Gingival and plaque decontamination: Can we take a bite out of VAP?

Abstract

Expanded AbstractCitationFourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmettre T, Pottier-Cau E, Boutigny H, Di Pompeo C, Durocher A, Roussel-Delvallez M: Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study. Crit Care Med 2005, 33:1728–1735 [1].BackgroundPoor oral hygiene and colonization of dental plaque is likely to play an important role in the development of ventilator-associated pneumonia (VAP) in many critically ill patients. Preliminary observations have suggested that dental plaque antiseptic decontamination (PAD) may reduce the frequency of VAP and ICU acquired bacteremia.MethodsDesign and settingProspective, multi-center, double-blind, placebo-controlled trial in six French ICUs.ObjectiveTo document the effect of gingival and dental plaque antiseptic decontamination on the rate of nosocomial bacteremias and respiratory infections acquired in the ICU.Patients and intervention228 non-edentulous patients requiring endotracheal intubation and mechanical ventilation with an anticipated ICU length of stay > 5 days were randomized to receive 0.2% chlorhexidine gel or placebo applied to dental and gingival surfaces three times daily for the duration of their ICU stay until day 28.OutcomesThe primary end point was the composite incidence of bacteremia, bronchitis and VAP acquired in the ICU. Secondary endpoints included ICU mortality, length of stay and medical and nursing care loads. Changes in bacterial colonization were evaluated in a subset of randomized patients.ResultsAll baseline characteristics were similar between the treated and the placebo groups. The trial was stopped based on an interim analysis showing statistical futility. The incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic decontamination group (p = NS). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days, mortality, length of stay, and care loads. On day 10, the number of positive dental plaque cultures was significantly lower in the treated group (29% vs. 66%; p < 0.05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination. No side effect was reported.ConclusionGingival and dental plaque antiseptic decontamination significantly decreased the oropharyngeal colonization by aerobic pathogens in ventilated patients. However, its efficacy was insufficient to reduce the incidence of respiratory infections due to multiresistant bacteria.