Chlorhexidine Bathing Research Articles

Universal decolonization with hypochlorous solution in a burn intensive care unit in a tertiary care community hospital

Infections are the leading cause of morbidity and mortality in burn patients. Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at higher risk of developing an invasive infection, and MRSA is endemic in many burn units. The typical decolonization regimen of mupirocin and chlorhexidine bathing is not optimal in burn patients because of chlorhexidine limitations on nonintact skin. We studied the impact of universal decolonization using mupirocin and hypochlorous acid bathing on health care-associated MRSA infections in a burn intensive care unit. We show a significant decrease in total MRSA infections.

The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units.

Background/AimsHealthcare-associated infections (HAIs) in critically ill patients with prolonged length of hospital stay and increased medical costs. The aim of this study is to assess whether daily chlorhexidine gluconate (CHG) bathing will significantly reduce the rates of HAIs in adult intensive care units (ICUs).MethodsPubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched until December 31, 2014 to identify relevant studies. Two authors independently reviewed and extracted data from included studies. All data was analyzed by Review Manager version 5.3.ResultsFifteen studies including three randomized controlled trials and 12 quasi-experimental studies were available in this study. The outcomes showed that daily CHG bathing were associated with significant reduction in the rates of primary outcomes: catheter-related bloodstream infection (risk ratio [RR], 0.44; 95% confidence interval [CI], 0.32 to 0.63; p < 0.00001), catheter-associated urinary tract infection (RR, 0.68; 95% CI, 0.52 to 0.88; p = 0.004), ventilator-associated pneumonia (RR, 0.73; 95% CI, 0.57 to 0.93; p = 0.01), acquisition of methicillin-resistant Staphylococcus aureus (RR, 0.78; 95% CI, 0.68 to 0.91; p = 0.001) and vancomycin-resistant Enterococcus (RR, 0.56; 95% CI, 0.31 to 0.99; p = 0.05).ConclusionsOur study suggests that the use of daily CHG bathing can significantly prevent HAIs in ICUs. However, more well-designed studies are needed to confirm these findings.

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty?

Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size. (1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol? In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category. Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9-20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1-60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5-9.6; p = 0.33] and RR, 11.3 [CI, 0.7-186.7; p = 0.09]). A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study. Level III, therapeutic study.

Beyond the Intensive Care Unit (ICU): Countywide Impact of Universal ICU Staphylococcus aureus Decolonization.

A recent trial showed that universal decolonization in adult intensive care units (ICUs) resulted in greater reductions in all bloodstream infections and clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) than either targeted decolonization or screening and isolation. Since regional health-care facilities are highly interconnected through patient-sharing, focusing on individual ICUs may miss the broader impact of decolonization. Using our Regional Healthcare Ecosystem Analyst simulation model of all health-care facilities in Orange County, California, we evaluated the impact of chlorhexidine baths and mupirocin on all ICU admissions when universal decolonization was implemented for 25%, 50%, 75%, and 100% of ICU beds countywide (compared with screening and contact precautions). Direct benefits were substantial in ICUs implementing decolonization (a median 60% relative reduction in MRSA prevalence). When 100% of countywide ICU beds were decolonized, there were spillover effects in general wards, long-term acute-care facilities, and nursing homes resulting in median 8.0%, 3.0%, and 1.9% relative MRSA reductions at 1 year, respectively. MRSA prevalence decreased by a relative 3.2% countywide, with similar effects for methicillin-susceptible S. aureus. We showed that a large proportion of decolonization's benefits are missed when accounting only for ICU impact. Approximately 70% of the countywide cases of MRSA carriage averted after 1 year of universal ICU decolonization were outside the ICU.

