Running head: PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

Preventing Ventilator-Associated Pneumonia with the use of Chlorhexidine Oral Care

Lindsey M. Swank
University of South Florida

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

Abstract
Clinical Problem: In the intensive care unit (ICU), many patients that require intubation and
mechanical ventilation have the chance to develop ventilator-associated pneumonia (VAP),
which is a serious complication that may prolong patients stay in the hospital as well as increase
mortality rates. These hospital-acquired infections, though easily preventable, can add
unnecessary costs to both the hospital and its patients.
Objective: To determine whether or not the use of chlorhexidine oral care can yield significant
results in regards to lowering the rates of ventilator-associated pneumonia in patients admitted to
the ICU.
Result: Grap, Munro, Hamilton, Elswick, Sessler, and Ward (2011) determined that single
application of a chlorhexidine mouth swab within 12 hours of intubation significantly reduces
the prevalence of VAP (p=.020) in patients in the ICU. Munro, Grap, Jones, McClish, and Sessler
(2009) studied whether the use of chlorhexidine, tooth brushing, or a combination of the two
could lower rates of VAP in critically ill patients. A statistically significant yield (p=.006)
determined that chlorhexidine reduced the incidence of VAP in patients with a Clinical
Pulmonary Infection Score (CPIS) of less than six. Scannapieco, Yu, Raghavendran, Vacanti,
Owens, Wood, and Mylotte (2009) analyzed whether the use of oral antiseptics, including
chlorhexidine, would reduce the amount of respiratory pathogens in patients that are
mechanically ventilated. A nonsignificant (p=0.15) reduction in the prevalence of VAP was
noted, however, it was noted that there was a decrease in the amount of Staphylococcus aureas in
dental plaque.
Conclusion: Studies that have yielded significant results have shown that the use of
chlorhexidine oral care in patients on mechanical ventilation can help to reduce the prevalence of

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

ventilator-associated pneumonia. More information may be necessary to further prove the
significance of chlorhexidine oral care.

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

Preventing Ventilator-Associated Pneumonia with Chlorhexidine Oral Care

In the ICU, many patients require intubation and mechanical ventilation for lifesustaining breathing support. After 24 hours of being on a mechanical ventilator, VAP may arise.
VAP is a serious and common complication that can be prevented with diligent use of
chlorhexidine oral care to prevent the colonization of respiratory pathogens. The use of
chlorhexidine oral care products, which is a part of the VAP prevention care bundle (Munro &
Ruggiero, 2014), can prevent microaspiration related to buildup of plaque and pathogens in the
oropharynx and oral cavity. In patients on ventilators, does the use of chlorhexidine oral care, as
opposed to not providing oral care, lower rates of ventilator-associated pneumonia during their
stay in the hospital?
Literature Search
When searching for articles, both PubMed and CINHAL were used. The keywords that
were searched on both sites were ventilator-associated pneumonia, chlorhexidine oral care, VAP,
and prevention. On both search engines, limits were set for randomized controlled trials, and no
specific timeframe was used. In total, three peer reviewed randomized controlled trials and one
scholarly article published by the American Association of Critical Care Nurses were used.
Literature Review
In a study conducted by Grap, Munro, Hamilton, Elswick, Sessler, and Ward (2011), the
purpose was to identify whether or not a single application of chlorhexidine soon after the patient
was placed on a ventilator would reduce the risk of developing VAP. One-hundred and forty-five
patients were randomly assigned control or intervention group, 74 being control and 71 being
intervention. They were then examined at both 48 and 72 hours after intubation. It was found that
while 55.6% of the control group developed VAP (P=.020), only 33.3% of the intervention group

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

developed VAP. It was concluded that a single chlorhexidine gluconate application within 12
hours of intubation reduces CPIS and therefore VAP.
Munro, Grap, Jones, McClish, and Sessler (2009) conducted a study that examinedthe
effectsofmechanical(toothbrushing),pharmacological(topicaloralchlorhexidine),and
combination(toothbrushingpluschlorhexidine)oralcareonthedevelopmentofVAPin
criticallyillpatientsreceivingmechanicalventilation.Fivehundredandfortysevenpatients
participatedinthestudy,beingrandomlyassignedtoachlorhexidinegroup,atoothbrushing
group,acontrolgroup,andagroupthatusedbothchlorhexidineandtoothbrushing.One
hundredandnineteenpatientswereinthechlorhexidinegroup,113patientswereinthe
toothbrushinggroup,116patientswereinthecombinationgroup,and123wereinthecontrol
group.The results determined no effect of either toothbrushing (P=.29) or chlorhexidine
(P=.95). However, chlorhexidine reduced incidence of VAP in patients with a CPIS of <6
(P=.006).
A study conducted by Scannapieco et al. (2009) investigated whether or not antiseptic
oral care helps to prevent colonization from respiratory pathogens in mechanically ventilated
patients in the ICU. A randomized microbiologic baseline data was available for only 146 of the
175 subjects, and the use of chlorhexidine gluconate versus a placebo was examined. Either the
placebo or the chlorhexidine gluconate was applied once or twice a day, and the amount of
pathogens was measured. Fifty-eight patients were given the chlorhexidine twice a day, 58
patients were given chlorhexidine once and a placebo once a day, and 59 patients were given a
placebo twice a day. Although a nonsignificant (P=0.15) reduction in the VAP rate was noted, the
administration of chlorhexidine reduced the numbers of S. aureus in dental plaque. No evidence
of resistance against chlorhexidine was noted.

