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Original Article Section: Anaesthesia Effectiveness of Oral Hygiene with

Chlorhexidine Mouthwash with 0.12% and 0.2% Concentration on Incidence

of Ventilator Associated Pneumonia (...

Article · April 2021

DOI: 10.21276/aimdr.2021.7.3.AN2

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DOI: 10.21276/aimdr.2021.7.3.AN2

Original Article ISSN (O):2395-2822; ISSN (P):2395-2814

Annals of International Medical and Dental Research, Vol (7), Issue (3) Page 6

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Effectiveness of Oral Hygiene with Chlorhexidine

Mouthwash with 0.12% and 0.2% Concentration on

Incidence of Ventilator Associated Pneumonia (VAP) in

Intubated Patients – A Parallel arm Double Blind

Randomized Controlled Trial Nagesh Vyas1, Priya Mathur2, Shailesh Jhawar3, Akash Prabhune4, Pradeep Vimal5

1Consultant, Department of critical care medicine, MD, Anaesthesiology IDCCM, Apex hospital Malviya Nagar, Jaipur, Rajasthan, India. 2Head, Department of critical care medicine, Apex hospital Malviya Nagar, Jaipur, Rajasthan, India. 3Fellowship in Critical Care and Cardiothoracic Anaesthesia. Director of Critical Care Medicine at Apex hospital Malviya Nagar, Jaipur Rajasthan, India. 4Public Health Specialist. 5Clinical Research Associate.

Received: October 2020

Accepted: November 2020

ABSTRACT Background: Patients on mechanical ventilation are on higher risk of developing pneumonia due to multiple factors. Incidence of Ventilator associated pneumonia (VAP) varies from 9 to 27 % for mechanically ventilated patients. Various mouth wash with different concentration are used for oral care to prevent VAP. Aim of this study was to find out the most efficacious concentration of chlorhexidine mouth wash to prevent VAP, with minimum adverse events. Materials and Methods: This double-blind randomized study included 140 patients in critical care unit requiring mechanical ventilation for more than 48 hours. The study was approved by the Institutional Ethics Committee and written informed consent was sought from the patients or next kin relative for comatose cases. Consenting patients were assigned to either group using block randomization and SNOSE allocation in two groups of 70 each. Group I and Group II received oral care with chlorhexidine 0.12% and chlorhexidine 0.2% respectively. The diagnosis of VAP was made by using CPIS. A score of ≥6 considered VAP. Results: In intervention group 7 VAP, 30 discharges, 11 LAMA (Left against Medical Advice), 8 deaths were reported while 2 VAP, 36 discharges, 9 LAMA, 11 deaths were reported in control group. On comparing the above- mentioned indicators and analysis of data we found a significant difference in VAP incidence but the safety, ICU stay, hospital stay, days on ventilator and mortality of both groups was similar. We found no significant relationship between incidence of VAP and oral microbial load. Conclusions: Oral hygiene with Chlorhexidine 0.12% is less effective than Chlorhexidine 0.20% for prevention of VAP in mechanically ventilated patients. Keywords: Chlorhexidine, Mouth wash, Ventilator associated pneumonia, Oral care, oral hygiene.

INTRODUCTION

Aspiration of colonized oropharyngeal secretion in

to the lung along the space between trachea and

endotracheal tube is the main presumed mechanism

of VAP development in mechanically ventilated

patients.[1] Apart from this other mechanism which

are reported by CDC include inhalation of

aerosolized organism, hematogenous spread and

translocation of bacteria from gastrointestinal wall.[2]

Colonization of oropharyngeal secretion with

pathogenic bacteria is primarily due to poor oral

hygiene and collection of tissue debris.[1,2]

