Running head: PNEUMONIA AND CHLORHEXIDINE 1

Decreasing Ventilator-Associated Pneumonia Using Chlorhexidine

Catherine Whitford

University of South Florida

PNEUMONIA AND CHLORHEXIDINE 2

Abstract

Clinical Problem: Ventilator-associated pneumonia (VAP) burdens ten to twenty percent of

mechanically ventilated (MV) patients and is correlated with increased mortality and morbidity

(Vincent et al., 2010).

Objective: The intention of this synthesis is to identify if using chlorhexidine (CHX) will reduce

incidences of VAP among MV, adult patients. PubMed and CINAHL were searched to find

randomized control trials (RCT) regarding the use of CHX to reduce VAP. The key terms were

ventilator-associated pneumonia, ventilator-associated pneumonia prevention, and oral care with

chlorhexidine.

Results: In MV, adult patients who receive oral care with CHX, there is a statistically significant

reduction in VAP compared to those who did not receive CHX treatment. Grap et al. (2011)

demonstrated the Clinical Pulmonary Infection Scores (CPIS) of the intervention group showed a

significant reduction in acquiring VAP at forty-eight hours post-intubation (p=.02) and at

seventy two hours post-intubation (p=.027). Lin et al. (2015) demonstrated that the incidence of

VAP appeared in four subjects (8.5%) in the intervention group and in eleven subjects (23.4%)

in the control group (p=.049). Özçaka et al. (2012) demonstrated the occurrence of VAP in the

intervention group (12) was incontrovertibly lower than that of the control (22, p=.03).

Scannapieco and Binkley (2012) demonstrated the occurrence of VAP was reduced in the CHX

(65%, p=.012) and CHX/COL (55%, p=.03) intervention groups compared to the control group.

Conclusion: Although CHX has been observed to decrease incidences of VAP, among MV adult

patients, more research is warranted to determine routine treatment of CHX and specific

concentrations for best results.

PNEUMONIA AND CHLORHEXIDINE 3

Decreasing Ventilator-Associated Pneumonia Using Chlorhexidine

VAP is the second most prevalent cause of hospital acquired infections and is the most

prevalent incitement documented in the intensive care unit (ICU) setting (Rotstein et al., 2008).

The prevalence of VAP, according to the National Nosocomial Infections Surveillance (NNIS)

data, is 7.6 incidents per 1,000 ventilator-days (Rotstein et al., 2008). In addition, VAP produces

the maximal mortality rate among hospital-acquired infections in MV patients (Rotstein et al.,

2008). VAP is also correlated with longer outstanding lengths of hospitalized stay compared with

patients without VAP (Rotstein et al., 2008). Early recognition of VAP is vital in ensuring the

implementation of effective antimicrobial therapy. The Centers for Disease Control and

Prevention (2003) advocate the use of an oral CHX rinse when implementing oral care

interventions to critically ill patients who are MV to prevent the incidence of VAP. In MV

patients, does using oral care with CHX, compared to not using CHX, decrease the incidence of

VAP, within 48 to 72-hours after intubation?

Literature Search

PubMed and CINAHL were searched to find RCTs regarding the use of CHX to reduce

VAP. The key terms were ventilator-associated pneumonia, ventilator-associated pneumonia

prevention, and oral care with chlorhexidine. The publication years searched were from 2011 to

2015.

Literature Review

Four RCTs were utilized to assess the efficacy of CHX in reducing VAP occurrences

among MV, adult patients. Grap et al. (2011) demonstrated that an initial, individual swab

application of 0.12% CHX oral solution reduced VAP after a traumatic casualty. The incidence

of VAP was declared by the presentation of symptoms after intubation. One hundred and forty-
PNEUMONIA AND CHLORHEXIDINE 4

five patients were mechanically ventilated within 12 hours upon admission to ICU. Patients in

the control group (n=74) were not swabbed with CHX, while the patients in the intervention

group (n=71) were provided a single CHX swab prior to intubation. Observing changes in

Clinical Pulmonary Infection Scores (CPIS), further assessed the presented symptoms of VAP.

CPIS scores of the experimental group showed a significant reduction in acquiring VAP at

fourty-eight hours post-intubation (p=.02) and at seventy-two hours post-intubation (p=.027).

