The effects of oral rinse with 0.2% and 2% chlorhexidine on oropharyngeal colonization and ventilator associated pneumonia in adults' intensive care units
Introduction
Ventilator Associated Pneumonia (VAP) is a subgroup of hospital-acquired pneumonia that occurs in patients under mechanical ventilation through an endotracheal tube or tracheostomy for at least 48–72 h [1]. This type of pneumonia occurs in 9–27% of patients in Intensive Care Units (ICUs) [2], [3]. In the United States, the cost of VAP is $2 billion annual and approximately $30000–40,000 per case [4]. The mortality rate of this infection ranges from 20 to 70% [3], [5]. VAP increases the duration of mechanical ventilation and of hospital stay [6]. It is also responsible for 50% of the antibiotics prescribed in ICUs [6], [7]. Yet, VAP is preventable [7].
The most important mechanism in the development of VAP is continuous micro-aspiration of oropharyngeal colonization into the lower respiratory tract. Twenty-four hours after a patient's admission to the ICU, normal oropharyngeal flora changes into gram-negative pathogens, which increases dental plaque. Plaques are suitable environments for the growth and accumulation of pathogens [8], [9]. In addition, the tracheal tube may operate as a conduit for oral cavity pathogens to the lungs. Several studies have also shown a relationship between dental plaque colonization and respiratory pathogens [10]. Fortunately, the incidence of VAP is reduced by identifying the risk factors and improving prevention methods. Recently, the mortality rate of VAP has been estimated at about 9–13% [7].
The Center for Disease Control and Prevention (CDC) and Institute for Healthcare Improvement (IHI) have introduced recommendations, as the VAP bundle, that include daily oral care with chlorhexidine [11], [12]. Oral care is a basic and special nursing care that helps create comfort for patients and prevent VAP [13], [14] and generally includes mechanical and pharmacological interventions. In this regard, common antiseptics are saline, chlorhexidine, and povidone iodine. Chlorhexidine is a broad spectrum antiseptic agent (gram-positive, gram-negative, and yeast) which is easy to use, safe, and cost-effective. Additionally, chlorhexidine's slow release properties maintain antimicrobial activity up to 12 h [15], [16]. Thus, it is known as an effective drug in controlling dental plaque and inflammation [17], [18]. Chlorhexidine has been studied at various concentrations (0.12%, 0.2%, 0.5%, 1%, and 2%) and forms [2], [19]. A large number of studies have confirmed that oral care with chlorhexidine reduces the incidence of VAP [20], [21], but there is no consensus on the best concentration of chlorhexidine, the frequency of its use, or oral care techniques [4]. Concentrations of 0.12% and 0.2% have shown conflicting results with respect to reduction of the incidence of VAP, but 2% chlorhexidine has been associated with a significant decrease in the incidence of VAP [2], [19]. The use of 0.2% chlorhexidine is also common in ICUs, but only a few studies have been conducted on 2% chlorhexidine. Therefore, the present study aimed to compare the effects of two different concentrations of chlorhexidine on reducing oropharyngeal colonization and the incidence of VAP.
Section snippets
Materials and methods
The present randomized clinical trial aimed to design and implement an oral care protocol and compare the effects of two different concentrations of chlorhexidine on reducing oropharyngeal colonization and VAP among patients hospitalized in the ICUs of Nemazee and Shahid Rajaee hospitals, Shiraz University of Medical Sciences, Shiraz, Iran. This study was approved by the Ethics Committee of Shiraz University of Medical Sciences and was registered in the Iranian Registry of Clinical Trials
Results
During the 5-month study period, 414 patients were admitted to the wards under study, but 297 patients were excluded from the study for not meeting the inclusion criteria. Three other patients were excluded because of their families' dissatisfaction. In total, 114 patients were enrolled in the study and were randomly allocated into the study groups (57 patients in each group). The mean ages of the patients in 0.2% chlorhexidine and 2% chlorhexidine groups were 45.43 ± 2.95 and 44.45 ± 2.72 years,
Discussion
Decreasing VAP through oral care is essential to avoid the spread of antibiotic-resistant microorganisms [4]. In the present study, 2% chlorhexidine was chosen because a previous study showed that this concentration was more effective than other concentrations in high-risk patients and showed better activity against multidrug-resistant bacteria in the laboratory environment [22].
The present study showed that the higher concentration of chlorhexidine (2%) was effective in reducing the incidence
Conflict of interest
None.
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