Running head: DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 1

Decreasing Ventilator-associated Pneumonia in Mechanically Ventilated Adults Using Oral Care

with Chorhexidine Gluconate

Hannah Lai

University of South Florida

DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 2

Abstract

Clinical Problem: Mechanically ventilated (MV) patients are at increased risk of developing

ventilator-associated pneumonia (VAP), which affects morbidity and mortality rates of MV

patients in the intensive care units (ICU) (Ozcaka et al., 2012).

Objective: This synthesis intends to deliberate if performing oral hygiene care (OHC) with

chlorhexidine (CHX) gluconate mouth rinse or gel will lower the incidence of VAP in MV, adult

patients. PubMed was searched using key words including VAP, ventilator, pneumonia, oral,

chlorhexidine, prevention, intervention, and ICU to find randomized controlled trials (RCT) in

the past 10 years concerning the use of CHX OHC to decrease VAP rates.

Results: In MV, adult patients who received CHX OHC, there is a statistically significant

reduction in VAP development compared to those who received standard OHC with saline.

Cabov et al. (2010) demonstrated that the control group without CHX had increased pathogenic

colonization in the dental plaque (p<0.09), developed more nosocomial infections (p = 0.039),

and stayed longer in the ICU (p = 0.0187). Both Ozcaka et al. (2012) and Sharma and Kaur

(2012) reported that VAP development rates were significantly higher in their control groups

compared to CHX groups (p=0.03, p<0.05, respectively). Although clinical guidelines recognize

the potential benefits of CHX OHC in lowering VAP rates, there is still insufficient data

regarding overall impact on duration of MV, length of stay and mortality.

Conclusion: Although CHX OHC has been observed to reduce VAP incidence among MV, adult

patients, more research is needed to determine its effect on overall length of hospitalization,

duration of MV and impact on patient outcome. Additionally, further research should be

conducted with standardized CHX concentration and consistent methodology in the delivery of

OHC and measurements of VAP incidence.

DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 3

Decreasing Ventilator-associated Pneumonia in Mechanically Ventilated Adults Using Oral Care

with Chorhexidine Gluconate

In the intensive care setting, mechanical ventilation (MV) is sometimes indicated to

sustain a patient’s life. However, maintaining an intubated patient on the MV does not come

without its own risks. Ventilator-associated pneumonia (VAP) is a frequent nosocomial

complication that can affect the mortality and morbidity of MV patients in the intensive care

units (ICU) (Ozcaka et al., 2012). Evidence shows that oral flora colonization and dental plaque

that harbors growth of potentially pathogenic microorganisms may lead to development of VAP

(Cabov et al., 2010). Additionally, aspiration pneumonia develops more frequently in patients

with teeth than patients without teeth, which suggests that improving oral hygiene and reducing

the amount of dental plaque may potentially reduce the risk of VAP (Ozcaka et al., 2012). The

aim of performing this literature review is to determine among MV adult patients in the ICU,

does performing oral hygiene care (OHC) with chlorhexidine (CHX) gluconate mouth rinse or

gel compared to standard OHC affect the incidence of VAP over a three-month period?

Literature Search

PubMed health database was used to obtain randomized controlled trials (RCT)

pertaining to OHC in the prevention of VAP. Key search terms included VAP, ventilator,

pneumonia, oral, chlorhexidine, prevention, intervention, and ICU. The results were restricted by

date of publication to RCTs within the past 10 years, from 2008-2018.

Literature Review

Three RCTs were utilized in addition to one clinical guideline to evaluate the

effectiveness of CHX gluconate OHC in the reduction of VAP incidence. The first RCT by

Cabov et al. (2010) evaluated the effect of oral health on nosocomial infection development;
DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 4

specifically, their study attempted to determine the impact of OHC on the rate of nosocomial

infections in patients in a surgical ICU. The sample size was 60 dentate patients over 18 years of

age hospitalized in the ICU for at least 3 days, requiring MV via oral or nasal tracheal intubation.

The patients were randomized into an intervention group (n= 30) or a control group (n= 30).

Patients in the intervention group experienced OHC using CHX gel of the oral mucosa and

dental plaque and the control group was treated with placebo gel. Oral health was measured by

assessing dental status using the caries-absent-occluded (CAO) score and amount of plaque was

given a semi-quantitative score. Samples of dental plaque, oral mucosa, nasal and tracheal

aspirates were collected for bacterial culture 24 hours after admission and then every three days

until discharge from the ICU to assess for nosocomial infections. Data was collected over nine

months. The authors reported that the control group showed increased colonization of aerobic

pathogens in dental plaque including P. aeruginosa (p<0.09), Enterococcus spp. (p < 0.0046),

and S. aureus (p<0.007) throughout their ICU stay, developed significantly more nosocomial

infections than the intervention group (p = 0.039), and stayed longer in the ICU (p = 0.0187).

