Public Health Sample Paper on Using Chlorhexidine in reducing Ventilator Associated Pneumonia in the ICU

Using Chlorhexidine in reducing Ventilator Associated Pneumonia in the ICU

Literature Review

Oral chlorhexidine in preventing ventilator-associated pneumonia in gravely ailing grown-ups in the ICU

This article primes its study with its goals set on evaluating the evidence on the efficiency of oral chlorhexidine in deterring ventilator-associated pneumonia in grown-ups who are critically ill and mechanically ventilated patients within the critical care clinic. Two separate parties selected the study independently. The inclusion criteria was met by eight randomized controlled trials which looked into the efficacy of Listerine, normal saline, power tooth brushing, bicarbonate isotonic serum rinse, and placebos versus oral chlorhexidine in deterring ventilator associated pneumonia in instinctively ventilated grown-ups. The review manager (version 5.1) did analysis of the data obtained. The risk ratio was the effect measure of choice with dichotomous data intervals of 95% confidence, using the random effects model with a p-value equal to 0.05. I2 and Cochrane Q statistic were used to assess heterogeneity (Snyders, Khondowe, & Bell, 2011).

            The research was conducted based on an extensive literature search of studies conducted between 2010 and 2011 June and June respectively. Information was obtained from MEDLINE, Cochrane Central Register of Controlled Trials, and the Cumulative Index of Nursing and Allied Health. The authors also conduct a research on textbooks, reference list of articles, and summaries of conferences, including hand searching (Snyders et al., 2011).

            The study focused on studies that reported on the use of placebo, tooth brushing, or any other oral care interventions comparators versus the use of chlorhexidine in reducing ventilator-associated pneumonia in instinctively aerated grown-ups, critically ill patients. The participants in the study were mechanically ventilated, aged, about 18 years and above, critically ill and admitted in the critical care clinics. The research also employed the exclusion research design, where the article was primarily focused on resources that looked into ventilator-associated pneumonia (Snyders et al., 2011).

The results obtained from the study found eight randomized controlled trials to have met the inclusion criteria, with a higher chance of 36 percent of respirator-associated pneumonia in the control group as compared to the chlorhexidine group. There was also a very small variation noted within the included studies. The article concludes that there is no evidence of effect of chlorhexidine on mortality, asserting that the risk of respirator-associated pneumonia could be reduced by 36 percent by use of chlorhexidine treatment. It is also asserted that using 2 percent of chlorhexidine would be most effectual in minimizing incidences of respirator-associated pneumonia (Snyders et al., 2011).

Prevention of Ventilator-Associated Pneumonia by use of oral caring, product assortment, and application models

The authors in this article have their main objective set on identifying the method that would be most effective for oral hygiene to minimize the occurrence of respirator-associated pneumonia. The authors assert that ventilator-associated pneumonia is the well-known nosocomial disease among patients that is treated through mechanical ventilation. As much as nurse education programs and implementation of oral care were found to reduce ventilator-associated pneumonia, the outcome also depicted that chlorhexidine is the widespread oral caring item for consumption; however, the authors assert that there was no consensus achieved on protocols or concentration for oral care.

It is concluded that patients being treated for mechanical ventilation on their oral hygiene had no particular consensus on their treatment and the finest application of oral hygiene. It was also concluded that evaluation, oral care set of rules, and educating nurses were vital in the reduction of the occurrence of ventilator-associated pneumonia and the popularity of chlorhexidine as the most effective product for oral care. The authors recommend that future research should examine the concentration of chlorhexidine, frequency of oral care, and techniques of application in order to optimize the deterrence of ventilator-associated pneumonia (Hillier, Wilson, Chamberlain, & King, 2013).

The research conducted a systematic review on available literature. The authors considered a systematic review method of research due to its effectiveness on conducting cause and effect analysis, which in turn would minimize cases of biasness significantly. The authors performed a comprehensive database search on a multiple of databases in order to evaluate research that was relevant to the occurrence of ventilator associated pneumonia and oral hygiene. The resources used in the study were obtained from MEDLINE database, Web of Science, Ovid nursing database, Google scholar, and Cumulative Index to Nursing and Allied Health Literature. 26 articles were retained and examined in detail out of the total of 391 articles that were retrieved. The articles used included two meta-analyses, one quasi-randomized controlled trial, seven intervention cohort studies, three survey studies; eight randomized controlled trials, and five observational cohort studies, with studies having been carried out in multinational centres (Hillier et al., 2013).

