Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients: Evidence-based Practice - Article Example

Running Head: EVIDENCE BASED PRACTICE Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients: Evidence-based Practice of thestudent Under the guidance of University Date of submission APA Format Word Count: Oral Chlorhexidine to Post-operative Pneumonia in Cardiac Surgery Patients Nosocomial infections, especially lower respiratory tract infections are a major cause for morbidity, mortality, prolonged hospital stay and increased cost of health care in patients who have undergone cardiac surgery. Many strategies have been developed to prevent such nosocomial infections, one such measure being chlorhexidine mouth wash. In this article, evidence based practice for such a strategy will be explored through review of literature while addressing the PICO question "In pre/post operative cardiac patients , what is the effect of Peridex (Chlorhexadine) oral rinse on preventing post operative pneumonia?" Relevance of the topic to nursing practice Nosocomial infections are common after cardiac surgeries. More than 20 percent of patients who have undergone cardiac surgeries develop nosocomial infections (Munro and Grap, 2004). Research has shown that these nosocomial infections are important contributors for morbidity, mortality, increased stay in the intensive care unit and hospital, increased need for antibiotics and higher costs of health care (Munro and Grap, 2004). One of the prerequisites for development of nosocomial infections is colonization of the patient by microorganisms which are potentially pathogenic. Of utmost importance is lower respiratory tract infections which are caused by colonization in the oropharyngeal region. Thus, decontamination of oropharynx becomes important to prevent pneumonia and associated problems following heart surgery. Several methods have been recommended to decontaminate oropharynx, one such being chlorhexidine solution. Many research studies have proved the role of this antimicrobial solution when used as mouth rinse in patients in critical care units and on mechanical ventilation. Some studies have explored the usefulness of such a treatment by administering the solution before and after cardiac surgery. Whether use of chlorhexidine rinse in pre/post cardiac surgery patients is effective in reducing the incidence of pneumonia in the post-operative period can be sought by reviewing literature for evidence based information based on the following PICO format. Problem: Post-operative pneumonia P: Pre/post operative cardiac surgery patients I: The use of chlorhexidine oral rinse C: As an effective pre/post operative antimicrobial agent O: Reduces the incidence of pneumonia in the post-operative period. To consider what articles must be included in the review to make the review more authentic and reliable, knowledge on the different levels of accorded studies is essential. The different levels of studies are called hierarchy. Hierarchy provides a confidence measure to the end-user (Evans, 2003). According to Evans (2003), random control trials can be considered of good standard and they are infact labeled as the gold standard of research for providing optimal research designs to answer pertinent questions. However, systemic reviews and meta-analysis have topped the hierarchy list. Search for studies relating to PICO Question The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. As Benton & Cormack (2000) mentioned, electronic databases are resourceful in presenting large amounts of recently published literature. Medline search Search in this electronic database was conducted using the MeSH terms "chlorhexidine", "peridex", "oral rinse", "mouth wash", "cardiac surgery patients", "heart surgery patients", "pneumonia", "lower respiratory tract infections". The only limits set was "English language article only" because lack of understanding of the reviewer of other languages. The search yielded 16 results. After reviewing the abstracts, the following article was chosen for review and discussion. Segers, P., Speekenbrink, R.G., Ubbink, D.T., van Ogtrop, M.L, de Mol, B.A. (2006). Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA, 296(20), 2460-6. Google scholar Search in google scholar was performed using the terms "chlorhexidine oral rinse" " cardiac surgery patients". The search yielded 2220 results. The abstracts of the first 2 pages was reviewed and the following articles were selected for study. It was found that all the articles found in the Medline search were there in google scholar also. DeRiso, A.J. 2nd, Ladowski, J.S., Dillon, T.A., Justice, J.W., Peterson, A.C. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest., 109(6), 1556-61. Berry, A.M., Davidson, P.M., Masters, J., and Rolls, K. (2007). Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation. American Journal of Critical Care, 16, 552-562. CINAHL Journal Search Search in this database was pursued after logging in and using the search terms "chlorhexidine", "peridex", "oral rinse", "mouth wash", "cardiac surgery patients", "heart surgery patients", "pneumonia", "lower respiratory tract infections". 10 articles were found from which the following article was chosen after review of abstracts. It was found that all the articles found in this database were found in Medline and google search. Houston, S., Hougland, P., Anderson, J.J., LaRocco, M., Kennedy, V., Gentry, L.O. