Lessons from a Community-Based Infection Prevention Study

Abstract

From Rush University Medical Center and Stroger Hospital of Cook County, Chicago, Illinois. Received July 20, 2010; accepted July 21, 2010; electronically published October 18, 2010. Infect Control Hosp Epidemiol 2010; 31(12):1216-1218 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3112-0002$15.00. DOI: 10.1086/657137 Chlorhexidine gluconate (CHG) is an antiseptic agent that has been used for multiple purposes including catheter insertion preparation and maintenance, body antisepsis, and application in the nasopharynx and oropharynx. Antisepsis with this agent is believed to reduce colonization with potential pathogens, which in turn would lead theoretically to a reduction in the number of infections. Bathing medical intensive care unit patients with CHG cloths has been effective in reducing the rate of central venous catheter–associated bloodstream infections and the rate of colonization with vancomycin-resistant Enterococcus. CHG bathing, often in combination with nasal application of mupirocin and oral antimicrobial agents, also has been found to decrease rates of colonization with and possibly rates of acquisition of methicillin-resistant Staphylococcus aureus (MRSA). Although it is a promising infection control intervention, examination of the efficacy of CHG bathing outside of the hospital has been limited. MRSA was once considered to be solely a nosocomial pathogen. However, the epidemiology of MRSA has changed—it has emerged in community settings among individuals without prior healthcare exposures, so-called community-associated MRSA (CA-MRSA). Although CA-MRSA can cause invasive disease, such as bloodstream infection, it predominantly causes skin and soft-tissue infection (SSTI). Several distinct groups—military recruits, prisoners, and amateur and professional athletes—have been identified as being at increased risk for CA-MRSA colonization and infection, possibly because of crowding or close contact with other individuals. Military recruits are a unique community population for studying an infection control intervention, given their crowded living conditions, decreased access to bathing, and increased opportunity for cuts and abrasions. CA-MRSA colonization rates have been found to be higher among military recruits than among the general population, with outbreaks of CA-MRSA SSTIs among military recruits reported. Therefore, enhanced prevention efforts in a population such as this may be needed. Standard infection control recommendations for MRSA infection prevention in the community include hand hygiene, covering of wounds, not sharing personal items, and proper environmental cleaning. Decolonization regimens with agents such as CHG have been suggested as an option for individuals with recurrent MRSA infections or if MRSA transmission is occurring despite standard infection control measures; data on the efficacy of this approach, however, are limited. In this issue of the journal, the study by Whitman et al— a cluster-randomized study of military recruits attending Officer Candidate School in Quantico, Virginia—seeks to examine the effectiveness of bathing thrice weekly with CHG cloths (Sage) in this population. They found that there were no significant differences in development of SSTIs in the CHG group versus the control group (Comfort Bath), although the incidence of colonization in the nares and axilla with methicillin-susceptible S. aureus and MRSA was lower in the CHG group. However, colonization in both groups increased during the study, demonstrating the at-risk environment that a military training camp may create and underscoring the importance of infection control in this setting. Most studies examining patient bathing with CHG have occurred in hospital settings with cleansing occurring daily. Daily patient bathing with CHG has been shown to be effective at reducing colonization of skin with potential pathogens; theoretically, the reduction in pathogen burden on patient skin should lead to a decrease in the rate of SSTIs. Although studies have typically assessed daily bathing with CHG, the study by Whitman et al used self-applied thriceweekly bathing because of feasibility issues and data supporting CHG activity for as long as 24 hours. The assessment of CHG cleansing among military recruits in this study, however, was limited by the thrice-weekly bathing in conjunction with relatively poor self-reported adherence with CHG cloths (49.4% of individuals in the CHG group reported use of at least 50% of wipes by week 6). Although the authors found that there were no differences