Published ahead of print on April 7, 2006, doi:10.1164/rccm.200505-820OC
Am. J. Respir. Crit. Care Med., Volume 173, Number 12, June 2006, 1348-1355
A more recent version of this article appeared on June 15, 2006
Submitted on May 26, 2005
Accepted on March 31, 2006
Oral Decontamination with Chlorhexidine Reduces Incidence of Ventilator-Associated Pneumonia
Mirelle Koeman1*, Andre J.A.M. van der Ven2, Eelko Hak3, Hans C.A. Joore1, Karin Kaasjager4, Annemarie G.A. de Smet5, Graham Ramsay6, Tom P.J. Dormans7, Leon P.H.J. Aarts8, Ernst E de Bel2, Willem N.M. Hustinx9, Ingeborg van der Tweel10, Andy M. Hoepelman1, and Marc J.M. Bonten11
1 Division of Medicine, Infectious Diseases and Geriatrics, Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands,
2 Department of Infectious Diseases, University Medical Centre Nijmegen, Nijmegen, The Netherlands,
3 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands,
4 Department of Internal Medicine and Intensive Care Medicine, Rijnstate Hospital Arnhem, Arnhem, The Netherlands,
5 Department of Perioperative Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands,
6 Hospital Board, Atrium Medical Center, Heerlen, The Netherlands,
7 Department of Intensive Care Medicine, Atrium Medical Heerlen, Heerlen, The Netherlands,
8 Department of Anesthesiology and Intensive Care Medicine, Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands,
9 Department of Intensive Care Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands,
10 Center for Biostatistics, University Medical Centre Utrecht, Utrecht, The Netherlands,
11 Division of Medicine, Infectious Diseases and Geriatrics, Department of Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; Eijkman Winkler Institute for Microbiology, Inflammation and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
* To whom correspondence should be addressed. E-mail: groenendijk-koeman{at}wanadoo.nl.
Rationale. Ventilator-Associated Pneumonia (VAP) is the most frequently occurring nosocomial infection associated with increased morbidity and mortality. Although oral decontamination with antibiotics reduces incidences of VAP, it is not recommended because of potential selection of antibiotic resistant pathogens. We hypothesized that oral decontamination with either chlorhexidine (CHX, 2%) or chlorhexidine-colistin (CHX/COL, 2%/2%) would reduce and postpone development of VAP, oral and endotracheal colonization.
Objectives. To determine the effect of oral decontamination with CHX or CHX/COL on VAP incidence and time to development of VAP.
Methods. Consecutive patients needing mechanical ventilation  48 hours were enrolled in a randomized, double blind placebo-controlled trial with 3 arms: CHX, CHX/COL and placebo (PLAC). Trial medication was applied every 6 hours into the buccal cavity. Oropharyngeal swabs were obtained daily and quantitatively analyzed for Gram-positive and Gram-negative microorganisms. Endotracheal colonization was monitored twice weekly.
Results: Of 385 patients included, 130 patients received PLAC, 127 CHX and 128 CHX/COL. Baseline characteristics were comparable. The daily risk of VAP was reduced in both treatment groups compared to PLAC: 65% (HR=0.352; 95%CI (0.160;0. 791); p=0.012) for CHX patients and 55% (HR=0.454; 95%CI (0.224;0. 925); p=0.030) for CHX/COL. CHX/COL sorted significant reduction in oropharyngeal colonization with both Gram-negative and Gram-positive microorganisms, whereas CHX mostly affected Gram-positive microorganisms. Endotracheal colonization was reduced for CHX/COL patients and to a lesser extent for CHX patients. No differences in duration of mechanical ventilation, ICU-stay or ICU-survival could be demonstrated.
Conclusions: Topical decontamination of the oral cavity with chlorhexidine or chlorhexidine-colistin reduces the incidence of VAP.
Key words: Ventilator-associated pneumonia, prevention, chlorhexidine, colistin
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