Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2018

Open Access 01-12-2018 | Research

Can probiotics be an alternative to chlorhexidine for oral care in the mechanically ventilated patient? A multicentre, prospective, randomised controlled open trial

Authors: Bengt Klarin, Anne Adolfsson, Anders Torstensson, Anders Larsson

Published in: Critical Care | Issue 1/2018

Login to get access

Abstract

Background

Pathogenic enteric bacteria aspirated from the oropharynx are the main cause of ventilator-associated pneumonia (VAP). Using chlorhexidine (CHX) orally or selective decontamination has been shown to reduce VAP. In a pilot study we found that oral care with the probiotic bacterium Lactobacillus plantarum 299 (Lp299) was as effective as CHX in reducing enteric bacteria in the oropharynx. To confirm those results, in this expanded study with an identical protocol we increased the number of patients and participating centres.

Methods

One hundred and fifty critically ill patients on mechanical ventilation were randomised to oral care with either standard 0.1% CHX solution (control group) or a procedure comprising final application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and subsequently at defined intervals.
Student’s t test was used for comparisons of parameters recorded daily and Fisher’s exact test was used to compare the results of microbiological cultures.

Results

Potentially pathogenic enteric bacteria not present at inclusion were identified in oropharyngeal samples from 29 patients in the CHX group and in 31 samples in the probiotic group. Considering cultures of tracheal secretions, enteric bacteria were found in 17 and 19 samples, respectively. Risk ratios show a difference in favour of the Lp group for fungi in oropharyngeal cultures. VAP was diagnosed in seven patients in the Lp group and in 10 patients among the controls.

Conclusions

In this multicentre study, we could not demonstrate any difference between Lp299 and CHX used in oral care procedures regarding their impact on colonisation with emerging potentially pathogenic enteric bacteria in the oropharynx and trachea.

