Appendix B: Oral Care with Chlorhexidine (CHG),
Literature Synopsis
Ventilator-Associated Pneumonia Prevention Bundle
Regular oral care with CHG is associated with decreased colonization of dental plaque,
and a decreased incidence of ventilator-associated pneumonia (VAP). Increasing evidence
to support this intervention has emerged over the past several years. Of the two most
recent guidelines, published in 2008, one states that its use should be considered and one
supports the use of regular oral care with an antiseptic solution, however the use of CHG
is not specifically addressed.
Most recently in 2011, a systematic review and meta-analysis of 12 randomized trials
supports the use of oral care with CHG for VAP prevention. Overall, this study found a 38%
VAP reduction. Favorable effects were more pronounced in cardiosurgical studies (up to a
59% VAP reduction).
2008- Society for Healthcare Epidemiology of America Guidelines: A guideline of practical recommendations
to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP)
prevention efforts.1

Perform regular oral care with an antiseptic solution in accordance with product guidelines. While the
use of chlorhexidine is not specifically addressed, the 3 studies cited by the guideline below all
demonstrated the efficacy of CHG.
Articles Cited in Guideline
Study Type and Author
0.12% CHG oral rinse vs placebo
(DeRiso, 1996) 2
0.12% CHG oral & nasogastric rinse
vs placebo
Segers, 2006) 3
Peridex (0.12% CHG) vs Listerine
(Houston, 2002) 4
Results - Details in Annotated Bibliography
Pro – Study focused on patients undergoing coronary artery bypass
grafting, valve or other open heart procedure. Overall nosocomial infection
rate decreased by 65%. Respiratory tract infections rate was reduced by
89%.
Pro – Study focused on adult patients undergoing elective cardiothoracic
surgery. Lower respiratory tract infections and deep SSIs were less
common in the CHG group. Decontamination of the nasopharynx and
oropharynx with CHG appears to be an effective method to reduce
nosocomial infection after surgery.
Pro – Study focused on patients undergoing aortocoronary bypass or valve
surgery requiring cardiopulmonary bypass. . In patients intubated for >24
hours with cultures that showed microbial growth, the rate of pneumonia
was 71% lower in the Peridex group than in the Listerine group. Rates of
nosocomial pneumonia were lower in patients treated with Peridex.
2004-Canadian VAP Prevention Guidelines: Evidence-based, clinical practice guidelines for the prevention of
ventilator-associated pneumonia.5


The use of the oral antiseptic chlorhexidine should be considered.
Based on 1 level 1 and 2 level 2 trials, the use of the oral antiseptic CHG may decrease the incidence of
VAP. Safety, feasibility, and cost considerations for this intervention are all very favorable.
Articles Cited in Guideline
Study Type and Author
Results - Details in Annotated Bibliography
1
0.2% CHG vs placebo
(Fourrier, 2005) 6
0.2% CHG vs standard oral care
(Fourrier, 2000) 7
2% CHG vs 2% CHG+2% colistin vs
placebo
(Koeman, 2006) 8
Con – Study focused on a population of nonedentulous patients requiring
endotracheal intubation and mechanical ventilation. Gingival and dental
plaque antiseptic decontamination significantly decreased the
oropharyngeal colonization by aerobic pathogens. Efficacy was insufficient
to reduce the number of respiratory infections due to MDR bacteria. No
difference was observed in the incidence of ventilator-associated
pneumonia per ventilator or intubation days.
Pro – Study focused on patients admitted to ICU requiring mechanical
ventilation with an expected >5 day stay. There was a trend to a reduction
of mortality, length of stay and duration of mechanical ventilation.
Decreases dental bacterial colonization and may reduce incidence of
nosocomial infections.
Pro – Study focused on patients needing mechanical ventilation for ≥ 48
hours. Risk of VAP reduced in both CHG groups. CHG+Colistin provided
significant reduction in oropharyngeal colonization with both gram-negative
and gram-positive microorganisms, whereas CHG mostly affected grampositive microorganisms. Endotracheal colonization was reduced for
CHG+Colistin patients and to a lesser extent for CHG patients..
2004-Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcareassociated pneumonia.9

Recommends regular oral care. States that chlorhexidine has prevented hospital-acquired pneumonia in
specific populations such as those undergoing coronary bypass grafting, However, also states that routine
use is not recommended until more data is available.
