title: Effectiveness of Intraoral Chlorhexidine Protocols in the Prevention of Ventilator-Associated Pneumonia: Meta-Analysis and Systematic Review.
abstract: BACKGROUND
  Ventilator-associated pneumonia (VAP) is common in critical patients and related with increased morbidity and mortality. We conducted a systematic review and meta-analysis, with intention-to-treat analysis, of randomized controlled clinical trials that assessed the effectiveness of different intraoral chlorhexidine protocols for the prevention of VAP.
  
  
  METHODS
  Search strategies were developed for the MEDLINE, EMBASE, and LILACS databases. MeSH terms were combined with Boolean operators and used to search the databases. Eligible studies were randomized controlled trials of mechanically ventilated subjects receiving oral care with chlorhexidine or standard oral care protocols consisting of or associated with the use of a placebo or no chemicals. Pooled estimates of the relative risk and corresponding 95% CIs were calculated with random effects models, and heterogeneity was assessed with the Cochran Q statistic and I(2).
  
  
  RESULTS
  The 13 included studies provided data on 1,640 subjects that were randomly allocated to chlorhexidine (n = 834) or control (n = 806) treatments. A preliminary analysis revealed that oral application of chlorhexidine fails to promote a significant reduction in VAP incidence (relative risk 0.80, 95% CI 0.59-1.07, I(2) = 45%). However, subgroup analyses showed that chlorhexidine prevents VAP development when used at 2% concentration (relative risk 0.53, 95% CI 0.31-0.91, I(2) = 0%) or 4 times/d (relative risk 0.56, 95% CI 0.38-0.81, I(2) = 0%).
  
  
  CONCLUSIONS
  We found that oral care with chlorhexidine is effective in reducing VAP incidence in the adult population if administered at 2% concentration or 4 times/d.
authors: Discipline of Periodontics, School of Dentistry villar@usp.br.
authors: Cristina C
authors: CC
authors: Villar
authors: Discipline of Periodontics, School of Dentistry.
authors: Claudio M
authors: CM
authors: Pannuti
authors: Complexo Hospitalar Municipal de São Bernardo do Campo, São Bernardo do Campo-São Paulo, Brazil.
authors: Danielle M
authors: DM
authors: Nery
authors: Discipline of Periodontics, School of Dentistry.
authors: Carlos M R
authors: CM
authors: Morillo
authors: Discipline of Anesthesiology, School of Medicine, University of São Paulo-São Paulo, Brazil.
authors: Maria José C
authors: MJ
authors: Carmona
authors: Discipline of Periodontics, School of Dentistry.
authors: Giuseppe A
authors: GA
authors: Romito
mesh_terms: D000287:Administration, Topical; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage* / Q000009:adverse effects; D002710:Chlorhexidine / Q000008:administration & dosage* / Q000009:adverse effects; D002985:Clinical Protocols; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D006801:Humans; D009910:Oral Hygiene / Q000379:methods; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000891:Anti-Infective Agents, Local; D002710:Chlorhexidine
keywords: chlorhexidine; clinical protocols; critical care; infection; meta-analysis; ventilator-associated pneumonia