related to this systematic review are included in the submitted manuscript. Competing interest All the authors declared no competing interest. Funding Samah Kamal Abuzaid, Suha Mohamed Awad, and Raneen Mohamed Awad funded all the cost related to this research in the framework of the partial fulfilment for their master in infection control and prevention thesis. Acknowledgements Heartfelt appreciation goes to all the authors whose paper facilitate the implementation of this systematic review, and we reassured them that any misinterpretation of their findings was not intentional but related to our skill in critical appraisal. Hence, we apologize for any inconvenience. References Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020;46(5):888–906. 10.1007/s00134-020-05980-0 . Wu Y, Su Y, Zhao L, et al. Continuous versus intermittent cuff pressure monitoring in preventing ventilator-associated pneumonia: a multicentre randomised controlled trial. Antimicrob Resist Infect Control. 2025;14:66. https://doi.org/10.1186/s13756-025-01579-6 . Magill SS, Li Q, Gross C, Dudeck M, Allen-Bridson K, Edwards JR. Incidence and Characteristics of Ventilator-Associated Events Reported to the National Healthcare Safety Network in 2014. Crit Care Med. 2016;44(12):2154–62. 10.1097/CCM.0000000000001871 . Kharel S, Bist A, Mishra SK. Ventilator-associated pneumonia among ICU patients in WHO Southeast Asian region: A systematic review. PLoS ONE. 2021;16(3):e0247832. https://doi.org/10.1371/journal.pone.0247832 . He Q, Wang W, Zhu S, et al. The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study. Crit Care. 2021;25:44. https://doi.org/10.1186/s13054-021-03484-x . Rosenthal VD, Memish ZA, Bearman G. Preventing ventilator-associated pneumonia: A position paper of the International Society for Infectious Diseases, 2024 update. Int J Infect Dis. 2025;151:107305. 10.1016/j.ijid.2024.107305 . Stone PW. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res. 2009;9(5):417–22. 10.1586/erp.09.53 . Cabrera-Tejada GG, Chico-Sánchez P, Gras-Valentí P et al. Estimation of Additional Costs in Patients with Ventilator-Associated Pneumonia. Antibiotics (Basel). 2023;13(1):2. Published 2023 Dec 19. 10.3390/antibiotics13010002 Alqaissi N, Qtait M. Knowledge and Practices of Intensive Care Unit Nurses Related to Prevention of Ventilator-Associated Pneumonia Cross-Sectional Study. SAGE Open Nurs. 2025;11:23779608251349956. Published 2025 Sep 5. 10.1177/23779608251349956 Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(6):687–713. 10.1017/ice.2022.88 . Marjanovic N, Boisson M, Asehnoune K, et al. Continuous pneumatic regulation of tracheal cuff pressure to decrease ventilator-associated pneumonia in trauma patients who were mechanically ventilated: The AGATE multicenter randomized controlled study. Chest. 2021;160(2):499–508. 10.1016/j.chest.2021.04.004 . Marjanovic N, Boisson M, Asehnoune K, et al. Continuous Pneumatic Regulation of Tracheal Cuff Pressure to Decrease Ventilator-associated Pneumonia in Trauma Patients Who Were Mechanically Ventilated: The AGATE Multicenter Randomized Controlled Study. Chest. 2021;160(2):499–508. 10.1016/j.chest.2021.03.007 . de Lacerda Vidal CF, Vidal AK, Monteiro JG Jr et al. Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infect Dis. 2017;17(1):112. 10.1186/s12879-017-2188-0 . Erratum in: BMC Infect Dis. 2017;17(1):173. doi: 10.1186/s12879-017-2273-4. PMID: 28143414; PMCID: PMC5286780. Elsheikh M, Kuriyama A, Goto Y, Takahashi Y, et al. Incidence and predictors of ventilator-associated pneumonia using a competing risk analysis: a single-center prospective cohort study in Egypt. BMC Infect Dis. 2024;24(1):1007. 10.1186/s12879-024-09909-6 . PMID: 39300386; PMCID: PMC11414232. Singh P, Arshad Z, Srivastava VK, et al. Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients. Cureus. 2022;14(4):e23750. 10.7759/cureus.23750 . PMID: 35518542; PMCID: PMC9064705. Akbiyik A, Hepçivici Z, Eşer I, et al. The effect of oropharyngeal aspiration before position change on reducing the incidence of ventilator- associated pneumonia. Eur J Clin Microbiol Infect Dis. 2021;40(3):615–22. 10.1007/s10096-019-03789-4 . Epub 2020 Nov 24. PMID: 33230628; PMCID: PMC7683036. Emami Zeydi A, Parvizi A, Haddadi S, et al. Effect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2023;11(1):e31. 10.22037/aaem.v11i1.1874 . PMID: 37215234; PMCID: PMC10197909. Additional Declarations No competing interests reported. 