Articles Cited in Guideline
Study Type and Author
0.12% CHG oral rinse vs placebo
(DeRiso, 1996) 2
Results - Details in Annotated Bibliography
Pro – Study focused on patients undergoing coronary artery bypass
grafting, valve or other open heart procedure. Overall nosocomial infection
rate decreased by 65%. Respiratory tract infections rate was reduced by
89%. (Previously cited in SHEA Guidelines, above)
2003-CDC Guidelines for preventing Health-Care-Associated Pneumonia10

No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of
health-care–associated pneumonia in all postoperative or critically ill patients and/or other patients at high
risk for pneumonia (Unresolved issue) (II)
Articles Cited in Guideline
Study Type and Author
0.12% CHG oral rinse vs placebo
(DeRiso, 1996) 2
Results - Details in Annotated Bibliography
Pro – Study focused on patients undergoing coronary artery bypass
grafting, valve or other open heart procedure. Overall nosocomial infection
rate decreased by 65%. Respiratory tract infections rate was reduced by
89%. (Previously cited in SHEA Guidelines, above)
2
Post Guideline Publications:
Post Guideline Publications, 2007-2012
Study Type and Author
Systematic Review (no metaanalysis)
(CHG and toothbrushing)
(Roberts, 2011) 11
Review and Meta-analysis
(CHG vs povidone-iodine)
(Labeau, 2011) 12
0.12% CHG vs placebo
(Jacomo, 2011) 13
Results - Details in Annotated Bibliography
Pro – Analyzed RCTs assessing the effectiveness of CHG and
toothbrushing to reduce VAP rates. CHG has been proven to be of value in
reducing VAP.
0.12% CHG+swab bid, toothbrushing tid,
0.12% CHG+toothbrushing tid and usual
care
(Munro, 2009) 20
Pro – Analyzed RCTs of mechanically ventilated adult patients receiving
oral care with CHG or povidone-iodine. CHG shown to be effective. Effect
more pronounced in cardiac surgery patients.
Con – Study focused on children undergoing surgery for congenital heart
disease. There was a non-statistical increase of VAP in the treatment
group.
Pro – Study focused on trauma patients requiring endotracheal intubation.
Treatment group had lower CPIS scores at 48 and 72 hours and a
statistically insignificant lower rate of VAP. In patients without pneumonia at
baseline, the reduction in the incidence of VAP was greater.
Con – There is no evidence to support the use of one oral rinse over
another in mouth care, exception of CHG in the cardiac surgery population.
Pro – Used a “bundle development strategy” to choose the most effective
interventions to include in a VAP Care Bundle. Oral care with chlorhexidine
is number 5 in the European care bundle.
Neutral – Study focused on intubated patients in a trauma ICU.
Nonsignificant reduction in pneumonia rate noted in groups treated with
CHG.
Con – This study does not specifically look at patients on mechanical
ventilation. Study focused on patients admitted to the ICU with a
prospective length of stay of over 48 hours. Overall incidence of respiratory
tract infections similar between treatment and control groups.
Pro – Study focused on oral colonization in 65 children receiving
mechanical ventilation. On day 2, number of children with an increase in
positive samples was higher in the control group. However, the difference
was not significant.
Pro – Study focused on adult patients enrolled within 24 hours of intubation.
Significantly reduced the incidence of pneumonia on day 3. CHG reduced
early ventilator-associated pneumonia in patients without pneumonia at
baseline.
0.12% CHG+gauze application vs 0.12%
CHG+electric toothbrush application
(Pobo, 2009) 21
Neutral – This study did not specifically address the effectiveness of CHG,
but addressed the appropriate use of CHG. Study focused on adult patients
intubated for >48 hours. Groups had similar rates of suspected VAP.
Single dose 5 mL CHG w/oral swab
vs control (no swab)
(Grap, 2011) 14
Consensus development
(Berry, 2011) 15
Consensus development
(Rello-2010) 16
0.12% CHG vs placebo(Scannapieco, 2009) 17
0.12% CHG vs placebo
(Bellissimo-Rodrigues, 2009) 18
0.12% CHG vs placebo
(Pedreira, 2009) 19
Review and Meta-analysis
(Chan, 2007) 22
Review
(Gastmeier, 2007) 23
Pro – This analysis did not specifically address the use of CHG, but
addressed the effect of using antibiotics and antiseptics for the prevention
of VAP. Analyzed RCTs evaluating the efficacy of daily oral application of
antibiotics or antiseptics with no prophylaxis on mechanically ventilated
adult patients. Oral decontamination can reduce the incidence of VAP. Of
the evaluated studies, only one did not use CHG. CHG efficacy may be
dependent on concentration.