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

Munro and Ruggiero (2014) examined the ventilator-associated pneumonia care bundle
was examined, as well as the definition of VAP. It was determined that the diagnosis of VAP
depends on three different criteria: radiographic, microbiological, and clinical criteria.
Radiographic signs include two or more chest x-rays with signs of progressive infiltration.
Microbiological criteria, while not essential for diagnosis, can include positive cultures in the
blood, urine, or in the lungs. Clinical signs include fever higher than 38 degrees Celsius, high or
low white blood cell count, altered mental status, or purulent sputum and secretions from the
lungs. The VAP care bundle was examined, which includes raising the head of bed, oral hygiene
care, deep vein thrombosis and peptic ulcer prophylaxis, and daily sedation vacations. The
implementation of these practices, among others, to the clinical setting can be beneficial to the
prevention of VAP. Oral antiseptics, including chlorhexidine, appeared to have a significant
reduction in the prevalence of VAP (confidence interval of 95%).
Synthesis
In the study conducted by Grap, Munro, Hamilton, Elswick, Sessler, and Ward, the
control group had a VAP development of 55.6% (P=.020), compared to the 33.3% of the
intervention group. Munro, Grap, Jones, McClish, and Sessler conducted a study that determined
no effect of either toothbrushing (P=.29) or chlorhexidine (P=.95) on the prevention of VAP.
However, chlorhexidine reduced incidence of VAP in pts with a Clinical Pulmonary Infection
Score of <6 (P=.006). A study conducted by Scannapieco et al. (2009) demonstrated a
nonsignificant (P=0.15) reduction in the prevalence of VAP. However, it was noted that there was
a reduction in the amount of S. aureus in dental plaque after administration of chlorhexidine. The
final article written by Munro and Ruggiero, although not a randomized control trial, was an
article that analyzed the effectiveness of VAP care bundles. This article analyzed the use of

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

chlorhexidine oral care as a standard of care in ICUs, and determined with a 95% confidence
interval that chlorhexidine decreases the incidence of VAP. This article was chosen due to its
relevance to the prevention of VAP.
Although the article written by Scannapieco et al. had a nonsignificant result, the other
two randomized control trials had significant results that further support the claim that
chlorhexidine oral care can prevent VAP. Research has shown that routine oral care has proven
successful in reducing the prevalence of VAP. However, more evidence and research is necessary
to determine further benefits and possible consequences of using chlorhexidine oral care. If
routine chlorhexidine oral care is implemented, the decreased amount of patients diagnosed with
VAP would lead to a decrease in mortality rate amongst patients in the ICU. Furthermore, if more
patients do not contract hospital-acquired infections such as VAP, that leads to a reduction in
costs for both the hospital and the patient. More research may be required to determine if length
of stay can be shortened with VAP prevention techniques.
Clinical Recommendations
Although several of the research studies presented have had results for the
implementation of chlorhexidine oral care, there is still not enough research done to properly
implement this preventative measure. Research should be done in regards to the amount of
chlorhexidine necessary to provide significant results. Additional research would be optimal in
regards to the study conducted by Scannapieco et al. (2009) due to the insignificant results. This
could be changed by reducing the amount of groups in the study. The standard VAP care bundle
should continue to involve the use of chlorhexidine oral care in combination with head of bed
elevation, DVT and ulcer prophylaxis, and daily sedation vacations. Furthermore, the use of
chlorhexidine oral care and the VAP care bundle should be implemented as soon as possible upon

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ventilation. Patients that have been intubated in the ICU should continue to receive this excellent
form of standardized care.

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. Care of the Critically Ill, E115-E122.
http://dx.doi.org/10.1016/j.hrtlng.2011.01.006
Munro, C., Grap, M., Jones, D., McClish, D., & Sessler, C. (2009). Chlorhexidine, tooth

PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA

brushing, and preventing ventilator-associated pneumonia in critical adults. American
Journal of Critical Care, 18(5), 428-37. doi: 10.4037/ajcc2009792.
Munro, N., & Ruggiero, M. (2014). Ventilator-Associated Pneumonia Bundle. Retrieved March
3, 2016, from http://www.aacn.org/WD/CETests/Media/ACC4322.pdf
Scannapieco, F. A., Yu, J., Raghavendran, K., Vacanti, A., Owens, S. I., Wood, K., & Mylotte, J.
M. (2009). A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in
mechanically ventilated patients. Critical Care, 13(4). http://dx.doi.org/10.1186/cc7967