Oropharyngeal Interventions in Intubated Patients for Preventing Ventilator Associated Pneumonia: A Systematic Review and Multi-Variate Network Meta-Analysis Evaluating Pharmacological Agents
Abstract
Background: Ventilator-associated pneumonia (VAP) is a prevalent and serious complication of invasive mechanical ventilation (MV), contributing to significant mortality and increased healthcare resource utilization. While numerous oropharyngeal interventions exist, their comparative efficacy across critical outcomes remains uncertain due to a lack of direct comparisons in clinical trials. Methods: We conducted a systematic review and network meta-analysis (NMA) with a comprehensive search of MEDLINE, EMBASE, and Cochrane CENTRAL up to September 2025 for randomized and non-randomized studies comparing topical oral interventions in intubated patients. The primary outcome was VAP incidence; secondary outcomes were intensive care unit (ICU) mortality, duration of MV, and ICU length of stay (LOS). Pairwise and network meta-analyses were performed, and the certainty of evidence was assessed. The effect estimates were odds ratios (OR) for categorical outcomes and mean difference (MD) for numerical outcomes represented with 95% confidence intervals (95% CI). Results: Ninety-six studies (20,650 patients) were included, evaluating 44 interventions. For VAP prevention, several interventions were superior to reference/control, including Antimicrobial combinations (OR: 0.21, 95% CI: 0.05–0.39), Povidone-iodine (OR: 0.47, 95% CI: 0.21–0.98), and Chlorhexidine (OR 0.61, 95% CI 0.39–0.95). However, only Chlorhexidine plus toothbrushing significantly reduced mortality (OR: 0.74, 95% CI:…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 20,650 participants or records.
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