Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay
Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay
Many strategies have been developed to prevent such nosocomial infections, one such measure being chlorhexidine mouth wash.
Nosocomial infections are common after cardiac surgeries. More than 20 percent of patients who have undergone cardiac surgeries develop nosocomial infections (Munro and Grap, 2004). Research has shown that these nosocomial infections are important contributors to morbidity, mortality, increased stay in the intensive care unit and hospital, increased need for antibiotics, and higher costs of health care (Munro and Grap, 2004). One of the prerequisites for the development of nosocomial infections is the colonization of the patient by microorganisms which are potentially pathogenic.Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. Of utmost importance is lower respiratory tract infections which are caused by colonization in the oropharyngeal region. Thus, the decontamination of oropharynx becomes important to prevent pneumonia and associated problems following heart surgery. Several methods have been recommended to decontaminate oropharynx, one such being chlorhexidine solution. Many research studies have proved the role of this antimicrobial solution when used as a mouth rinse in patients in critical care units and on mechanical ventilation. Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. Some studies have explored the use of such treatment by administering the solution before and after cardiac surgery. Whether the use of chlorhexidine rinse in pre/post-cardiac surgery patients is effective in reducing the incidence of pneumonia in the post-operative period can be sought by reviewing literature for evidence-based information based on the following PICO format.
To consider what articles must be included in the review to make the review more authentic and reliable, knowledge on the different levels of accorded studies is essential. The different levels of studies are called hierarchy. The hierarchy provides a confidence measure to the end-user (Evans, 2003).
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Objective: Postoperative pneumonia is one of the most common complications after cardiac surgery, entailing increased patient morbidity, mortality, and health care burden. The primary aim of this study was to assess whether preoperative chlorhexidine mouthwash is associated with reduced postoperative pneumonia after cardiac surgery. Methods: A comprehensive systematic search of NLM Pubmed, Embase, Scopus, and Cumulative Index of Nursing and Allied Health was executed to include the studies since inception to June 27, 2017, which assessed the effects of preoperative chlorhexidine gluconate mouthwash on postoperative pneumonia.Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. Studies were identified by 2 independent reviewers, and data were extracted using a predefined protocol. Random effects models were run to obtain risk ratios with 95% confidence intervals. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation criteria. Postoperative pneumonia after cardiac surgery was the primary outcome of the study. Results: Five studies including a cumulative of 2284 patients were included. A total of 1125 patients received preoperative chlorhexidine. Use of chlorhexidine gluconate was associated with reduced risk of postoperative pneumonia compared with the patients who did not receive it (risk ratio, 0.52; 95% confidence interval, 0.39-0.70; P < .001). No adverse effects from chlorhexidine gluconate mouthwash were reported by any of these studies. Conclusions: Among the patients receiving preoperative chlorhexidine mouthwash, the risk of postoperative pneumonia is reduced by approximately one-half; its adoption in preoperative protocols could help improve patient outcomes.
Objective: Postoperative pneumonia is one of the most common complications after cardiac surgery, entailing increased patient morbidity, mortality, and health care burden. The primary aim of this study was to assess whether preoperative chlorhexidine mouthwash is associated with reduced postoperative pneumonia after cardiac surgery.
Methods: A comprehensive systematic search of NLM Pubmed, Embase, Scopus, and Cumulative Index of Nursing and Allied Health was executed to include the studies since inception to June 27, 2017, which assessed the effects of preoperative chlorhexidine gluconate mouthwash on postoperative pneumonia. Studies were identified by 2 independent reviewers, and data were extracted using a predefined protocol. Random effects models were run to obtain risk ratios with 95% confidence intervals. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation criteria. Postoperative pneumonia after cardiac surgery was the primary outcome of the study. Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay.
Results: Five studies including a cumulative of 2284 patients were included. A total of 1125 patients received preoperative chlorhexidine. Use of chlorhexidine gluconate was associated with reduced risk of postoperative pneumonia compared with the patients who did not receive it (risk ratio, 0.52; 95% confidence interval, 0.39-0.70; P < .001). No adverse effects from chlorhexidine gluconate mouthwash were reported by any of these studies.