Antimicrobial, lubricating and buffering properties

with optimal flow and secretion of saliva is normal

Name & Address of Corresponding Author Dr. Nagesh Vyas Ananta Institute of Medical science and research Centre. A 31, 6th floor, Residential apartment, N.H. 8, Village Kaliwas, Rajsamand, Rajasthan, India. E-mail: [email protected]

natural defense mechanism in our oral cavity which

prevent colonization of pathogenic organism. This

natural defense of saliva hamper in mechanically

ventilated patients. Based on several studies on

selective decontamination of oral cavity by using

various antiseptic agents, it is found that by reducing

oropharyngeal bacterial load, the incidence of VAP

can significantly be reduced.[3]

Although multiple studies have investigated the

effect of different topical antiseptic solution for oral

care in VAP prevention but chlorhexidine has given

better result in this context.[3,4]Chlorhexidine has

broad spectrum antimicrobial properties, at low

concentration it acts as bacteriostatic while at higher

concentration the action is bactericidal. Most of the

studies show that oral hygiene with chlorhexidine

(0.2% and 0.12%) in intubated patients have low

incidence of VAP as compared to placebo or

povidone iodine.[3,5,6]

Several studies which were done in dental practice

shows reduction in oral microbial load following

chlorhexidine mouth wash.[6-10]The aim of this study

Vyas et al; Oral hygiene with chlorhexidine mouthwash and incidence of VAP

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was to add on evidence to support use of

Chlorhexidine oral prophylaxis in endotracheal

intubated patient to reduce incidence of VAP in

Indian context. In this study we had to find the most

efficacious strength of chlorhexidine used as mouth

wash while minimizing the side effects.

Objectives

The primary objective of this study was to compare

the effectiveness of oral prophylaxis of

chlorhexidine 0.12% against chlorhexidine 0.20%,

measured in terms of incidence of VAP

Secondary outcome was to understand the difference

in duration of mechanical ventilation, duration of

ICU stay and hospital stay, all-cause mortality rate,

side effect (stomatitis) of chlorhexidine 0.12%

against chlorhexidine 0.20%, and correlation

between oral microbial load and incidence of

Ventilator associated pneumonia.

MATERIALS AND METHODS

The prospective double-blind randomized control

trial was carried out in 35 bedded ICU in tertiary

care private hospital in Jaipur, Rajasthan State, India.

Participants were recruited from critical care unit if

they satisfied inclusion and exclusion criteria for the

study.

Inclusion criteria

a) Individuals admitted to critical care unit of study site

and aged 18 years and above and 75 years or less.

b) Individuals requiring mechanical ventilation for 48

hours or more with normal hemodynamic and with

or without vasopressor support.

Exclusion criteria a) Diagnosed case of Pneumonia.

b) Case of Chronic Obstructive Lung Disease with

active Chest Infections.

c) Patients who have aspirated/with chest x-rays

already showing infiltrates.

d) Development of pneumonia within 48 hours of

intubation (was considered Community acquired

pneumonia (CAP) or Hospital acquired pneumonia

(HAP) according to definition.

e) Individuals diagnosed with Oral Mucositis.

f) Individuals undergoing organ transplantation

procedure, or long-term steroid therapy.

g) Individuals receiving immunosuppressive therapy or

known hypersensitivity to chlorhexidine gluconate.

h) Patients already received mechanical ventilation for

more than 24 hours.

i) Patients who died or discharged or went LAMA

within 48 hours of intubation in the ICU.

The study was reviewed and approved by

institutional review committee of Apex Hospital

Jaipur and was registered with Clinical Trials

Registry of India, under registration id

CTRI/2019/05/019116.Author NV was involved in

patient recruitment and overseeing data collection

and data entry into the data collection software. The

study staff, comprising of two critical care nurses

administered oral prophylaxis. Another staff, a

Critical Care Technician was involved in sample

collection and data collection into case report forms.

The case report forms were reviewed and authorized

by author NV for entry into the data collection

software.

Randomization: The study was designed as parallel

arm, standard control, double blind randomized

controlled with allocation ration 1:1 in intervention

and control arm. The study used block

randomization with block size of four. The

randomization list was generated by authors AP and

PV; who were not located at study site and allocation

concealment was done using Sequentially Numbered

Opaque Sealed Envelope (SNOSE). The Envelopes

were couriered to study site using secure packaging.