Pro – Reviewed articles published since 2004 dealing with infection control
measures for prevention of VAP. Special emphasis was placed on RCTs,
meta-analyses, systematic reviews and studies reviewing multimodal
interventions. The data lead to the conclusion that topical use of
chlorhexidine for oral care is beneficial.
3
Annotated Bibliography
1. Coffin S, MD, Klompas M, MD, Classen D, MD, et al. Strategies to prevent Ventilator‐Associated pneumonia in acute care hospitals •
. Infection Control and Hospital Epidemiology. 2008;29(S1, A Compendium of Strategies to Prevent Healthcare‐Associated Infections in
Acute Care Hospitals):pp. S31-S40. Available from: http://www.jstor.org/stable/10.1086/591062.
2. DeRiso AJ,2nd, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence
of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest.
1996;109(6):1556-1561.
Pro – 0.12% CHG oral rinse vs placebo – This study looked at all HAIs in 353 cardiac surgery patients ondergoing coronary artery bypass grafting, valve or
other open heart procedure. The overall nosocomial infection rate was decreased in the CHG-treated patients by 65% (24/180 vs 8/173; p<0.01). We also
noted a 69% reduction in the incidence of total respiratory tract infections in the CHG-treated group (17/180 vs 5/173; p<0.05). Gram-negative organisms
were involved in significantly less (p<0.05) of the nosocomial infections and total respiratory tract infections by 59% and 67%, respectively. No change in bacterial
antibiotic resistance patterns in either group was observed. The use of nonprophylactic IV antibiotics was lowered by 43% (42/180 vs 23/173; p<0.05). A reduction
in mortality in the CHG-treated group was also noted (1.16% vs 5.56%). Inexpensive and easily applied oropharyngeal decontamination with CHG oral rinse
reduces the total nosocomial respiratory infection rate and the use of nonprophylactic systemic antibiotics in patients undergoing heart surgery. This results in
significant cost savings for those patients who avoid additional antibiotic treatment. [[ for respiratory infections, NNT= 15.25 ]]
3. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by
decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: A randomized controlled trial. JAMA.
2006;296(20):2460-2466.
Pro – 0.12% CHG oral & nasogastric rinse vs placebo – This study looked at all HAIs in 954 cardiac surgery patients. The incidence of nosocomial infection in the
chlorhexidine gluconate group and placebo group was 19.8% and 26.2%, respectively (absolute risk reduction [ARR], 6.4%; 95%confidence interval [CI], 1.1%11.7%; P=.002). In particular, lower respiratory tract infections and deep surgical site infections were less common in the chlorhexidine gluconate group than in
the placebo group (ARR, 6.5%; 95% CI, 2.3%-10.7%; P=.002; and 3.2%; 95% CI, 0.9%-5.5%; P=.002, respectively) [[ for lower respiratory tract infections,
NNT= 15.38 ]]
4. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse
in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care. 2002;11(6):567-570.
Pro – Peridex (0.12% CHG) vs Listerine – Study focused on a population of 561 patients undergoing aortocoronary bypass or valve surgery requiring
cardiopulmonary bypass. The rate of nosocomial pneumonia was reduced by 52% (4/270 vs 9/291; p=.21) in the Peridex-treated patients. Among patients
intubated for more than 24 hours who had cultures that showed microbial growth (all pneumonias occurred in this group), the pneumonia rate was
reduced by 58% (4/19 vs 9/18; p=.06) in patients treated with Peridex. In patients intubated for > 24 hours , with cultures showing the most growth, the
rate was 71% lower in the Peridex group (2/10 vs 7/10; p=.02). [[ for nosocomial pneumonia, for patients intubated for >24 hours, NNT= 3.45; for
pneumonia among patients intubated for more than 24 hours who had cultures that showed microbial growth, NNT=2 ]]
5. Muscedere J, Dodek P, Keenan S, et al. Comprehensive evidence-based clinical practice guidelines for ventilator-associated
pneumonia: Diagnosis and treatment. J Crit Care. 2008;23(1):138-147.
6. Fourrier F, Dubois D, Pronnier P, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections
acquired in the intensive care unit: A double-blind placebo-controlled multicenter study. Crit Care Med. 2005;33(8):1728-1735.
