Table 3. Comparison of incidence of VAP .
| Study design | Study group | Intervention | Comparison | Comparison | Result with respect to total participants (VAP) | Conclusion | |
| Pugin et al21 1991 |
Randomized, controlled, double-blind clinical trial | Mix | NATAa(150 mg polymyxin B sulfate, 1g neomycin sulfate, and 1g vancomycin hydrochloride) continued until extubation or death. | Placebo | Intervention | Control | Use of NATAdecreasing the prevalence of VAP |
| 25(4) | 27(21) | ||||||
| DeRiso et al221996 | Multicenter, prospective, randomized controlled trial | Cardiothoracic (open heart surgery) | CHXb 0.12% 15 ml preoperatively and twice daily postoperatively until discharge from intensive care or death | Placebo | 173(5) | 180(17) | SOD with CHX reduces the total HAPc rate. |
| Bergmans et al23 2001 | Prospective, randomized, double-blind, controlled trial | Mix | NATAconsisting 2% gentamicin, 2% colistin, and 2% vancomycin every 6 h, until extubation or death | Two Placebo group(A,B) | 87(9) | 78(24) and 61(14) |
Modulation of oropharyngeal colonization, reduces the incidence of late-onset VAP. |
| Fourrier et al24 2005 | Randomized, double-blind, controlled trial | Mix | The Specific gel containing CHX0.2%. The gel was left in place and the oral cavity was not rinsed until the next application. It was applied at least three times a day during the entire ICU stay until discharge or death. | Placebo | 114 (13) | 114 (12) | Significantly decreased the oropharyngeal colonization. However, its efficacy was insufficient to reduce the incidence of respiratory infections due to multi-resistant bacteria. |
| Kollef et al25 2006 |
Multinational, double-blind, randomized, controlled trial | 83% non-trauma, 27% trauma patients | Receive 3 ml Iseganand oral solution (9mg) or six times per day for up to 14 d. | Placebo | 282/(45) VAP in alive patients 80/(7) VAP in dead patients |
284/(57) in alive patients 63/(5) VAP in dead patients |
There were no significant differences in the rate of VAP. |
| Seguin et al26 2006 |
Prospective randomized controlled, trial | Severe closed head trauma | Nasopharynx and oropharynx rinsing with 20 mL of a 10% povidone-Iodine aqueous solution reconstituted in a 60-mL solution with sterile water, followed by aspiration of oropharyngeal secretions every 4 h until discharge from intensive care or death. | Nasopharynx and oropharynx rinsing with 60 mL of saline solution, followed by aspiration of oropharyngeal secretions and standard regimen without any instillation but with the aspiration of oropharyngeal secretions. | 36 (3) | 31 (12) and 31 (13) |
The regular administration of povidone-Iodine maybe an effective strategy for decreasing the prevalence of VAP. |
| Koeman et al27 2006 | Randomized, double-blind, controlled trial | Mixed and surgical ICUs | CHX 2% with COLe 2% in Vaseline was administered four times daily, after removing remnants of the previous dose with a gauze moistened with saline Until the diagnosis of VAP, death, extubation, or withdrawal of consent. | CHX 2% in petroleum jelly [Vaseline] And the placebo administered as same as the intervention group. | 128(16)/ | 127(13) and 130(23) |
SOD with either CHX or CHX/COL reduced and delayed the development of VAP. |
| Segers et al28 2006 | Prospective, randomized, double-blind, controlled clinical trial | Cardiothoracic surgery | 0.12% CHX was used as an oral rinse and as a gel for nasal application, 4 times daily continued until the nasogastric tube was removed. | Placebo | 485(45) | 469(74) | SOD with CHX be an effective method to reduce VAP. |
| Bellissimo-Rodrigues et al29 2009 | Double-blind, randomized, controlled trial | Mix | 0.12% CHX applied orally 3 times a day were continued as long as the patient remained in the ICU. | Placebo | 98(21) | 96(25) | 0.12% CHX does not prevent VAP. |