            The research employed the inclusion criteria basing on several conditions as outlined herein. First, the resources for the study were those between 1996 and 2011 as was outlined by the hierarchy of evidence guidelines by the National Health and Medical Research Council. The study focused on the impact of oral caring including protocols on ventilator associated pneumonia and oral hygiene. The research was focused on resources that had their studies conducted in critical care setting, intensive care unit, or acute care. It was also a requirement that the resources feature adult participants of 18 years of age and above and that they were presented in English (Hillier et al., 2013).

The results obtained from the study found eight randomized controlled trials to have met the inclusion criteria, with a higher chance of 36 percent of respirator-associated pneumonia in the control group as compared to the chlorhexidine group. There was also a very small variation noted within the included studies. The article concludes that there is no evidence of effect of chlorhexidine on mortality, asserting that the risk of respirator-associated pneumonia might be reduced by 36 percent by use of chlorhexidine treatment. It is also asserted that using 2 percent of chlorhexidine would be most effective in minimizing the occurrence of this form of pneumonia (Snyders et al., 2011).

Chlorhexidine, tooth brushing, and the prevention of Ventilator Associated Pneumonia in gravely ill grown-ups

Increased mortality and morbidity is linked with ventilator-associated pneumonia. The primary focus is on determining the effect experienced on development of ventilator-associated pneumonia in seriously sick individuals under mechanical ventilation as a result of a combination of oral care and tooth brushing, topical oral chlorhexidine, and mechanical tooth brushing. The authors develop the understanding of ventilator associated pneumonia as pneumonia that was neither emerging during the period of intubation nor present, in patients under mechanical ventilation. The authors assert that an individual’s oral health could be compromised by mechanical ventilation and critical illness resulting from nursing care (Munro, Grap, Jones, McClish, & Sessler, 2009).

The methodology and research designed used in the study entailed enrollment of critically ill adults in three intensive care units within a duration of a day of intubation in a 2 x 2 factorial design in a randomized clinical trial that was controlled. There was random assigning of patients (n=547) to either one or four treatments with those having clinical diagnosis of pneumonia being excluded during the period of intubation. The randomly assigned patients were treated with either control care, 0.12 percent by solution of chlorhexidine oral swab administered twice a day, tooth brushing twice in a day, or both chlorhexidine and tooth brushing. The study employed the use of Clinical Pulmonary Infection Score in order to effectively determine the outcome of respirator-associated pneumonia (Munro et al., 2009).

The results obtained from the study depicted that there wasn’t much significant difference in the characteristics of the four groups that were chosen. There was no effect indicated on mixed models analysis on either tooth brushing (P = 0.95) or chlorhexidine (P =0.29) when data obtained from all patients was analyzed in a pool. Chlorhexidine was however found to decrease the occurrence of pneumonia significantly on the third day with the Clinical Pulmonary Infection Score (CPIS) being larger than or equivalent to six in patients with an initial CPIS<6 at baseline (P = 0.006). Tooth brushing was found to neither have effect on CPIS nor promote the reaction of chlorhexidine. The article concludes that the incidence of early ventilator associated pneumonia would be reduced in patients without pneumonia by use of chlorhexidine but not tooth brushing (Munro et al., 2009).

Oral Sanitization with Chlorhexidine lessens the occurrence of Ventilator-associated Pneumonia

The most frequent occurring nosocomial infection that is related to increase in mortality and morbidity is asserted to be ventilator-associated pneumonia. As much as the occurrences of this kind of pneumonia may be reduced through oral decontamination by use of antibiotics, it would not be recommended due to the potential selection that is bound to occur as a result of pathogens that are antibiotic resistant. The article hypothesizes that endotracheal and oral colonization, and postponed advancement of respirator-associated pneumonia would be reduced by oral decontamination with either colistin/CHX (COL/CHX, 2%/2%) or chlorhexidine (CHX, 2%). This study is primarily aimed at distinguishing the effect on ventilator associate pneumonia as a result of decontamination with chlorhexidine, or colistin (Koeman et al., 2006).

The methodology used in the study involved patients enrolled in a double-minded, randomized, placebo controlled trial with three arms orthosethat needed mechanical ventilationfor 48 hours. As trial medication was being applied within six hour intervals into the patient’s buccal cavity, oropharyngeal swabs were collected on a daily basis which was then analyzed quantitatively for gram-negative and gram-positive micro-organisms. A close observation was also made twice a week on the endotracheal colonization. The research employed a double blind, randomized and placebo-controlled trial research design where patients were assigned to their respective study groups randomly by use of a computerized randomization schedule. Medication was administered four times a day with randomization being stratified in each hospital (Koeman et al., 2006).

