Reappraisal of Routine Oral Care With Chlorhexidine Gluconate for Patients Receiving Mechanical Ventilation

Abstract

IMPORTANCE Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality. OBJECTIVE To evaluate the impact of routine oral care with chlorhexidine on patient-centered outcomes in patients receiving mechanical ventilation. DATA SOURCES PubMed, Embase, CINAHL, and Web of Science from inception until July 2013 without limits on date or language. STUDY SELECTION Randomized clinical trials comparing chlorhexidine vs placebo in adults receiving mechanical ventilation. Of 171 unique citations, 16 studies including 3630 patients met inclusion criteria. DATA EXTRACTION AND SYNTHESIS Eligible trials were independently identified, evaluated for risk of bias, and extracted by 2 investigators. Differences were resolved by consensus. We stratified studies into cardiac surgery vs non-cardiac surgery and open-label vs double-blind investigations. Eligible studies were pooled using random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Ventilator-associated pneumonia, mortality, duration of mechanical ventilation, intensive care unit and hospital length of stay, antibiotic prescribing. RESULTS There were fewer lower respiratory tract infections in cardiac surgery patients randomized to chlorhexidine (relative risk [RR], 0.56 [95% CI, 0.41-0.77]) but no significant difference in ventilator-associated pneumonia risk in double-blind studies of non-cardiac surgery patients (RR, 0.88 [95% CI, 0.66-1.16]). There was no significant mortality difference between chlorhexidine and placebo in cardiac surgery studies (RR, 0.88 [95% CI, 0.25-2.14]) and nonsignificantly increased mortality in non-cardiac surgery studies (RR, 1.13 [95% CI, 0.99-1.29]). There were no significant differences in mean duration of mechanical ventilation or intensive care length of stay. Data on hospital length of stay and antibiotic prescribing were limited. CONCLUSIONS AND RELEVANCE Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.

Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia

“…• We undertook a subgroup analysis for a dose-response relationship for chlorhexidine, as recent research suggests a possible relationship between chlorhexidine dose and mortality/effectiveness in VAP reduction (Klompas 2014;Zhang 2013). …”

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

“…These interventions can lower the frequency of positive endotracheal aspirates, which in turn leads to fewer perceived pneumonias, but neither intervention has been shown to decrease mean duration of mechanical ventilation, ICU stay, or mortality rates. [16][17][18] Failure to impact these outcomes begs the question of whether these interventions prevented true pneumonias or if they simply decreased the frequency of false positive pneumonias. Indeed, oral care with chlorhexidine may even be harmful to patients: 2 meta-analyses of oral care with chlorhexidine found higher mortality rates among patients randomized to chlorhexidine.…”

“…Indeed, oral care with chlorhexidine may even be harmful to patients: 2 meta-analyses of oral care with chlorhexidine found higher mortality rates among patients randomized to chlorhexidine. 18,19 The Genesis of VAE Definitions VAE definitions were developed by a working group of professional society representatives convened by the Centers for Disease Control and Prevention (CDC) in 2011 and 2012. Their intent was to overcome many of the limitations of traditional VAP definitions, specifically to make surveillance more objective, to broaden the focus of surveillance beyond pneumonia alone, and to allow for the possibility of automating surveillance using electronic health data.…”

The Vexing Problem of Ventilator-Associated Pneumonia: Observations on Pathophysiology, Public Policy, and Clinical Science

“…121,122 However, a recent metaanalysis of oral chlorhexidine treatment suggests that it does not reduce the incidence of VAP in the general ICU population. 123 Irrespective of these findings, the extent to which oral care with chlorhexidine would be effective in patients with advanced periodontal/dental disease is unknown.…”