The Envelopes were accessible, only to study author

PM, who was not involved in data collection or

implementation of randomization protocol. The

author SJ implemented randomization protocol.

The randomization procedure included, assessment

of individuals admitted to critical care unit for

inclusion and exclusion criteria by critical care

physician, once the individual was deemed suitable

for inclusion, author SJ would access the

sequentially numbered envelops bundle from author

PM and open envelop to write down randomization

number and Group A or Group B on participants

CRF. The critical care technician would proceed for

opening of envelop and individual either of the

groups.

Sample Size Calculation

We used the sample size formula for comparing two

means, the study by Ronankiet al.[11] compared the

efficacy of commercially available chlorhexidine

mouth rinses in concentration of 0.12% and 0.2%

against Streptococcus Mutans and compared the size

of means inhibitory zone created in mouth at

24hours. We used the mean inhibitory zone (in mm)

and standard deviation to compare the antibacterial

effect exerted by two concentrations on oral flora.

We anticipated mean response on the Chlorhexidine

0.12% concentration as 10.2,anticipated mean

response on the Chlorhexidine 0.2% concentration as

10.7,standard deviation of response as 0.7, type I

error 5%, type II error 80%. Thus, the required

sample size is 61 participants in each group, total

sample size 122. We enrolled total of 140

participants in the study.

Description of the intervention and control

Intervention

Chlorhexidine 0.12% was be prepared by diluting

commercially available chlorhexidine 0.2% (60 ml

0.2% chlorhexidine + 40ml sterile water).

Vyas et al; Oral hygiene with chlorhexidine mouthwash and incidence of VAP

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Control

Chlorhexidine 0.2 % was commercially available

and purchased in June 2019

Standard Treatment Protocol

The oral care practices were aimed to remove

microhabitat of the organisms including cleaning of

the oral cavity by the nurse with chlorhexidine

soaked sterile gauze in intubated patients.

The procedure was as follows:

1. Any particulate matter from the oropharyngeal area

was rinsed off with sterile water soaked in

approximately 15-20 cc of sterile water.

2. The sterile gauze was soaked in 15 ml of

chlorhexidine solution.

3. The chlorhexidine soaked sterile gauze was used to

swab the entire oropharyngeal mucosa, teeth and

part of the endotracheal tube inside the

oropharyngeal area.

The average amount of chlorhexidine solution used

per oral care provision is about 15 ml and was

repeated 8 hourly till extubation. Clinical parameters

(heart rate, temperature and blood pressure spo2,

RR) were recorded hourly. Investigations included

daily TLC and DLC; Chest X ray done on baseline

then after every 48 hours and when indicated.

Endotracheal secretion was sent at baseline (after

intubation) then at 48 hours, at 96 hours and after 4

days as clinically indicated.

Evaluation of microbial load count -Oral secretion or

saliva 1 ml was sent at base line (after intubation

before oral care),at 48 hours, at 96 hours and after 4

day at the time of ET secretion sampling (after 30

min of oral care) for bacterial count (colony forming

unit/ ml or CFU/ml) and microscopy at the

department of Microbiology in our institute.

Evaluation of microbial load done by using bacterial

count (colony forming unit/ ml or CFU/ml).As per

our routine protocol Arterial Blood Gas analysis was

done twice a day in intubated patients or clinically

indicated. Every intubated patient was suctioned

tracheally with close suction device. There was strict

adherence to VAP BUNDLE including elevation of

head end of bed (30 to 45 degree), daily sedation

interruption and extubation assessment, ET tube cuff

pressure was maintained as per standard protocol

and was checked in every shift. Standard infection

control procedures were enforced.

All intubated patients received chest physiotherapy 8

hourly by physiotherapist unless contraindicated.All

intubated resumed gastric feeding as soon as

possible by nasogastric tube. We used injection

pantoprazole once daily as ulcer prophylaxis.

Antibiotics used as per hospital antibiotics

policy.Clinical Pulmonary Infection Score (CPIS) is

calculated according to parameters showed in

[Table 7].

