We read with interest the recent article by Warren and colleagues reporting favorable results using an oral care protocol, including chlorhexidine mouthwashes, to reduce the risk of hospital-acquired pneumonia ("A Nurse-Driven Oral Care Protocol to Reduce Hospital-Acquired Pneumonia, Cultivating Quality, February).
Recently however, the safety of chlorhexidine oral care was questioned in two independent meta-analyses.1, 2 Based on 16 randomized controlled trials, Klompas and colleagues found a trend toward increased mortality.1 In a selection of general intensive care units (excluding specialty units), Price and colleagues found chlorhexidine oral care to be significantly associated with an increased risk of death.2 Additionally, Deschepper and colleagues found a strong link between exposure to the antiseptic mouthwash and mortality in a large hospital-wide population.3 These data call for a reappraisal of chlorhexidine as an oral antiseptic.4
The reason why the harmful effect of chlorhexidine was able to stay under the radar for such a long period of time is the high number of patients required to demonstrate a significant increase in mortality. Warren and colleagues reported a decrease in pneumonia-related mortality. However, given the safety issue, it seems more fitting to report overall mortality rates for chlorhexidine exposed or nonexposed patients, rather than pneumonia-related mortality.
Stijn Blot, PhD, MNSc, RN
Ghent University, Ghent, Belgium
Lead author Chastity Warren responds:
Ours was an evidence-based practice/quality improvement project, not a research study. Our focus was on the prevention of hospital-acquired pneumonia in nonventilated patients. For this group, we used prepackaged short-term and at-risk oral care kits, neither of which contained chlorhexidine. Use of the chlorhexidine-containing ventilator kit every four hours was already established in the ventilated patient population.
We wanted to focus on standardizing oral care delivery and increase its frequency by improving awareness about the importance of oral hygiene.
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