Ventilator-associated pneumonia with or without toothbrushing: a randomized controlled trial

  • L. Lorente
  • M. Lecuona
  • A. Jiménez
  • S. Palmero
  • E. Pastor
  • N. Lafuente
  • M. J. Ramos
  • M. L. Mora
  • A. Sierra


Certain guidelines for the prevention of ventilator-associated pneumonia (VAP) recommend oral care with chlorhexidine, but none refer to the use of a toothbrush for oral hygiene. The role of toothbrush use has received scant attention. Thus, the objective of this study was to compare the incidence of VAP in critical care patients receiving oral care with and without manual brushing of the teeth. This was a randomized clinical trial developed in a 24-bed medical-surgical intensive care unit (ICU). Patients undergoing invasive mechanical ventilation for than 24 h were included. Patients were randomly assigned to receive oral care with or without toothbrushing. All patients received oral care with 0.12 % chlorhexidine digluconate. Tracheal aspirate samples were obtained during endotracheal intubation, then twice a week, and, finally, on extubation. There were no significant differences between the two groups of patients in the baseline characteristics. We found no statistically significant differences between the groups regarding the incidence of VAP (21 of 217 [9.7 %] with toothbrushing vs. 24 of 219 [11.0 %] without toothbrushing; odds ratio [OR] = 0.87, 95 % confidence interval [CI] = 0.469–1.615; p = 0.75). Adding manual toothbrushing to chlorhexidine oral care does not help to prevent VAP in critical care patients on mechanical ventilation.



This study was supported, in part, by a grant from Instituto de Salud Carlos III (I3SNS-INT-11-063) (Madrid, Spain).

Competing interests

The authors do not have any financial interests to disclose.


Hospital funding.