Outcomes

Diagnostic criteria’s for VAP was based on CPIS

Score. CPIS SCORE >6 OR 6 was consider VAP.

Duration of study: Data collection phase of the

study lasted from June 2019 till Jan 2020, posted

approval of study by research ethical committee.

Data collection and analysis

Data was collected on paper forms and entered

electronically into CSpro 7.2 (US Census Bureau)

software. Data was analyzed using SATA 14

(STATA corp.) We used Intention to Treat analysis.

Clinical Endpoints – Diagnosis of VAP, Discharge

from ICU, Death, Left Against Medical Advice

(LAMA). We used per protocol analysis for the

study; all the 140 were analyzed irrespective of

outcome of their treatment.

RESULTS

Baseline characteristics of study participants are

presented in [Table 1]. 140 participants eligible for

enrolment criteria were provided with written

informed consent and randomized on a 1:1 basis, i.e.

70 intervention arm (Chlorhexidine 0.12%) and 70

control arms (Chlorhexidine 0.20%). A total 78.57%

were males and 21.43% were females with a mean

age of47 years in intervention group and in control

group 68.57% were males and 31.43% were females

with a mean age of 48.5 years. Clinical

characteristics did not differ significantly among

groups. Comparison of the 140 participants in this

sample analysis who were enrolled indicated no

significant difference in baseline variables (Gender,

personal and medical history, Diagnosis of Current

Episode Related to Respiratory System, Days

admitted to the hospital, Days admitted in ICU, Days

on ventilator and mortality.

[Table 2] presents the Day wise Clinical and

Laboratory Parameters across both the study groups.

Comparison of day wise participants data in the

sample analysis did not see significant differences

about CPIS score, Total Leukocyte Count, Presence

of organisms (gram negative bacteria, gram positive

bacteria, fungi) and Oral Microbial load among the

intervention and control groups.

Outcome measurements across the both study groups

are shown in the [Table 3]. A total of140 participants

were enrolled in the both groups, 70 in group 1 and

70 in group 2. In intervention group 7 Ventilator

Associated Pneumonia, 30 discharge, 11 LAMA, 8

deaths were diagnosed. On the other hand, 2

Ventilator Associated Pneumonia, 36 discharge, 9

LAMA, 11 deaths were found in control group.

Comparison of above-mentioned indicators analysis

data we found significance difference in both

groups. We also performed the subgroup analysis

between the groups in which 20 participants

underwent tracheostomy in group 1 and 24

participants in group 2. We also found that

significant difference between Mean APACHE

Score 15.8 (6.7) in group 1 and 18.4 (6.8) in group 2.

[Table 4] presents Subgroup analysis for Participants

underwent tracheostomy.

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[Table 5] presents 15% LAMA cases with outcome

were observed in group 1 and 13% LAMA cases

with outcome were observed in group 2.

[Table 6] presents Radiographic Findings at

admission

[Figure 1 and Figure 2] presents CPIS Score

correlation with Microbial load in Group 1 and

Group 2 respectively.

To understand the association between oral

microbial load and incidence of VAP we ran logistic

regression with VAP as outcome variable. The Odds

of developing VAP in the intervention arm was 0.76

(CI -0.82 to 1.13) and odds of developing VAP in

control arm was 0.56 (CI-0.21 to 0.93) for oral

microbial load more than 300 Indicating no relation

between VAP and Oral microbial load.

We also did the chest radiographic findings analysis

between the both groups. [Table 6] 67.14%

participants normal, 5.71% participants Old Koch’s

chest, 4.29% participants Haziness, 8.57%

participants ARDS and 2.86 % Pleural effusion were

reported in group 1 and 77.14% participants normal,

2.86% participants Old Koch’s chest, 2.86%

participants Haziness, 2.86% participants ARDS and

1.43 % Pleural effusion were reported in group 2.