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16:43:18","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61974,"visible":true,"origin":"","legend":"","description":"","filename":"3f321911303240a8bdcd95c5c1a1ec6c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8203437/v1/b70ff3fd555d5832ebde0b67.xml"},{"id":98427234,"identity":"e512f3e5-5ff5-4542-a135-c0d7cc97289f","added_by":"auto","created_at":"2025-12-17 16:40:01","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72621,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8203437/v1/3de6c2784797fc6852d8562b.html"},{"id":98429033,"identity":"60d46974-c35d-4f82-9581-63fe0ed915c1","added_by":"auto","created_at":"2025-12-17 16:42:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40538,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram of the assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 by Samah K. Abuzaid, Suha M. Awad, Raneen M. Awad.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8203437/v1/1d3ff1d99d9a271d0c1c9ffa.png"},{"id":98074241,"identity":"d219d6ca-b739-409a-887e-5ecddc3c93fc","added_by":"auto","created_at":"2025-12-12 13:26:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":35637,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot that assess the precision and reliability of this systematic review\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8203437/v1/4e9062c42eb7fce756cc84f4.png"},{"id":105788074,"identity":"6643a598-b5c5-4ee8-9400-097a7320940a","added_by":"auto","created_at":"2026-03-31 06:58:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":849067,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8203437/v1/8e7baa5a-2fab-439a-bc5d-3cd44713ab2f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 - A Systematic Review","fulltext":[{"header":"Background","content":"\u003cp\u003eVentilator associated pneumonia is a nosocomial infection, which occurs in intensive care units in patients intubated and under mechanical ventilation for over 48 hours. Clinical signs in affected patients include fever, respiratory distress, and purulent tracheal secretions\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Globally, VAP incidence was reported to vary from 5.0% to 65.0% based on different diagnostic criteria. In the USA, 2.0 to 11.9 cases/1000 ventilators days was recorded it raised up to 116/1000 ventilator in Southeast Asia, however in western China an incidence of 1.64/1000 days was published\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn the literature\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, a worldwide variation of the costs associated to VAP was reported. In the USA, Stone PW \u003csup\u003e7\u003c/sup\u003e pointed out that VAP ranked second among the health care associated infections (HAIs) with an annual average of 250,205 infection cases and 35,967 deaths cases/year, which led to a mean hospital cost of US \u003cspan\u003e$\u003c/span\u003e 9966. While the cost analysis of Cabrera-Tejada GG et al\u003csup\u003e8\u003c/sup\u003e revealed that patients with VAP had a significantly extended stay in the critical care units (CCUs) compared to their counterparts without VAP, with respective durations of 26.20\u0026thinsp;\u0026plusmn;\u0026thinsp;18.77 days and 12.78\u0026thinsp;\u0026plusmn;\u0026thinsp;12.33 days (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, the duration of the stay in medical services was not significantly different (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.04) between the VAP (13.20\u0026thinsp;\u0026plusmn;\u0026thinsp;18.73 days) and non-VAP groups (13.06\u0026thinsp;\u0026plusmn;\u0026thinsp;27.39 days).\u003c/p\u003e\u003cp\u003eVAP prolongs hospital stays, increases morbidity and mortality, and had a significant financial burden on healthcare systems. Between 15% and 50% of patients with VAP may die. A key factor contributing to the development of VAP is the introduction of bacterial organisms in the lower respiratory tract via an endotracheal tube, which increases the risk of pulmonary infections. Six key strategies for patients on mechanical ventilation were recommended (i) avoiding intubation, when possible, (ii) minimizing the duration of mechanical ventilation, (iii) provide regular oral care, (iv) elevating the head of the bed, (iv) maintaining ventilator circuits, and (vi) properly selecting and managing endotracheal tubes. The cost remains significant, emphasising the need for effective preventive measures. Therefore, reducing the incidence of VAP can reduce the use of antimicrobials, and thereby decreases the development and spread of antimicrobial resistance in intensive care units (ICU)\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOral health in patients requiring critical care is vital because it can affect the health and clinical outcomes of these individuals. Oral epithelium cells are easily damaged in ICU patients due to poor circulation, lack of fluid and food intake, and toxicity of administered drugs. Oral microflora in ICU patients differs with healthy individuals; since it contains organisms that may rapidly cause pneumonia. Within 48 hours