Con – 0.2% CHG vs placebo - Study focused on a population of 228 nonedentulous patients requiring endotracheal intubation and mechanical ventilation. The
incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic
decontamination group (not significant). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days,
mortality, length of stay, and care loads (secondary end points). On day 10, the number of positive dental plaque cultures was significantly lower in the
treated group (29% vs. 66%; p < .05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated
pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination.
7. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic
decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med. 2000;26(9):1239-1247.
Pro - 0.2% CHG vs standard oral care - Study focused on patients admitted to the ICU with a medical condition suggesting an ICU stay of 5 days and requiring
mechanical ventilation. Sixty patients were included; 30 in the treated group and 30 in the control one (mean age: 51 +/- 16 years; mean Simplified Acute
Physiological Score II: 35 +/- 14 points)````. On admission, no significant differences were found between both groups for all clinical and dental data. Compared
with the control group, the nosocomial infection rate and the incidence densities related to risk exposition were significantly lower in the treated group (18 vs 33%
days in the ICU and 10.7 vs 32.3% days of mechanical ventilation; P < 0.05). These results were consistent with a significant preventive effect of the antiseptic
decontamination (Odds Ratio: 0.27; 95% CI: 0.09; 0.80) with a 53% relative risk reduction. There was a trend to a reduction of mortality, length of stay, and
duration of mechanical ventilation.
8. Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated
pneumonia. Am J Respir Crit Care Med. 2006;173(12):1348-1355.
Pro - CHG vs CHG+Colistin vs placebo - Study focused on 385 patients needing mechanical ventilation for ≥ 48 hours. 130 received placebo, 127 CHG and 128
CHG+Colistin. The daily risk of VAP was reduced in both treatment groups compared with placebo: 65% (hazard ratio [HR] 0.352; 95% confidence interval [CI],
0.160, 0. 791; p _ 0.012) for CHG and 55% (HR _ 0.454; 95% CI, 0.224, 0. 925; p _ 0.030) for CHG+Colistin. CHG+Colistin provided significant reduction in
oropharyngeal colonization with both gram-negative and gram-positive microorganisms, whereas CHG mostly affected gram-positive microorganisms.
Endotracheal colonization was reduced for CHG+Colistin patients and to a lesser extent for CHG patients.
9. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416.
10. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidleines for preventing healthcare-associated pneumonia, 2003:
Recommendations of CDC and the healthcare infection control practices advisory committee. MMWR Recomm Rep. 2004;53:1-36.
11. Roberts N, Moule P. Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates.
Nurs Crit Care. 2011;16(6):295-302.
Pro – Systematic Review of 17 papers addressing the use of CHG and toothbrushing to reduce VAP rates. The use of chlorhexidine has been proven to be of
some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended
in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study
design and inconsistency in results suggest that further research is required into the effects of tooth-brushing. [[Pooled estimates of efficacy not calculated]]
12. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral
antiseptics: A systematic review and meta-analysis. Lancet Infect Dis. 2011.
Pro – Review and meta-analysis of 14 papers looking at the effect of oral care with CHG or povidone-iodine vs. standard oral care to reduce VAP rates. 12
studies looked at CHG and 2 at povidone-iodine. Chlorhexidine application was shown to be effective (RR 0·72; 95% CI 0·55–0·94; p=0·02), whereas the
effect resulting from povidone-iodine remains unclear (RR 0·39; 95% CI 0·11–1·36; p=0·14). Heterogeneity was moderate (I²=29%; p=0·16) for the trials using
chlorhexidine and high (I²=67%; p=0·08) for those assessing povidone-iodine use. Favourable eff ects were more pronounced in subgroup analyses for 2%
chlorhexidine (RR 0·53, 95% CI 0·31–0·91), and in cardiosurgical studies (RR 0·41, 95% CI0·17–0·98)
4
13. Jacomo AD, Carmona F, Matsuno AK, Manso PH, Carlotti AP. Effect of oral hygiene with 0.12% chlorhexidine gluconate on the
incidence of nosocomial pneumonia in children undergoing cardiac surgery. Infect Control Hosp Epidemiol. 2011;32(6):591-596.