Table 1: Presents the baseline characteristics of the study participants

Variables Chlorhexidine

0.12%

N = 70

Chlorhexidine

0.20%

N = 70

P Value

Age (Mean, SD) 47 (16.9) 48.5 (17) 0.37

Gender Males (%)

Females (%)

78.57%

21.43%

68.57%

31.43%

0.18

0.23

Education

Matriculation (%) Higher Secondary (%)

Vocational Training (%)

Graduate (%) Post Graduate (%)

28.57% 28.57%

10%

30% 2.86%

35.71% 15.71%

10%

37% 1.43%

0.34 0.4

0.8

0.12 0.49

Personal History

Tobacco Smoking (%) Tobacco Smokeless (%)

Alcohol Consumption (%)

22.86% 3.08%

27.94%

20% 1.47%

16.42%

0.68 0.53

0.10

Medical History

Diabetes (%)

Hypertension (%)

Coronary Artery Disease (%)

Hyperthyroidism (%) Hypothyroidism (%)

Substance Abuse (%)

Depression (%) Anaemia (%)

17.14%

24.29%

13.04%

1.45% 2.94%

0%

1.43% 4.35%

11.43%

30.43%

12.86%

0% 2.86%

2.86%

1.43% 4.29%

0.33

0.24

0.78

0.79

0.65 0.58

Diagnosis of Current Episode

Related to Respiratory System (%)

19.71%

9.85%

0.07

Number of days admitted to the hospital

(mean, SD)

10 (6.8) 9 (7%) 0.18

Number of days admitted in ICU (mean, SD) 8.9 (6.6) 7.8 (4.2) 0.45

Number of days on ventilatory (mean, SD) 5.2 (3.7) 4.1 (2.1) 0.32

Tracheostomy (%) 32% 30% 0.48

Table 2: Day wise Clinical and Laboratory Parameters across both the study groups

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

Chlorhexidine 0.12% (Intervention – Group 1)

CPIS Score

(mean, sd)

2.1 (1.4) 1.8 (1.5) 1.3 (1.3) 1.3 (1.5) 1.5 (2.2) 1.4 (2.0) 1.4 (1.4) 1.8 (1.2) 2.7

(1)

2.3 (1.6)

Total

Leukocyte

Count (mean,sd)

15532

(7405)

13802

(7003)

12103

(5503)

11050

(4157)

11551

(4887)

11847

(7907)

11870

(7433)

13214

(6565)

12756

(7479)

10663

(4468)

Presence of

micro-

organism in ET secretion

27% 20% 33% 50% 33%

Oral

Microbial load (mean,

sd)

203

(150)

219

(140)

228

(138)

233

(136)

175

(50)

Chlorhexidine 0.20% (Control – Group 2)

CPIS Score (mean, sd)

2 (1.4)

2.1 (1.7)

1.5(1.8) 1.2 (1.1) 1 (1.4)

1 (1.8)

0.9 (0.7) 1 (1.5)

0.5 (0.8) 1 (1.2)

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Total

Leukocyte Count

(mean,sd)

14606

(7403)

14415

(7158)

13570

(7614)

11771

(6550)

11254

(5651)

11033

(4681)

10533

(3484)

9320

(2578)

8985

(2585)

9450

(3480)

Presence of

micro- organism in

ET secretion

26% 32% 50% 50%

Oral Microbial

load (mean,

sd)

257 (165)

239 (129)

166 (57)

300 (173)

Table 3: Outcome Measurement across the study groups

Indicators Chlorhexidine 0.12%

(Intervention – Group 1)

Chlorhexidine 0.20%

(Control – Group 2)

Odds Ratio P value

Diagnosed Diagnosed

Ventilator Associated Pneumonia 7 2 4.2 0.03

Discharge 30 36 0.65 0.001

LAMA 11 9 1.3 0.045

Death 8 11 0.68 0.04

Table 4: Subgroup analysis for Participants undergoing tracheostomy

Variable Chlorhexidine 0.12%

(Intervention – Group 1)

Chlorhexidine 0.20%

(Control – Group 2)

