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Correspondence |

Oral Hygiene and Nosocomial Pneumonia in Critically III Patients FREE TO VIEW

Christopher D. Hingston, MB, ChB; Jade M. Cole, BSc; Emma J. Hingston, MPaedDent, RCS; Paul J. Frost, MB, ChB; Matt P. Wise, DPhil
Author and Funding Information

From Adult Critical Care (Drs C. D. Hingston, Cole, Frost, and Wise), University of Wales; and the Department of Paediatric Dentistry (Dr E. J. Hingston), Dental School.

Correspondence to: Matt P. Wise, DPhil, Adult Critical Care, University Hospital of Wales, Cardiff, UK CF14 4XW; e-mail: mattwise@doctors.org.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):237-238. doi:10.1378/chest.09-1319
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To the Editor:

We read with interest the recent study by Panchabhai et al in CHEST (May 2009),1 which examined the impact of twice-daily cleansing with 0.2% chlorhexidine on the development of pneumonia in critically ill patients. Although the overall incidence of pneumonia decreased during the study, cleansing with 0.2% chlorhexidine was not superior to the control solution, potassium permanganate. It was argued that the lack of efficacy might be explained by the use of 0.2% chlorhexidine and that higher concentrations (2%) of this drug might be effective in ICU patients as supported by data from recent studies.2,3 However, these disparate results may be explained by the mechanism of action of this antiseptic. Chlorhexidine is unusual in that it is a more effective antiplaque agent than other drugs with greater antimicrobial activity in vitro, because chlorhexidine binds to oral surfaces and is released over time. This property, known as substantivity, is well recognized among dental health care workers and depends on adherence to clean oral surfaces. Thus chlorhexidine is effective at inhibiting plaque formation in a clean mouth but is otherwise of limited value.4 Mechanical methods of cleaning, such as tooth brushing, are efficient at removing plaque, but this was not undertaken in the current study.1 In the absence of a reduction of plaque by brushing it was unlikely that the addition of 0.2% chlorhexidine would prevent nosocomial pneumonia. Plaque scores are higher among critically ill patients than healthy adults and increase over time.5 A 10-fold increase in antiseptic dose to 2% chlorhexidine may overcome the microbial burden of higher plaque scores in some patients, but in one of the supporting studies tooth brushing was also undertaken.3 The randomized controlled trials in patients undergoing cardiac surgery differ substantially from those undertaken on ICU patients because these elective patients will have brushed their teeth prior to surgery and chlorhexidine will therefore have a substantial effect.

Chlorhexidine remains an attractive drug for use in critically ill patients because it is active against a broad spectrum of microbes, with few side effects, and has a low incidence of resistance. We suggest that future studies examining the efficacy of chlorhexidine in preventing nosocomial pneumonia should also address efficient removal of plaque by brushing.

Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest. 2009;1355:1150-1156. [CrossRef] [PubMed]
 
Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;17312:1348-1355. [CrossRef] [PubMed]
 
Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;292:131-136. [CrossRef] [PubMed]
 
Zanatta FB, Antoniazzi RP, Rösing CK. The effect of 0.12% chlorhexidine gluconate rinsing on previously plaque-free and plaque-covered surfaces: a randomized, controlled clinical trial. J Periodontol. 2007;7811:2127-2134. [CrossRef] [PubMed]
 
Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med. 1998;262:301-308. [CrossRef] [PubMed]
 

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References

Panchabhai TS, Dangayach NS, Krishnan A, Kothari VM, Karnad DR. Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest. 2009;1355:1150-1156. [CrossRef] [PubMed]
 
Koeman M, van der Ven AJ, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;17312:1348-1355. [CrossRef] [PubMed]
 
Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2008;292:131-136. [CrossRef] [PubMed]
 
Zanatta FB, Antoniazzi RP, Rösing CK. The effect of 0.12% chlorhexidine gluconate rinsing on previously plaque-free and plaque-covered surfaces: a randomized, controlled clinical trial. J Periodontol. 2007;7811:2127-2134. [CrossRef] [PubMed]
 
Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med. 1998;262:301-308. [CrossRef] [PubMed]
 
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