Oral care reduced ventilator associated pneumonia

Aspiration of oropharyngeal organisms is an important mechanism for the development of ventilator associated pneumonia (VAP). VAP may affects between 10-30% of patients receiving mechanical ventilation. The aim of this review was to assess the effects of oral care with antiseptics on the prevalence of VAP and other clinical outcomes in critically ill patients undergoing mechanical ventilation.

Methods

Searches were conducted in PubMed, Embase, Web of Science Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov without language restrictions. Randomised controlled trials in adults receiving mechanical ventilation comparing oral care with antiseptics with control group (standard oral care without antiseptics) were considered.

Two reviewers carried out study selection independently with study quality being assessed using the Jadad scale. Relative risks (RRs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated and pooled using a fixed-effects model or random-effects model.

Results

17 RCTs involving a total of 4249 patients were included.
15 studies (4032 patients) assessed the effect of chlorhexidine.
2 studies (217 patients) assessed the effect of povidine-iodine.
Meta-analysis (17 studies) showed that oral care with antiseptics significantly reduced the prevalence of VAP (RR=0.72, 95% CI: 0.57, 0.92; P=0.008).
- Chlorhexidine (15 studies) was associated with a relative risk of 0.73 (95%CI: 0.57, 0.93; P=0.012), indicating a 27% relative risk reduction for VAP for that patient population.
- Povidone-iodine did not show any effect on prevalence of VAP (RR=0.51, 95% CI: 0.09, 2.82 P=0.438).
For ICU mortality meta-analysis (11 studies) suggested that oral antiseptics did not decrease the ICU mortality (RR=1.11, 95% CI: 0.95, 1.29; P=0.201).
- Subgroup analysis based on type of antiseptics showed that, neither oral care with chlorhexidine or povidone-iodine would significantly reduce the ICU mortality.
Meta-analysis for length of ICU stay (8 studies) revealed that oral antiseptics were not associated with a decrease in the length of ICU stay (WMD= -0.10 days, 95% CI: -0.25, 0.05; P=0.188).
Meta-analysis of duration of mechanical ventilation oral care (7 studies) found antiseptic was not associated with a significantly decrease in the duration of mechanical ventilation (WMD= -0.05 days, 95% CI: -0.14, 0.04; P=0.260).

Conclusions

The authors concluded: –

this meta-analysis suggests that oral care with antiseptics significantly reduces the prevalence of VAP, especially in cardiac surgery patients, but does not have effect on other important clinical outcomes, such as ICU mortality, length of ICU stay, duration of mechanical ventilation.

Comments

The authors have conducted a broad database search and identified 17 RCTs for inclusion in their review. This topic was addressed by the Cochrane Oral Health group review in 2013 (Dental Elf -19^th Aug 2013). The Cochrane review included 35 studies with similar findings ie:-

Oral Health care that includes either chlorhexidine mouthwash or gel is associated with a 40% reduction in the odds of developing ventilator-associated pneumonia in critically ill adults. However, there is no evidence of a difference in the outcomes of mortality, duration of mechanical ventilation or duration of ICU stay.

The difference in the number of included studies is probably related to the decision to exclude studies with a sample size of less than 50. The authors in this new review chose to assess study quality using the Jadad scale with all but two of the studies scoring ≥ 3 and being considered of high quality. Use of scales such as the Jadad scale are no longer recommended with many authors now using the Cochrane risk of bias tool.