Odds

Ratio

P Value

Undergone Tracheostomy (n) 20 24

Diagnosed with VAP (n) 4 1 5.75 0.058

Mean APACHE Score (SD) 15.8 (6.7) 18.4 (6.8) 0.001

Deaths (n) 1 2 0.75 0.91

Table 5: Side effects and LAMA cases

Variables Chlorhexidine 0.12%

(Intervention – Group 1)

Chlorhexidine 0.20%

(Control – Group 2)

Left Against Medical Advice (LAMA) (n, %) 14 (20%) 16 (23%)

LAMA cases with outcome (n, %) 11 (15%) 9 (13%)

Oral Ulcer (n, %) 1 (1.5%) 0

Table 6: Radiographic Findings at admission

Chest Radiograph findings Group 1 Group 2

N % n %

Normal 47 67.14 54 77.14

Old Koch’s chest 4 5.71 2 2.86

Haziness 3 4.29 2 2.86

Normal 44 62.86 51 72.86

ARDS 6 8.57 2 2.86

Pleural effusion 2 2.86 1 1.43

Table 7: CPIS

CPIS

Temperature (*C ) Oxygenation (P/F ratio)

36.5-38.4 0

38.5-38.9 1 >240 or ARDS 0

≥39.0 or ≤36 2 ≤240 or No ARDS 2

White blood cells count (10*3/ µl) Pulmonary radiography

4-11 0 No infiltrate 0

≤4 or ≥11 1 Diffuse or patchy infiltrate 1

Either ≤4 or ≥11 plus band form ≥500 2 Localize infiltrate 2

Tracheal secretion Culture of tracheal aspirate

<14 0 Pathogenic bacteria cultured in

light quantity or no growth

0

≥14 1 Pathogenic bacteria cultured in moderate or heavy quantity

1

≥14 plus purulent 2 Same pathogenic bacteria seen

on gram stain

2

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Figure 1: CPIS Score correlation with Microbial load

(Group 1)

Figure 2: CPIS Score correlation with Microbial load

(Group 2)

Figure 3: Pie charts for gender, Chlorhexidine 0.12%

(Intervention – Group 1), Chlorhexidine 0.20%

(Control – Group 2)

Figure 5: Pie Charts for participants undergone

tracheostomy or not undergone tracheostomy,

Chlorhexidine 0.12% (Intervention – Group 1),

Chlorhexidine 0.20% (Control – Group 2)

DISCUSSION

VAP is a common nosocomial infection in the

(ICU). Based on 2011 survey the average incidence

of VAP was found 2.6% on 1000 mechanical

ventilation days. The presence of similar clinical

finding in many patients in the ICU, make the

diagnosis of VAP very difficult. CPIS ≥ 6 is used for

diagnosing VAP which is based on high sensitivity

and negative predictive value in one multi centre

randomized VAP diagnostic strategy study.[9]

So many previous studies reported that aspiration of

oropharyngeal secretion which contains organism is

a major cause of VAP and high microbial load is

also associated with high incident of VAP in

mechanically ventilated patients. Several studies also

reported that oral hygiene using Chlorhexidine was

more effective in preventing VAP compared to the

other drugs or placebo but optimal concentrations

remain unknown. Chlorhexidine is active against

both Gram positive and gram-negative strain as well

as fungi. Chlorhexidine has both bacteriostatic and

bactericidal action.

In low chlorhexidine concentrations, this interaction

slows the reproduction of the microbes

(bacteriostatic). In high concentrations, the

interaction causes damage to the cell membrane,

kills the microbe (bactericidal).Chlorhexidine is

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available in various forms and varying strength

0.2%, 0.12% and up to 5%. Lower concentration

0.10%, 0.12% (9) and 0.2% (6) is used as mouth

rinses and higher concentration 2% and 5% is used

as a surface disinfectant

Most of the studies used much less Chlorhexidine

concentration solution of 0.12% or 0.2% for oral

hygiene. Some recent studies reported that oral

application of a 0.12 solution of Chlorhexidine was

not superior to a placebo for preventing VAP among

ICU patients.

