Chlorhexidine within a standardized oral-care bundle for the prevention of ventilator-associated pneumonia: a pragmatic cluster-randomized crossover trial in six medical intensive care units
In brief
Adding chlorhexidine did not lower pneumonia rates in ventilated ICU patients
In six medical ICUs, a trial of 1,035 ventilated adults found no reduction in pneumonia when 0.12% chlorhexidine was added to standard oral care: rates were 18.8 versus 16.9 cases per 1,000 ventilator-days. Mortality was also similar, while ICU stays averaged 0.89 days longer with chlorhexidine; the single-hospital findings offer no clear case for routine use.
- Journal
- Critical care (London, England) (Q1)
- Published
- 29 October 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- S Anushapreethi, Pritam Chhotray, Samir Samal, Sagarika Panda, Rohit Patnaik, Shakti Bedanta Mishra
- PMID
- 42958418
- DOI
- 10.1186/s13054-026-06217-0
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (paper of the day, 31 October 2026): Cluster-randomized trial of ventilator-associated pneumonia prevention
Abstract
BACKGROUND: Chlorhexidine (CHX) has been a long-standing component of oral-care bundles for preventing ventilator-associated pneumonia (VAP), but recent evidence has questioned its benefit in non-cardiac-surgery ICU. We evaluated whether adding 0.12% CHX to standardized oral-care bundle provides incremental benefit in a mixed medical ICU. METHODS: We conducted a prospective, pragmatic cluster-randomized crossover (AB/BA) trial in six adult medical ICUs of a single tertiary-care academic hospital in Bhubaneswar, India. ICUs were randomized as three ICUs of two Period of 9 months with the multicomponent oral-care bundle without chlorhexidine and three with the same bundle plus 0.12% chlorhexidine with a 1-month wash-in and re-training interval. Consecutive adults ventilated for ≥ 48 h were included. The primary outcome was VAP incidence density (Clinical Pulmonary Infection Score (CPIS) > 6) as per 1,000 ventilator-days. Secondary outcomes were 28-day all-cause mortality, duration of mechanical ventilation, ICU length of stay, 28- day ventilator-free days, Beck Oral Assessment Scale (BOAS) and Critical-Care Pain Observation Tool (CPOT) scores. The primary model was a population-averaged Poisson generalized estimating equation (GEE) and adjustment for treatment, period, sequence, age, sex, APACHE II, and SOFA. RESULTS: A total of 1,035 patients (637 No CHX, 398 CHX) accrued 10,024 ventilator-days (5,918 vs. 4,106). Groups were well balanced at baseline (mean age ≈ 55 years; APACHE II ≈ 19.6; SOFA ≈ 13.4). VAP occurred in 100/5,918 ventilator-days (16.9 per 1,000) vs. 77/4,106 (18.8 per 1,000) (No CHX vs. CHX). The adjusted Poisson incidence rate ratio was 1.08 (95% CI 0.84-1.38; p = 0.56). 28-day mortality was 28.7% vs. 26.4% (no CHX vs. CHX) (adjusted OR 0.87, 95% CI 0.65-1.15; p = 0.33). ICU length of stay was longer in the CHX arm (adjusted mean difference + 0.89 days, 95% CI + 0.19 to + 1.58; p = 0.013). BOAS and CPOT scores did not differ. CONCLUSIONS: In this trial, adding 0.12% chlorhexidine to a standardized oral-care bundle did not reduce VAP incidence density or 28-day mortality and was associated with a modest increase in ICU length of stay. Routine CHX use provided no clear incremental benefit in a mixed medical ICU population. TRIAL REGISTRATION: Clinical Trials Regisrty- India (CTRI) identifier [CTRI/2024/02/062201], registered [01 February 2024].
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.