after admission, the microflora changes from Gram-positive streptococci to Gram-negative pathogens, most of which cause ventilator-associated pneumonia (VAP). Guarantying oral hygiene and care is one of the main responsibilities of health care providers. It is an essential component of ICU nursing care. Dental plaque, a main cause of VAP in ICUs, can be removed through toothbrush and antimicrobial agents like mouthwash. VAP can be prevented by use of antibacterial chemical solutions; the most conventional of these solutions is chlorhexidine mouthwash. Chlorhexidine is a broad-spectrum antibiotic, widely used by healthy people to prevent dental plaque formation and prevent or treat gingivitis, yet, the Centres for Disease Control and Prevention (CDC) has not approved it due the absence of evidence of its efficacy\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe tracheal cuff is essential in preventing ventilator-associated pneumonia (VAP) by maintaining an airtight seal to block aspiration of contaminated secretions. The percentage of time cuff pressure (Pcuff) recommended to ensure effective ventilation and mucosal protection ranged from 25 to 30 cm H\u003csub\u003e2\u003c/sub\u003eO\u003csub\u003e2\u003c/sub\u003e.\u003c/p\u003e\u003cp\u003eMaintaining the tracheal cuff pressure at this optimal level is of critical importance. However, regulation of tracheal cuff pressure using a pneumatic device was superior to manual assessment in preventing VAP in patients with severe trauma\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis systematic review assessed the impact of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019\u0026ndash;2024.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSearch Strategy\u003c/h2\u003e\u003cp\u003eThis systematic review covered the period from January 2019 to December 2024 inclusive. It was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines The search of all relevant articles published during the period of study was performed through the database engine PUBMED. The working language adopted by the researchers was English. Their search combined Boolean logic operators \u0026ldquo;OR, and \u0026ldquo;AND\u0026rdquo; and They used predefined keywords which were \u0026ldquo;ventilator-associated pneumonia\", \u0026ldquo;prevalence or incidence of ventilator associated pneumonia\", \u0026ldquo;Trends and factors associated to ventilator-associated pneumonia\u0026rdquo;. \u0026ldquo;Challenges of ventilator-associated to pneumonia\u0026rdquo;, \u0026ldquo;oral hygiene and cuff pressure optimization\u0026rdquo;, \u0026ldquo;Ventilator-associated pneumonia and oral hygiene\u0026rdquo;, \u0026ldquo;Ventilator-associated pneumonia and oral care\u0026rdquo;, \u0026ldquo;Ventilator-associated pneumonia, pathobiological heterogeneity and diagnostic challenges\u0026rdquo;, risk factors for ventilator associated pneumonia\u0026rdquo;, \"oral care\", \u0026lsquo;\u0026lsquo;mouthwash\u0026rsquo;\u0026rsquo; OR \u0026lsquo;\u0026lsquo;chlorhexidine\u0026rsquo;\u0026rsquo;,, \u0026lsquo;\u0026lsquo;tooth brushing\u0026rsquo;\u0026rsquo; \"cuff pressure\" ,\"endotracheal cuff pressure\", \"subglottic secretion drainage\".\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSelection and Eligibility Criteria\u003c/h3\u003e\n\u003cp\u003eA team of three members adopted the inclusion and exclusion criteria for the publications to be included in their systematic review. The inclusion criteria encompassed all the papers related to their research question published in English language on Africa and Middle East between January 2019 and December 2024. Their inclusion criteria were published articles on adult patients critically ill, intubated, and admitted in intensive care units (ICUs) for VAP. They also restricted their selection on management of VAP, oral care and/or cuff pressure optimization, outcomes and prevention.\u003c/p\u003e\n\u003ch3\u003eData Extraction and Synthesis\u003c/h3\u003e\n\u003cp\u003eThe search of published papers was performed by a team of three members. Each of them firstly used a standardized data extraction developed in MS Excel to record the following information authors, journal name. year of publication, page numbers, article title, study design, study setting, study population, sample size, statistical tests, main findings and conclusions of the authors. A member of research team merged the three Excel files into a master data file which was shared with the two other members of the team. Independently, these two members of the team search for duplicate papers in the master file and they remove all the duplicates. The two members produced a second master file, which was handled to the third member who screened this master file to ensure that all the duplicates were