In our study we found that oral hygiene with

Chlorhexidine 0.12% is less effective than

Chlorhexidine 0.20% for VAP prevention in

mechanically ventilated (tracheally intubated or

tracheostomized) cases.

Our study failed to find a relationship between VAP

and Oral microbial load. The reason for this could be

low incidence of VAP in our study and low

incidence might be because we were using

chlorhexidine in both groups. There is no significant

difference in Days admitted to the hospital, Days

admitted in ICU, Days on ventilator and mortality.

Limitation- In the multicenter randomized VAP

diagnostic strategy study performed by Luytet. al.

the sensitivity of CPIS Score >- 6 for diagnosing

VAP patient with bronchoscopy result was 89% and

the specificity 47% and negative predictive value

was 84%.CPIS is a preliminary test for VAP

diagnosis but it is not a definite diagnostic test alone,

this clinical scoring has been used as screening

tool.[10]

To diagnose VAP for microbiological examination

Broncho alveolar lavage (BAL) sampling is more

sensitive and specific than tracheal secretion sample.

We used tracheal secretion as sample for

microbiological examination. Leukocyte count and

body temperature changes which are of the CPIS

criteria are observed in many diseases.

Aspiration pneumonitis (chemical pneumonitis),

alveolar hemorrhage, lung contusion, drug reaction

and TRALI can mimic chest x-ray opacity as in

pneumonia. Fever and leukocytosis observed in the

first 72 hours post operatively can be observed in

also pulmonary edema, pulmonary infarction,

vascular tissue and atelectasis, this may change CPIS

score.

Patient already on antibiotics due to other reason

may prevent VAP or delay VAP. Patient on drug

paracetamol round the clock as analgesic may

interfere with body temperature.

In our study LAMA rate was high that reduces actual

days on mechanical ventilator and might interfere

with incidence of VAP.

CONCLUSION

• Chlorhexidine 0.12% is less effective than

Chlorhexidine 0.20% for prevention of Ventilator

Associated Pneumonia in mechanically ventilated

patients, while the safety of 0.12% and 020% is

similar.

• There is no significant difference in ICU stay,

hospital stay, Days on ventilator and mortality. This

study also found no relation between incidence of

VAP and oral microbial load.

Summary:

Chlorhexidine solution has broad spectrum

antimicrobial property. It is used as skin disinfectant

at higher concentration (1%, 2%) and topical oral

antiseptics at lower concentration (0.12% and

0.2%),Most of the larger RCT showed that oral

hygiene with chlorhexidine (0.2% and 0.12%) in

intubated patients have low incidence of VAP as

compared to placebo or povidone iodine but optimal

concentration of chlorhexidine was still unknown.

Our study was aimed to find out most efficacious

concentration of chlorhexidine mouth wash to

prevent VAP in mechanically ventilated patients.

It was hypothesized that concentration of

chlorhexidine (0.12%) will might be similar

effective as chlorhexidine (0.2%) in terms of

prevention of VAP in mechanically ventilated

patients and similar or more safety concern. Our

study found that oral hygiene with chlorhexidine

0.12% is not much efficacious for prevention of

VAPwhen compared with 0.2% while having similar

safety.

Abbreviations: VAP- Ventilator associated

pneumonia, HAP- Hospital acquired pneumonia,

CAP –Community acquired pneumonia, LAMA-

Left against medical advice, CPIS- Clinical

pulmonary infection score, ICU- Intensive care unit.

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How to cite this article: Vyas N, Mathur P, Jhawar S,

Prabhune A, Vimal P. Effectiveness of Oral Hygiene with

Chlorhexidine Mouthwash with 0.12% and 0.2%

Concentration on Incidence of Ventilator Associated

Pneumonia (VAP) in Intubated Patients – A Parallel arm

Double Blind Randomized Controlled Trial.Ann. Int. Med.

Den. Res. 2021; 7(3):AN06-AN13.

Source of Support: Nil, Conflict of Interest: None declared

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