Trial registration




  1. 1.
    Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C (1993) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94:281–288PubMedCrossRefGoogle Scholar
  2. 2.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 159:1249–1256PubMedGoogle Scholar
  3. 3.
    Bercault N, Boulain T (2001) Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case–control study. Crit Care Med 29:2303–2309PubMedCrossRefGoogle Scholar
  4. 4.
    Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, Cohen MM, Fraser VJ (2003) Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 31:1312–1317PubMedCrossRefGoogle Scholar
  5. 5.
    Safdar N, Dezfulian C, Collard HR, Saint S (2005) Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med 33:2184–2193PubMedCrossRefGoogle Scholar
  6. 6.
    Lorente L, Blot S, Rello J (2007) Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J 30:1193–1207PubMedCrossRefGoogle Scholar
  7. 7.
    Lorente L, Blot S, Rello J (2010) New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 182:870–876PubMedCrossRefGoogle Scholar
  8. 8.
    Pineda LA, Saliba RG, El Solh AA (2006) Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Crit Care 10:R35PubMedCrossRefGoogle Scholar
  9. 9.
    Kola A, Gastmeier P (2007) Efficacy of oral chlorhexidine in preventing lower respiratory tract infections. Meta-analysis of randomized controlled trials. J Hosp Infect 66:207–216PubMedCrossRefGoogle Scholar
  10. 10.
    Chlebicki MP, Safdar N (2007) Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 35:595–602PubMedCrossRefGoogle Scholar
  11. 11.
    Chan EY, Ruest A, Meade MO, Cook DJ (2007) Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 334:889PubMedCrossRefGoogle Scholar
  12. 12.
    Carvajal C, Pobo A, Díaz E, Lisboa T, Llauradó M, Rello J (2010) Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials. Med Clin (Barc) 135:491–497CrossRefGoogle Scholar
  13. 13.
    Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI (2011) Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis 11:845–854PubMedCrossRefGoogle Scholar
  14. 14.
    Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M (2006) Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 32:230–236PubMedCrossRefGoogle Scholar
  15. 15.
    Hutchins K, Karras G, Erwin J, Sullivan KL (2009) Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control 37:590–597PubMedCrossRefGoogle Scholar
  16. 16.
    Sona CS, Zack JE, Schallom ME, McSweeney M, McMullen K, Thomas J, Coopersmith CM, Boyle WA, Buchman TG, Mazuski JE, Schuerer DJ (2009) The impact of a simple, low-cost oral care protocol on ventilator-associated pneumonia rates in a surgical intensive care unit. J Intensive Care Med 24:54–62PubMedCrossRefGoogle Scholar
  17. 17.
    Pobo A, Lisboa T, Rodriguez A, Sole R, Magret M, Trefler S, Gómez F, Rello J; RASPALL Study Investigators (2009) A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest 136:433–439PubMedCrossRefGoogle Scholar
  18. 18.
    Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN (2009) Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care 18:428–437PubMedCrossRefGoogle Scholar
  19. 19.
    Masterton RG, Galloway A, French G, Street M, Armstrong J, Brown E, Cleverley J, Dilworth P, Fry C, Gascoigne AD, Knox A, Nathwani D, Spencer R, Wilcox M (2008) Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 62:5–34PubMedCrossRefGoogle Scholar
  20. 20.
    Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D; VAP Guidelines Committee and the Canadian Critical Care Trials Group (2008) Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care 23:126–137PubMedCrossRefGoogle Scholar
  21. 21.
    Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS (2008) Practice recommendation of Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA). Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 29(Suppl 1):S31–S40PubMedCrossRefGoogle Scholar
  22. 22.
    Torres A, Ewig S, Lode H, Carlet J; European HAP working group (2009) Defining, treating and preventing hospital acquired pneumonia: European perspective. Intensive Care Med 35:9–29PubMedCrossRefGoogle Scholar
  23. 23.
    Rello J, Lode H, Cornaglia G, Masterton R; VAP Care Bundle Contributors (2010) A European care bundle for prevention of ventilator-associated pneumonia. Intensive Care Med 36:773–780PubMedCrossRefGoogle Scholar
  24. 24.
    Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD (2006) The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 295:324–327PubMedCrossRefGoogle Scholar
  25. 25.
    Rello J, Koulenti D, Blot S, Sierra R, Diaz E, De Waele JJ, Macor A, Agbaht K, Rodriguez A (2007) Oral care practices in intensive care units: a survey of 59 European ICUs. Intensive Care Med 33:1066–1070PubMedCrossRefGoogle Scholar
  26. 26.
    Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone–alphadolone. Br Med J 2:656–659PubMedCrossRefGoogle Scholar
  27. 27.
    van Saene HKF, Damjanovic V, Murray AE, de la Cal MA (1996) How to classify infections in intensive care units—the carrier state, a criterion whose time has come? J Hosp Infect 33:1–12PubMedCrossRefGoogle Scholar
  28. 28.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829PubMedCrossRefGoogle Scholar
  29. 29.
    Lisboa T, Diaz E, Sa-Borges M, Socias A, Sole-Violan J, Rodríguez A, Rello J (2008) The ventilator-associated pneumonia PIRO score: a tool for predicting ICU mortality and health-care resources use in ventilator-associated pneumonia. Chest 134:1208–1216PubMedCrossRefGoogle Scholar
  30. 30.
    Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710PubMedCrossRefGoogle Scholar
  31. 31.
    Gibbons RJ (1989) Bacterial adhesion to oral tissues: a model for infectious diseases. J Dent Res 68:750–760PubMedCrossRefGoogle Scholar
  32. 32.
    Fourrier F, Duvivier B, Boutigny H, Roussel-Delvallez M, Chopin C (1998) Colonization of dental plaque: a source of nosocomial infections in intensive care unit patients. Crit Care Med 26:301–308PubMedCrossRefGoogle Scholar
