Impact of Oral Chlorhexidine on Bloodstream Infection in Critically Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVES: Oropharyngeal overgrowth of microorganisms in the critically ill is a risk factor for lower respiratory tract infection and subsequent invasion of the bloodstream. Oral chlorhexidine has been used to prevent pneumonia, but its effect on bloodstream infection never has been assessed in meta-analyses. The authors explored the effect of oral chlorhexidine on the incidence of bloodstream infection, the causative microorganism, and on all-cause mortality in critically ill patients. DESIGN: Systematic review and meta-analysis of published studies. SETTING: Intensive care unit. PARTICIPANTS: The study comprised critically ill patients receiving oral chlorhexidine (test group) and placebo or standard oral care (control group). INTERVENTIONS: PubMed and the Cochrane Register of Controlled Trials were searched. Odds ratios (ORs) were pooled using the random-effects model. MEASUREMENTS AND MAIN RESULTS: Five studies including 1,655 patients (832 chlorhexidine and 823 control patients) were identified. The majority of information was from studies at low or unclear risk bias; 1 study was at high risk of bias. Bloodstream infection and mortality were not reduced significantly by chlorhexidine (OR 0.74; 95% confidence interval [CI] 0.37-1.50 and OR 0.69; 95% CI 0.31-1.53, respectively). In the subgroup of surgical, mainly cardiac, patients, chlorhexidine reduced bloodstream infection (OR 0.47; 95% CI 0.22-0.97). Chlorhexidine did not affect any microorganism significantly. CONCLUSION: In critically ill patients, oropharyngeal chlorhexidine did not reduce bloodstream infection and mortality significantly and did not affect any microorganism involved. The presence of a high risk of bias in 1 study and unclear risk of bias in others may have affected the robustness of these findings.

Salmonella sepsis simulating gastrointestinal ischaemia following cardiopulmonary bypass.

Cardiac surgery is commonly associated with gastrointestinal complications. The incidence of severe abdominal pathology ranges from 0.5% to 3% and is associated with a 30% risk of mortality. Frequently occurring complications include splanchnic infarction, perforated bowel, pancreatitis, upper intestinal bleeding and diverticulitis. Systemic and localised infections are also common after open heart surgery. Plasma proteins, neutrophils, monocytes, endothelial cells and lymphocytes are all altered by cardiopulmonary bypass (CPB). Cell mediated immunity is depressed following exposure to the extra-corporeal circuit leading to an increased susceptibility and vulnerability to pathogens. Typhoid fever is the systemic manifestation of Salmonella typhi septicaemia. Its presentation can be similar to that of abdominal ischaemia making the diagnosis of this potentially fatal multi-systemic illness challenging. We report a fatal case of salmonella septicaemia convincingly masquerading as mesenteric ischaemia following routine CPB.