| Munro et al30 2009 | Randomized controlled factorial trial | Medical, surgical trauma, and neuroscience ICUs | 0.12% CHX 5 mL by oral swab twice daily. | Tooth brushing 3 times a day combination care (tooth brushing 3 times a day and CHX every 12 hours), or control (usual care). | 92(38) | 100(50) | CHX, but not tooth brushing, reduced early VAP Because dislodgement of dental plaque organisms during tooth brushing could provide a larger pool of organisms for translocation from the mouth to subglottic secretions or the lung |
| Özçaka et al31 2012 | Randomized, double-blind, controlled clinical trial | Respiratory ICU | Oral care was provided by swabbing the oral mucosa with either 30 mL of 0.2% CHX or saline on sponge pellets, four times a day. | Routine oral care provided by saline application. | 29(12) | 32(22) | Oral care with CHX swabbing reduces the risk of VAP. |
| Haghighi et al32 2016 | Randomized clinical trial | Mix | All surfaces of teeth and gums were brushed and rinsed with normal saline 0.9% solution. Then a syringe was used to spray 5cc CHX 0.2% on teeth, tongue, gum and mucosa following a mouth and throat deep suctioning after 30 s. Finally, Moisten lips and mouth with vitamin A+D. 2 to 6 times a day. CHX was sprayed every 12 hours. | Routine oral care including brushing the teeth with a toothpaste once a day and mouth washing with CHX 0.2% solution twice a day. | 50(5) | 50(7) | There was no significant difference in the incidence of VAP. |
| Nasiriani et al33 2016 | Randomized clinical trial | Trauma patients | In addition to routine oral care, the oral surface was brushed twice a day with a children’s soft toothbrush and distilled water, Subsequently, CHX was rubbed on the surface of the mouth twice daily for the next five days. | Routine oral care (control of endotracheal tube cuff, rinsing the mouth with normal saline, applying CHX to a swab and rubbing it on the surface of the tongue and oropharyngeal suction) three times a day. | 84(25) | 84(40) | Tooth brushing twice daily with distilled water reduced the incidence of VAP. |
| Fernanda de Lacerda Vidal et al34 2017 | Prospective, randomized clinical trial | Mix | Tooth brushing plus 0.12% CHX gel every 12 h, up to28 days. | Oral hygiene with 0.12%CHX every 12h | 105(17) | 108(28) | Patients undergoing tooth brushing there was a tendency to reduce the incidence of VAP. |
| Zand et al35 2017 | Randomized, clinical trial | Trauma, surgery neurosurgery, and general ICUs |
%2 CHX twice daily continued until discharge or death. | %0.2 CHX | 57(3) | 57(13) | SOD is more effective with 2% CHX than with 0.2% CHX in incidence of VAP. |
| Chacko et al36 2017 | Prospective, randomized, double-blind clinical trial | Medical ICU | Toothbrush and CHX 0.2% was instilled into the oral cavity Three times a day until discharge from ICU. | Routine oral care: the oral cavity was swabbed with sponges soaked in CHX 0.2%. | 104(5) | 102(7) | There was no significant difference in the incidence of VAP. |
| Khaky et al37 2018 | Prospective, a randomized clinical trial | Mix | Nanosilf mouthwash three times a day or until obtaining the exit criteria (death, extubation, transfer to other wards and performing any diagnostic and therapeutic procedures in the oral and throat areas). | CHX 0.12% mouthwash three times a day for five days that involved brushing the teeth, suctioning oral secretions, and rubbing the oropharyngeal mucosa. | 40(1) | 40(9) | Nanosil is better than CHX for the prevention of VAP. |
aNATA: non-absorbable topical antibiotic, bCHX: chlorohexidine, cHAP: Hospital-acquired pneumonia, dIseganan HCl is a synthetic protegrin analog that possesses a broad spectrum of activity in vitro against aerobic and anaerobic gram-positive and gram-negative bacteria and yeasts, is rapidly microbicidal in saliva, and has a low propensity for inducing resistance, eCOL: colistin, fNanosil mouthwashes are hydrogen peroxide and few silver ions. Hydrogen peroxide destroyed bacterial and viral protective membranes and therefore prevents anaerobic bacterial proliferation. Silver ions bind to bacterial proteins with extremely firm covalent bonds and causing bacterial deactivation.