The strengths of the study included randomization of the two groups, random allocation was

concealed from participants who were initially enrolling patients into the study, and the

instruments used to quantify the outcomes were accurate. Also, subjects were blind to the study

group, rationale was provided for participants who were unable to complete the study, and

follow-up evaluations were organized appropriately in regards to the effect of treatment.

Weaknesses of the study included that patients in both groups did not share similar baseline

clinical variables, the study was conducted in a single site, and providers were not blind to the

study group.

Lin et al. (2015) studied the effectiveness of prior use of 0.2% CHX on the incidence of

VAP after surgery. The sample (N=94) was allocated to an intervention (n=47) or control group

(n=47). The day prior to surgery, participants gargled three times with either saline (control) or

2% CHX (intervention), 30 minutes after meals and five minutes after teeth brushing before bed.

CPIS scores were used to determine the existence of VAP. VAP developed in four subjects in

the intervention group (8.5%) and in 11 patients in the control group (23.4%, p=.049). Although

scores were similar between both groups on the first day postoperation, they were significantly

lower in the intervention group on the third (p=.024) and fifth (p=.005) days, compared with

controls. The strengths of the study included subjects were blind to the study group, patients
PNEUMONIA AND CHLORHEXIDINE 5

were randomly allocated to the intervention and control groups, and subjects in both groups had

no baseline clinical variables that were statistically significant. Also, follow-up evaluations were

organized appropriately in regards to the effect of the intervention, rationale was provided for

participants who did not complete the study, and the instruments used to quantify the outcomes

were accurate. In addition, random assignment was concealed from facilitators who were first

enrolling subjects into the study. Weaknesses of the study included that the study was conducted

in a single site and providers were not blind to the study group.

Özçaka et al. (2012) discovered the effect of oral swabbing with 0.2% CHX on

decreasing VAP in ICU patients. The sample (N=61) was allocated to an intervention (n=29) or

control group (n=32). Patients were provided oral care by swabbing the oral mucosa four times a

day with either saline (control) or CHX (intervention). The incidence of VAP in the intervention

group (12) was significantly lower than that of the control group (22, p=.03). The strengths of

this study included subjects were randomly allocated to intervention and control groups, random

assignment was concealed from facilitators who were initially enrolling subjects into the study,

and subjects were blind to the study group. Also, the instruments used to quantify the outcomes

were accurate, subjects in both groups shared no significant differences in demographics and

baseline clinical variables, and rationale was provided for participants who did not complete the

study. In addition, participants were analyzed in the group to which they were randomly

assigned; Follow-up assessments were organized appropriately in regards to the effect of

intervention. Weaknesses of the study included providers were not blind to the study group, the

control group was not appropriate, and the study was conducted in a single site.

Scannapieco and Binkley (2012) evaluated the effect of oral CHX, on reducing

occurrences of VAP after intubation. Of the total sample (N=385), patients were randomly
PNEUMONIA AND CHLORHEXIDINE 6

allocated into three groups. The three groups: a control group (n=130), a CHX intervention group

(n=127), and a CHX/COL intervention group (n=128). Each group was provided Vaseline as a

means to create a paste for topical application. The control group was only provided Vaseline as

a placebo-control group. Two centimeters of paste was applied to each side of the buccal cavity

four times a day. The mouth was cleaned before each administration. VAP was reduced in both

the CHX (65%, p = .012) and CHX/COL (55%, p = .03) compared to the control group. The

strengths of the study included subjects were randomly allocated to the experimental and control

groups, random assignment was concealed from the facilitators who were first enrolling patients

into the study, and subjects were blind to the study group. Also, rationale was given to explain

why subjects did not complete the study, follow-up evaluations we organized long enough to

accurately study the effects of the intervention, and subjects were analyzed in the group to which

they were randomly assigned. In addition, the control group was appropriate the instruments

used to quantify the outcomes were accurate. The weaknesses of this study include patients in

each of the groups did not have comparable demographics or baseline clinical conditions and it

was unknown if providers were blind to the study groups.

