Chlorhexidine Inefficacy in Ventilated Patients: Reply

We thank Dr. Kempen for his interest in our work.¹  Dr. Kempen states that we “failed to address the specific known pulmonary toxicity.” Dr. Kempen failed to understand that this was not the objective of our study. Dr. Kempen has forgotten that high-quality research recommends to address one question at a time in a study. So the question of chlorhexidine pulmonary toxicity is a completely different question from the one we wished to answer. We would, however, be delighted if Dr. Kempen addresses this interesting issue in a clinical study. Of note, however, we have recently alerted clinicians on the risk of excess mortality linked to chlorhexidine exposure.² 

We thank Dr. Kempen for mentioning the article regarding the hidden financial ties and the Health Quality Group. This reminds us of the utmost importance of disclosing potential conflicts of interest.

Regarding toothbrushing, there is—to date—no clear clinical effect of toothbrushing to reduce ventilator-associated pneumonia in ventilated patients. Indeed, the most recent Cochrane systematic review regarding oral hygiene care³  clearly indicates: “We are uncertain as to the effects of toothbrushing (± antiseptics) on the outcomes of [ventilator-associated pneumonia].” So, Dr. Kempen’s recommendation regarding toothbrushing is purely speculative. In addition, the reference Dr. Kempen used to support his claim⁴  has nothing to do with ventilator-associated pneumonia prevention and does not address intensive care unit patients but individuals of any age with no reported disability that might affect toothbrushing. Importantly, authors of this systematic review cited by Dr. Kempen state: “The clinical importance of these findings [i.e., the greater removal of dental plaque by powered toothbrushing compared with manual toothbrushing] remains unclear.”⁴ 

Finally, Dr. Kempen is wrong when he mentions early tracheostomy as a means to reduce ventilator-associated pneumonia. Large single- or multicenter trials have all failed to show any benefit of early tracheostomy on ventilator-associated pneumonia reduction.^5–7 

Although we welcome all contributions to the debate regarding ventilator-associated pneumonia prevention, scientific accuracy is mandatory for the contribution to be seriously considered.

Drs. La Combe and Ricard have provided this Reply to the Letter to the Editor on behalf of all authors of the original article.¹ 

The authors declare no competing interests.