Con – CHG vs placebo - Study focused on 160 children undergoing surgery for congenital heart disease. There was no difference between the two groups.CHG
vs placebo - The incidence of nosocomial pneumonia was 29.8% versus 24.6% (p=0.46) and the incidence of VAP was 18.3% versus 15% (p=0.57) in the
chlorhexidine and the control group, respectively. There was no difference in intubation time (p=0.34), need for reintubation (p=0.37), time interval between
hospitalization and nosocomial pneumonia diagnosis (p=0.63), time interval between surgery and nosocomial pneumonia diagnosis (p=0.10), and time on
antibiotics (p=0.77) and vasoactive drugs (p=0.16) between groups. Median length of PICU stay (3 vs 4 days; p=0.53), median length of hospital stay (12 vs 11
days; p=0.67), and 28-day mortality (5.7% vs 6.8%; p=0.77) were also similar in the chlorhexidine and the control group.
14. Grap MJ, Munro CL, Hamilton VA, Elswick RK,Jr, Sessler CN, Ward KR. Early, single chlorhexidine application reduces ventilatorassociated pneumonia in trauma patients. Heart Lung. 2011;40(5):e115-22.
Pro – Single dose 5 mL CHG w/oral swab vs control (no swab) - Study focused on 145 trauma patients requiring endotracheal intubation. A significant treatment
effect was found on CPIS scores both from admission to 48 hours (P =.020) and to 72 hours (P = .027). In those subjects without pneumonia at baseline (CPIS
< 6) (n=17), 55.6% of the control patients (10/18) had developed VAP by 48 or 72 hours versus only 33.3% of the intervention patients (7/21). [[ for VAP
rates, NNT = 4.5 ]]
15. Berry AM, Davidson PM, Nicholson L, Pasqualotto C, Rolls K. Consensus based clinical guideline for oral hygiene in the critically ill.
Intensive Crit Care Nurs. 2011;27(4):180-185.
Pro – Consensus development process - At the present time there is no evidence to support the use of one oral rinse over another in mouth care: The
exception is the use of chlorhexidine gluconate 0.12% in the cardiac surgical patient population.
16. Rello J, Lode H, Cornaglia G, Masterton R, VAP Care Bundle Contributors. A european care bundle for prevention of ventilatorassociated pneumonia. Intensive Care Med. 2010;36(5):773-780
Pro - Consensus development process - Through a “bundle development strategy” a bundle of interventions for the prevention of VAP was developed. Oral care
with CHG was considered to be number 5 in the list of included items for VAP prevention.
17. Scannapieco FA, Yu J, Raghavendran K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in
mechanically ventilated patients. Crit Care. 2009;13(4):R117.
Neutral – 0.12% CHG once or twice per day vs placebo - This study focused on oral colonization in 175 intubated patients in a trauma unit. 60 patients were
dropped due to insufficient data. Using intent-to-treat analysis (n=175), a 41% of reduction in the rate of pneumonia was noted between the treated and
placebo group (odds ratio (OR) = 0.54, 95% confidence interval (CI): 0.23 to 1.25, P = 0.1459); however, the differences were found not to be statistically
significant. The incidence of pneumonia by survival analysis showed that the onset of pneumonia tended to be delayed in the treated groups when
compared with the control group; however, these differences were not statistically significant (hazards ratio (HR) = 0.555, 95% CI: 0.256 to 1.201, P =
0.1348). A nonsignificant reduction in pneumonia rate was noted in groups treated (n=116) with chlorhexidine compared with the placebo group (n=59)
(OR = 0.54, 95% CI: 0.23 to 1.25, p= 0.15). No evidence for resistance to chlorhexidine was noted, and no adverse events were observed. No differences were
noted in microbiologic or clinical outcomes between treatment arms. However, it did reduce the number of S. aureus in dental plaque of trauma intensive care
patients. [[ for VAP rates in the intent-to-treat analysis, NNT = 11.5 ]]
18. Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, et al. Effectiveness of oral rinse with chlorhexidine in preventing
nosocomial respiratory tract infections among intensive care unit patients. Infect Control Hosp Epidemiol. 2009;30(10):952-958.