  33. 33.
    El-Solh AA, Pietrantoni C, Bhat A, Okada M, Zambon J, Aquilina A, Berbary E (2004) Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest 126:1575–1582PubMedCrossRefGoogle Scholar
  34. 34.
    Scannapieco FA, Stewart EM, Mylotte JM (1992) Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 20:740–745PubMedCrossRefGoogle Scholar
  35. 35.
    Lorente L, Lecuona M, Málaga J, Revert C, Mora ML, Sierra A (2003) Bacterial filters in respiratory circuits: an unnecessary cost? Crit Care Med 31:2126–2130PubMedCrossRefGoogle Scholar
  36. 36.
    Lorente L, Lecuona M, Galván R, Ramos MJ, Mora ML, Sierra A (2004) Periodically changing ventilator circuits is not necessary to prevent ventilator-associated pneumonia when a heat and moisture exchanger is used. Infect Control Hosp Epidemiol 25:1077–1082PubMedCrossRefGoogle Scholar
  37. 37.
    Lorente L, Lecuona M, Martín MM, García C, Mora ML, Sierra A (2005) Ventilator-associated pneumonia using a closed versus an open tracheal suction system. Crit Care Med 33:115–119PubMedCrossRefGoogle Scholar
  38. 38.
    Lorente L, Lecuona M, Jiménez A, Mora ML, Sierra A (2006) Tracheal suction by closed system without daily change versus open system. Intensive Care Med 32:538–544PubMedCrossRefGoogle Scholar
  39. 39.
    Lorente L, Lecuona M, Jiménez A, Mora ML, Sierra A (2006) Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583]. Crit Care 10:R116PubMedCrossRefGoogle Scholar
  40. 40.
    Heo SM, Haase EM, Lesse AJ, Gill SR, Scannapieco FA (2008) Genetic relationships between respiratory pathogens isolated from dental plaque and bronchoalveolar lavage fluid from patients in the intensive care unit undergoing mechanical ventilation. Clin Infect Dis 47:1562–1570PubMedCrossRefGoogle Scholar
  41. 41.
    Bahrani-Mougeot FK, Paster BJ, Coleman S, Barbuto S, Brennan MT, Noll J, Kennedy T, Fox PC, Lockhart PB (2007) Molecular analysis of oral and respiratory bacterial species associated with ventilator-associated pneumonia. J Clin Microbiol 45:1588–1593PubMedCrossRefGoogle Scholar
  42. 42.
    Scannapieco FA, Bush RB, Paju S (2003) Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol 8:54–69PubMedCrossRefGoogle Scholar
  43. 43.
    Fourrier F, Dubois D, Pronnier P, Herbecq P, Leroy O, Desmettre T, Pottier-Cau E, Boutigny H, Di Pompéo C, Durocher A, Roussel-Delvallez M; PIRAD Study Group (2005) 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 33:1728–1735PubMedCrossRefGoogle Scholar
  44. 44.
    Scannapieco FA, Yu J, Raghavendran K, Vacanti A, Owens SI, Wood K, Mylotte JM (2009) A randomized trial of chlorhexidine gluconate on oral bacterial pathogens in mechanically ventilated patients. Crit Care 13:R117PubMedCrossRefGoogle Scholar
  45. 45.
    Attin T, Hornecker E (2005) Tooth brushing and oral health: how frequently and when should tooth brushing be performed? Oral Health Prev Dent 3:135–140PubMedGoogle Scholar
  46. 46.
    Löe H (2000) Oral hygiene in the prevention of caries and periodontal disease. Int Dent J 50:129–139PubMedCrossRefGoogle Scholar
  47. 47.
    Bellini HT, Arneberg P, von der Fehr FR (1981) Oral hygiene and caries. A review. Acta Odontol Scand 39:257–265PubMedCrossRefGoogle Scholar
  48. 48.
    Needleman IG, Hirsch NP, Leemans M, Moles DR, Wilson M, Ready DR, Ismail S, Ciric L, Shaw MJ, Smith M, Garner A, Wilson S (2011) Randomized controlled trial of toothbrushing to reduce ventilator-associated pneumonia pathogens and dental plaque in a critical care unit. J Clin Periodontol 38:246–252PubMedCrossRefGoogle Scholar
  49. 49.
    Roca Biosca A, Anguera Saperas L, García Grau N, Rubio Rico L, Velasco Guillén MC (2011) Prevention of mechanical ventilator-associated pneumonia: a comparison of two different oral hygiene methods. Enferm Intensiva 22:104–111PubMedCrossRefGoogle Scholar
  50. 50.
    Torres A, Gatell JM, Aznar E, el-Ebiary M, Puig de la Bellacasa J, González J, Ferrer M, Rodriguez-Roisin R (1995) Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med 152:137–141PubMedGoogle Scholar
  51. 51.
    Leal-Noval SR, Márquez-Vacaro JA, García-Curiel A, Camacho-Laraña P, Rincón-Ferrari MD, Ordoñez-Fernández A, Flores-Cordero JM, Loscertales-Abril J (2000) Nosocomial pneumonia in patients undergoing heart surgery. Crit Care Med 28:935–940PubMedCrossRefGoogle Scholar
  52. 52.
    Kollef MH, von Harz B, Prentice D, Shapiro SD, Silver P, St John R, Trovillion E (1997) Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia. Chest 112:765–773PubMedCrossRefGoogle Scholar
  53. 53.
    Canadian Critical Care Trials Group (2006) A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 355:2619–2630CrossRefGoogle Scholar
  54. 54.
    Rello J, Lorente C, Bodí M, Diaz E, Ricart M, Kollef MH (2002) Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivists. Chest 122:656–661PubMedCrossRefGoogle Scholar
  55. 55.
    McGuckin M, Waterman R, Govednik J (2009) Hand hygiene compliance rates in the United States—a one-year multicenter collaboration using product/volume usage measurement and feedback. Am J Med Qual 24:205–213PubMedCrossRefGoogle Scholar
  56. 56.
    Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, Valles J, Diaz E; FADO Project Investigators (2012) A care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect (accepted for publication). doi: 10.1111/j.1469-0691.2012.03808.x

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • L. Lorente
    • 1
  • M. Lecuona
    • 2
  • A. Jiménez
    • 3
  • S. Palmero
    • 1
  • E. Pastor
    • 1
  • N. Lafuente
    • 1
  • M. J. Ramos
    • 2
  • M. L. Mora
    • 1
  • A. Sierra
    • 2
  1. 1.Department of Critical CareHospital Universitario de CanariasSanta Cruz de TenerifeSpain
  2. 2.Department of MicrobiologyHospital Universitario de CanariasSanta Cruz de TenerifeSpain
  3. 3.Research UnitHospital Universitario de CanariasSanta Cruz de TenerifeSpain

Personalised recommendations