removed, all the articles retained fulfil their inclusion criteria. After the team members agreed on the master file from which all the duplicates were removed, and which fulfilled their inclusion criteria. The three members worked online and completed their PRISMA Follow Diagram. The clean master file was sorted by study design, and the retrieved papers were shared proportionally to the number of research team and the study designs (cross-sectional, case control, cohort, randomized clinical trial). Each of the team members used a standardized data abstraction developed in MS Excel to record the following variables, author et al year, mean, 95% confidence intervals (lower and upper limits), sample size and inverse variance. Any of these variables except the authors and year of publication were computed by the team members as below. The Inverse variance was computed as 1/SEM or 1 /SE(p) where SEM\u0026thinsp;=\u0026thinsp;standard error for mean\u0026thinsp;=\u0026thinsp;SD/\u0026radic;n and SE(p)\u0026thinsp;=\u0026thinsp;standard error for a proportion = \u0026radic;(pq/n). The Sample size was the number of study participants mentioned by the authors in the concerned article. The 95% confidence intervals if not provided were computed for mean as mean\u0026plusmn; (1.96x SEM) and for proportion as mean/pooled proportion \u0026plusmn; (1.96 x SE(p)).\u003c/p\u003e\n\u003ch3\u003eRisk of Bias and Quality Assessment\u003c/h3\u003e\n\u003cp\u003eThe data recorded by the research team were copied and pasted in forest plot generator developed Bailey, T.M. (2009) developed in MS Excel workbook and downloadable from URL ttp://\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.cardiff.ac.uk/psych/home2/mat/\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.cardiff.ac.uk/psych/home2/mat/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. It is free for use by any research to interpret and assess the risk of bias related to various articles and to assess the quality of various articles.\u003c/p\u003e\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe team of three members retrieved an initial sample of 2349 articles related to their research question. They removed 736 articles, which were duplicated. The team screened 1613 articles. Finally, after applying their inclusion criteria, they ended up by including in their systematic review a final sample of 4 articles which fulfil their inclusion criteria. Figure 1 described the framework used by the researchers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFigure 1\u003c/u\u003e\u003c/strong\u003e: \u003cstrong\u003ePRISMA flow diagram of\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;the assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 \u0026ndash; 2024 by Samah K. Abuzaid, Suha M. Awad, Raneen M. Awad.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 summarized the four articles (cross-sectional, cohort, radomized control experimental and systematic review and meta-analysis) \u0026nbsp;included in this systematic review. The findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. The prevalence of VAP in patients in emergency, surgery and reintubation was estimated to be 19.7%. VAP developed in patients under mechanical ventilator in 3 to 18 days with mean duration of 7.50 days\u0026plusmn;5.07. The use of povidone-iodine in providing oral health care to patients under ventilator reduced the length of stay in ICU and consequently the mortality rate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 1\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e: Summary results of findings of studies included in this systematic review (n=4)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 195px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTitle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain Findings\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003eNasrolahzadeh et al. 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 195px;\"\u003e\n \u003cp\u003eEvaluation of ventilator-associated pneumonia care practice in the intensive care units of a comprehensive specialized hospital in Northwest Ethiopia: a 1.5-year prospective observational study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003eObservational cross sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eThe findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. Furthermore, certain measures\u0026mdash;such as maintaining endotracheal tube cuff pressure within the recommended range of 20\u0026ndash;25 cmH₂O and the use of subglottic suction endotracheal tubes\u0026mdash;were considered not applicable in this setting.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003eElsheikh et al. 