Conclusions: Among the patients receiving preoperative chlorhexidine mouthwash, the risk of postoperative pneumonia is reduced by approximately one-half; its adoption in preoperative protocols could help improve patient outcomes.
Oral antiseptics reduce nosocomial infections and ventilator-associated pneumonia in critically ill medical and surgical patients intubated for prolonged periods. However, the role of oral antiseptics given before and after planned surgery is not clear. The aim of this systematic review and meta-analysis is to determine the effect of oral antiseptics (chlorhexidine or povidone–iodine) when administered before and after major elective surgery.
Methods
Searches were conducted of the MEDLINE, EMBASE and Cochrane databases. The analysis was performed using the random-effects method and the risk ratio (RR) with 95 % confidence interval (CI).
Results
Of 1114 unique identified articles, perioperative chlorhexidine was administered to patients undergoing elective surgery in four studies. This identified 2265 patients undergoing elective cardiac surgery, of whom 1093 (48.3 %) received perioperative chlorhexidine. Postoperative pneumonia and nosocomial infections were observed in 5.3 and 20.2 % who received chlorhexidine compared to 10.4 and 31.3 % who received a control preparation, respectively. Oral perioperative chlorhexidine significantly reduced the risk of postoperative pneumonia (RR = 0.52; 95 % CI 0.39–0.71; p < 0.01) and overall nosocomial infections (RR = 0.65; 95 % CI 0.52–0.81; p < 0.01), with no effect on in-hospital mortality (RR = 1.01; 95 % CI 0.49–2.09; p = 0.98).
Conclusions
Perioperative oral chlorhexidine significantly decreases the incidence of nosocomial infection and postoperative pneumonia in patients undergoing elective cardiac surgery. There are no randomised controlled studies of this simple and cheap intervention in patients undergoing elective non-cardiac surgery. Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay.
Trial Registration
This systematic review was registered with the International prospective register of systematic reviews (PROSPERO). The registration number is CRD42015016063.
Background
An estimated 234 million patients undergo major surgery worldwide every year. Nosocomial infections, particularly postoperative pneumonia, following surgery are common, affecting 1.5–57 % of patients depending on the type and extent of surgery (Weiser et al. 2008; Hemmes et al. 2014; Niggebrugge et al. 1999; Treschan et al. 2012; Seiler et al. 2009; Hulscher et al. 2002). Following major elective abdominal surgery, postoperative pneumonia results in six to nine extra hospital days and costs the healthcare system an additional $30,000 per patient (Khuri et al. 2005). Even after risk adjustment, it is associated with a 66 % lower survival at 5 years following surgery (Khuri et al. 2005). In those who do survive, the limited available evidence suggests a detrimental effect on early and late health-related quality of life (Thompson et al. 2006).
The definition of postoperative pneumonia used in the majority of studies is based on clinical, radiological and microbiological criteria defined by the Center of Disease Control and Prevention (CDC) for nosocomial pneumonia between the 2nd and 30th postoperative days (Garner et al. 1988). One of the primary causes of postoperative pneumonia is aspiration of oral and pharyngeal secretions at the time of intubation before surgery. Continued micro-aspiration of secretions due to small folds in the endotracheal tube cuff with prolonged ventilation (days to weeks) contributes to ventilator-associated pneumonia (VAP) (du Moulin et al. 1982; Cook et al. 1998; American Thoracic Society 2005). Oral antiseptics such as chlorhexidine gluconate or povidone–iodine have been shown to reduce the oral bacterial load in patients mechanically ventilated for 3 days or more. Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. Chlorhexidine gluconate is a broad-spectrum antimicrobial, effective against gram-positive and gram-negative bacteria, anaerobes and fungi within 20 s (Horner et al. 2012; Fitzgerald et al. 1989). Three recent systematic reviews demonstrate reduction in VAP by 20 % with regular oral chlorhexidine application after intubation in critically ill patients mechanically ventilated for 3 days or more, with conflicting effects on early mortality (Labeau et al. 2011; Klompas et al. 2014; Price et al. 2014). Recent recommendations support daily chlorhexidine mouth care to prevent VAP in the intensive care setting (Scottish Intensive Care Society Audit Group 2008). However, the majority of elective surgical patients are extubated immediately following surgery in the operating room. These recommendations of daily chlorhexidine mouth care do not apply to this group, and pre-anaesthesia oral decontamination or prophylaxis with oral antiseptics is currently not part of the routine care. The aim of this systematic review and meta-analysis is to determine the effect of oral decontamination using antiseptics (chlorhexidine or povidone–iodine) before and after major elective surgery on infective complications and postoperative mortality.
