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Chlorhexidine, Toothbrushing, and Preventing Ventilator Associated

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Chlorhexidine, Toothbrushing, and Preventing Ventilator Associated Pulmonary Critical Care CHLORHEXIDINE, TOOTH BRUSHING, 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 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 develop- 1.5 Hours ment of ventilator-associated pneumonia in critically ill patients C E receiving mechanical ventilation. Methods Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized con- Notice to CE enrollees: trolled clinical trial with a 2 x 2 factorial design. Patients with A closed-book, multiple-choice examination a clinical diagnosis of pneumonia at the time of intubation following this article tests your under standing of and edentulous patients were excluded. Patients (n = 547) the following objectives: were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice 1. Identify the questions or lack of evidence sur- daily, both toothbrushing and chlorhexidine, or control (usual rounding the effect of oral care interventions care). Ventilator-associated pneumonia was determined by on the development of ventilator-associated using the Clinical Pulmonary Infection Score (CPIS). pneumonia. Results The 4 groups did not differ significantly in clinical 2. Describe the effects of chlorhexidine, tooth- characteristics. At day 3 analysis, 249 patients remained in brushing, and a combination of both on the the study. Among patients without pneumonia at baseline, development of pneumonia in critically ill patients receiving mechanical ventilation. pneumonia developed in 24% (CPIS ≥6) by day 3 in those 3. Discuss the conclusions drawn by the treated with chlorhexidine. When data on all patients were researchers in this study and their implica- analyzed together, mixed models analysis indicated no effect tions for nurses caring for critically ill of either chlorhexidine (P = .29) or toothbrushing (P = .95). patients receiving mechanical ventilation. However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS ≥6) among patients who had CPIS To read this article and take the CE test online, <6 at baseline (P = .006). Toothbrushing had no effect on CPIS visit www.ajcconline.org and click “CE Articles and did not enhance the effect of chlorhexidine. in This Issue.” No CE test fee for AACN members. Conclusions Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline. (American Journal of Critical Care. ©2009 American Association of Critical-Care Nurses doi: 10.4037/ajcc2009792 2009:18:428-438). 428 AJCCAMERICAN JOURNAL OF CRITICAL CARE, September 2009, Volume 18, No. 5 www.ajcconline.org entilator-associated pneumonia (VAP) is defined as pneumonia in patients receiv- ing mechanical ventilation that was neither present nor developing at the time of intubation. VAP increases mortality,1 hospital length of stay,2,3 and health care costs.2,4,5 Oral health can be compromised by critical illness and by mechanical ventilation and is influenced by nursing care.6,7 The effect of oral care interventions Von the development of VAP has been of interest to clinicians; however, data from well-controlled experimental research with adequate sample sizes have not been published. Many risk factors for VAP have been identified.8 to reduce bacteria in the oral cavity have been inves- Major ones include inadequate hand washing by tigated. Several studies19-21 have indicated that appli- staff, ventilatory circuit management practices, supine cation of topical oral chlorhexidine, initiated before positioning of patients without backrest elevation, intubation, reduces nosocomial infections in patients previous antibiotic therapy, presence of a nasogastric having elective cardiac surgery. Importantly, however, tube, and gastric alkalinization.9,10 Interventions cardiac surgery patients are generally extubated included in the Institute for Healthcare Improve- within 48 hours and thus have a ment’s ventilator bundle11 to reduce risk of complica- low risk for VAP. However, in a Dental plaque can tions in patients treated with mechanical ventilation recent meta-analysis, Pineda et al22 include elevating the head of the bed to 30º or more, found that chlorhexidine did not provide a habitat prophylaxis for peptic ulcer disease and deep vein reduce nosocomial pneumonia or for microorganisms thrombosis, daily interruption of sedation (sedation mortality rate. A recommendation vacation), and assessment of readiness to extubate. for use of chlorhexidine in patients responsible for Another risk factor for VAP