Impact of gargling on respiratory infections

Respiratory infection is one of the leading causes of death in the world. The outbreaks of influenza and the Middle East respiratory syndrome have added to the miseries of human beings. Interventions such as the use of masks, social distancing, hand washing, and the use of personal protective equipment by health care professionals have minimized the transmission of pathogens from infected to healthy individuals. Another intervention is gargling which is most commonly performed by the Japanese to avoid respiratory infections. PubMed was used to search articles on gargling in respiratory infections published in the last three decades. Gargling is effective in upper respiratory infections (URTIs). URTI precedes lower respiratory tract infection;early intervention could prevent complications. The gargling agents in this review are classified as synthetic and natural gargling agents. The mouthwashes or gargling agents reviewed in this article have proven efficacy in reducing either bacterial or viral (or both) respiratory infections. The mouthwashes available over the counter may also have side effects. The use of mouthwash should be based on the potential benefit of oral and systemic conditions.

Recommendation of the German Society of Hospital Hygiene (DGKH): Prevention of COVID-19 by virucidal gargling and virucidal nasal spray - updated version April 2022.

The German Society of Hospital Hygiene develops guidelines, recommendations and standard operation procedures on a voluntary basis, published on the DGKH-website (https://www.krankenhaushygiene.de/). The original German version of this recommendation was published in April 2022 and has now been made available to the international professional public in English. Evaluating the current data on the efficacy of virucidal gargle/mouthwash solutions and nasal sprays against SARS-CoV-2 in vitro and in clinical trials, conducted with preventive or therapeutic objectives, recommendations are given for the prevention of COVID-19. The following areas are considered: Protection of the community when regional clusters or high incidences of infection become knownProtection of the community at low risk of infectionPre-exposure prophylaxis for the protection of healthcare workersPost-exposure prophylaxis.

Impact of Steam Inhalation, Saline Gargling, and Povidone-Iodine Gargling on Clinical Outcome of COVID-19 Patients in Bengaluru, Karnataka: A Randomized Control Trial.

Context: In the absence of any specific treatment available for COVID-19, people started practicing traditional nonpharmacological preventive home remedies such as salt water gargling and steam inhalation. The available research evidence on some of these measures opines that steam inhalation, saline gargling, and povidone-iodine gargling does have virucidal properties and do provide symptomatic relief. Aims: The aim is to test this hypothesis, and the present trial was undertaken with an objective to assess the effect of steam inhalation, saline gargling, and povidone-iodine gargling among the COVID-19-positive patients with respect to early test negativity and clinical recovery. Methodology: Open-labeled, parallel, randomized controlled trial was conducted among asymptomatic or mild COVID-19-positive patients in Bangalore from September 2020 to February 2021. In each group of steam inhalation, saline gargling, povidone-iodine gargling, and control, twenty participants were allocated. Daily follow-up was done for 21 days to assess early test negativity and clinical recovery. Trial Registry Number: Clinical Trial Registry India/2020/09/027687. Results: Among 80 participants recruited, 65 (81.3%) were symptomatic. Early test negativity was seen in povidone-iodine gargling group of 6 days (KaplanMeier survival curve, BreslowGeneralized Wilcoxon test P = 0.7 as per the intention-to-treat and as per-protocol P = 0.8). Significant clinical recovery was seen in saline gargling group (4 days, P = 0.01). Conclusion: Povidone-iodine gargling was effective in providing early test negativity, whereas saline gargling was effective in early clinical recovery.