Trial registration

ClinicalTrials.gov, NCT01105819. Registered on 9 April 2010.
First part: Current Controlled Trials, ISRCTN00472141. Registered on 22 November 2007 (published Critical Care 2008, 12:R136).
Literature
1.
Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol. 2012;33:250–6.CrossRef
2.
Leistner R, Kankura L, Bloch A, Sohr D, Gastmeier P, Geffers C. Attributable costs of ventilator-associated lower respiratory tract infection (LRTI) acquired on intensive care units: a retrospectively matched cohort study. Antimicrob Resist Infect Control. 2013;2:13.CrossRef
3.
Muscedere J, Sinuff T, Heyland DK, Dodek PM, Keenan SP, Wood G, et al. The clinical impact and preventability of ventilator-associated conditions in critically ill patients who are mechanically ventilated. Chest. 2013;144:1453–60.CrossRef
4.
Skrupky LP, McConnell K, John Dallas J, Kollef MH. A comparison of ventilator-associated pneumonia rates as identified according to the National Healthcare Safety Network and American College of Chest Physicians criteria. Crit Care Med. 2012;40:281–4.CrossRef
5.
Zeng J, Wang C-T, Zhang F-S, et al. Effect of probiotics on the incidence of ventilator-associated pneumonia in critically ill patients: a randomized controlled multicenter trial. Intensive Care Med. 2016;42:1018–28.CrossRef
6.
Vincent J-L. Ventilator-associated pneumonia. J Hosp Infection. 2004;57:272–80.CrossRef
7.
Rouzé A, Jaillette E, Poissy J, Préau S, Nseir S. Tracheal tube design and ventilator-associated pneumonia. Respir Care. 2017;62:1316–23.CrossRef
8.
Speck K, Rawat N, Weiner NC, Tujuba HG, Farley D, Sean Berenholtz S. A systematic approach for developing a ventilator-associated pneumonia prevention bundle. Am J Infect Control. 2016;44:652–6.CrossRef
9.
de Jonge E, Schultz MJ, Spanjaard L, Bossuyt PMM, Vroom MB, Dankert J, Kesecioglu J. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomized controlled trial. Lancet. 2003;362:1011–6.CrossRef
10.
de Smet AMGA, Kluytmans JAJW, Cooper BS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009;360:20–31.CrossRef
11.
Chan EY, Ruest A, O Meade M, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. Br Med J. 2007;334:889–99.CrossRef
12.
Di Zhao JS, Gao X, Gao F, Wu Y, Lu Y, Hou K. Selective oropharyngeal decontamination versus selective digestive decontamination in critically ill patients: a meta-analysis of randomized controlled trials. Drug Des Devel Ther. 2015;9:3617–24.CrossRef
13.
Price R, MacLennan G, John Glen J. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. Br Med J. 2014;348:2197–211.CrossRef
14.
Buelow E, Bello González T, Verslius D. Effects of selective digestive decontamination (SDD) on the gut resistome. J Antimicrob Chemother. 2014;69:2215–23.CrossRef
15.
Buelow E, Bello González TDJ, Fuentes S, et al. Comparative gut microbiota and resistome profiling of intensive care patients receiving selective digestive tract decontamination and healthy subjects. Microbiome. 2017;5:88.CrossRef
16.
Halaby T, al Naiemi N, Jan Kluytmans J, van der Palen J, Vandenbroucke-Graulsb CMJE. Emergence of colistin resistance in Enterobacteriaceae after the introduction of selective digestive tract decontamination in an intensive care unit. Antimicrob Agents Chemother. 2013;57:3224–9.CrossRef
17.
18.
Koeman M, Andre J, van der Ven AM, Hak E, et al. Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 2006;173:1348–55.CrossRef
19.
Hua F, Xie H, Worthington HV, Furness S, Zhang Q, Li C. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2016;10:CD008367.PubMed
20.
Veitz-Keenan A, Ferraiolo DM. Oral care with chlorhexidine seems effective for reducing the incidence of ventilator-associated pneumonia. Evidence-Based Dentistry. 2017;18:113–4.CrossRef
21.
Hughes C, Ferguson J. Phenotypic chlorhexidine and triclosan susceptibility in clinical Staphylococcus aureus isolates in Australia. Pathology. 2017;49:633–7.CrossRef
22.
Opstrup MS, Johansen JD, Garvey LH. Chlorhexidine allergy: sources of exposure in the health-care setting. Br J Anaesth. 2015;114:705–6.CrossRef
23.
Sharp G, Green S, Rose M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg. 2016;86:237–43.CrossRef
24.
Adlerberth I, Ahrné S, Johansson M-L, Molin G, Hansson LÅ, Wold AE. A mannose-specific adherence mechanism in Lactobacillus plantarum conferring to the human colonic cell line HT-29. Appl Environ Microbiol. 1996;62:2244–51.PubMedPubMedCentral
25.
Johansson M-L, Molin G, Jeppsson B, Nobaek S, Ahrné S, Bengmark S. Administration of different Lactobacillus strains in fermented oatmeal soup: in vivo colonization of human intestinal mucosa and effect on the indigenous flora. Appl Environ Microbiol. 1993;59:15–20.PubMedPubMedCentral
26.
Klarin B, Johansson M-L, Molin G, Larsson A, Jeppsson B. Adhesion of the probiotic bacterium Lactobacillus plantarum 299v onto the gut mucosa in critically ill patients: a randomised open trial. Crit Care. 2005;9:R285–93.CrossRef
27.
Stjernquist-Desatnik A, Warfving H, Johansson M-L. Persistence of Lactobacillus plantarum DSM 9843 on human tonsillar surface after oral administration in fermented oatmeal gruel. Acta Otolaryngol. 2000;6(Suppl 543):215–9.CrossRef
28.
Klarin B, Molin G, Jeppsson B, Larsson A. Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study. Crit Care. 2008;12:R136.CrossRef
29.
Johansson M-L, Quednau M, Molin G, Ahrné S. Randomly amplified polymorphic DNA (RAPD) for rapid typing of Lactobacillus plantarum strains. Lett Appl Microbiol. 1995;21:155–9.CrossRef
30.
