title: Preintubation application of oral chlorhexidine does not provide additional benefit in prevention of early-onset ventilator-associated pneumonia.
abstract: BACKGROUND
  Daily application of oral chlorhexidine gluconate (CHX) following intubation to reduce the risk of ventilator-associated pneumonia (VAP) is now the standard of care in many ICUs. This randomized clinical trial evaluated the benefit of adding a preintubation CHX dose to the known benefit of postintubation CHX to reduce the risk of early-onset VAP. A secondary aim was to test the effect of a preintubation oral application of CHX on early endotracheal tube (ETT) colonization.
  
  
  METHODS
  Subjects (N = 314) were recruited from two teaching hospitals and were randomly assigned to oral application of 5 mL CHX 0.12% solution before intubation (intervention group, n = 157), or to a control group (n = 157) who received no CHX before intubation. All subjects received CHX bid after intubation. Groups were compared using a repeated-measures model with Clinical Pulmonary Infection Score (CPIS) as the response variable. In a planned subset of subjects, ETTs were cultured at extubation.
  
  
  RESULTS
  Application of a preintubation dose of CHX did not provide benefit over the intervention period beyond that afforded by daily oral CHX following intubation. ETT colonization at extubation was < 20% in both groups (no statistically significant difference). Mean CPIS remained below 6 (VAP threshold score) in both groups.
  
  
  CONCLUSIONS
  Although it is feasible to deliver CHX prior to intubation (including emergent or urgent intubation), the results suggest that preintubation CHX may be inconsequential when the ventilator bundle, including daily oral CHX, is in place. During the preintubation period, providers should focus their attention on other critical activities.
  
  
  BACKGROUND
  ClinicalTrials.gov; No.: NCT00893763; URL: www.clinicaltrials.gov.
authors.affiliation: University of South Florida, Tampa, FL. Electronic address: cmunro2@health.usf.edu.
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Munro
authors.affiliation: Virginia Commonwealth University, Richmond, VA.
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Grap
authors.affiliation: Virginia Commonwealth University, Richmond, VA.
authors.forename: Curtis N
authors.initials: CN
authors.lastname: Sessler
authors.affiliation: Virginia Commonwealth University, Richmond, VA.
authors.forename: Ronald K
authors.initials: RK
authors.lastname: Elswick
authors.affiliation: Tampa General Hospital and Florida Gulf to Bay Anesthesiology, Tampa, FL.
authors.forename: Devanand
authors.initials: D
authors.lastname: Mangar
authors.affiliation: Tampa General Hospital and Florida Gulf to Bay Anesthesiology, Tampa, FL.
authors.forename: Rachel
authors.initials: R
authors.lastname: Karlnoski-Everall
authors.affiliation: University of South Florida, Tampa, FL.
authors.forename: Paula
authors.initials: P
authors.lastname: Cairns
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D002710:Chlorhexidine / Q000008:administration & dosage*; D004202:Disinfectants / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009055:Mouth / Q000382:microbiology; D009960:Oropharynx / Q000382:microbiology; D053717:Pneumonia, Ventilator-Associated / Q000209:etiology / Q000517:prevention & control*
chemical_list: D004202:Disinfectants; D002710:Chlorhexidine