Methods
Study selection
The meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al. 2009). A systematic review was conducted by searching the MEDLINE, EMBASE and Cochrane databases. The full search criteria used are included at Appendix A. They contain search terms used relating to “surgery” and any combination of “chlorhexidine”, “iodine”, “povidone” with terms relating to “mouth”, “oral” and “decontamination”. This was limited to a 20-year period between October 1994 and 2014 and English language publications. All trial designs and interventions (mouthwash, nasal, gel) were included. Studies in patients under 18 years and including dental, oral or maxillofacial surgery were excluded.
Data extraction and synthesis
Two investigators independently reviewed the search results. A third investigator resolved any disagreements. Two additional investigators assessed all included papers. The perioperative period was defined as any time period before and after the operation. Risk of bias was assessed using the Cochrane Collaboration checklist and the Jadad score (Jadad et al. 1996). Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay.
Main outcomes and measures
Outcomes assessed were postoperative pneumonia and overall nosocomial infections, mortality, and intervention-related adverse events. Postoperative pneumonia was defined as nosocomial pneumonia between the 2nd and 30th postoperative days based on the CDC criteria (Garner et al. 1988). Nosocomial infections were defined as surgical site infections and any other infections including postoperative pneumonia, urinary tract infections and bacteraemia between the 2nd and 30th postoperative days (Garner et al. 1988). The additional following information was sought from all the included papers: study design, eligibility criteria, randomization method, allocation method, risk category, strength of solutions used, treatment regime and number of randomised patients.
Statistical analysis
A meta-analysis methodology was applied to determine the effect of a perioperative oral antiseptic on the incidence of postoperative pneumonia, nosocomial infections and mortality following surgery (Higgins and Green 2011). Data were analysed on an intention-to-treat principle. When this information was not available, per-protocol data were used. The outcome measures were the risk ratio (RR), with 95 % confidence interval (CI), weighted by the inverse of their variances. In this meta-analysis, mouthwash is considered the “experimental” treatment with RR reported as mouth wash-to-placebo/observation ratios.
We assessed heterogeneity using chi2-based Cochran’s Q test and I2 statistic tests. Inconsistency across studies was considered low, moderate and high for I2 statistic values lower than 25 %, between 25 and 50 % and greater than 50 %, respectively. Heterogeneity was significant when the I2 statistic was greater than 50 %, the Cochran’s Q test p value was smaller than 0.1 or both. A random-effects model was used to calculate the overall effect.
Results
One thousand six hundred seventy-six articles were identified (Fig. 1). Five hundred sixty-two duplicates and a further 1100 were excluded after abstract review. Full text was not available for 3 of the 14 remaining abstracts. Four of the 11 publications met the criteria after full manuscript review. These studies included 2205 participants of whom 1093 received perioperative chlorhexidine mouthwash or gel. Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. None of the studies reported iodine use. All four studies, three randomised controlled and one quasi-experimental, included patients having elective cardiac surgery only. Table 1 summarises the sample sizes, population, intervention regime and outcomes of the eligible studies. Additional preparations were administered in two studies with nasal chlorhexidine gel in one, and dental brushing in another. All four studies included a placebo (mouthwash, gel or nasal ointment).
