Running head: The Effect of Chlorhexidine
The Effect of Chlorhexidine on the Rate of Ventilator Associated Pneumonia
Fion Kung
University of South Florida, College of Nursing
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THE EFFECT OF CHLORHEXIDINE
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Abstract
Clinical problem: Ventilator-associated pneumonia (VAP) is the second most common health
care-associated infection in the United States. Ventilator-associated pneumonia is associated
with increases in death rates, length of stay, and health care costs. There were about 250,000
cases of healthcare-associated pneumonia developed in United States hospitals and 36,000 of the
cases were associated with deaths in 2002.
Objective: To determine if there is adequate evidence to reduce the rate of ventilator-associated
pneumonia by using 0.12% chlorhexidine compared to sterile water in ICU patients.
Data sources: Search engines including PubMed and CINAHL were used to locate three
applicable current research studies using the key words: oral care, ventilator-associated
pneumonia, chlorhexidine, periodontal disease, sterile water, and intensive care unit. Evidence
based practice was also retrieved by Sedwick et al., (2012).
Result: The results indicate 0.12% chlorhexidine reduce the chance of developing ventilatorassociated pneumonia.
Conclusion: Through a synthesis of selected literature, it has been concluded that 0.12%
chlorhexidine with oral care significantly reduces the chance of developing ventilator-associated
pneumonia in mechanically ventilated patients.
THE EFFECT OF CHLORHEXIDINE
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The Effect of Chlorhexidine on the Rate of Ventilator Associated Pneumonia
Ventilator-associated pneumonia (VAP) is the second most common health careassociated infection in the United States and is a leading cause of morbidity and mortality in
intensive care units (ICU) (Sedwick, Lance, Reeder and Nardi, 2012). Furthermore, it is also
associated with increase in the length of hospital stay and health care costs. VAP is an infectious
complication that allows bacteria into the lung, which it can cause some lung or immune system
problems. VAP usually occurs in mechanically ventilated patients. According to Centers for
Disease Control and Prevention (2013), this is an important clinical issue that needs to be
evaluated due to the incidence of about 250,000 healthcare-associated pneumonia cases
developed in United States hospitals, while 36,000 of the cases were associated with deaths in
2002. In addition, there was more than 3,525 cases of VAP reported with an estimate of 0.0-4.9
per 1,000 ventilator days from the National Healthcare Safety Network (NHSN) facilities in
2011 (CDC, 2013). Furthermore, among patients treated with mechanical ventilation, there were
46% mortality rate for those who developed VAP and 32% mortality rate for those who did not
developed VAP (Sedwick et al., 2012).
Current research aims to discover the effectiveness of oral care by using 0.12%
chlorhexidine for mechanically ventilated patients to prevent ventilator-associated pneumonia. In
order to evaluate the use of 0.12% chlorhexidine for mechanically ventilated patients a PICOT
question was formulated. In patients admitted to the intensive care unit, how does daily use of
chlorhexidine compared to sterile water reduce ventilator-associated pneumonia during the
hospitalized stay? This paper will focus on the review of applicable current research articles and
evidence based projects for implementation of findings.
THE EFFECT OF CHLORHEXIDINE
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Literature Search and Review
Articles were found regarding the effect of chlorhexidine on the rate of ventilatorassociated pneumonia (Table 1). Search engines including PubMed and CINAHL were used to
locate applicable current researchable information using the key words: oral care, chlorhexdine,
intensive care unit, periodontal disease, sterile water, ventilator-associated pneumonia.
Chlorhexidine Oral Swab
Özçaka et al. (2012) completed a randomized, double-blind, controlled trial to examine
how effective 0.2% chlorhexidine gluconate (CHX) with oral swabbing is for reducing the
chances of developing ventilator-associated pneumonia in ICU patients. Sixty-one patients who
were mechanically ventilated and expected to remain ventilated for at least 48 hours after
admission were selected for inclusion to the study (Özçaka et al., 2012). There were twenty-nine
patients in the intervention group who received an oral swab of 30 mL of 0. 2% chlorhexidine
gluconate four times per day. On the other hand, the control group had thirty-two patients that
only used an oral swab with normal saline. In the study, clinical periodontal measurements and
lower- respiratory-tract specimens were used for further analysis after detecting the early stages
of VAP (Özçaka et al., 2012). The authors found that ventilator-associated pneumonia was
significantly higher in control group (68.8%) than chlorhexidine group (41.4%); p=0.03 (Özçaka
et al., 2012). The strength of the study is that they used the randomized, double blind, controlled
study method to divide patients into different groups. Lack of knowledge about the patients'
background and disease can therefore avoid any bias. However, the weakness of the study is a
small size of population with only sixty-one patients. Due to the small population size, the result
might not be as accurate as it would be with a larger population. Therefore, additional studies
with larger samples are needed to validity the findings.
