FAR EASTERN UNIVERSITY INSTITUTE OF NURSING MORAYTA, MANILA August 27, 2010

QUEZON INSTITUTE
EVIDENCE BASED NURSING
(COMMUNICABLE DISEASES)

CLINICAL QUESTION:
“IN PATIENTS REQUIRING MECHANICAL VENTILATION FOR ≥48 HOURS, IS ORAL DECONTAMINATION WITH CHLORHEXIDINE (CHX) OR CHX PLUS COLISTIN (COL) EFFECTIVE FOR REDUCING VENTILATOR ASSOCIATED PNEUMONIA (VAP)?”

SUBMITTED BY: IGNACIO, LYRA CAMILLE T. GROUP 158

SUBMITTED TO:

double-blind. Does the study focus on a significant problem in clinical practice? Yes. placebo-controlled trial with three arms: CHX. pregnancy. Methodology/Design: A. Methodology used Consecutive patients needing mechanical ventilation for 48 h or more were enrolled in a randomized. B. Clinical Question: “IN PATIENTS REQUIRING MECHANICAL VENTILATION FOR ≥48 HOURS. All medications were mixed with petroleum jelly (Vaseline) FNA to form a paste. 60% men) requiring mechanical ventilation for ≥48 hours. Exclusion criteria were preadmission immunocompromised status (defined as leucopaenia <3 × 109/l. or inability to take oral medication. C. Endotracheal colonization was monitored twice weekly. Citation: Effectiveness of oral decontamination with chlorhexidine (chx) or chx plus colistin (col) for reducing ventilator associated pneumonia (vap) patients requiring mechanical ventilation for ≥48 hours III. LIZA VILLACORTE I. or human immunodeficiency virus). 2% CHX plus 2% COL. Trial medication was applied every 6 h into the buccal cavity. or placebo . CHX/COL. because it is one of the most frequently occurring nosocomial infection associated with increased morbidity and mortality.MS. Design randomised double blind placebo controlled trial C. cumulative dose of corticosteroids >750 mg/y. Setting . Secondary outcomes were all cause ICU mortality and oral and endotracheal tube (ETT) colonisation D. IS ORAL DECONTAMINATION WITH CHLORHEXIDINE (CHX) OR CHX PLUS COLISTIN (COL) EFFECTIVE FOR REDUCING VENTILATOR ASSOCIATED PNEUMONIA (VAP)?” II. Interventions compared 2% CHX . B. Study Characteristics: A. and placebo (PLAC).5 g was applied 4 times/day to each side of the buccal cavity. Outcomes monitored Incidence of VAP. Patients included 385 patients >18 years of age (mean age 62 y. Oropharyngeal swabs were obtained daily and quantitatively analyzed for gram-positive and gram-negative microorganisms. and 0. IV.