CONSORT flow diagram of articles included in the systematic review
Table 1
Summary of sample sizes, population, regime, and outcomes
| Author | Location | Patients (chlorhexidine vs. control) | Population | Chlorhexidine strength | Regime | Overall nosocomial infection | Postoperative pneumonia | Mortality |
|---|---|---|---|---|---|---|---|---|
| De Riso 1996 | USA | 353 (173 vs. 180) | Cardiac | 0.12 % | Preop (no time scale given) and postop (discharge from ITU or death). Mean = 8.2 days | 8/173 (4.6 %) 24/180 (13.3 %) |
5/173 (2.9 %) 17/180 (9.4 %) |
3/173 (1.7 %) 10/180 (5.6 %) |
| Houston et al 2002 | USA | 561 (270 vs. 291) | Cardiac | 0.12 % | Preop (no time scale given) and postop (10 days or extubation, tracheostomy, development of POP or death) | – | 4/270 (1.5 %) 9/291 (3.1 %) |
6/270 (2.2 %) 3/291 (1 %) |
| Nicolosi et al 2014 | Argentina | 300 (150 vs. 150) | Cardiac | 0.12 % | Preop (3 days) | 46/150 (30.7 %) 69/150 (46 %) |
4/150 (2.7 %) 13/150 (8.7 %) |
8/150 (5.3 %) 7/150 (4.7 %) |
| Segers et al. 2006 | USA | 991 (500 vs. 491) | Cardiac | 0.12 % | Preop (mean = 1.9 days) and postop (no time scale given) | 116/500 (23.2 %) 164/491 (33.4 %) |
45/500 (9 %) 74/491 (15.1 %) |
8/500 (1.6 %) 6/491 (1.2 %) |
All four studies reported postoperative pneumonia rates and mortality, while three reported nosocomial infection rates (Segers et al. 2006; DeRiso et al. 1996; Nicolosi et al. 2014). Three studies used intention-to-treat analysis (DeRiso et al. 1996; Nicolosi et al. 2014; Houston et al. 2002), and one a per-protocol analysis (Segers et al. 2006). The risk of bias and Jadad scores are summarised in Table 2. The chlorhexidine regime used varied. All four studies included preoperative chlorhexidine. Three studies continued the intervention postoperatively with varying duration and preparations (Segers et al. 2006; DeRiso et al. 1996; Houston et al. 2002). Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay. Only one study reported duration and dosing (Nicolosi et al. 2014).
Table 2
Risk of bias in studies
| Study | Random sequence generation | Allocation concealment | Blinding | Incomplete data outcome addressed |
|---|---|---|---|---|
| Nicolosi et al. 2014 | N/A | N/A | N/A | N/A |
| Segers et al. 2006 | Low risk | Low risk | Low risk | Low risk |
| Houston et al. 2002 | High risk | Unclear | Unclear | Low risk |
| DeRiso et al. 1996 | Low risk | Low risk | Low risk | Low risk |
N/A not applicable
Postoperative pneumonia
Three of the four studies used the CDC definition (American Thoracic Society 2005; Segers et al. 2006; DeRiso et al. 1996; Houston et al. 2002; Rotstein et al. 2008). Timing of the diagnosis was variable and not reported in one study (Segers et al. 2006; DeRiso et al. 1996; Nicolosi et al. 2014; Houston et al. 2002). Fifty-eight (5.3 %) patients in the chlorhexidine group developed postoperative pneumonia compared with 113 (10.2 %) patients in the control group (RR = 0.52; 95 % CI 0.39–0.71; p < 0.01). There was no statistical significant between study heterogeneity (p = 0.45; I2 = 0 %). This produced a number needed to treat of 14 (Fig. 2).
Forest plot comparing postoperative pneumonia in patients with or without chlorhexidine cover. A Mantel–Haenszel random-effects model was used for meta-analysis. Risk ratios are shown with 95 % confidence interval
Nosocomial infections
Of the three studies that reported nosocomial infection rates, 170 (20.7 %) patients in the chlorhexidine group, compared with 265 (31.3 %) in the control arm, developed a nosocomial infection (RR = 0.65; 95 % CI 0.52–0.81; p < 0.01). There was no statistical significant between study heterogeneity (p = 0.23; I2 = 32 %). This produced a number needed to treat of 9 (Fig. 3). Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Essay.
