title: Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia.
abstract: BACKGROUND
  Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality. Although oral decontamination with antibiotics reduces incidences of VAP, it is not recommended because of potential selection of antibiotic-resistant pathogens. We hypothesized that oral decontamination with either chlorhexidine (CHX, 2%) or CHX/colistin (CHX/COL, 2%/2%) would reduce and postpone development of VAP, and oral and endotracheal colonization.
  
  
  OBJECTIVE
  To determine the effect of oral decontamination with CHX or CHX/COL on VAP incidence and time to development of VAP.
  
  
  METHODS
  Consecutive patients needing mechanical ventilation for 48 h or more were enrolled in a randomized, double-blind, placebo-controlled trial with three arms: CHX, CHX/COL, and placebo (PLAC). Trial medication was applied every 6 h into the buccal cavity. Oropharyngeal swabs were obtained daily and quantitatively analyzed for gram-positive and gram-negative microorganisms. Endotracheal colonization was monitored twice weekly.
  
  
  RESULTS
  Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX/COL. Baseline characteristics were comparable. The daily risk of VAP was reduced in both treatment groups compared with PLAC: 65% (hazard ratio [HR]=0.352; 95% confidence interval [CI], 0.160, 0. 791; p=0.012) for CHX and 55% (HR=0.454; 95% CI, 0.224, 0. 925; p=0.030) for CHX/COL. CHX/COL provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHX mostly affected gram-positive microorganisms. Endotracheal colonization was reduced for CHX/COL patients and to a lesser extent for CHX patients. No differences in duration of mechanical ventilation, intensive care unit stay, or intensive care unit survival could be demonstrated.
  
  
  CONCLUSIONS
  Topical oral decontamination with CHX or CHX/COL reduces the incidence of VAP.
authors.affiliation: University Medical Center Utrecht, Department of Internal Medicine and Dermatology, and Department of Internal Medicine and Intensive Care Medicine, Rijnstate Hospital Arnhem, The Netherlands. groenendijk-koeman@wanadoo.nl
authors.forename: Mirelle
authors.initials: M
authors.lastname: Koeman
authors.forename: Andre J A M
authors.initials: AJ
authors.lastname: van der Ven
authors.forename: Eelko
authors.initials: E
authors.lastname: Hak
authors.forename: Hans C A
authors.initials: HC
authors.lastname: Joore
authors.forename: Karin
authors.initials: K
authors.lastname: Kaasjager
authors.forename: Annemarie G A
authors.initials: AG
authors.lastname: de Smet
authors.forename: Graham
authors.initials: G
authors.lastname: Ramsay
authors.forename: Tom P J
authors.initials: TP
authors.lastname: Dormans
authors.forename: Leon P H J
authors.initials: LP
authors.lastname: Aarts
authors.forename: Ernst E
authors.initials: EE
authors.lastname: de Bel
authors.forename: Willem N M
authors.initials: WN
authors.lastname: Hustinx
authors.forename: Ingeborg
authors.initials: I
authors.lastname: van der Tweel
authors.forename: Andy M
authors.initials: AM
authors.lastname: Hoepelman
authors.forename: Marc J M
authors.initials: MJ
authors.lastname: Bonten
mesh_terms: D000287:Administration, Topical; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage / Q000627:therapeutic use*; D002710:Chlorhexidine / Q000008:administration & dosage / Q000627:therapeutic use*; D003091:Colistin / Q000008:administration & dosage / Q000627:therapeutic use; D003422:Critical Care; D004311:Double-Blind Method; D004338:Drug Combinations; D005260:Female; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D006094:Gram-Positive Bacteria / Q000302:isolation & purification; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009055:Mouth / Q000187:drug effects* / Q000382:microbiology; D009960:Oropharynx / Q000382:microbiology; D010919:Placebos; D018410:Pneumonia, Bacterial / Q000517:prevention & control*; D013997:Time Factors; D014132:Trachea / Q000382:microbiology; D012122:Ventilators, Mechanical / Q000009:adverse effects*
chemical_list: D000900:Anti-Bacterial Agents; D000891:Anti-Infective Agents, Local; D004338:Drug Combinations; D010919:Placebos; D002710:Chlorhexidine; D003091:Colistin