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 195px;\"\u003e\n \u003cp\u003eIncidence and predictors of ventilator-associated pneumonia using a competing risk analysis: a single-center prospective cohort study in Egypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;Prospective cohort study\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003e19.7% of patients developed VAP, emergency surgery, reintubation, and increased duration of MV were independent risk factors for VAP development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003eAkbiyik A et al 2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 195px;\"\u003e\n \u003cp\u003eThe effect of oropharyngeal aspiration before position change on reducing the incidence of ventilator- associated pneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003eRandomized controlled experimental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eThe mean duration of VAP development was 7.50\u0026plusmn;5.07 days of mechanical ventilation (min 3 days; max 18 days).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 108px;\"\u003e\n \u003cp\u003eEmami Z.A 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 195px;\"\u003e\n \u003cp\u003eEffect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003eSystematic Review and Meta-Analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 293px;\"\u003e\n \u003cp\u003eThe present systematic review and meta-analysis assessed the effect of oral care with PI in preventing VAP, improving the length of ICU stay, and on the mortality rate among mechanically ventilated ICU patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;The quality assessment for reliability and bias was performed through a forest plot (figure 2). All the for articles included in the research was contributing positive to address the research as all of them are their box located on the right the vertical axis which the horizontal axis of effect of size. All the four articles reliable. The study of Akbiyik A et al 2020, had an effect size between 10%-15% with two equal whiskers (tails) of size indicating a large variability of the data used by the authors. Furthermore, the tail left cross on the left the vertical 0 axis. The remaining three articles were not only reliable with an effect size ranging 20% to about 30%, by they were accurate as their respective tails were short indicating low variability in the data collected.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eVentilator associated pneumonia (VAP) constitute nearly 9% to 40% of intensive care unit acquired infections, one of the etiological factors of VAP is endotracheal tube, which act as a conductor of microorganisms of the oropharynx and lower respiratory tract, as well as oral cavity microbiota which plays an important role in development of VAP Lacerda Vidal CF et al\u003csup\u003e13\u003c/sup\u003e. This systematic review found a prevalence of 19.7% which is in the range of published VAP global prevalence in patients in emergency, surgery and reintubation as reported elsewhere in the litterature\u003csup\u003e\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e varying from 5.0% to 65.0% according to various diagnostic criteria.\u003c/p\u003e\u003cp\u003eThe findings of this systematic review highlighted that both oral hygiene practices and optimization of cuff pressure play a crucial role in reducing the burden of ventilator-associated pneumonia (VAP) among critically ill patients in Africa and Middle East. Elsheikh M et al \u003csup\u003e14\u003c/sup\u003e revealed that 20% of mechanically ventilated patients developed VAP with an incidence rate of 17.1%; they hypothesized that the risk of VAP increased due to reintubation which allowed the aspiration of either oropharyngeal secretion or gastric content into lower respiratory tract. Various authors\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e also highlighted the importance of oral hygene in occurrence of VAP. In this systematic review Singh P et al\u003csup\u003e15\u003c/sup\u003e pointed out that the compulsory tooth brushing decreases the number of VAP patients, as well as the length of ICU stay and ventilator time as stated by various authors\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this systematic review Akbiyik A et al\u003csup\u003e16\u003c/sup\u003e revealed that the effect of oral care with povidone-iodine in preventing VAP, reducing the length of ICU stay, as well as the mortality rate among mechanically ventilated ICU patients. Authors\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e also pointed out the benefits of the use of chloroxidine in oral health care to prevent VAP in ICUs. In this review Akbiyik A et al\u003csup\u003e16\u003c/sup\u003e regarding cuff pressure optimization found a significant reduction (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) in VAP when performing oropharyngeal aspiration before changing the patient position. Marjanovic N et al\u003csup\u003e12\u003c/sup\u003e confirmed also this crucial importance of tracheal cuff pressure in preventing VAP in patients with severe trauma.