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72 3.2a. Prevention of VAP Oral

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72 3.2a. Prevention of VAP Oral Powered By Docstoc
					3.2a. Prevention of VAP: Oral Antispetic: Chlorhexidine (New Topic)

Discussion:
Based on only 1 level 1 and 2 level 2 studies, we conclude that the use of the oral antiseptic chlorhexidine may be associated with a decreased
incidence of VAP. Safety, feasibility and cost considerations for this intervention were all very favourable.

Recommendation:
The use of the oral antiseptic chlorhexidine should be considered.

Values                     Definition                                                                                                                                          Score: 0, 1, 2, 3
                                                                                                                                                                                          3
Effect size                magnitude of the absolute risk reduction attributable to the intervention listed--a higher score indicates a larger effect size

                                                                                                                                                                                          1
Confidence interval        95% confidence interval around the point estimate of the absolute risk reduction, or the pooled estimate (if more than one trial)--a higher score
                           indicates a smaller confidence interval
Validity                   refers to internal validity of the study (or studies) as measured by the presence of concealed randomization, blinded outcome adjudication, an                 3
                           intention to treat analysis, and an explicit definition of outcomes--a higher score indicates presence of more of these features in the trials
                           appraised
                                                                                                                                                                                          0
Homogeneity                 similar direction of findings among trials--a higher score indicates greater similarity of direction of findings among trials

                                                                                                                                                                                          3
Safe                       estimated probability of avoiding any significant harm that may be associated with the intervention listed--a higher score indicates a lower
                           probability of harm
                                                                                                                                                                                          3
Feasible                   ease of implementing the intervention listed--a higher score indicates greater ease of implementing the intervention in an average ICU


                                                                                                                                                                                          3
Cost                       estimated cost of implementing the intervention listed--a higher score indicates a lower cost to implement the intervention in an average ICU




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3.2a. Prevention of VAP: Oral Antispetic: Chlorhexidine (New topic)

Question: Does the use of the oral antiseptic chlorhexidine reduce the incidence of VAP?

Summary of Evidence: There were 1 level 1 and 2 level 2 studies reviewed. Two studies compared the use of oral rinses of gingival and dental
plaque with a 0.2% chlorhexidine gel to an identical placebo/standard mouthwash routine and one study compared oral rinses of chlorhexidine to a
combination of chlorhexidine and colistin and to an identical placebo. Two level 1 studies were excluded as the intervention was started before ICU
admission (Houston 2004, DeRiso 1996) and one involved patients with short duration of ventilation (Houston 2004). Another study was excluded
from the summary as it reported on the change in the clinical pulmonary infection score (CPIS) and oral culture scores instead of the incidence of
VAP (Grap 2004).

Pneumonia: When the data from the 3 studies were aggregated, the use of chlorhexidine was associated with a trend towards a reduction in the
incidence of VAP (RR =0.57, 95 % CI 0.28, 1.17, p =0.13, figure 1) but there was significant heterogeneity present (p=0.06, I2 interclass correlation
=64%). When the data from the 2 experimental groups in the Koeman paper were combined (i.e. chlorhexidine alone plus combination of
chlorhexidine and colistin) and compared to control/placebo, there was still a trend towards a reduction in the incidence of VAP (RR =0.60, 95 % CI
0.31, 1.17, p =0.13, figure 2) but there was significant heterogeneity present (p=0.06, I2 interclass correlation =64%).

Mortality: When the data from the 2 trials that reported on mortality were aggregated, the use of the chlorhexidine had no effect on mortality (RR
0.87, 95% CI 0.31,2.46, p=0.80, figure 3).

Length of stayWhen the data from the 3 trials that reported on ICU length of stay were aggregated, the use of the chlorhexidine gel had no effect on
ICU LOS (standardized mean difference SMD 0.03, 95 % -0.16, 0.22, p = 0.75, figure 4).
Conclusions:
   1) Use of the oral antiseptic chlorhexidine may be associated with a reduction in the incidence of VAP.
   2) Use of the oral antiseptic chlorhexidine has no effect on mortality or ICU length of stay.

