The Effect of Chlorhexidine on the Oral and Lung Microbiota in Chronic Obstructive Pulmonary Disease

Our hypothesis is that 8 weeks of chlorhexidine oral rinse will decrease microbiota biomass
compared to baseline and those on placebo. Furthermore, we hypothesize that chlorhexidine
treatment will: i) decrease lung and oral microbiota diversity; ii) alter microbiota
taxonomic composition in the lung and oral cavity; iii) decrease systemic inflammation as
measured by blood high sensitivity C-reactive protein (hsCRP), fibrinogen and leukocyte
count; and iv) demonstrate a trend towards improvement in respiratory health status as
measured by the Breathlessness, Cough, and Sputum Scale (BCSS)[1, 2] and St. George's
Respiratory Questionnaire (SGRQ).

Subaim 1: Determine if chlorhexidine alters the lung and oral rinse microbiota diversity and
taxonomic composition. Our hypothesis is that chlorhexidine oral rinse will decrease the
diversity (Shannon and inverse Simpson diversity indices) and taxonomic composition of both
oral and lung microbiota compared to those on placebo as determined by next-generation
sequencing of the bacterial 16S rRNA gene.

Subaim 2: Determine the impact of chlorhexidine on systemic inflammation. Our hypothesis is
that the decrease in lung microbiota biomass is associated with a decrease in systemic
inflammation as measured by blood hsCRP, fibrinogen, and leukocyte count.

Subaim 3: Determine if respiratory symptoms associate with the lung microbiota biomass. Our
hypothesis is that chlorhexidine will demonstrate improved respiratory health status as
measured by the BCSS and SGRQ.

Inclusion Criteria:

- Willingness to undergo sputum induction

- Capability to provide written informed consent

- Age ≥ 40 years and ≤ 85 years

- FEV1/FVC ratio (post bronchodilator) ≤70%

- FEV1 (post bronchodilator) ≤ 65%

- Presence or high likelihood of chronic cough and sputum production defined as one of
the following:

Presence of chronic cough and sputum will be defined by responses to the first two
questions on the SGRQ. Subjects who respond positively to both question 1 (cough) and
question 2 (sputum) on the SGRQ as either "several days per week" or "almost every day"
will be eligible.

COPD exacerbation within the previous 12 months defined as taking antibiotics and/or
prednisone for respiratory symptoms, hospitalization or emergency department visit for
respiratory illness.

- Current or former smoker with lifetime cigarette consumption of > 10 pack-years

- Negative serum pregnancy test at the baseline visit if patient is a pre-menopausal
female (menopause defined as absence of a menstrual cycle in the last 12 months)

- Must be fluent in speaking the English language

- Have a minimum of four teeth

Exclusion Criteria:

- Not fully recovered for at least 30 days from a COPD exacerbation.

- Treated with antibiotics in the last 2 months.

- The presence of dentures (full plate).

- Active oral infection being treated by health care professional.

- Current use of chlorhexidine or over-the-counter mouth washes in the last 2 months.

- Known allergy or sensitivity to chlorhexidine

- Unstable cardiac disease

- Clinical diagnosis of asthma, bronchiectasis, cystic fibrosis, or severe alpha-1
antitrypsin deficiency

- Active lung cancer or history of lung cancer if it has been less than 2 years since
lung resection or other treatment. If history of lung cancer, must have no evidence of
recurrence in the 2 years preceding the baseline visit.