Results obtained from the research depicted that out of the total of 385 patients who were included, 128 received CHX/COL, 130 PLAC, and the remaining 127 CHX, with their baseline characteristics being observed to be comparable. Both treatment groups had their daily risk of respirator-associated pneumonia reduced as compared to PLAC. There was significant decline in the frequency of endotracheal colonization in the case of patients that used CHX/COL as compared to those who only used CHX who depicted a slightly lower reduction in the same. There was however no demonstration on the difference in intensive care unit survival, period of reflex ventilation, and stay on intensive care. The authors conclude that the occurrence of ventilator-associated pneumonia may be reduced by chlorhexidine, or chlorhexidine/colistin with topical oral decontamination (Koeman et al., 2006).

A Random restricted experiment and meta-analysis of oral Sanitization with 2% chlorhexidine mixture for the deterrence of ventilator-associated pneumonia

The authors examine the use of chlorhexidine in decreasing the rate of ventilator-associated pneumonia, with their primary objective set on establishing the efficacy of oral cleansing by use of 2 percent of solution of chlorhexidine in deterring ventilator-associated pneumonia. The article uses a methodology and research design that employs meta-analysis and randomized controlled trial. The research was conducted in a tertiary care university hospital located in Bangkok in Thailand with the participants being hospitalized adult patients receiving general medication or in the critical care clinic, undergoing mechanical ventilation (Tantipong, Morkchareonpong, Jaiyindee, & Thamlikitkul, 2008).

The participants were randomly picked to be given oral cleansing under normal saline solution with a 2 percent solution of chlorhexidine administered four times on a daily basis till the removal of the endotracheal tube was done. The combination of results from a separate randomized controlled trial which made use of 2 percent by concentration of chlorhexidine composition for oral cleansing with those obtained from the present study facilitated performing of a meta-analysis. The results obtained from the study did not depict any significant difference in the characteristics observed on patients in a typical saline group (n = 105), and the chlorhexidine group (n = 102). The rate of ventilator-associated pneumonia in the normal saline group was found to be 11.4 percent (P = 0.08) while that of the chlorhexidine group was 4.9 percent. The rate of ventilator-associated pneumonia in the saline group was found to be 21 episodes for every 1000-ventilator days in the saline group, and seven episodes for every 1000 ventilators days in the chlorhexidine group (Tantipong et al., 2008).

There was either a delay or reduction on oropharyngeal colonization with gram-negative bacilli in the chlorhexidine group, with the level of oral irritation of the mucosa being witnessed in 0.9 percent of the patients in the standard saline grouping and 9.8 percent of their counterparts in the chlorhexidine group. There was no significant difference in the general deaths of the patients however, it was revealed when a meta-analysis was conducted on two randomized control trials that there was an overall relative risk of ventilator associated pneumonia of 0.53 in the chlorhexidine group. It was therefore concluded that two percent of chlorhexidine solution was a very safe and effective method of avoiding the rate of ventilator-associated pneumonia, in the course of oral decontamination, n patients getting mechanical respiration (Tantipong et al., 2008).

Topical chlorhexidine for deterring ventilator-associated pneumonia

The article primes the study with the primary goal of assessing the efficacy of chlorhexidine in deterring the rate of ventilator-associated pneumonia in a meta-analysis. It is asserted to be the most prevalent nosocomial infection in the intensive care unit, with a record of between ten and twenty percent of patients in receipt of mechanical aeration developing ventilator associated pneumonia (VAP). Prolonged hospital stay, two-folded increased mortality risk, and increased costs have been associated with VAP. The methodology of the research involved MEDLINE search and computerized PubMed searches to supplement for manual searches for relevant resources. The research employed the randomized controlled trials research design which was used in evaluating the efficacy of placebo/standard care versus chlorhexidine when applied to the oropharynx for deterrence of ventilator-associated pneumonia (Chlebicki & Safdar, 2007).  

The research data was obtained from the patient population taking into consideration the concentration of chlorhexidine used, the exclusion and inclusion criteria, overall mortality, criterion for diagnosing VAP, and the occurrence of VAP. Synthesis of the collected data involved the abstraction of mortality and ventilator associated pneumonia data as dichotomous variables. The Laird random, Haenszel fixed effect, and DerSimonian effects models were used to obtain 95 percent confidence intervals and pooled estimates of the relative risk. I2 and Cochran Q statistics were employed in the assessment of heterogeneity, with analyses conducted on subgroups being used to examine heterogeneity (Chlebicki & Safdar, 2007).