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Chlorhexidine versus Toothbrushing
Munro, Grap, Jones, McClish and Sessler (2009) conducted research to test if two oral
care interventions, toothbrushing and 0.12% solution chlorhexidine, would decrease the risk for
VAP during the first week of intubation for mechanically ventilated patients. The population of
the study was critically ill adults in the ICU who were intubated within 24 hours of admission.
The study was completed by conducting a randomized control trial where a total of 547 patients
were randomly assigned to one of four groups (Munro et al., 2009). The groups were divided
randomly into 0.12% solution chlorhexidine oral swab twice daily (n=119), toothbrushing thrice
daily (n=113), combination of toothbrushing and chlorhexidine (n=116) and control group
(n=123). The data were collected from the day of admission to day 7 of intubation or until
extubation (Munro et al., 2009). However, due to early extubation, the smaller sample size on
days 5 through 7 did not allow conclusions regarding the effect of the study. Therefore, the
authors used data up to day 3 for analysis of the results of the study. The results showed that
there was no significant differences for developing VAP between chlorhexidine and
toothbrushing group compared to the chlorhexidine group alone. However, the study showed
0.12% chlorhexidine with oral swab twice daily significantly decreased the incidence of VAP by
day 3 (Munro et al., 2009). One of the strengths in the study is that they also elevated
toothbrushing to assess alternative methods to reduce the VAP rate. However, the improvement
in the study is there were 547 patients in the study, and by the third day there were only 249
patients in the study remained intubated.
Early Application of Chlorhexidine
The final study examined how effective an early single dose of 0.12% chlorhexidine
decreases the chance of developing VAP on patients who are intubated within twelve hours after
THE EFFECT OF CHLORHEXIDINE
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admission to the hospital (Grap et al., 2011). A total of 145 patients were randomly assigned to
the intervention or control group. Seventy-one patients in the intervention group used a single
application of 5 mL of 0.12% chlorhexidine solution swab for the oral cavity. On the other hand,
there were 74 patients in the control group who only had standardized oral care without 0.12%
chlorhexidine swab. The authors used the clinical pulmonary infection score to evaluate the
effect of the intervention at 48 and 72 hours after patients were intubated. Grap et al. (2011)
showed that the VAP development rate was significantly higher in the patients only receiving
standard oral care at 55.6%, while the infection rate was only 33.3% for those who received a
single dose of chlorhexidine after intubation. The strength of the study is that they used a
randomized controlled clinical trial which meant that patients were randomly assigned to groups
without any bias. On the other hand, the weakness of the article is that the population is too
small; therefore, additional studies with larger samples are needed.
Evidence Based Project
Sedwick, Lance, Reeder and Nardi, (2012) discussed specific evidence based research to
develop a ventilator bundle as well as practices for critical care nurses to decrease the VAP rate.
The authors were attempting to determine evidence based projects to be used regarding
mechanically ventilated patients to decrease the risk of ventilator-associated pneumonia. The
evidence based projects stated that in order to decrease the incidence of VAP, nurses should
provide multiple interventions to mechanically ventilated patients including elevating the head of
bed, daily sedation vacation, peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis,
and oral care with chlorhexidine (Sedwick et al., 2012).
Synthesis
THE EFFECT OF CHLORHEXIDINE
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Research has shown that there is a significant reduction of developing ventilatorassociated pneumonia when 0.12% chlorhexidine is used for mechanically ventilated patients in
ICU. The research shows that promoting oral care by using 0.12% chlorhexidine can reduce
bacterial growth. Implementation of good oral care has positive effects for mechanically
ventilated patients including the following: improving patient's outcomes, decreasing patients'
length of stays in the hospital, and reducing health care costs. While in other country a high
concentration of 0.2% chlorhexidine is used, because of the United States of Food and Drug
Administration regulating, a 0.12% chlorhexidine is recommended. Future research needs to
continue to evaluate how 0.12% chlorhexidine prevented ventilator-associated pneumonia with
more controlled trials and larger population groups.
Clinical Recommendations
Florida Hospital is one of the largest non-profit health care providers with twenty-two
campuses that are located in different communities throughout Florida. Florida Hospital of
Tampa and affiliates have proven their importance in the community. The hospital has several
opportunities to educate the staff and raise awareness of the importance of oral care by using
0.12% chlorhexidine, especially with the mechanically ventilated patients. In order to utilize the
evidence based research and guidelines appropriately, the unit educator in the ICU need to
implement evidence based oral care by educating the nurses to use 0.12% chlorhexidine for
mechanically ventilated patients. The charge nurses also ensure the staff and faculties are
implementing good oral care by using 0.12% chlorhexidine to mechanically ventilated patients.
