Chlorhexidine and tooth-brushing as prevention strategies in reducing VAP

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Nurs Crit Care. 2011 Nov-Dec;16(6):295-302. doi: 10.1111/j.1478-5153.2011.00465.x. Epub 2011 Jul 26.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates.

Roberts N, Moule P.

Source

Gwynedd, UK. nesta_01@hotmail.com

AbstractBACKGROUND:

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising.

AIM:

This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings.

METHODS:

A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed.

FINDINGS:

CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive careand had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene.

CONCLUSIONS:

The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing.

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Med Clin (Barc). 2010 Oct 9;135(11):491-7. Epub 2010 Jun 16.

[Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials].

[Article in Spanish]

Carvajal C, Pobo A, Díaz E, Lisboa T, Llauradó M, Rello J.

Source

Unidad de Cuidados Intensivos, Fundación Clínica Shaio, Bogotá, Colombia.

AbstractBACKGROUND AND OBJECTIVE:

Mechanical ventilation is used in about one third of patients in intensive cares units (ICU). Ventilator Associated-Pneumonia (VAP) is a frequent infectious complication, affecting approximately 8 to 28% patients. Strategies to prevent the development of VAP are key factors in the management of ICU patients. There have been proposed several strategies to prevent VAP. One of these is oral hygiene with clorhexidine. We evaluated the effect of chlorhexidine on the prevention of VAP.

PATIENTS AND METHODS:

We conducted a systematic review of controlled clinical trials evaluating the effect of oral hygiene on VAP prevention. A PubMed search was performed using the following keywords: "oral care OR oral hygiene OR chlorhexidine AND ventilator-associated pneumonia". An independent reviewer evaluated the studies according to the inclusion criteria and extracted the data.

RESULTS:

A total of 120 articles were found, and 10 of them met the inclusion criteria. A lack of uniformity was appreciated in the application of chlorhexidine. There was a reduction in the risk of VAP in the chlorhexidine group versus control (OR: 0,56, 95% CI: 0,44-0,73). However, neither a reduction in mortality, nor a length of MV nor an ICU length of stay were seen.

CONCLUSIONS:

Oral hygiene with chlorhexidine in combination with other strategies for VAP prevention should be included in the patient's ICU care

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Chest. 2009 Aug;136(2):433-9. Epub 2009 May 29.

A randomized trial of dental brushing for preventing ventilator-associated pneumonia.

Pobo A, Lisboa T, Rodriguez A, Sole R, Magret M, Trefler S, Gómez F, Rello J; RASPALL Study Investigators.

Collaborators (30)

Source

Critical Care Department, Joan XXIII University Hospital, 43007 Tarragona, Spain.

AbstractBACKGROUND:

Poor oral hygiene is associated with respiratory pathogen colonization and secondary lung infection. The impact of adding electric toothbrushing to oral care in order to reduce ventilator-associated pneumonia (VAP) incidence is unknown.

METHODS:

The study design was a prospective, simple-blind, randomized trial of adult patients intubated for > 48 h. Controlling for exposure to antibiotic treatment, patients were randomized to oral care every 8 h with 0.12% chlorhexidine digluconate (standard group) or standard oral care plus electric toothbrushing (toothbrush group). VAP was documented by quantitative respiratory cultures. Mechanical ventilation (MV) duration, hospital ICU length of stay (LOS), antibiotic use, and hospital ICU mortality were secondary end points.

RESULTS:

The study was terminated after randomizing 147 patients (74 toothbrush group) in a scheduled interim analysis. The two groups were comparable at baseline. The toothbrush group and standard group had similar rates of suspected VAP (20.3% vs 24.7%; p = 0.55). After adjustment for severity of illness and admission diagnosis, the incidence of microbiologically documented VAP was also similar in the two groups (hazard ratio, 0.84; 95% confidence interval, 0.41 to 1.73). The groups did not differ significantly in mortality, antibiotic-free days, duration of MV, or hospital ICU LOS.

CONCLUSIONS:

Our findings suggest that the addition of electric toothbrushing to standard oral care with 0.12% chlorhexidine digluconate is not effective for the prevention of VAP. Trial registration: ClinicalTrials.gov Identifier: NCT00842478.

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Am J Crit Care. 2009 Sep;18(5):428-37; quiz 438.

Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults.

Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN.

Source

Adult Health Department, School of Nursing, Virginia Commonwealth University, Richmond, Virginia 23298-0567, USA. cmunro@vcu.edu

AbstractBACKGROUND:

Ventilator-associated pneumonia is associated with increased morbidity and mortality.

OBJECTIVE:

To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation.

METHODS:

Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS).

RESULTS:

The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS >or=6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS >or=6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine.

CONCLUSIONS:

Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.