The results obtained depicted the inclusion criteria to have been met by seven randomized controlled trials. When a fixed effect model was employed, chlorhexidine resulted in reduced VAP incidence, with similar estimates depicted when a more consecutive random effects model was used. An analysis on the subgroup depicted that the benefit of chlorhexidine would be most noticeable in cardiac surgery patients, with moderate heterogeneity being depicted on the I2 test. Despite the sample size used being small, there was no benefit of mortality with chlorhexidine. The article concludes that chlorhexidine would be beneficial in preventing the rate of ventilator-associated pneumonia, with the benefits being more prevalent in patients undertaking cardiac surgery. It was also concluded that a randomized trial with a large population would be necessary in determination of the precise effect of chlorhexidine on mortality (Chlebicki & Safdar, 2007).

Preventing ventilator-associated pneumonia with oral antiseptics: an organized evaluation and meta-analysis

The article features a random effects meta-analysis and systematic review carried out through randomized trials in order to determine the effect of povidone-iodine/chlorhexidine with oral care on the prevalence of oral care versus ventilator associated pneumonia without use of antiseptics in adults. The research design used involved narrowing down to the list of publications that met the predetermined inclusion criteria, exclusively including the randomized controlled trials on patients under povidone-iodine/chlorhexidine undergoing mechanical ventilation (Labeau, Van de Vyver, Brusselaers, Vogelaers, & Blot, 2011).

The methodology used in the study was identification of resources thought Web of Science, complementary manual searches, PubMed, CENTRAL, and CINAHI. The study was conducted through randomized trials of adult patients who were mechanically ventilated and under oral care with chlorhexidine/povidone-iodine. The Mantel-Haenszel model was used to determine 95 percent of CIs and relative risk with the I2 being used to assess heterogeneity (Labeau et al., 2011). 

Results obtained were from 14 studies with a total population of 2481 patients with 12 of the studies focusing on the effect of chlorhexidine, accounting for a total of 2341 out of the whole population of study, with the remaining two studies focusing on povidone-iodine, accounting for the remaining 140. Chlorhexidine was found to be more efficient in minimizing the rate of ventilator-associated pneumonia, with favorable effects being noticed on subgroup analyses with 2 percent of chlorhexidine and cardio-surgical studies. It was concluded that there was significant benefit accruing from use of oral antiseptics in preventing the rate of ventilator-associated pneumonia. The researchers recommended that clinicians should take into considerations obtained from the study in the process of providing oral care to patients that are intubated (Labeau et al., 2011).

Efficiency of 0.12% chlorhexidine gluconate oral wash in minimizing occurrence of ventilator-associated pneumonia in patients undertaking heart operation

This article examines various means for decreasing bacteria levels in the oropharynx and the effect on prevalence of nosocomial pneumonia. It primes the study with the primary goal being set on analyzing the efficiency of 0.12 percent of chlorhexidine gluconate oral wash in minimizing the effect of microbial immigration of the respiratory tract and nosocomial pneumonia in patients under open-heart surgery.

The methodology used in the research involved the use of a potential, randomized, controlled medical experimental design. The experimental drug used was 0.12 percent of chlorhexidine gluconate phenolic mixture (Listerine) being the control experimental drug. In total, 561 patients under aortocoronary bypass obligating cardiopulmonary detour were randomized to a control of n = 291 or an experimental of n = 270. The criterion that was established by the Centre for Disease Control and Prevention was used to diagnose ventilator-associated pneumonia.

Results obtained from the study found the overall occurrence of ventilator-associated pneumonia to have been scaled down by 52 percent in the peridex-treated patients. The patients treated with peridex were found to have reduced their rate of pneumonia by 58 percent, among the intubated patients for a time span exceeding 24 hours. The article concludes that in as much as there were lower rates in patients treated in peridex more than in those treated with Listerine, there was significant difference witnessed in patients with the highest level of bacterial colonization and incubated beyond 24 hours.

Preventing ventilator-associated pneumonia, mortality and all ICU obtained illnesses by topically practical antimicrobial or antiseptic agents

The authors assert that prevention have a key role in managing patients under mechanical ventilation especially with the high rate of mortality and morbidity which has been accredited to ventilator-associated pneumonia. This study employs a meta-analysis methodology in its study of randomized controlled trials. Various sources used were obtained from online databases including MEDLINE, Cochrane Library computerized bibliographic database, and the U.S. National Library of Medicine’s. The criteria for selection included primary studies, randomized controlled trials, assessing the reduction of VAP among others (Pileggi, Bianco, Flotta, Nobile, & Pavia, 2011).