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care, 11(6), 567-70. It was noted that most search engines placed the results in a hierarchical order with the most relevant articles coming first or accorded higher star ratings. This search yielded valuable papers all which have been identified in all the 3 databases. Analysis of the studies in each database 1. Segers, P., Speekenbrink, R.G., Ubbink, D.T., van Ogtrop, M.L, de Mol, B.A. (2006). Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA, 296(20). Retrieved on 29th November, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/17119142?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor. Segers, Speekenbrink, Ubbink et al (2006) conducted a double-blind, prospective, randomized and placebo-controlled trial in Netherlands to ascertain the effectiveness of oropharyngeal rinse and nasal ointment application of chlorhexidine gluconate in preventing nosocomial infections like staphylococcus aureus pneumonia. The main outcomes measured in this study were, nosocomial infection rates, rate of staphylococcus aureus nasal carriage and duration of stay in the hospital. The interventions used in the study were oropharyngeal rinse of chlorhexidine against placebo. The results of the study were that the incidence of nosocomial infection in the chlorhexidine gluconate group was 19.8% as against 26.2% of the placebo group (Statistical analysis: absolute risk reduction or ARR, 6.4%; 95% confidence interval 1.1%-11.7%; P = .002). Of the nosocomial infections, lower respiratory tract infections (ARR, 6.5%; 95% CI, 2.3%-10.7%; P = .002) and deep surgical site infections (ARR, 3.2%; 95% CI, 0.9%-5.5%; P = .002) were predominantly decreased in the study group indicating the efficiency of chlorhexidine prophylaxis in decreasing the rates of pneumonia in cardiac surgery patients. Based on these results, the authors concluded that decontamination of oropharynx and nasopharynx is a suitable method to prevent lower respiratory tract infections in patients who have undergone cardiac surgery. The level of evidence of this study is 1b (Oxford, 2001). This study addresses the PICO problem in out article "post-operative pneumonia" and it answers the PICO question by ascertaining that chlorhexidine is a useful method of preventing post-operative pneumonia in patients who undergo cardiac surgery. 2. DeRiso, A.J. 2nd, Ladowski, J.S., Dillon, T.A., Justice, J.W., Peterson, A.C. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest., 109(6). Retrieved on 29th November, 2009 from http://chestjournal.chestpubs.org/content/109/6/1556.abstract The purpose of the study by DeRiso, Ladowski, Dillon et al (1996) was to evaluate the effectiveness of decontamination of the oropharynx with chlorhexidine gluconate oral rinse in preventing nosocomial infections in patients undergoing heart surgery. the study was a double-blind, prospective randomized controlled clinical trial. The intervention studied was 0.12 percent chlorhexidine gluconate oral rinse. The study revealed that administration of the drug decreased the infection rate by 65 percent (4/270 vs 9/291; P = .21). The study also revealed that the incidence of respiratory tract infections following surgery decreased by 69 percent. other important implications for practice derived from the study was decrease in the use of nonprophylactic antibiotics and reduction in mortality. The level of evidence of this study is 1b (Oxford, 2001). The authors opined that chlorhexidine mouth was administration to perioperative cardiac surgery patients is an inexpensive and easy method of decontamination of the oropharynx that reduces the incidence of nosocomial respiratory tract infection significantly, thus contributing to decreased mortality and cost to health care. 3. Berry, A.M., Davidson, P.M., Masters, J., and Rolls, K. (2007). Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation. American Journal of Critical Care, 16. Retrieved on 29th November, 2009 from http://ajcc.aacnjournals.org/cgi/content/abstract/16/6/552 The study by Berry, Davidson, Masters et al (2007) conducted a systematic review and appraisal of literature to ascertain the best evidence for providing appropriate oral care for patients admitted to intensive care units and receiving mechanical ventilation. Another purpose of the study was to document research agenda of provision of oral care in optimizing outcomes of patients. The search retrieved 55 articles, 11 of which were prospective controlled trials, from various electronic databases. The systematic review explored various oral hygiene methods, one of which was chlorhexidine mouth wash. According to the review, chlorhexidine oral rinse is an useful measure to prevent nosocomial pneumonia in patients undergoing cardiac surgery, however; the implications of the reviewed studies pertaining to this aspect cannot be generalized to all intensive care patients and more trials are needed to ascertain the role of chlorhexidine mouthwash in preventing nosocomial pneumonia following cardiac surgery. The level of evidence of this study is 1a (Oxford, 2001). 4. Houston, S., Hougland, P., Anderson, J.J., LaRocco, M., Kennedy, V., Gentry, L.O. