- Design
- Pragmatic cluster-randomised crossover trial, single centre
- Population
- 1,035 adults ventilated ≥48 h in six medical ICUs, India
- Primary outcome
- VAP per 1,000 ventilator-days
- Effect
- 18.8 vs 16.9; adjusted IRR 1.08 (95% CI 0.84–1.38)
This pragmatic cluster-randomised crossover trial ran in six adult medical ICUs at a tertiary hospital in Bhubaneswar. Each ICU used a standardised multicomponent oral-care bundle for nine months with 0.12% chlorhexidine and nine months without, in randomised order. It enrolled 1,035 adults ventilated for at least 48 hours.
VAP occurred at 18.8 per 1,000 ventilator-days with chlorhexidine and 16.9 without (adjusted IRR 1.08). Mortality at 28 days was 26.4% against 28.7% (adjusted OR 0.87, not significant). ICU stay was 0.89 days longer with chlorhexidine.
The result fits earlier meta-analyses suggesting chlorhexidine helps after cardiac surgery but not in general ICU populations, and some suggesting possible harm. This is Indian evidence from an Indian ICU population, which makes it directly relevant to bundles used here. The trial was single-centre, and VAP was diagnosed by clinical score rather than microbiology.
- Consider dropping routine chlorhexidine from oral care in medical ICU patients.
- Keep the rest of the bundle — toothbrushing, head-of-bed elevation, cuff pressure checks and sedation breaks.
- Retain chlorhexidine where there is a specific indication, such as after cardiac surgery.
- Review local VAP bundles against this evidence.
Why it matters
A step done many times a day in Indian ICUs showed no benefit and a small increase in stay.
Don't overread it
This was a single hospital, and VAP was defined by a clinical score, which is imprecise.
The statistics, in plain English
An IRR of 1.08 (0.84–1.38) means VAP rates were statistically indistinguishable; the interval includes a modest benefit or a modest harm. The longer ICU stay is a secondary outcome and may be chance.
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