\u003c/p\u003e\u003cp\u003eIn the Overall, this review indicates that effective VAP prevention requires a combination of evidence-based oral care and Precise cuff pressure management.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e The variation in implementation of oral hygiene and cuff pressure optimization practices across Africa and Middle East highlights the need for a specific guidelines and continuous education of ICU staff. Although most studies demonstrated positive impacts on reducing VAP incidence and hospital stay, the lack of uniform methodologies and limited regional data remain key of challenges. Therefore, future regional research based multi-country hospital based trials is required to develop standardized strategies to issues guidelines and protocols for VAP management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCDC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentres for Disease Control and Prevention\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHAIs\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Care Associated Infections\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eICU\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePcuff\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePercentage of time Cuff Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePovidone-Iodine\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePRISMA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePreferred Reporting Items for Systematic Review and Meta-Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eVAP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVentilator Associated Pneumonia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSKA\u003c/strong\u003e: Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSMA\u003c/strong\u003e: Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRMA\u003c/strong\u003e: Developed the research proposal, implemented the research including the data evaluation, draft the initial and final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTR\u003c/strong\u003e: Review the manuscript and proofread the final manuscript prior its submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSGEM\u003c/strong\u003e: Review the manuscript and proofread the final manuscript prior its submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMN\u003c/strong\u003e: Supervised the research proposal and its Implementation, read the manuscript and proof read the final manuscript prior its submission\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eEthics approval and consent to participate\u003c/h4\u003e\n\u003cp\u003e\u0026nbsp;Not applicable, it was a systematic review which proposal was approved by the Review Committee of the Faculty of Medical Laboratory Sciences.\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eAll the data related to this systematic review are included in the submitted manuscript.\u003c/p\u003e\n\u003ch3\u003eCompeting interest\u003c/h3\u003e\n\u003cp\u003eAll the authors declared no competing interest.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eSamah Kamal Abuzaid, Suha Mohamed Awad, and Raneen Mohamed Awad funded all the cost related to this research in the framework of the partial fulfilment for their master in infection control and prevention thesis.\u003c/p\u003e\n\u003ch3 id=\"_Toc211076233\"\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eHeartfelt appreciation goes to all the authors whose paper facilitate the implementation of this systematic review, and we reassured them that any misinterpretation of their findings was not intentional but related to our skill in critical appraisal. Hence, we apologize for any inconvenience.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePapazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020;46(5):888\u0026ndash;906. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00134-020-05980-0\u003c/span\u003e\u003cspan address=\"10.1007/s00134-020-05980-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu Y, Su Y, Zhao L, et al. Continuous versus intermittent cuff pressure monitoring in preventing ventilator-associated pneumonia: a multicentre randomised controlled trial. Antimicrob Resist Infect Control. 