Prevention of respiratory viral infections by virucidal mucosal antisepsis among medical staff and in the community

Aim: To prevent COVID-19 all preventive hygiene measures possible must be taken for the protection of, in particular, medical personnel but also the general population, because even if a vaccine is available its protective effect will not be known. A literature search was conducted to analyse whether virucidal mucosal antisepsis is an adequate measure for the prevention of COVID-19. In addition, the role of mouthwash/gargling was analysed as an unspecific measure for the prevention of respiratory infections. The methodology was designed to present in vitro results and study findings as a synopsis. Results: As from a concentration of 0.45%, povidone (PVP) iodine inactivates in vitro enveloped viruses, including SARS-CoV-2. One Japanese PVP iodine gargle/mouthwash formulation was effective even in a concentration of 0.23% against SARS-CoV-1, MERS-CoV and influenza virus H1N1. Above 42.6%, ethanol is effective against SARS-CoV-1, MERS-CoV, influenza A and B viruses. In combination with etheric oils, 21.6% ethanol sufficed to inactivate influenza virus and SARS-CoV-2. 0.2% sodium hypochlorite is effective against coronaviruses. Chlorhexidine digluconate (0.12%) is in vitro > 2 lg less effective against SARS-CoV-2 as 1% PVP iodine. 0.1% octenidine dihydrochloride is in vitro as effective against SARS-CoV-2 as chlorhexidine. Replication of coronaviruses is completely suppressed through the induction of interferons when the active substance is brought into contact with cell cultures before infection. 1.5% hydrogen peroxide does not reach the effectiveness of chlorhexidine. Hypertonic saline solution (3%, 2.5% and 2%) inhibits virus replication in rhino- as well as coronaviruses. Sage extract is effective against vesicular stomatitis virus, avian infectious bronchitis and herpes simplex virus. Combined rhubarb and sage cream was as effective against labial herpes (cold sores) as acyclovir. Hence, efficacy against coronaviruses is assumed. PVP iodine is considered to be the active ingredient of choice when used for pre- and post-exposure prophylaxis based on the state of knowledge on virucidal efficacy and mucosal tolerance based on the scientific insights gained over decades. If contraindicated by the patient’s history, (hyperthyroidism, autonomic adenoma, allergy), alternative, albeit less-well studied, substances should be considered. In aerosol-generating medical procedures, e.g. before bronchoscopy, intubation and dental treatment, irrigation of the patient’s oral cavity with 1% or 1.25% aqueous PVP iodine solution, if possible in combination with gargling, is recommended as pre-exposure prophylaxis, while prior to ear, nose and throat (ENT) diagnostic interventions/procedures its application as a spray into the nasal vestibule is recommended. After accidental exposure of the eyes and nasal cavity, 1.25 aqueous PVP iodine solution can be used as postexposure prophylaxis. It must be ensured that ophthalmic agents are sterile. So long as there are regional/local clusters of SARS-CoV-2 infections, gargling in the morning and evening with 0.23% aqueous PVP iodine solution and its application as a nasal spray are likely to provide additional protection to healthcare workers. In Japan gargling with 0.23% aqueous PVP iodine solution is recommended for the entire population. In April 2020, the WHO has included a PVP-I gargle solution in its list of experimental treatments for COVID-19. As seen at the beginning of the epidemic spread of influenza in the population, daily gargling with e.g. 0.23% aqueous PVP iodine solution, in combination with ethanol/etheric oils or hypertonic saline solution, is recommended. Just as with the advent of the COVID-19 pandemic the wearing of face masks/face coverings has assumed a new role in the general population, so too will the Japanese tradition of antiseptic gargling perhaps experience a resurgence in Europe. Conclusion: Clinical and epidemiological studies are indispensable to corroborate the in vitro findings and inferred recommendations. © 2020 mhp-Verlag GmbH. All rights reserved.

The role of mouthwash sampling in SARS-CoV-2 diagnosis.

BACKGROUND: The current practice of COVID-19 diagnosis worldwide is the use of oro-nasopharyngeal (ONP) swabs. Our study aim was to explore mouthwash (MW) as an alternative diagnostic method, in light of the disadvantages of ONP swabs. METHODS: COVID-19 outpatients molecular-confirmed by ONP swab were repeatedly examined with ONP swab and MW with normal saline (0.9%). Other types of fluids were compared to normal saline. The Cq values obtained with each method were compared. RESULTS: Among 137 pairs of ONP swabs and MW samples, 84.6% (116/137) of ONP swabs were positive by at least one of the genes (N, E, R). However MW detected 70.8% (97/137) of samples as positive, which means 83.6% (97/116) out of positive ONP swabs, missing mainly Cq value > 30. In both methods, the N gene was the most sensitive one. Therefore, MW samples targeting N gene, which was positive in 95/137 (69.3%), are comparable to ONP swabs targeting E and R genes which gave equal results-95/137 (69.3%) and 90/137 (65.7%), respectively. Comparing saline MW to distilled water gave equal results, while commercial mouth-rinsing solutions were less sensitive. CONCLUSIONS: MW with normal saline, especially when tested by N gene, can effectively detect COVID-19 patients. Furthermore, this method was not inferior when compared to R and E genes of ONP swabs, which are common targets in many laboratories around the world.