Dubois D.2. What were the risks and benefits of the nursing action / intervention tested in the study? Benefits of the actions/ interventions include the main result of the use of chlorhexidine and chlorhexidine plus colistin. The daily risk of VAP was reduced in both treatment groups compared with PLAC: 65% (hazard ratio [HR] = 0. 0. 0. 791. VI. 127 CHX and 128 CHX/COL. Data sources Fourrier F. whereas CHX mostly affected gram-positive microorganisms.160. Preventing VAP using oral decontamination with non-absorbable antibiotics is not widespread because of concerns about emergence of antibiotic resistance. CHX/COL provided significant reduction in oropharyngeal colonization with both gram-negative and gram-positive microorganisms. 95% confidence interval [CI]. or inability to take oral medication. intensive care unit stay. Although clorhexidine has potential lower efficacy against gramnegative microorganisms it is still effective and beneficial to patient. Pronnier P. V. Author’s Conclusions /Recommendations: In patients requiring mechanical ventilation for ≥48 hours. 95% CI. 0. No differences in duration of mechanical ventilation.012) for CHX and 55% (HR = 0.1. 925. Inclusion criteria 385 patients >18 years of age (mean age 62 y.454. p = 0. Subject selection E.352.. Results of the Study: Of 385 patients included.2 mixed and 2 surgical intensive care units (ICUs) in 2 university hospitals and mixed ICUs in 3 general hospitals in the Netherlands. 130 received PLAC.33:1728–35 E. cumulative dose of corticosteroids >750 mg/y. Exclusion criteria Exclusion criteria were preadmission immunocompromised status (defined as leucopaenia <3 × 109/l. F. G. pregnancy. p = 0. the original study has been replicated. The only difference is that there had been changes in what is to be assessed after the interventions. Endotracheal colonization was reduced for CHX/COL patients and to a lesser extent for CHX patients. E.030) for CHX/COL. et al. D. 0. 60% men) requiring mechanical ventilation for ≥48 hours. oral decontamination with chlorhexidine reduced ventilator associated pneumonia. Baseline characteristics were comparable. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. or human immunodeficiency virus). Oropharyngeal colonisation with potential pathogens is central in the pathogenesis of VAP. Koeman et al used orally applied CHX or CHX plus COL as alternative agents and found both treatments to be effective in VAP prevention. Has the original study been replicated? Yes. or intensive care unit survival could be demonstrated. Crit Care Med 2005. This placebo .224.

Combining oral hygiene with CHX decontamination may have enhanced the removal of oral micro-organisms. normal tooth brushing and saline cleansing of the oral cavity were administered to all patients. It also had standard protocols regarding head elevation to minimise confounders. Applicability: A. Based on the trial by Koeman et al. This strategy to modulate oropharyngeal colonisation is simple. Although oral decontamination with antibiotics reduces incidences of VAP. Other strategies such as semirecumbent positioning should also be used whenever possible. Considering their low potential for induction and selection of antibiotic resistance and costs. The combination of COL and CHX resulted in better oropharyngeal decontamination for gram-negative microorganisms. with 65 and 55% for CHX and CHX/COL. VIII. VII. inexpensive. modulation of oropharyngeal colonization with CHX and CHX/COL reduced the daily probability of VAP. Does the study provide a direct enough answer to your clinical question in terms of type of patients. 2%/2%) would reduce and postpone development of VAP. had explicit inclusion and exclusion criteria and outcomes. Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality. Its use should complement rather than replace basic oral hygiene. The safety profile regarding selection and induction of antibiotic resistance and the presumed cost benefits of CHX make it highly attractive for prevention of VAP. and had complete follow up for the primary end point. besides the treatment. Considering the growing role of COL as ultimate treatment of multiresistant gram-negative bacteria. oropharyngeal decontamination with CHX or CHX/COL is an attractive infection prevention measure. Evaluating Nursing Care Practices . results are accurate and shows difference in the outcomes of the interventions provided with the method of observation. 2%) or CHX/colistin (CHX/COL. In this trial. CHX decontamination is promising for patients mechanically ventilated for ≥48 hours. although its routine use for all ICU patients should probably await studies on the acquisition of long term resistance. Daily risks of VAP decreased. respectively. B. and minimally labour intensive. intervention and outcome? Yes.controlled trial was methodologically rigorous because it was adequately powered. CHX seems to be preferred for preventive implications. The preventive effects on the occurrence of VAP were underscored by reduced colonization rates with gram-negative and gram-positive bacteria in oropharynx and trachea. blinded. and oral and endotracheal colonization. IX. In conclusion. Is it feasible to carry out the nursing action in the real world? Yes. randomised. but both regimens appeared equally effective in VAP prevention. Reviewer’s Conclusion / Commentary Oropharyngeal decontamination with either CHX or CHX/COL reduced and delayed the development of VAP in critically ill patients receiving mechanical ventilation. and concealed. an integral aspect of nursing. it is not recommended because of potential selection of antibiotic-resistant pathogens. We hypothesized that oral decontamination with either chlorhexidine (CHX.

This would be very helpful to health care practitioners as studies were also conducted before and revealed same results. .

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