Survey on the use of chlorhexidine and toothpaste as part of oral care in UK ICUs

Introduction

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among ventilated patients and is associated with increased mortality and morbidity [1]. Oral chlorhexidine has been used to decontaminate the airway in critically ill patients, as studies suggest a risk reduction in VAP [2]. Chlorhexidine reacts with soaps in toothpaste to form inactive insoluble salts [3]. A minimum delay of 30 minutes between tooth brushing and the subsequent application of chlorhexidine is therefore recommended [4].

Methods

A telephone questionnaire was conducted on all ICUs in the UK to assess current oral decontamination procedures with regards to chlorhexidine use and the timing of tooth brushing with toothpaste.

Results

Sixty-five per cent of ICUs in the UK responded to our survey (n = 157). Ninety-seven per cent (n = 152) used chlorhexidine and 96% (n = 150) used it as part of a ventilator care bundle. Forty-six per cent (n = 70) used a gel, 32% (n = 48) used a mouthwash and 23% (n = 34) used both preparations. The frequency of chlorhexidine application varied between ICUs; 15 (9.9%) applied 4-hourly, 91 (59.9%) 6-hourly, 20 (13.2%) 8-hourly, 19 (12.5%) 12-hourly and seven (4.6%) applied at variable times. Ninety-seven per cent (n = 152) brushed patient's teeth; 86% (n = 130) used toothpaste, 3% (n = 5) used chlorhexidine gel and 11% (n = 17) used both. Ninety-seven per cent (n = 147) of ICUs using chlorhexidine also brushed patient's teeth with toothpaste. Forty-eight per cent (n = 70) administered chlorhexidine within 30 minutes of toothpaste application (Table 1).

Table 1 Timing difference between toothpaste and chlorhexidine (minutes)

Conclusion

Chlorhexidine is being used too soon after the application of toothpaste in 48% of ICUs in the UK. This results in attenuation of its effect and may remove its beneficial risk reduction in VAP. Awareness of this interaction should be emphasised.