Summary of findings for the main comparison. Chlorhexidine (mouthrinse or gel) versus placebo/usual care for critically ill patients to prevent ventilator‐associated pneumonia.
| Chlorhexidine (mouthrinse or gel) versus placebo/usual care for critically ill patients to prevent ventilator‐associated pneumonia (VAP) | ||||||
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Patient or population: critically ill adults and children receiving mechanical ventilation
Settings: intensive care units (ICU)
Intervention: chlorhexidine (mouthrinse or gel) Comparison: placebo or usual care | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Quality of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control (placebo or usual care) | Chlorhexidine (mouthrinse or gel) | |||||
| Ventilator‐associated pneumonia Follow‐up: mean 1 month | 243 per 10001 | 180 per 1000 (148 to 221) | RR 0.75 (0.62 to 0.91) | 2451 (18 studies) | ⊕⊕⊕⊕ high | This equates to an NNTB of 17 (95% CI 9 to 50) |
| Mortality Follow‐up: mean 1 month | 222 per 10001 | 242 per 1000 (213 to 273) | RR 1.09 (0.96 to 1.23) | 2014 (14 studies) | ⊕⊕⊕⊝ moderate2 | |
| Duration of ventilation Days of ventilation required Follow‐up: mean 1 month | The mean duration of ventilation in the control groups ranged from 7 to 18 days | The mean duration of ventilation in the intervention groups was 0.09 days fewer (1.73 fewer to 1.55 more) | 800 (5 studies) | ⊕⊕⊝⊝ low3 | ||
| Duration of ICU stay Follow‐up: mean 1 month | The mean duration of ICU stay in the control groups ranged from 10 to 24 days | The mean duration of ICU stay in the intervention groups was 0.21 days more (1.48 fewer to 1.89 more) | 833 (6 studies) | ⊕⊕⊕⊝ moderate 4 |
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| Adverse effects | Most of the studies did not provide information on adverse events. Information on adverse events were identified from 2 studies. One study stated there were none, the other study reported on mild reversible irritation of the oral mucosa | ⊕⊝⊝⊝ very low5 | ||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: confidence interval; NNTB: number needed to treat for an additional beneficial outcome; RR: risk ratio | ||||||
| GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Very low quality: We are very uncertain about the estimate | ||||||
1Assumed risk is based on the median event rate in the control groups of the included studies.
2Downgraded one level due to serious risk of bias: eight studies at high risk of bias, four at unclear risk of bias and three at low risk of bias. The sensitivity analysis based on three low‐risk‐of‐bias studies gave similar effect estimate (RR = 1.13), but further research may change this estimate.
3Downgraded two levels due to serious imprecision and serious risk of bias: two studies at high risk of bias, three at low risk of bias. The sensitivity analysis based on three studies at low risk of bias gave an effect estimate of 0.84 days, which is not clinically important in the context of median duration of 12 days.
4Downgraded one level due to serious imprecision.
5Downgraded three levels due to very serious imprecision and serious inconsistency: only two studies reported on this outcome, and they did not report data adequately to enable us to evaluate the risk of adverse events.