Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults.
BACKGROUND
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.
Munro
Cindy L
CL
Adult Health Department, School of Nursing, Virginia Commonwealth University, Richmond, Virginia 23298-0567, USA. cmunro@vcu.edu
Grap
Mary Jo
MJ
Jones
Deborah J
DJ
McClish
Donna K
DK
Sessler
Curtis N
CN
D000328:Adult; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage / Q000627:therapeutic use*; D002710:Chlorhexidine / Q000008:administration & dosage / Q000627:therapeutic use*; D003422:Critical Care; D016638:Critical Illness; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009910:Oral Hygiene; D053717:Pneumonia, Ventilator-Associated / Q000382:microbiology / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000009:adverse effects*; D014099:Toothbrushing / Q000379:methods*
D000891:Anti-Infective Agents, Local; D002710:Chlorhexidine