Comparative efficacy of different concentrations of chlorhexidine for prevention of ventilator‐associated pneumonia in intensive care units: A systematic review and network meta‐analysis

Abstract

AbstractBackgroundVentilator‐associated pneumonia is a common type of hospital‐acquired infection in critically ill patients. The implementation of effective oral care with chlorhexidine is known to be an effective intervention to prevent ventilator‐associated pneumonia. Nonetheless, no well‐supported evidence exists yet to rank the efficacy of various concentrations of chlorhexidine.AimTo compare the efficacy of different concentrations of chlorhexidine (0.12%, 0.20% and 2.0%) for prevention of ventilator‐associated pneumonia.Study DesignElectronic databases, as well as bibliographies, were systematically searched to find relevant studies published in English from inception until January 1, 2022. We included randomized controlled trials of mechanically ventilated adult patients in intensive care settings comparing at least two of the following treatments: 0.12% chlorhexidine, 0.2% chlorhexidine, 2.0% chlorhexidine, or placebo. The selected outcome was the incidence of ventilator‐associated pneumonia. A frequentist network meta‐analysis was performed. We ranked the concentrations of chlorhexidine for the selected outcome by p score (estimate of the probability of being the best treatment).ResultsWe included 19 trials with 3183 participants, conducted across nine countries. The use of 2.0% chlorhexidine and 0.12% chlorhexidine decreased the risk of ventilator‐associated pneumonia compared with placebo (OR 0.46, 95% CI = 0.28–0.75; OR 0.49, 95% CI = 0.33–0.71, respectively), whereas the effect resulting from 0.02% chlorhexidine remains unclear (OR 0.78, 95% CI = 0.54–1.13). Our network meta‐analysis ranked the 2.0% concentration as the most beneficial for ventilator‐associated pneumonia prevention (p score: 0.92).ConclusionThe 2.0% chlorhexidine and the 0.12% chlorhexidine reduce the risk of ventilator‐associated pneumonia in mechanically ventilated patients. According to the results of our network meta‐analysis, 2.0% chlorhexidine seems more beneficial. Chlorhexidine needs to be further evaluated in large‐scale controlled trials.Relevance to clinical practiceIn patients in intensive care units, and within the inevitable limitations of a network meta‐analysis, this study proposes that 2.0% chlorhexidine is superior to other chlorhexidine concentrations in terms of preventing ventilator‐associated pneumonia.