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care, 11(6) (CINAHL database). The study by Houston, Houghland and Anderson (2002) was conducted based on background information that decreasing bacterial levels in the oropharyngeal region should decrease the prevalence of nosocomial pneumonia. The test was performed to ascertain the effectiveness of chlorhexidine gluconate mouth wash in decreasing colonization of microorganisms in the respiratory tract, thus preventing nosocomial pneumonia, in patients undergoing open heart surgery. The study was a randomized, case-controlled prospective trial. The control used was Listerine. According to the statistical results of the study, the rate of nosocomial pneumonia decreased by 52 percent in patients who used chlorhexidine (4/270 vs 9/291; P = .21). Also, another interesting finding of the study was the decrease in rate of pneumonia by 58 percent in patients who were intubated for more than 24 hours and whose microbial cultures showed evidence of microbial growth. Infact, when compared to the control group, the rate of pneumonia was 71 percent lower. From this study, it is evident that chlorhexidine mouth wash is effective in preventing nosocomial pneumonia in postoperative cardiac patients and the effect is pronounced in patients who already have established microbial colonisation. The level of evidence of this study is 1b (Oxford, 2001). This study addresses the PICO problem "post-operative pneumonia" and ascertains the important role of chlorhexidine mouth rinse in preventing post-operative nosocomial infections in patients who have undergone cardiac surgery. Best evidence To ascertain as to whether chorhexidine mouthwash is an useful antimicrobial measure to prevent post-operative nosocomial infection in patients who undergo cardiac surgery, 2 studies were selected for evidence based practice. They are studies by Houston et al (2002) and DeRisco et al (1997). Both the studies are at higher level of hierarchy (level 1 b evidence). The validity of these studies may be evaluated using Duffys Research appraisal method (Burns & Grove, 1997). There are 3 types of validity which need to be evaluated. They are construct validity, internal validity and external validity. Construct validity may be defined as the extent to which a scale measures a certain construct (Parahoo, 2006) in which the link between conceptual definitions and operational definitions is examined. In both studies, the essence of construct validity was intact. Both the studies used 0.12 percent chlorhexidine solution for oropharyngeal rinse for the purpose of preventing nosocomial infections in the port-operative period following cardiac surgery. Internal validity is the extent to which the findings in the study reflect reality. It provides an effective measure in studies investigating causality (Burns & Grove, 1997). The factors attributed to internal validity are biases and confounders (Parahoo, 2006). Both the trials are randomised control trials and thus there is no source of bias. Confounding factors like age, sex, oral health prior to surgery may influence the results which were not taken into account. External validity is a measure of the applicability of study findings and conclusions to other similar settings and populations (Burns & Grove, 1997). This aspect is important to know in the study because it gives an idea as to what extent the suggested causality is likely to hold true in other settings. Both the studies were conducted in cardiac surgery patients and the findings cannot be generalized to other surgical and intensive care patients. However, the studies do ascertain that chlorhexidine oral rinse is a useful measure to prevent post-operative nosocomial infection in patients undergoing cardiac surgery. Conclusion Evidence based practice is essential to deliver the most appropriate treatment. While looking for evidence from research article, those with higher levels of hierarchy have better level of evidence. Addressing a clinical problem is possible through analysis of the problem in PICO format. Through such an evaluation it has been possible to ascertain that chlorhexidine solution is a useful preventive measure to prevent post-operative pneumonia in patients undergoing cardiac surgery. References Benton, D.C. and Cormack, D.F.S. (2000). Reviewing and evaluating the literature: In: Cormack, D.F.S. (Ed.). The Research Process in Nursing. 4th Edition. Oxford: Blackwell Publishers Limited, 103 – 113. Berry, A.M., Davidson, P.M., Masters, J., and Rolls, K. (2007). Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation. American Journal of Critical Care, 16. Retrieved on 29th November, 2009 from http://ajcc.aacnjournals.org/cgi/content/abstract/16/6/552 Burns, N., Grove, S. K. (1997). The Practice of Nursing Research: Conduct, Critique and Utilisation. 3rd edition. Philadelphia: W. B. Saunders Co. DeRiso, A.J. 2nd, Ladowski, J.S., Dillon, T.A., Justice, J.W., Peterson, A.C. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest, 109(6). Retrieved on 29th November, 2009 from http://chestjournal.chestpubs.org/content/109/6/1556.abstract Evans, D. (2003). Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), p. 77 – 84. Houston, S., Hougland, P., Anderson, J.J., LaRocco, M., Kennedy, V., Gentry, L.O. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care, 11(6). [CINAHL] Munro, C.L. and Grap, M.J. (2004). Oral Health and Care in the Intensive Care Unit: State of the Science. American Journal of Critical Care, 13, 25-34. Oxford Centre for Evidence-based Medicine. (2001). Levels of Evidence. Retrieved on 29th November, 2009 from http://www.cebm.net/index.aspx?o=1047 Parahoo, L. (2006). Nursing research: Principles, Process, and Issues. London: Macmillan. Segers, P., Speekenbrink, R.G., Ubbink, D.T., van Ogtrop, M.L, de Mol, B.A. (2006). Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA, 296(20). Retrieved on 29th November, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/17119142?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&log$=citationsensor Read More