In addition, the nurses need to develop strategies to put evidence-based practices together into
the daily care for mechanically ventilated patients. In relation to the stated PICOT question, since
using 0.12% chlorhexidine for ICU mechanically ventilated patients has been shown to reduce
THE EFFECT OF CHLORHEXIDINE
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the incidence of ventilator-associated pneumonia, healthcare workers should begin to implement
current practices to prevent complications. Therefore, recommendations are to provide oral care
by using 0.12% chlorhexidine for the mechanically ventilated patients.
THE EFFECT OF CHLORHEXIDINE
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References
Centers for Disease Control and Prevention. (2013). NHSN Protocol Clarifications. Retrieved
October 19, 2013, from http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf
Grap, M., Munro, C., Hamilton, V., Elswick, R., Sessler, C., & Ward, K. (2011). Early, single
chlorhexidine application reduces ventilator-associated pneumonia in trauma patients.
Heart & Lung: The Journal Of Critical Care, 40(5), e115-e122.
doi:10.1016/j.hrtlng.2011.01.006
Munro, C.L., Grap, M.J., Jones, D.J., McClish, D.K., & Sessler, C.N. (2009). Chlorhexidine,
toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults.
American Journal of Critical Care, 18(5), 428-37; doi: 10.4037/ajcc2009792
Özçaka, Ö., Başoğlu, Ö. K., Buduneli, N., Taşbakan, M. S., Bacakoğlu, F. & Kinane, D. F.
(2012). Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive
care unit patients: A randomized clinical trial. Journal of Periodontal Research, 47, 584–
592. doi: 10.1111/j.1600-0765.2012.01470.x
Sedwick, M.B., Lance-Smith, M., Reeder, S.J., & Nardi, J. (2012). Using evidence-based
practice to prevent ventilator-associated pneumonia. Critical Care Nurse, 32(4), 41-51.
doi: 10.4037/ccn2012964
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Table 1
Summary of studies reviewed
Reference
Özçaka, Ö.,
Başoğlu, Ö. K.,
Buduneli, N.,
Taşbakan, M. S.,
Bacakoğlu, F. &
Kinane, D. F.
(2012).
Chlorhexidine
decreases the risk
of ventilatorassociated
pneumonia in
intensive care unit
patients: A
randomized clinical
trial. Journal of
Periodontal
Research, 47, 584–
592. doi:
10.1111/j.16000765.2012.01470.x
Munro CL, Grap
MJ, Jones DJ,
McClish DK,
Sessler CN. (2009)
Chlorhexidine,
toothbrushing, and
preventing
ventilatorassociated
pneumonia in
critically ill adults.
American Journal
of Critical Care,
18(5):428-37; quiz
438. doi:
10.4037/ajcc20097
92.
Aims
Design and
Measures
To examine how
Randomized,
effective 0.2%
double-blind,
chlorhexidine
clinical control
gluconate with oral study.
swabbing is
reducing the
chances of
developing
ventilatorassociated
pneumonia in ICU
patients.
Sample
To determine the
use of mechanical
toothburshing,
0.12%
chlorhexidine, and
combination of
toothburshing and
chlorhexidine
effect to develop
VAP in critically
ill patients.
547 patients in
ICU were
intubated
within 24
hours. 119
patients on
chlorhexidine
group, 113
patients in
toothbrushing
group, 116
patients on
combination of
chlorhexidine
and
toothbrushing
group, and 123
patients in the
control group.
Randomized,
controlled
clinical trial
with 2x2
factorial
designs.
Clinical
pulmonary
infection score
was used to
determine how
many patients
develop VAP.
61 dentate
patients
scheduled for
invasive
mechanical
ventilation. 29
patients in the
intervention
group. 32
patients in the
control group.
Outcomes /
statistics
The percentage
of VAP rate in
control group
was 68.8%,
and
chlorhexidine
group was
41.4%; p=
0.03.
Chlorhexidine
significantly
reduced the
incidence of
pneumonia on
day 3 (CPIS >
6) (p=0.006).
THE EFFECT OF CHLORHEXIDINE
Grap, M., Munro,
C., Hamilton, V.,
Elswick, R.,
Sessler, C., &
Ward, K. (2011).
Early, single
chlorhexidine
application reduces
ventilatorassociated
pneumonia in
trauma patients.
Heart & Lung: The
Journal Of Critical
Care, 40(5), e115e122.doi:10.1016/j.
hrtlng.2011.01.006
To examine how
effective of single
0.12%
chlorhexidine
decrease chance of
develop VAP on
patients who
intubed within 12
hours in the
hospital.
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Randomized,
controlled
clinical trial.
Clinical
pulmonary
infection score
was used to
evaluated on the
study admission
and at 48 and
72 hours after
intubation.
145 patients
who were
required
endotracheal
intubation. 71
patients in the
intervention
and 74 patients
in the control
group.
The percentage
of VAP rate in
control group
was 55.6%,
and
intervention
group was
33.3%.
The CPIS from
admission to
48 hours
(p=0.020) and
admission to
72 hours (p=
0.027)