2025;14:66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13756-025-01579-6\u003c/span\u003e\u003cspan address=\"10.1186/s13756-025-01579-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMagill SS, Li Q, Gross C, Dudeck M, Allen-Bridson K, Edwards JR. Incidence and Characteristics of Ventilator-Associated Events Reported to the National Healthcare Safety Network in 2014. Crit Care Med. 2016;44(12):2154\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/CCM.0000000000001871\u003c/span\u003e\u003cspan address=\"10.1097/CCM.0000000000001871\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKharel S, Bist A, Mishra SK. Ventilator-associated pneumonia among ICU patients in WHO Southeast Asian region: A systematic review. PLoS ONE. 2021;16(3):e0247832. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0247832\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0247832\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe Q, Wang W, Zhu S, et al. The epidemiology and clinical outcomes of ventilator-associated events among 20,769 mechanically ventilated patients at intensive care units: an observational study. Crit Care. 2021;25:44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13054-021-03484-x\u003c/span\u003e\u003cspan address=\"10.1186/s13054-021-03484-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRosenthal VD, Memish ZA, Bearman G. Preventing ventilator-associated pneumonia: A position paper of the International Society for Infectious Diseases, 2024 update. Int J Infect Dis. 2025;151:107305. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijid.2024.107305\u003c/span\u003e\u003cspan address=\"10.1016/j.ijid.2024.107305\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStone PW. Economic burden of healthcare-associated infections: an American perspective. Expert Rev Pharmacoecon Outcomes Res. 2009;9(5):417\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1586/erp.09.53\u003c/span\u003e\u003cspan address=\"10.1586/erp.09.53\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCabrera-Tejada GG, Chico-S\u0026aacute;nchez P, Gras-Valent\u0026iacute; P et al. Estimation of Additional Costs in Patients with Ventilator-Associated Pneumonia. Antibiotics (Basel). 2023;13(1):2. Published 2023 Dec 19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/antibiotics13010002\u003c/span\u003e\u003cspan address=\"10.3390/antibiotics13010002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlqaissi N, Qtait M. Knowledge and Practices of Intensive Care Unit Nurses Related to Prevention of Ventilator-Associated Pneumonia Cross-Sectional Study. SAGE Open Nurs. 2025;11:23779608251349956. Published 2025 Sep 5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/23779608251349956\u003c/span\u003e\u003cspan address=\"10.1177/23779608251349956\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(6):687\u0026ndash;713. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/ice.2022.88\u003c/span\u003e\u003cspan address=\"10.1017/ice.2022.88\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarjanovic N, Boisson M, Asehnoune K, et al. Continuous pneumatic regulation of tracheal cuff pressure to decrease ventilator-associated pneumonia in trauma patients who were mechanically ventilated: The AGATE multicenter randomized controlled study. Chest. 2021;160(2):499\u0026ndash;508. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chest.2021.04.004\u003c/span\u003e\u003cspan address=\"10.1016/j.chest.2021.04.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarjanovic N, Boisson M, Asehnoune K, et al. Continuous Pneumatic Regulation of Tracheal Cuff Pressure to Decrease Ventilator-associated Pneumonia in Trauma Patients Who Were Mechanically Ventilated: The AGATE Multicenter Randomized Controlled Study. Chest. 2021;160(2):499\u0026ndash;508. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chest.2021.03.007\u003c/span\u003e\u003cspan address=\"10.1016/j.chest.2021.03.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Lacerda Vidal CF, Vidal AK, Monteiro JG Jr et al. Impact of oral hygiene involving toothbrushing versus chlorhexidine in the prevention of ventilator-associated pneumonia: a randomized study. BMC Infect Dis. 2017;17(1):112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12879-017-2188-0\u003c/span\u003e\u003cspan address=\"10.1186/s12879-017-2188-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Erratum in: BMC Infect Dis. 2017;17(1):173. doi: 10.1186/s12879-017-2273-4. PMID: 28143414; PMCID: PMC5286780.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElsheikh M, Kuriyama A, Goto Y, Takahashi Y, et al. Incidence and predictors of ventilator-associated pneumonia using a competing risk analysis: a single-center prospective cohort study in Egypt. BMC Infect Dis. 2024;24(1):1007. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12879-024-09909-6\u003c/span\u003e\u003cspan address=\"10.1186/s12879-024-09909-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39300386; PMCID: PMC11414232.