The results obtained from the studies were as a result of an analysis conducted on 28 articles, which were incorporated in the meta-analysis after having met the inclusion criteria. The effectiveness of SDRD in preventing all the illnesses obtained in the ICU was significant statistically with an efficacy of 29 percent; 95 percent CI of efficiency, which ranged between 14 and 41 percent. The article concludes that the result of ventilator-associated pneumonia in the ICU could be significantly reduced by use of antimicrobials or antiseptics. The authors assert however that the use of topical antibodies also seems to be effective even though their effectiveness on mortality needs to be examined in future researches (Pileggi et al., 2011).

Combination of ventilator care bundle and regular oral caring with chlorhexidine was associated with reduction in ventilator associated pneumonia

This article identifies ventilator-associated pneumonia as being a vital source of mortality and morbidity in patients under mechanical ventilation. The authors assert that ventilator associated pneumonia is related to prolonged period of mechanical ventilation, increase in costs, and hospital and ICU stay. The research deploys the use of a quality improvement project method of research. Oral care with 2 percent chlorhexidine by concentration was administered to patients under mechanical ventilation every 8 hours. In order to evaluate the level of compliance with the various ventilator bundles, a formal process was devised (Azab, Sayed, Abdelkarim, Mutairi, Saqabi, & Demerdash, 2013).

The ventilator bundles in question included: assess of readiness to extubate and daily seduction vacation, provision of profound vein thrombosis prophylaxis and provision of peptic disease prophylaxis, and 30 to 40 degrees to elevation of head of the bed. After analysis was done, the results obtained depicted that there was 16.2 cases for every a thousand-ventilator days noted in the first six months of the year on the occurrence of ventilator-associated pneumonia before the project was commenced. After commence of the project, and application of the quality improvement project method, there was a reduction in the occurrence of ventilator-associated pneumonia to 5.6 cases for every a thousand-ventilator days. As a result, the project was able to reduce the rate of mortality and span of admission in the hospital and ICU (Azab et al., 2013).

The authors deduce that the combination of 2 percent chlorhexidine by concentration with regular oral hygiene and implementation of ventilator care bundle in a rigorous manner would result to a significant decrease in the occurrence of ventilator-associated pneumonia in patients under mechanical ventilation. It was also concluded that the combination of the above methods would also significantly reduce the rate of mortality to 19.1 percent down from 23.4 percent, and the length of stay in hospital and ICU to 6.5 days down from 9.7 days (Azab et al., 2013).

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References

Azab, S. R. E., Sayed, A. E. E., Abdelkarim, M., Mutairi, K. B. A., Saqabi, A. A., & Demerdash, S. E. (2013). Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia. Egyptian Journal of Anaesthesia29(3), 273-277.

Chlebicki, M. P., & Safdar, N. (2007). Topical chlorhexidine for prevention of ventilator-associated pneumonia: A meta-analysis. Critical care medicine, 35(2), 595-602.

Hillier, B., Wilson, C., Chamberlain, D., & King, L. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application method: A literature review. AACN advanced critical care24(1), 38-58.

Houston, S., Hougland, P., Anderson, J. J., LaRocco, M., Kennedy, V., & Gentry, L. O. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of ventilator associated pneumonia in patients undergoing heart surgery. American Journal of Critical Care11(6), 567-570.

Koeman, M., van der Ven, A. J., Hak, E., Joore, H. C., Kaasjager, K., de Smet, A. G., … & Bonten, M. J. (2006). Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. American journal of respiratory and critical care medicine173(12), 1348-1355.

Labeau, S. O., Van de Vyver, K., Brusselaers, N., Vogelaers, D., & Blot, S. I. (2011). Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. The Lancet infectious diseases11(11), 845-854.

Munro, C. L., Grap, M. J., Jones, D. J., McClish, D. K., & Sessler, C. N. (2009). Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American journal of critical care18(5), 428-437.

Pileggi, C., Bianco, A., Flotta, D., Nobile, C. G., & Pavia, M. (2011). Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units. Critical Care15(3), R155.

Snyders, O., Khondowe, O., & Bell, J. (2011). Oral chlorhexidine in the prevention of ventilator-associated pneumonia in critically ill adults in the ICU: A systematic review. Southern African Journal of Critical Care27(2), 48-56.

Tantipong, H., Morkchareonpong, C., Jaiyindee, S., & Thamlikitkul, V. (2008). Randomized controlled trial and meta‐analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator‐associated pneumonia. Infection control and hospital epidemiology29(2), 131-136.