Korean J Adult Nurs.  2019 Apr;31(2):109-122. 10.7475/kjan.2019.31.2.109.

Effects of Oral Care Using Chlorhexidine Gluconate on Ventilator-associated Pneumonia and Mortality: A Systematic Review and Meta-analysis

• Kim NY
• Ryu S
• Kim YH

• KMID: 2444130
• DOI: http://doi.org/10.7475/kjan.2019.31.2.109

Abstract

PURPOSE
This review aimed to determine the effectiveness of oral care using Chlorhexidine Gluconate (CHX) in Ventilator-Associated Pneumonia (VAP) in the intensive care unit.
METHODS
An electronic databases search was conducted with Ovid-MEDLINE, EMBASE, CENTRAL, CINAHL and four domestic databases from July 10 to 16, 2018. Two reviewers independently selected the studies; three reviewers assessed their methodological quality and extracted relevant data. We conducted a meta-analysis of the effect of CHX oral care versus placebo using the Review Manager 5.3 software program and summarized the results of intervention from the included studies.
RESULTS
Of the 512 articles identified, 17 randomized controlled trials met the inclusion criteria for review. The incidence of VAP differed significantly between the CHX and placebo groups (Relative Risk [RR]=0.72, 95% Confidence Interval [CI]=0.63~0.84). The pooled effects of oral care using 0.12% CHX were RR=0.65 (95% CI=0.52~0.80) and RR=0.68 (95% CI=0.54~0.86) using CHX solution, which were statistically significant. When CHX oral care was performed three times a day, the size of the effect was statistically significant (RR=0.63, 95% CI=0.40~0.99). There was no significant difference in mortality between the CHX oral care and placebo groups (RR=1.08, 95% CI=0.94~1.28).
CONCLUSION
This review provides evidence that performing oral care using a 0.12% CHX solution three times a day could decrease the incidence of VAP. For improving the quality of nursing practice, the results of this review should be used as the basis for the oral care evidence-based practice guidelines for critical patients.

MeSH Terms

Chlorhexidine*
Critical Illness
Evidence-Based Practice
Humans
Incidence
Intensive Care Units
Mortality*
Nursing
Oral Hygiene
Pneumonia
Pneumonia, Ventilator-Associated*
Chlorhexidine

Figure

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  Figure 1. Flow diagram of study selection process.

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  Figure 2. Forest plot of the effect of chlorhexidine gluconate oral care and funnel plot.

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Appendix 1. Studies included in a Systematic Review

A1. Bellissimo-Rodrigues F, Bellissimo-Rodrigues WT, Viana JM, Teixeira GCA, Nicolini E, Auxiliadora-Martins M, et al. Effectiveness of oral rinse with chlorhexidine in preventing nosocomial respiratory tract infections among intensive care unit patients. Infection Control & Hospital Epidemiology. 2009; 30(10):952–8. https://doi.org/10.1086/605722.

A2. Berry AM, Davidson PM, Masters J, Rolls K, Ollerton R. Effects of three approaches to standardized oral hygiene to reduce bacterial colonization and ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial. International Journal of Nursing Studies. 2011; 48(6):681–8. https://doi.org/10.1016/j.ijnurstu.2010.11.004.

A3. Bopp M, Darby M, Loftin KC, Broscious S. Effects of daily oral care with 0.12% chlorhexidine gluconate and a standard oral care protocol on the development of nosocomial pneumonia in intubated patients: a pilot study. Journal of Dental Hygiene. 2006; 80(3):1–13.

A4. Ć abov T, Macan D, Husedžinović , Škrlin-Šubić J, Bošnjak D, Šestan-Crnek S, et al. The impact of oral health and 0.2% chlorhexidine oral gel on the prevalence of nosocomial infections in surgical intensive-care patients: a randomized placebo-controlled study. Wiener Klinische Wochenschrift. 2010; 122(13-14):397–404. https://doi.org/10.1007/s00508-010-1397-y. A5. DeRiso II AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and non-prophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996; 109(6):1556–61. https://doi.org/10.1378/chest.109.6.1556.

A6. 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 Medicine. 2000; 26(9):1239–47.

A7. Fourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmet-tre T, et al. Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the inten sive care unit: a double-blind placebo-controlled multicenter study. Critical Care Medicine. 2005; 33(8):1728–35. https://doi.org/10.1097/01.CCM.0000171537.03493.B0.

A8. Grap MJ, Munro CL, Hamilton VA, Elswick Jr. RK, Sessler CN, Ward KR. Early, single chlorhexidine application reduces ventilator-associated pneumonia in trauma patients. Heart & Lung. 2011; 40(5):e115–22. https://doi.org/10.1016/j.hrtlng.2011.01.006.

A9. Ko M, Kim J, Choi E. The effect of oral care with 0.12% chlorhexidine for VAP and oral health in critically ill patients. Asia Pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology. 2017; 7(3):461–76. https://doi.org/10.14257/AJMAHS.2017.03.08.

A10. Koeman M, van der Ven AJAM, Hak E, Joore HCA, Kaasja-ger K, de Smet AGA, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine. 2006; 173(12):1348–55. https://doi.org/10.1164/rccm.200505-820OC.

A11. Macnaughton PD, Bailey J, Donlin N, Branfield P, Williams A, Rowswell H. A randomised controlled trial assessing the efficacy of oral chlorhexidine in ventilated patients. Intensive Care Medicine. 2004; 30(suppl 1):S12.

A12. Meinberg MCDA, Cheade MDFM, Miranda ALD, Fachini MM, Lobo SM. The use of 2% chlorhexidine gel and tooth-brushing for oral hygiene of patients receiving mechanical ventilation: effects on ventilator-associated pneumonia. Re-vista Brasileira de Terapia Intensiva. 2012; 24(4):369–74. https://doi.org/10.1590/S0103-507X2012000400013.

A13. Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associ-ated pneumonia in critically ill adults. American Journal of Critical Care. 2009; 18(5):428–37. https://doi.org/10.4037/ajcc2009792.

A14. Özçaka Ö, Baş oğ lu Ö K, Buduneli N, Taş bakan MS, Bacakoğ lu F, Kinane DF. Chlorhexidine decreases the risk of ventilator- associated pneumonia in intensive care unit patients: a randomized clinical trial. Journal of Periodontal Research. 2012; 47(5):584–92. https://doi.org/10.1111/j.1600-0765.2012.01470.x.

A15. Scannapieco FA, Yu J, Raghavendran K, Vacanti A, Owens SI, Wood K, et al. A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Critical Care. 2009; 13(4):R117. https://doi.org/10.1186/cc7967.

A16. Segers P, Speekenbrink RGH, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and orophar-ynx with chlorhexidine gluconate: a randomized controlled trial. The Journal of the American Medical Association. 2006; 296(20):2460–6. https://doi.org/10.1001/jama.296.20.2460.

A17. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and metaanalysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infection Control & Hospital Epidemiology. 2008; 29(2):131–6. https://doi.org/10.1086/526438.