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Customizing the indication of chlorhexidine mouthwash for critically ill patients: A reply letter to Honore P.M. and colleagues

      Dear Editor,
      We read with great interest the comments performed by Honore and colleagues
      • Honore PM
      • Afonso EP
      • Blot S
      Dental care and hospital mortality in ICU patients.
      about our recently published article addressing the impact of a dental care intervention on the in-hospital mortality of critically ill patients.
      • Ribeiro ILA
      • Bellissimo-Rodrigues WT
      • Mussolin MG
      • et al.
      Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: a quasi-experimental study [e-pub ahead of print].
      We do agree with them that there is now enough evidence for not routinely using oral topical chlorhexidine among hospitalized patients, for the purpose of preventing healthcare-associated infections.
      • 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.
      • Price R
      • MacLennan G
      • Glen J
      SuDDICU Collaboration
      Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis.
      • Bellissimo-Rodrigues WT
      • Menegueti MG
      • de Macedo LD
      • Basile-Filho A
      • Martinez R
      • Bellissimo-Rodrigues F
      Oral mucositis as a pathway for fatal outcome among critically ill patients exposed to chlorhexidine: post hoc analysis of a randomized clinical trial.
      Unfortunately, in Brazil, chlorhexidine mouthwashes are still largely used, especially in the intensive care setting, despite all the evidence of its negative impact on mortality.
      On the other hand, our results point in the direction that chlorhexidine topical cautious application may do more good than harm to a specific subset of critical patients. We are talking here about people with intra-oral infectious diseases, such as deep caries, oral abscesses, or periodontal disease, for example. In most of these cases, the oral microbiome has long been deeply compromised, and, therefore, the negative impact of using chlorhexidine on that would be offset by its positive impact on controlling the oral infection and inflammation. Among our last study population, chlorhexidine was used in approximately one-third of all oral hygiene procedures (723/2136) performed by dentists. In such cases, dentists managed to focus the antiseptic application on the source(s) of infection, rather than generally applying it in the whole oral cavity.
      If we do parallel thinking with systemic antibiotic use, similar outcomes are found. We mean, if adequate antibiotics are prescribed to patients with a treatable infectious disease, a clear clinical benefit is produced in most cases. However, when prophylactic antibiotics are prescribed for long periods of time, superinfections with C. difficille, yeasts, and multidrug-resistant microorganisms frequently arise, and no clinical benefit is obtained for the patient.
      • Hranjec T
      • Rosenberger LH
      • Swenson B
      • et al.
      Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study.
      ,
      • Gaspar GG
      • Bellissimo-Rodrigues F
      • Andrade LN
      • Darini AL
      Induction and nosocomial dissemination of carbapenem and polymyxin-resistant Klebsiella pneumoniae.
      So, in conclusion, our perception goes in the direction that “one size does not fit all”, and a customized approach is the best way to go when considering the use of chlorhexidine mouthwash among critically ill patients.

      Acknowledgments

      This letter has received no specific funding.

      References

        • Honore PM
        • Afonso EP
        • Blot S
        Dental care and hospital mortality in ICU patients.
        Am J Infect Control. 2022; (In this issue)
        • Ribeiro ILA
        • Bellissimo-Rodrigues WT
        • Mussolin MG
        • et al.
        Impact of a dental care intervention on the hospital mortality of critically ill patients admitted to intensive care units: a quasi-experimental study [e-pub ahead of print].
        Am J Infect Control. 2022; (https://doi.org/10.1016/j.ajic.2022.01.022)
        • 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: 1017-1026
        • Price R
        • MacLennan G
        • Glen J
        • SuDDICU Collaboration
        Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis.
        BMJ. 2014; 348: 1-15
        • Bellissimo-Rodrigues WT
        • Menegueti MG
        • de Macedo LD
        • Basile-Filho A
        • Martinez R
        • Bellissimo-Rodrigues F
        Oral mucositis as a pathway for fatal outcome among critically ill patients exposed to chlorhexidine: post hoc analysis of a randomized clinical trial.
        Crit Care. 2019; 23: 382-383
        • Hranjec T
        • Rosenberger LH
        • Swenson B
        • et al.
        Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study.
        Lancet Inf Dis. 2012; 12: 774-780
        • Gaspar GG
        • Bellissimo-Rodrigues F
        • Andrade LN
        • Darini AL
        Induction and nosocomial dissemination of carbapenem and polymyxin-resistant Klebsiella pneumoniae.
        Rev Soc Bras Med Trop. 2015; 48: 483-487