Gargling with 7.5% Sodium Bicarbonate Solution for SARS-CoV-2 Viremia Clearance: Our Institutional Clinical Experience.

BACKGROUND: Gargling had been reported to have some roles in the prevention and treatment of respiratory tract infections. The purpose of this study was to assess the ability of regular gargling using 7.5% sodium bicarbonate to eliminate SARS-CoV-2 in the oropharynx and nasopharynx. MATERIALS AND METHODS: This pilot, open-labeled, nonrandomized, parallel single-center study. The effect of 30 seconds, three times per day gargling using 7.5% sodium bicarbonate solution-25 mL on SARS-CoV-2 viral clearance among coronavirus disease-2019 (COVID-19) patients in a dedicated COVID hospital at All India Institute of Medical Sciences, Patna, Bihar, India. We monitored the progress on by days 0, 1, 2, 3, 4, 5, 6, and 7 by observing variables like clinical category, P/F ratio, neutrophil/lymphocyte ratio (NLR) ratio, platelet count, ferritin, lactate dehydrogenase (LDH), CRP, procalcitonin, d-dimer, INR, APTT, and sequential organ function assessment (SOFA) score. We have also done repeat reverse transcription-polymerase chain reaction (RT-PCR) testing on day 5 and day 7. RESULTS: A total of 10 patients (7 males and 3 females) were included in our study after confirmed COVID positivity. The age range was from 30 to 61 years. Based on clinical severity and P/F ratio, 7 patients were included in the milder group as their ratio was more than 200 and the rest 3 patients were included in the moderate group as P/F ratio was less than 200. Two respondents had comorbidities, which were non-Hodgkin's lymphoma and ovarian carcinoma. Viral clearance was achieved at day 7 in 3 of 10 patients. However, the analysis of using 7.5% sodium bicarbonate 25 mL gargle statistically showed nonsignificant p-value for all of our studied variables. However, the PCR results were negative on 24 hours apart, i.e., on day 5 and day 7. CONCLUSIONS: This is only a preliminary study which showed that gargling with 7.5% sodium bicarbonate may not be effective in achieving early SARS-CoV-2 viral clearance among mild COVID-19 patients. However, still larger studies are required to ascertain the benefit of gargling for different stages of COVID-19 patients with keeping in mind the important variables suggestive of viremia clearance. HOW TO CITE THIS ARTICLE: Kumar N, Kumar A, Mahto M, Singh PK. Gargling with 7.5% Sodium Bicarbonate Solution for SARS-CoV-2 Viremia Clearance: Our Institutional Clinical Experience. Indian J Crit Care Med 2021;25(7):791-794.

Do saline water gargling and nasal irrigation confer protection against COVID-19?

This report provides a perspective on the relevance of saline water gargling and nasal irrigation to the COVID-19 crisis. While there is limited evidence concerning their curative or preventive role against SARS-CoV-2 infection, previous work on their utility against influenza and recent post-hoc analysis of the Edinburgh and Lothians Viral Intervention Study (ELVIS) provide compelling support to their applicability in the current crisis. Saline water gargling and nasal irrigation represent simple, economical, practically feasible, and globally implementable strategies with therapeutic and prophylactic value. These methods, rooted in the traditional Indian healthcare system, are suitable and reliable in terms of infection control and are relevant examples of harmless interventions. We attempt to derive novel insights into their usefulness, both from theoretical and practical standpoints.