Summary of findings 1. 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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Population: critically ill adults and children receiving mechanical ventilation
Setting: intensive care units (ICU)
Intervention: chlorhexidine (mouthrinse or gel) Comparison: placebo or usual care | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | Number of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control (placebo or usual care) | Chlorhexidine (mouthrinse or gel) | |||||
| Incidence of VAP Follow‐up: mean 1 month | 261 per 10001 | 175 per 1000 (123 to 253) | RR 0.67 (0.47 to 0.97) | 1206 (13 studies) | ⊕⊕⊕⊝ moderate2 | This equates to an NNTB of 12 (95% CI 7 to 128); probably reduces the incidence of VAP |
| Mortality Follow‐up: mean 1 month | 190 per 10001 | 247 per 1000 (192 to 319) | RR 1.03 (0.80 to 1.33) | 944 (9 studies) | ⊕⊕⊕⊝ moderate3 | The evidence does not show a difference in mortality |
| 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 12 days | The mean duration of ventilation in the intervention groups was 1.10 days fewer (3.20 fewer to 1.00 more) | 594 (4 studies) | ⊕⊝⊝⊝ verylow4 | The evidence does not show a difference in duration of ventilation | |
| Duration of ICU stay Follow‐up: mean 1 month | The mean duration of ICU stay in the control groups ranged from 10 to 15 days | The mean duration of ICU stay in the intervention groups was 0.89 days fewer (3.59 fewer to 1.82 more) | 627 (5 studies) | ⊕⊕⊝⊝ low 5 |
The evidence does not show a difference in duration of ICU stay | |
| 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 low6 | There was a lack of evidence about adverse effects | |||
| *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 certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect. | ||||||
1Assumed risk was based on the median event rate in the control groups of the included studies.
2Downgraded one level due to substantial heterogeneity (I2 = 66%).
3Downgraded one level due to imprecision.
4Downgraded three levels due to serious imprecision, substantial heterogeneity (I2 = 74%), and serious risk of bias: two studies at high risk of bias.
5Downgraded two levels due to serious imprecision and substantial heterogeneity (I2 = 69%).
6Downgraded three levels due to very serious imprecision and serious inconsistency: only two studies reported on this outcome, and they did not report data adequately enough to enable us to evaluate the risk of adverse events.