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


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].


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.


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)


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.


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Kangesan, I., Millinchamp, F., Williams, J. et al. Survey on the use of chlorhexidine and toothpaste as part of oral care in UK ICUs. Crit Care 18 (Suppl 1), P330 (2014).

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