Berggren A, Lazou A’n I, Larsson N, Önning G. Randomised, double-blind and placebo-controlled study using new probiotic lactobacilli for strengthening the body immune defence against viral infections. Eur J Nutr. 2011;50:203–10.CrossRef
31.
Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. 2007;297:1583–93.CrossRef
32.
Plantinga NL, Wittekamp BHJ, Leleu K, Depuydt P, Van den Abeele A-M, Christian Brun-Buisson C, Bonten MJM. Oral mucosal adverse events with chlorhexidine 2% mouthwash in ICU. Intensive Care Med. 2016;42:620–1.CrossRef
33.
Spijkervet FKL, van Saene HKF, Panders AK, Vermey A, van Saene JJM, Mehta DM, Fidler V. Effect of chlorhexidine rinsing on the oropharyngeal ecology in patients with head and neck cancer who have irradiation mucositis. Oral Surg Oral Med Oral Pathol. 1989;67:154–61.CrossRef
34.
Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis. 2013;13:665–71.CrossRef
35.
Komljenovic I, Marquardt D, Harroun TA, Sternin E. Location of chlorhexidine in DMPC model membranes: a neutron diffraction study. Chem Phys Lipids. 2010;163:480–7.CrossRef
36.
Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systemic review and meta-analysis. JAMA Intern Med. 2014;174:751–61.CrossRef
37.
Klompas M. Oropharyngeal decontamination with antiseptics to prevent ventilator-associated pneumonia: rethinking the benefits of chlorhexidine. Semin Respir Crit Care Med. 2017;38:381–90.CrossRef
38.
Pemberton MN, Gibson J. Chlorhexidine and hypersensitivity reactions in dentistry. Br Dental J. 2012;213:547.CrossRef
39.
Klarin B, Wullt M, Palmquist I, Molin G, Larsson A, Jeppsson B. Lactobacillus plantarum 299v reduces colonisation of Clostridium difficile in critically ill patients treated with antibiotics. Acta Anaesthesiol Scand. 2008;52:1096–102.CrossRef
40.
Oudhuis GJ, Bergmans DC, Dormans T, Zwaveling J-H, Kessels A, Prins MH Stobberingh EE, Verbon A. Probiotics versus antibiotic decontamination of the digestive tract: infection and mortality. Intensive Care Med. 2011;37:110–7.CrossRef
41.
Oláh A, Belágyi T, Issekutz Á, Gamal ME, Bengmark S. Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis. Br J Surg. 2002;89:1103–7.CrossRef
42.
Rayes N, Seehofer D, Hansen S, Boucsein K, Muller AR, Serke S, Bengmark S, Neuhaus P. Early enteral supply of Lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients. Transplantation. 2002;74:123–8.CrossRef
43.
Rayes N, Hansen S, Seehofer D, Müller AR, Serke S, Bengmark S, Neuhaus P. Early enteral supply of fiber and lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery. Nutrition. 2002;18:609–15.CrossRef
44.
Klarin B, Larsson A, Molin G, Jeppsson B. Susceptibility to antibiotics in isolates of Lactobacillus plantarum RAPD-type Lp299v, harvested from antibiotic treated, critically ill patients after administration of probiotics. Microbiology. 2018;24:e00642. https://​doi.​org/​10.​1002/​mbo3.​642 [Epub ahead of print].CrossRef
45.
Doron S, Snydman DR. Risk and safety of probiotics. Clin Inf Diseases. 2015;60(S2):S129–34.CrossRef
46.
Morrow LE, Kollef MH, Casale TB. Probiotic prophylaxis of ventilator-associated pneumonia: a blinded, randomized, controlled trial. Am J Respir Crit Care Med. 2010;182:1058–64.CrossRef
47.
Silvestri L, Weir I, Gregori D, Taylor N, Zandstra DF, Van Saene JJM, Van Saene HKF. Effectiveness of oral chlorhexidine on nosocomial pneumonia, causative micro-organisms and mortality in critically ill patients: a systematic review and meta-analysis. Minerva. 2014;80:805.
48.
Manzanares W, Margot Lemieux M, Langlois PI, Wischmeyer PE. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Crit Care. 2016;20:262.CrossRef
49.
Bo L, Li J, Tao T, Bai Y, Ye X, Hotchkiss RS, Kollef MH, Crooks NH, Deng X. Probiotics for preventing ventilator-associated pneumonia. Cochrane Database Syst Rev. 2014;10:CD009066.PubMedCentral
50.
Barraud D, Bollaert P-E, Gibot S. Impact of the administration of probiotics on mortality in critically ill adult patients. A meta-analysis of randomized controlled trials. Chest. 2013;143:646–55.CrossRef
51.
Deschepper M, Waegeman W, Eeckloo K, Vogelaers D, Blot S. Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide observational cohort study. Intensive Care Med. 2018;44:1017–26.CrossRef
52.
53.
Abbasi J. Infectious disease expert sees threat from colistin-resistant superbug. JAMA. 2016;316:806–7.CrossRef
Metadata
Title
Can probiotics be an alternative to chlorhexidine for oral care in the mechanically ventilated patient? A multicentre, prospective, randomised controlled open trial
Authors
Bengt Klarin
Anne Adolfsson
Anders Torstensson
Anders Larsson
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2018
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-018-2209-4

Other articles of this Issue 1/2018

Critical Care 1/2018 Go to the issue

Research

Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula

Research

A complete and multifaceted overview of antibiotic use and infection diagnosis in the intensive care unit: results from a prospective four-year registration

Research

Value and mechanisms of EEG reactivity in the prognosis of patients with impaired consciousness: a systematic review

Letter

Use of a meta-analysis to assess the preventive effect of dexmedetomidine on cardiac surgery-associated acute kidney injury

Research

Copeptin levels and commonly used laboratory parameters in hospitalised patients with severe hypernatraemia - the “Co-MED study”

Research

Evidence for a protective role for the rs805305 single nucleotide polymorphism of dimethylarginine dimethylaminohydrolase 2 (DDAH2) in septic shock through the regulation of DDAH activity