Level 1 study: if all of the following are fulfilled: concealed randomization, blinded outcome adjudication and an intention to treat analysis.
Level 2 study: If any one of the above characteristics are unfulfilled




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Table 1. Randomized studies evaluating the effect of chlorhexidine on VAP

   Study            Population                    Intervention                    Co-                Allocation          Intent to   Blinding   Level of
                                                                             interventions           (scoring)             treat                 Study
 1) Fourrier         ICU patients          Oral gel with 0.2%                 Not described           Concealed            Yes        Double       1
    2005       Expected to stay > 5 days   chlorhexidine vs. identical                              randomization
                 oral or nasotracheal      placebo T.I.D. (started within                               (11)
                       intubation          24 hrs admission to ICU)
  2) DeRiso      Patients undergoing         Oral rinse or application of   Well described and        Concealed            Yes        Double       1
     1996          cardiac surgery               0.12% chlorhexidine              equal             randomization
                                             gluconate for 30 seconds                                   (14)
                                               twice a day pre-op and
                                             continued until ICU d/c vs.
                                                placebo (sterile water,
                                                alcohol, dye, flavour)
 3) Houston    Patients undergoing            Oral rinses with Peridex      Well described and    Randomization not        Yes        Single       1
    2002       cardiac surgery                  (0.12% chlorhexidine              equal          concealed or not sure
                                             gluconate) pre-op twice a                                   (12)
                                             day X 10 days post-op or
                                                   until extubation,
                                                trachesotomy, death,
                                            diagnosis of pneumonia vs.
                                            Listerine (phenolic mixture)
 4) Koeman     Mixed ICU patients                Oral rinses with 2%          Not described       Randomization not        Yes        Double       2
    2006                                        chlorhexidine vs. 2%                             concealed or not sure
                                                chlorhexidine plus 2%                                    (9)
                                           Colistin vs. Placebo (0.5 gms
                                            X 4 times/day) for ICU stay
 5) Fourrier   Medical, surgical ICU                 Oral gel with            Not described           Concealed            Yes        Single       2
    2000       patients                     0.2%Chlorhexidine T.I.D vs.                             randomization
                                              rinses with bicarbonate                                    (9)
                                           serum X 4 times/day for ICU
                                                          stay




                                                                                                                                                       74
Table 1 continued. Randomized studies evaluating the effect of chlorhexidine on VAP

         Study                  Pneumonia definition                       Pneumonia # (%)              Mortality # (%)           Length of stay (days)
1) Fourrier 2005          T >38C or < 36 C; new infiltrates on X          CHX         Placebo         CHX          Placebo        CHX               Placebo
                          ray, WBC >10X103/mm3 or <3X                  13/114 (11)     12/114        28 day         28 day         ICU                ICU
                          103/mm3; +ve tracheal aspirate culture                        (11)       31/114 (27)    24/114 (21)    14 ± 8.5          13.3 ± 8.8
                          and /or +ve culture of BAL fluid (≥106
                          CFU/ml)
2) DeRiso 1996            According to CDC definition                    CHX          Placebo        CHX         Placebo           CHX        Placebo
                                                                         3/173         9/180       Hospital      Hospital        Hospital     Hospital
                                                                          (2)            (5)        2/173          10/180 (6)    7.9 ± 6.1    8.5 ± 0.6
                                                                                                      (1)
3) Houston 2002           According to CDC definition                   Peridex       Listerine    Peridex       Listerine
                                                                         4/270          9/291        ICU              ICU          NR         NR
                                                                          (1)            (3)         NR               NR
                                                                                                   Hospital         Hospital
                                                                                                    7/270            3/291
                                                                                                      (3)              (1)
4) Koeman 2006            Presence of a new, persistent or                CHX         Placebo        CHX            Placebo        CHX           Placebo
                          progressive infiltrate on xray plus at       13/127 (10)   23/130 (18)     NR               NR            ICU             ICU
                          least 3 of the following: rectal T > 38 or    CHX+Col                    CHX+Col                      13.8 ± 17.4     12.5 ± 12.9
                          < 35.5 C; WBC >10X103/mm3 or <3X             16/128 (13)                   NR                          CHX+Col
                          103/mm3 ;purulent tracheal aspirates;                                                                 13.3 ± 18.2
                          positive semiquantitative culture from
                          tracheal aspirate after 48 hrs of
                          ventilation.
5) Fourrier 2000          Temp > 38 or < 36 C; infiltrates on             CHX         Control         CHX          Control        CHX               Control
                          Xray; WBC >10X103/mm3 or <3X                 5/30 (17)*    18/30 (60)     Hospital       Hospital        ICU                ICU
                          103/mm3; +ve culture from tracheal           patient or                   3/30 (10)      7/30 (23)     18 ± 16            24 ± 19
                          aspirate and/or positive culture BAL.        episodes
Legend:
CHX: chlorhexidine
Col: Colistin
NR: not reported
* assumption: 1 episode of pneumonia per pt.




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Figure 1. Meta-analysis showing data from Chlorhexidine group only (Koeman 2006)




Figure 2. Meta-analysis showing the data from Chlorhexidine group combined with Chlorhexidine + Colistin (Koeman 2006)




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Figure 3.




Figure 4.




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