These results suggest OHC with CHX significantly reduced oropharyngeal colonization, the

occurrence of hospital-acquired infections, length of ICU hospitalization and mortality in these

patients. Strengths of this study included randomization into the two groups and double blinding

because neither the patients nor the investigators knew who received the intervention as the

placebo gel had the same color, taste, and odor as the CHX gel. Additionally, patients that did

not complete the study were noted as a result of discharge from ICU or death, the control group

was appropriate, each group was analyzed according to their respective groups using reliable

methods, and both groups had similar demographics. Weaknesses of this study include no

mention of whether allocation was concealed from patients or not and unknown follow-up
DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 5

assessments conducted to fully study the effects of the CHX intervention. Another possible

weakness is the low patient numbers in each group.

The second RCT by Ozcaka et al. (2012) assessed whether oral swabbing with 0.2%

CHX gluconate lowered the risk of VAP in ICU patients. The sample size was 61 non-

edentulous patients admitted to respiratory ICU and scheduled for MV for at least 48 hours. The

patients were randomized into an intervention group (n= 29) or a control group (n= 32). Patients

in the intervention group were provided OHC by swabbing the oral mucosa with CHX gluconate

on sponge pellets, four times a day. The patients in the control group were provided the same

OHC except with saline on the sponge pellets. Risk of VAP development was measured by

recording clinical periodontal measurements, obtaining lower‐respiratory‐tract specimens for

microbiological analysis on admission and when VAP was suspected, and identifying pathogens

by quantifying colonies using standard culture techniques. Data was collected over two years.

The authors reported that the VAP development rate was significantly higher in the control group

than in the CHX group (68.8% vs. 41.4%, respectively; p=0.03). These results suggest that

providing OHC in ICU patients using 0.2% CHX four times a day reduces the risk of VAP

development. Strengths of this study included random assignment into both groups, there was

allocation concealment from the patients, and neither the patients nor the investigators knew who

received the CHX intervention. Rationale was provided in the study to explain any exclusion of

patients from the study, but there were no patients that did not complete the study. Each patient

was followed up to 14 days or until discharge from the ICU, until extubation or death.

Additionally, the control group was appropriate, each group was analyzed according to their

respective groups using reliable methods, and both groups had similar demographics. There was
DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 6

limited to no biases identified in this study. One possible weakness is the low patient numbers in

each group.

The third RCT by Sharma and Kaur (2012) aimed to determine the efficacy of 0.12%

CHX gluconate mouth care to prevent VAP among MV patients admitted to the ICU. The

sample size was 260 MV patients admitted to the Medical, Surgical, and Neuro-surgery ICU.

The patients were randomized into an intervention group (n= 130) or a control group (n= 130).

Patients in the intervention group received twice daily OHC with 0.12% CHX and the control

group received twice daily OHC with placebo normal saline. VAP was measured by using a

clinical pulmonary infection score system (CPIS), which evaluated fever, leukocytosis, new

infiltrate, secretions, and PaO2/FiO2; if the CPIS score was 6 or more, then the deep endotracheal

tube suctioned catheter tip was sent for culture. Data was collected over four months. The

authors reported that significantly more number of patients developed VAP in the control group

(46; 35.4%) as compared to the intervention group (7; 5.7%); (p<0.05). These results suggest that

using 0.12% CHX gluconate for OHC can markedly reduce the incidence of VAP among MV,

adult ICU patients. Strengths of this study include random assignment into both groups, random

assignments concealed using sealed envelopes, and double blinding of group assignments from

both patients and investigators. Additionally, there were no patients that did not complete the

study, the control group was appropriate, both groups were analyzed in their respective groups

using reliable methods, and both groups had similar baseline demographics. Weaknesses of this

study include unknown long-term follow-up assessments to study the effects of the intervention

and a different strength of CHX used (0.12%) compared to the previous two RCTs that used

0.2% CHX as the intervention.

DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 7

According to the Society for Healthcare Epidemiology of America (SHEA) and the

Infectious Disease Society of America (IDSA), best practice clinical guidelines recommend a set

of strategies to prevent VAP in acute care hospitals (Klompas et al., 2014). These guidelines

recognize the importance of VAP prevention and other ventilator associated conditions in MV

adult patients and provide grading of the quality of evidence to support various interventions for

best practice (Klompas et al., 2014). There is only moderate quality of evidence to support

performing OHC with CHX as an intervention to reduce VAP rates because there is insufficient

data currently to determine overall impact on duration of MV, length of stay and mortality

(Klompas et al., 2014). While the benefits of OHC with CHX has been well documented in

preventing postoperative respiratory tract infections in cardiac surgery patients, there is currently

only suggestive benefits of reduced rates of VAP in non-cardiac surgical patients (Klompas et

al., 2014). Therefore, the recommendation of providing regular OHC with CHX falls under

special approaches, which are interventions with unproven but minimal risk of harm and

potential impact on VAP rates but is not included in basic practices (Klompas et al., 2014).