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh P, Arshad Z, Srivastava VK, et al. Efficacy of Oral Care Protocols in the Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Patients. Cureus. 2022;14(4):e23750. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.23750\u003c/span\u003e\u003cspan address=\"10.7759/cureus.23750\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35518542; PMCID: PMC9064705.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkbiyik A, Hep\u0026ccedil;ivici Z, Eşer I, et al. The effect of oropharyngeal aspiration before position change on reducing the incidence of ventilator- associated pneumonia. Eur J Clin Microbiol Infect Dis. 2021;40(3):615\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10096-019-03789-4\u003c/span\u003e\u003cspan address=\"10.1007/s10096-019-03789-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Nov 24. PMID: 33230628; PMCID: PMC7683036.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEmami Zeydi A, Parvizi A, Haddadi S, et al. Effect of Oral Care with Povidone-Iodine in the Prevention of Ventilator-Associated Pneumonia; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2023;11(1):e31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22037/aaem.v11i1.1874\u003c/span\u003e\u003cspan address=\"10.22037/aaem.v11i1.1874\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37215234; PMCID: PMC10197909.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cuff pressure optimization, Intensive care unit, Infection prevention, Oral hygiene, Ventilator assisted pneumonia","lastPublishedDoi":"10.21203/rs.3.rs-8203437/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8203437/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e\u003cp\u003ePatient under mechanical ventilator for longer than 48 hours are susceptible to the nosocomial infection known as ventilator-associated pneumonia (VAP). This systematic review assessed the impact of endotracheal cuff pressure optimization and good oral hygiene habits on the prevalence of VAP in intensive care units in Africa and Middle East during 2019\u0026ndash;2024.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e\u003cp\u003e A team of three members implemented a systematic review during the period of January 2019 to September 2024 in accordance with PRISMA guidelines. Their working language was English; they agreed on their research question and inclusion and exclusion criteria. They set the keywords and embarked on search of articles relevant to their research question through PUBMED as a database engine. They retrieved an initial sample of 2349 published articles and included in their study 4 articles fulfilling inclusion criteria. The data were summarized in tabular form for qualitative assessment and graphically as a forest plot to assess the quality and risk of bias across the retrieved publications.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e\u003cp\u003eThe team retrieved an initial sample of 2349 articles related to their research question. They removed 736 articles, which were duplicated. The team screened 1613 articles. After applying their inclusion criteria, they ended by included in their systematic review a final sample of 4 articles which fulfil their inclusion criteria. The findings revealed that compliance with oral hygiene practices using a 0.5% chlorhexidine solution was absent in both medical and surgical intensive care units. The prevalence of VAP in patients in emergency, surgery and reintubation was estimated to be 19.7%. VAP developed in patients under mechanical ventilator in 3 to 18 days with mean duration of 7.50 days\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07. The use of povidone-iodine in providing oral health care to patients under ventilator reduced the length of stay in ICU and consequently the mortality rate.\u003c/p\u003e\u003ch2\u003eConclusion.\u003c/h2\u003e\u003cp\u003eIn intensive care units, throughout Africa and Middle East, oral cleanliness and cuff pressure optimization are still underutilized. The adoption of evidence-based VAP prevention measures should be top priority policy to be implemented in health care services including ongoing staff training.\u003c/p\u003e","manuscriptTitle":"Assessment of oral hygiene and cuff pressure optimization on the burden of ventilator associated pneumonia in Africa and Middle East 2019 – 2024 - A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 13:26:17","doi":"10.21203/rs.3.rs-8203437/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"845fa559-34f8-4eff-b91e-cb3908d86ced","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-31T06:57:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 13:26:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8203437","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8203437","identity":"rs-8203437","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}