is colonization of other than those having elective car- the oropharynx by potential pathogens such as diac surgery is not included in ventilator-associated Staphylococcus aureus, Streptococcus pneumoniae, or national ventilator bundles or in pneumonia. gram-negative rods.12-15 Several factors contribute to recommendations from the Centers the association between oral health and development for Disease Control and Prevention because no evi- of VAP. Within 48 hours of admission to the inten- dence of the effectiveness of chlorhexidine in gen- sive care unit (ICU), oral flora of critically ill patients eral critical care patients is available. Controlled undergoes a change to predominantly gram-negative studies of the effects of toothbrushing on VAP have flora that includes more virulent organisms.16,17 Den- not been reported. tal plaque can provide a habitat for microorganisms Oral care in critically ill adults is now emerging responsible for VAP, and dental plaque of patients as an important issue but has not been well studied in the ICU can be colonized by potential respiratory in patients other than those having elective cardiac pathogens such as methicillin-resistant S aureus and surgery. We conducted a randomized, controlled Pseudomonas aeruginosa.18 clinical trial to test the effects of toothbrushing Because contamination of the oral cavity by path- and/or chlorhexidine in reducing the risk for VAP in ogenic bacteria is associated with VAP, interventions adult ICU patients receiving mechanical ventilation. We hypothesized that oral interventions would reduce About the Authors the incidence of VAP. Cindy L. Munro and Mary Jo Grap are professors in the Adult Health Department, School of Nursing; Donna K. Methods McClish is an associate professor, Department of Biosta- tistics; and Curtis N. Sessler is a professor in the Divi- Design and Sample sion of Pulmonary and Critical Care Medicine, A randomized controlled 2 × 2 factorial experi- Department of Internal Medicine, School of Medicine, at mental design was used, and staff who performed Virginia Commonwealth University, Richmond, Virginia. Deborah J. Jones is an assistant professor, Acute and interventions had no knowledge of patients’ Clinical Continuing Care Department, University of Texas School Pulmonary Infection Score (CPIS). The study was of Nursing at Houston. approved by the Office of Research Subjects Protec- Corresponding author: Cindy L. Munro, RN, PhD, ANP, Pro- tion of Virginia Commonwealth University, Rich- fessor, School of Nursing, Virginia Commonwealth Uni- versity, Box 980567, Richmond, VA 23298-0567 (e-mail: mond, Virginia, and prospective informed consent [email protected]). for participation was obtained from each patient’s www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2009, Volume 18, No. 5 429 Screened (N = 10 910) Patients were recruited from 3 ICUs at Virginia Commonwealth University Medical Center, a large Did not meet criteria Met study criteria urban hospital. All patients older than 18 years (n = 1416) (n = 9494) (n = 10913) in medical, surgical/trauma, and neuro- Not intubated (n = 6119) science ICUs were screened for inclusion. The Figure Intubated >24 hours (n = 963) provides information about screening, enrollment, Other (n = 2412) and attrition. Patients were randomized to treatment within each ICU according to a permuted block design developed by the biostatistician (D.K.M.) Unable to obtain Consent obtained before the start of the study. Patients receiving consent (n = 869) (n = 547) mechanical ventilation were enrolled within 24 hours of intubation. Because reintubation increases 23,24 Patient enrolled and randomized to group assignment (n = 547) the risk for VAP, patients who had had a previous endotracheal intubation during the current hospital admission were excluded. Edentulous patients were Intervention and data collection excluded because dental plaque could not be assessed. Patients with a clinical diagnosis of pneu- Tooth- Both chlorhexidine Usual monia at the time of intubation were excluded Chlorhexidine brushing and toothbrushing care because determination of nosocomial pneumonia is Patients confounded in patients with preexisting pneumonia. remaining Consent was obtained for 547 patients. intubated Patients remained in the study for a maximum Day 1 119 113 116 123 of 7 days unless extubated; for patients extubated (n = 471) before day 7, participation in the study ended on Day 2 79 79 84 88 the day of extubation. This step was necessary because (n = 330) VAP was scored by using the CPIS, and variables
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