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American Journal of Critical Care. 2009;18: 428-437 doi:10.4037/ajcc2009792
Copyright © 2009 by the American Association of Critical-Care Nurses.
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CE Article

Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pneumonia in Critically Ill Adults

By Cindy L. Munro, RN, PhD, ANP, Mary Jo Grap, RN, PhD, ACNP, Deborah J. Jones, RN, PhD, Donna K. McClish, PhD and Curtis N. Sessler, MD. Cindy L. Munro and Mary Jo Grap are professors in the Adult Health Department, School of Nursing; Donna K. McClish is an associate professor, Department of Biostatistics; and Curtis N. Sessler is a professor in the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, at Virginia Commonwealth University, Richmond, Virginia. Deborah J. Jones is an assistant professor, Acute and Continuing Care Department, University of Texas School of Nursing at Houston.

Corresponding author: Cindy L. Munro, RN, PhD, ANP, Professor, School of Nursing, Virginia Commonwealth University, Box 980567, Richmond, VA 23298-0567 (e-mail: cmunro{at}vcu.edu).

Background Ventilator-associated pneumonia is associated with increased morbidity and mortality.

Objective To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation.

Methods Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS).

Results The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS ≥6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine (P = .29) or toothbrushing (P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS ≥6) among patients who had CPIS <6 at baseline (P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine.

Conclusions Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Identify the questions or lack of evidence surrounding the effect of oral care interventions on the development of ventilator-associated pneumonia.
  2. Describe the effects of chlorhexidine, toothbrushing, and a combination of both on the development of pneumonia in critically ill patients receiving mechanical ventilation.
  3. Discuss the conclusions drawn by the researchers in this study and their implications for nurses caring for critically ill patients receiving mechanical ventilation.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.


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