Neutral – CHG vs placebo - Study focused on patients admitted to the ICU with a prospective length of stay greater than 48 hours, regardless of whether they
received mechanical ventilation. This study was not specifically targeted at mechanically ventilated patients. The overall incidence of respiratory tract
infections in the treatment group vs placebo was 21 (n=98) and 25 (n=96), respectively (RR, 1.0 [95% CI, 0.63–1.60) and the rates of ventilator-associated
pneumonia per 1,000 ventilator-days were similar in both experimental and control groups (22.6 vs 22.3; p=0.95). Respiratory tract infection–free survival time (7.8
vs 6.9 days; p=0.61), duration of mechanical ventilation (11.1 vs 11.0 days; p=0.61), and length of stay (9.7 vs 10.4 days; p=0.67) did not differ between the
chlorhexidine and placebo groups. However, patients in the chlorhexidine group exhibited a larger interval between ICU admission and onset of the first respiratory
tract infection (11.3 vs 7.6 days; p=0.05). [[ for respiratory tract infections, NNT= 21 ]]
19. Pedreira ML, Kusahara DM, de Carvalho WB, Nunez SC, Peterlini MA. Oral care interventions and oropharyngeal colonization in
children receiving mechanical ventilation. Am J Crit Care. 2009;18(4):319-28; quiz 329.
Pro - 0.12% CHG vs placebo - Study focused on 56 children (47 intubated and 9 with < 24 hours intubation) admitted to the PICU. They evaluated colonization of
the oropharynx at day 0, 2, 4, and PICU discharge. During the first 48 hours of PICU admission, the number of children colonized with pathogenic
microorganisms decreased in the experimental group and increased in the control group. Colonization by pathogenic bacteria did not differ between
the 2 groups of children. From day 0 to day 2, the number of children with an increase in the number of samples positive for pathogenic flora was
greater in the control group than in the experimental group, but the difference was not significant. Similarly, the colonization of the oral cavity by normal
flora did not differ between the 2 groups of children. The 2 groups did not differ significantly in the colonization of normal (P= .72) or pathogenic (P= .62) flora, in
the duration of mechanical ventilation (P= .67), or in length of stay in the intensive care (P= .22).
20. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated
pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428-37; quiz 438.
Pro - 0.12% CHG+swab bid, toothbrushing tid, 0.12% CHG+toothbrushing tid and usual care - Study focused on 547 adult patients enrolled within 24 hours of
intubation. However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (n=87) among patients who had CPIS <6 at baseline (P =
.006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine. Chlorhexidine, but not toothbrushing, reduced early ventilatorassociated pneumonia in patients without pneumonia at baseline.
21. Pobo A, Lisboa T, Rodriguez A, et al. A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest.
2009;136(2):433-439.
Neutral – This study looks at the effect of adding toothbrushing to care with CHG. Standard care, defined as 0.12% CHG oral care (20 mL applied with
gauze and a 10 mL rinse) vs standard care with the addition of an electronic toothbrush - Study focused on adult patients expected to be mechanically ventilated
for >48 hours (n=147) The standard care and standard care + toothbrush groups had similar rates of suspected VAP (20.3% vs 24.7%; p _ 0.55). After adjustment
for severity of illness and admission diagnosis, the incidence of microbiologically documented VAP was also similar in the two groups (hazard ratio, 0.84; 95%
confidence interval, 0.41 to 1.73). The groups did not differ significantly in mortality, antibiotic-free days, duration of MV, or hospital ICU LOS. [[ to
assess the effect of toothbrushing added to oral care with CHG, NNT=23
5
22. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically
ventilated adults: Systematic review and meta-analysis. BMJ. 2007;334(7599):889.
Pro - This study does not specifically address the use of CHG. Rather, it assesses the effect of antibiotics and antiseptics in general.
Study focused on 11 RCTs enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or
antiseptics with no prophylaxis. In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the
incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). Of the evaluated studies, only one did not use CHG. CHG efficacy
may be dependent on concentration. Oral decontamination of mechanically ventilated adults using antiseptics is associated with a
lower risk of ventilator associated pneumonia.
23. Gastmeier P, Geffers C. Prevention of ventilator-associated pneumonia: Analysis of studies published since 2004.
J Hosp Infect. 2007;67(1):1-8.
Pro - Systematic review - Special emphasis was placed on randomized controlled trials (RCTs), meta-analyses or systematic reviews and
studies applying multi-module interventions. A total of 15 RCTs and seven meta-analyses or systematic reviews were found. In addition to
these, five cohort studies were identified where multi-module programmes were introduced for reducing VAP rates. The data lead to the
conclusion that topical use of chlorhexidine for oral care is beneficial and subglottic secretion drainage may lead to delayed
onset of VAP. Often simple interventions are useful for the reduction of VAP rates, for which the best chances appeared to be the
application of multi-module programmes. On average a reduction of more than 40% seems to be possible.
5