Chlorhexidine in the prevention of ventilator associated pneumonia : a systematic review

[摘要] ENGLISH ABSTRACT: Ventilator-Associated Pneumonia (VAP) is a hospital acquired infection, not present orincubating at the time of admission and developing in patients during the process of care withinthe hospital setting. Between nine and twenty-seven percent of patients who are mechanicallyventilated will develop ventilator-associated pneumonia. Mortality rates for ventilated patientswho develop ventilator-associated pneumonia are estimated to be between 33-50%. The Institutefor Healthcare Improvements (IHI) in 2006 recommended the use of 'care bundles' to reduceVAP but no statistically significant decline has been noted.Despite the completion of an extensive literature search for purposes of this review, no statisticaldata on nosocomial infections or nosocomial pneumonia relevant to South Africa was found.Mechanical ventilation, a support therapy used in approximately one third of patients,significantly increases the patient's risk of developing this nosocomial pneumonia. Critically illpatients are by virtue of their critical illness more prone to the development of infections,especially ventilator-associated pneumonia. Consistent evidence suggests that oropharyngealcolonization can be associated with the development of VAP. Studies focusing on standard oralcare, with or without the concurrent use of chlorhexidine, have not provided sufficient evidencefor the use of chlorhexidine in VAP prevention. Chlorhexidine is an antiseptic agent, whichwhen tested, proved to reduce total respiratory tract infections by up to 69% (DeRiso et al,1996:1558).Objective: The aim of this study was to systematically appraise and review evidence on theeffectiveness of chlorhexidine in reducing the incidence of ventilator-associated pneumonia inadult patients. The secondary aim was to systematically summarize evidence on the use ofchlorhexidine in reducing mortality.Methodology: An extensive literature search of studies published in English was undertaken.Electronic databases searched were CENTRAL, CINAHL, EMBASE and MEDLINE. Referencelists of articles, textbooks and conference summaries were examined. Literature searches were conducted using Medical Subject Headings (MeSH). These included: Ventilator-associatedpneumonia, chlorhexidine, VAP and oral care. Eight randomized controlled trials, investigatingthe efficacy of Chlorhexidine in ventilator-associated pneumonia prevention in adults met theinclusion criteria. The effect measure of choice was Risk ratio with 95% confidence intervals fordichotomous data using the random effects (Mantel-Haenszel) model; (p=value of 0.05).Heterogeneity was assessed using the Cochrane Q statistic and I².Results: Eight randomized controlled trials met the inclusion criteria for this review. Pooled riskratio for the incidence of ventilator-associated pneumonia was 0.64 (95% CI; 0.44-0.91; p=0.18). Treatment with chlorhexidine decreased the risk of ventilator-associated pneumonia by36%. There was no evidence of Chlorhexidine reducing mortality.Conclusions: Chlorhexidine is a cost effective safe treatment in the prevention of VAP. The useof 2% chlorhexidine may be more effective in reducing the incidence of VAP. No studies werefound conducted in developing countries. More rigorously designed trials using 2%chlorhexidine are recommended.

[发布机构] Stellenbosch University