Fast track — ArticlesPrevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis
Introduction
Ventilator-associated pneumonia is defined as pneumonia in people who have a device to continuously assist or control respiration through a tracheostomy or by endotracheal intubation within 48 h before the onset of infection, inclusive of the weaning period.1 Affecting 10–30% of mechanically ventilated patients, this type of pneumonia is one of the most frequent nosocomial infections in intensive care units.2, 3 Depending on the casemix, disease severity, microorganisms involved, and adequacy of anti-infective management, the attributable mortality (mortality in exposed patients in excess to mortality in matched unexposed patients) can exceed 50%.4 Moreover, ventilator-associated pneumonia is an important cause of morbidity, increased use of health-care resources, and excess cost.3 As such, prevention of this disease is a priority in quality improvement programmes in intensive care units5, 6 and plenty of efforts have been taken to elucidate the effect of distinct preventive measures.7, 8, 9
The most important mechanism for development of ventilator-associated pneumonia is aspiration of colonised oropharyngeal secretions into the lower respiratory tract.10 Oral bacterial colonisation results from accumulation of debris in the oral cavity. Adequate salivary flow is an important factor for maintainance of oral health through its antimicrobial, lubricating, and buffering properties. In intubated patients, however, a constantly open mouth and the use of drugs such as antihypertensives, anticholinergics, antipsychotics, and diuretics predispose for xerostomia and subsequent reduction in salivary immune factors. Additionally, an endotracheal tube can hamper thorough inspection of the oral cavity and limit access for oral care.11, 12
Reduction of the number of oral microorganisms might hold a potential for prevention of ventilator-associated pneumonia.13, 14 Both chlorhexidine and povidone-iodine have been proposed as powerful antiseptic drugs against oral bacteria, but studies aiming to determine the most effective product, its optimum concentration, and frequency of use have yielded inconclusive results. We did a systematic review and subsequent meta-analysis postulating that oral care with chlorhexidine or povidone-iodine reduced the occurrence of ventilator-associated pneumonia in mechanically ventilated adults compared with absence of oral care or oral care with a placebo, saline 0.9%, or another active product.
Section snippets
Search strategy
Our systemic search for relevant publications included the electronic databases PubMed, CINAHL, Web of Science, and The Cochrane Central Register of Controlled Trials (CENTRAL). We searched combinations of the keywords “oral care”, “oral health”, “oral hygiene”, “oral decontamination”, “antiseptics”, “intubation”, “(mechanical) ventilation”, “ventilator-associated pneumonia”, “prevention”, “reduction”, “pneumonia”, “respiratory (tract) infection”, “chlorhexidine”, “iodine”, “betadine”,
Results
Our broad search strategy yielded 1720 abstracts (873 in PubMed, 502 in Web of Science, 78 in CINAHL, and 267 in CENTRAL). After elimination of identical publications and studies that did not meet inclusion criteria, 13 studies13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 were selected. Scanning of reference lists yielded one additional study.27 As a result, 14 studies published in English between January, 1996 and February, 2011 consisting of 2481 patients were included in the systematic
Discussion
This meta-analysis of 14 randomised trials providesstrong evidence that oral care with chlorhexidine or povidone-iodine effectively reduces rates of ventilator-associated pneumonia when compared with oral care without these antiseptics. This effect was most prominent for chlorhexidine 2%. For chlorhexidine 0.12%, which is currently the recommended dosage by the CDC for cardiosurgical patients,29 the risk reduction was not significant. With regard to povidone-iodine application, only two rather
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Both authors contributed equally