These special approaches are recommended in the event that hospitals do not experience a

reduction in VAP rates despite consistent implementation of basic practices (Klompas et al.,

2014).

Synthesis

The results from Cabov et al. (2010), Ozcaka et al. (2012) and Sharma and Kaur (2012)

suggest that providing OHC in MV, adult ICU patients using CHX is an effective intervention

that reduces the risk of VAP development. Results from Cabov et al. (2010) demonstrate that the

control group without CHX had increased pathogenic colonization in the dental plaque (p<0.09)

throughout their ICU stay, developed more nosocomial infections than the intervention group (p
DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 8

= 0.039), and stayed longer in the ICU (p = 0.0187). Similarly, Ozcaka et al. (2012) reported that

the VAP development rate was also significantly higher in the control group than in the CHX

group (68.8% vs. 41.4%, respectively; p=0.03). Sharma and Kaur (2012) also reported that

significantly more number of patients developed VAP in the control group (46; 35.4%) as

compared to the intervention group (7; 5.7%); (p<0.05).

All three RCTs were similar in that all used CHX as an intervention compared to a saline

control group. However, differences in the studies included a variation in the strength of CHX

(0.2% vs 0.12%) used, with variability in frequency (twice a day, three times a day, vs four times

a day) and methodology of how OHC was provided. Methodology of how VAP incidence was

measured also differed between studies. Additionally, there were no consistent findings on

whether the reduction of VAP demonstrated any significant differences in length of

hospitalization or duration of MV.

Despite results from these three RCTs that demonstrate a reduction of VAP incidence

through the use of CHX OHC, the current clinical guidelines do not support this intervention in

basic practice. The clinical guidelines recognize the potential benefits of CHX OHC in lowering

VAP rates, but there is still insufficient data regarding overall impact on duration of MV, length

of stay and mortality (Klompas et al., 2014). Further studies would need to be conducted with

standardized CHX concentration and delivery methods of OHC among a larger sample

population to determine if there is a direct correlation between CHX OHC and VAP incidence as

well as overall impact on patient outcome.

Clinical Recommendations

Research suggests that CHX OHC may be an effective intervention in reducing VAP

incidence among MV, adult ICU patients. Although current clinical guidelines do not include
DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 9

CHX OHC in basic practice due to insufficient data, these guidelines recognize CHX OHC as a

minimal risk intervention with potential benefits to lower VAP rates (Klompas et al., 2014).

Current guidelines recommend high quality evidence-based practices that prevent VAP and

decrease the duration of MV, length of stay and mortality; these basic practices include avoiding

intubation if possible, minimizing sedation, maintaining and improving physical condition,

minimizing pooling of secretions above the endotracheal tube cuff, elevating the head of bed,

and changing out ventilator circuits as needed (Klompas et al., 2014). Research confirms that

using CHX OHC in place of standard OHC as a complement to these basic practice strategies

can reduce pneumonia rates in this population by 10%-30%, but there is no definitive impact on

average duration of MV, ICU length of stay or mortality (Klompas et al., 2014). Although

further research is needed to examine whether CHX OHC has a direct correlation to length of

ICU stay and duration on MV, it has minimal adverse effects and can be implemented as an

adjunct treatment to reduce VAP rates in the clinical ICU setting.

DECREASING PNEUMONIA WITH CHORHEXIDINE ORAL CARE 10

References

Cabov, T., Macan, D., Husedzinovic, I., Skrlin-Subic, J., Bosnjak, D., Sestan-Crnek, S., . . .

Golubovic, V. (2010). The impact of oral health and 0.2% chlorhexidine oral gel on the

prevalence of nosocomial infections in surgical intensive-care patients: A randomized

placebo-controlled study. Wiener Klinische Wochenschrift, 122(13-14), 397-404.

doi:10.1007/s00508-010-1397-y

Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G., . . .

Berenholtz, S. M. (2014). Strategies to prevent ventilator-associated pneumonia in acute

care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(8), 915-

936. doi:10.1086/677144

Ozcaka, O., Basoglu, O. K., Buduneli, N., Tasbakan, M. S., Bacakoglu, F., & Kinane, D. F.

(2012). Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive

care unit patients: A randomized clinical trial. Journal of Periodontal Research, 47(5),

584-592. doi:10.1111/j.1600-0765.2012.01470.x

Sharma, S. K., & Kaur, J. (2012). Randomized control trial on efficacy of chlorhexidine mouth

care in prevention of ventilator associated pneumonia (VAP). Nursing and Midwifery

Research Journal, 8(2).