Synthesis

Grap et al. (2011) demonstrated that patients of the intervention group showed a

significant reduction in acquiring VAP at forty-eight hours post-intubation (p=.02) and at

seventy-two hours post-intubation (p=.027). Likewise, Lin et al. (2015) demonstrated that in the

CHX group, patients developed more cases of late onset VAP, whereas patients in the control

group developed early onset VAP (p= .027). Özçaka et al. (2012) confirmed that patients testing

positive for VAP, within the control group, had a significantly longer hospital stay compared to

the VAP negative patients in the intervention group (p=.03). Scannapieco and Binkley (2012)
PNEUMONIA AND CHLORHEXIDINE 7

recognized that tooth brushing, or in conjunction with CHX, did not significantly reduce the

incidence of VAP, versus CHX alone (p=.006).

The major weakness of all four of these studies was that providers were not blind to the

study group, some patients could not be blinded to interventions, and some control groups were

not placebo controlled for CHX. Two out of the four RCTs used CPIS scores as a means to

measure incidence of VAP, which is currently being debated the validity as a gold standard for

diagnosis of VAP. Further research needs to be conducted in which study groups are blindly

selected, facilitators develop a more appropriate control group, and measures used should

consider updated gold standards.

Clinical Recommendations

Research suggests that oral care using CHX may be an effective pharmacological method

to reducing incidences of VAP among MV patients. There are not yet any guidelines about the

use of CHX in reducing VAP in MV patients. Research confirms elimination of bacterial

colonization by the use of oral CHX can prevent ICU-acquired VAP in MV patients (Rotstein et

al., 2008). Because VAP is related to longer hospital visits, using CHX is a feasible intervention

that could decrease the length of time a patient stays in the hospital. More research is warranted

to determine the routine use of CHX and specific concentrations of CHX for best results.
PNEUMONIA AND CHLORHEXIDINE 8

References

Grap, M. J., Munro, C. L., Hamilton, V. A., Elswick, R. K., Sessler, C. N., & Ward, K. R.

(2011). Early, single chlorhexidine application reduces ventilator-associated pneumonia

in trauma patients. Heart & Lung, 40(5), e115-22.

https://doi.org/10.1016/j.hrtlng.2011.01.006

Guidelines for Preventing Health-Care-Associated Pneumonia. (2003). Recommendations of

CDC and the Healthcare Infection Control Practices Advisory Committee.

http://www.cdc.gov/hicpac/pdf/guidelines/HApneu2003guidelines.pdf

Klarin, B., Adolfsson, A., Torstensson, A., & Larsson, A. (2018). Can probiotics be an

alternative to chlorhexidine for oral care in the mechanically ventilated patient? A

multicenter, prospective, randomized controlled open trial. Critical Care, 22(1), N.PAG.

https://www.ncbi.nlm.nih.gov/pubmed/30368249

Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-

associated pneumonia: A review of the evidence. Nursing in Critical Care,16(5), 222-

234. doi:10.1111/j.1478-5153.2010.00430.x

Lin, Y. J., Xu, L., Huang, X. Z., Jiang, F., Li, S. L., Lin, F., … Lin, J. L. (2015). Reduced

occurrence of ventilator-associated pneumonia after cardiac surgery using preoperative

0.2% chlorhexidine oral rinse: Results from a single-centre single-blinded randomized

trial. Journal of Hospital Infection, 91(4), 362–366.

https://doi.org/10.1016/j.jhin.2015.08.018

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

PNEUMONIA AND CHLORHEXIDINE 9

care unit patients: A randomized clinical trial. Journal of Periodontal Research, 47(5),

584–592. https://www.ncbi.nlm.nih.gov/pubmed/22376026

Rotstein, C., Evans, G., Born, A., Grossman, R., Light, R. B., Magder, S., & Zhanel, G. G.

(2008). Clinical Practice Guidelines for Hospital-Acquired Pneumonia and Ventilator-

Associated Pneumonia in Adults. Canadian Journal of Infectious Diseases and Medical

Microbiology,19(1), 19-53. doi:10.1155/2008/593289

Scannapieco, F. A., & Binkley, C. J. (2012). Modest Reduction in Risk for Ventilator-Associated

Pneumonia in Critically ill Patients Receiving Mechanical Ventilation Following Topical

Oral Chlorhexidine. Journal of Evidence Based Dental Practice,12(3).

doi:https://www.sciencedirect.com/science/article/abs/pii/S1532338212000358

Vincent, J.-L., de Souza Barros, D., & Cianferoni, S. (2010). Diagnosis, management and

prevention of ventilator-associated pneumonia: An update. Drugs, 70(15), 1927–1944.

https://www.ncbi.nlm.nih.gov/pubmed/20883051