A 2×1 oral care strategy (2% chlorhexidine + 1% sodium bicarbonate) significantly lowers VAP rates in mechanically ventilated CKD patients.

Abstract

Background & objective: Chronic kidney disease (CKD) patients in the ICU have elevated ventilator-associated pneumonia (VAP) risk. Chlorhexidine (CHX) oral care is standard, but efficacy may be enhanced by adding sodium bicarbonate (NaHCO₃) to alkalinize the oral environment and inhibit pathogenic colonization. We conducted this study to determine whether combining 2% CHX with 1% NaHCO₃ reduces VAP incidence versus CHX alone in mechanically ventilated CKD patients.

Methodology: In this prospective, randomized, double‑blind, placebo-controlled trial, 100 CKD patients (18–65 yrs) ventilated > 48 h were randomized to 2% CHX + 1% NaHCO₃ (n = 50) or 2% CHX + saline placebo (n = 50) twice daily for 5 days. Primary outcome: VAP incidence (CPIS ≥ 6 + clinical/radiological criteria). Secondary: oral pH, oropharyngeal colonization, microbiology, ventilation/ICU/hospital stay, mortality. Data analyzed with appropriate parametric/non‑parametric tests; P < 0.05 significant.

Results: Baseline characteristics were comparable. VAP incidence was halved with combination care (16.0% vs 32.0%; P = 0.048), with delayed onset (median 4.5 vs 3.0 days, P = 0.032) and higher Day‑5 VAP‑free survival (84% vs 68%). Oral pH rose significantly from Day 3 in the intervention arm (Day 5: 7.54 vs 7.29; P = 0.001). Heavy oral colonization was lower, but non‑significant. MDRO rates (37.5% vs 56.3%) and carbapenem resistance were reduced. Ventilation duration (6.2 ± 2.1 vs 7.8 ± 2.5 days, P = 0.004) and ICU stay (8.9 ± 3.0 vs 10.5 ± 3.4 days, P = 0.011) were shorter. However, the mortality differences were non‑significant.

Conclusions: In high‑risk CKD ICU patients, adding 1% NaHCO₃ to standard 2% CHX oral care halved VAP incidence, delayed onset, improved oral pH, reduced resistance rates, and shortened ventilation/ICU stays. This simple, low‑cost measure warrants incorporation into VAP prevention bundles.

Keywords: Ventilator‑associated pneumonia, chronic kidney disease, chlorhexidine, sodium bicarbonate, oral pH, multidrug‑resistant organisms, intensive care.

Citation: Sankaralingam S, Bhalekar A, Singh AK, Loha S, Kumar S, Nayak AP. A 2×1 oral care strategy (2% chlorhexidine + 1% sodium bicarbonate) significantly lowers VAP rates in mechanically ventilated CKD patients. Anaesth. pain intensive care 2025;29(9):1184-95. DOI: 10.35975/apic.v29i9.3052

Received: August 14, 2025; Revised: August 20, 2025; Accepted: August 25, 2025