Using New Technology to Prevent Healthcare-Associated Infection in Pediatric Patients

Healthcare-associated infections have a great impact in patients’ morbidity and mortality, as well as increasing the length of stay in the hospital and treatment costs. Progresses in the study of epidemiologic health care and researches in its implementation have led to a better comprehension of the effective strategies to prevent the foresaid infections. The objective of this study is to present and discuss the technological innovations in the prevention of healthcare-associated infections. The following data bases were accessed: PUBMED, EMBASE, Scielo, Scopus, and Cochrane, using the key words: healthcare-associated infections, prevention, innovations, innovative, ventilator-associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI). The evidence degree from the Canadian Task Force on Preventive Health Care was used. For every item, the recommendation degree from the Society for Healthcare Epidemiology of America (SHEA/IDSA) was used. Telemedicine, computerized training, realistic training, hand hygiene monitoring technology, chlorhexidine bathing, chlorhexidine-impregnated dressings, antimicrobial-impregnated catheters, high-flow nasal cannula, subglottic aspiration cannula, and silver-coated endotracheal tubes are examples of the new technologies discussed in the article. However, they do not replace cultural measures, such as the healthcare team’s education, the establishment and compliance to protocols, and multidisciplinary visits where the need for devices and mechanical ventilation is questioned.

Direct care nurses on the shared governance journey towards positive patient outcomes.

To describe shared governance in action through the example of one paediatric institution's decision to institute daily chlorhexidine bathing. Shared governance processes are discussed extensively in the literature; however, implementation of the processes can be challenging. Recently nurses at one paediatric hospital were involved in a hospital-wide practice change where the theoretical approach of shared governance was actualised. Several questions arose from direct care nurses about unwarranted variations in bathing practices across settings and whether bathing standardisation could address the recent increase in central line-associated bloodstream infections. Shared governance council members identified daily chlorhexidine bathing as a potential intervention to standardise bathing across the hospital and to decrease infection rates. At this time, chlorhexidine bathing had been widely adopted in adult hospitals but was less commonly practiced in paediatric institutions. This is a position paper describing the use of shared governance to make a house-wide practice decision and positively impact patient outcomes. Inquiry Council members conducted a systematic evidence search on best practices around chlorhexidine bathing. This evidence was used in Practice Council discussions to standardise house-wide practice. Once consensus was achieved, council members collaborated with Education Council to ensure understanding, competency, and the adoption and sustainment of the practice change. Patients with central lines are at decreased risk for acquiring a central line-associated blood stream infection due, in part, to the change in nursing practice to include daily chlorhexidine bathing. The shared governance structure was the vehicle through which this practice was vetted and instituted. This paper provides a real-life example of leveraging shared governance structures and the direct care nurse leaders within the councils when an organisation faces critical needs in patient care.

The effect of targeted decolonization on methicillin-resistant Staphylococcus aureus colonization or infection in a surgical intensive care unit

The effect of decolonization on the control of methicillin-resistant Staphylococcus aureus (MRSA) may differ depending on intensive care unit (ICU) settings and the prevalence of antiseptic resistance in MRSA. This study was conducted in a 14-bed surgical ICU over a 40-month period. The baseline period featured active surveillance for MRSA and institution of contact precautions. MRSA decolonization via chlorhexidine baths and intranasal mupirocin was implemented during a subsequent 20-month intervention period. Pre-post and interrupted time series analysis were used to evaluate changes in the clinical incidence of hospital-acquired MRSA colonization or infection. MRSA isolates were tested for the presence of qacA/B genes and mupirocin resistance. In pre-post analysis, the clinical incidence of MRSA significantly decreased by 61.6% after implementation of decolonization (P < .001). Meanwhile, interrupted time series analysis showed decreases in both the level (β = -0.686; P = .210) and trend (β = -0.011; P = .819) of clinical MRSA incidence, but these changes were not statistically significant. Of 169 MRSA isolates, 64 (37.8%) carried the qacA/B genes, and 22 (13.0%) showed either low- (n = 20) or high-level (n = 2) resistance to mupirocin. Low-level mupirocin resistance significantly increased from 0%-19.4% during the study period. Although decolonization using antiseptic agents was helpful to decrease hospital-acquired MRSA rates, the emergence of antiseptic resistance should be monitored.

Chlorhexidine Induces VanA-Type Vancomycin Resistance Genes in Enterococci.

Chlorhexidine is a bisbiguanide antiseptic used for infection control. Vancomycin-resistantE. faecium(VREfm) is among the leading causes of hospital-acquired infections. VREfm may be exposed to chlorhexidine at supra- and subinhibitory concentrations as a result of chlorhexidine bathing and chlorhexidine-impregnated central venous catheter use. We used RNA sequencing to investigate how VREfm responds to chlorhexidine gluconate exposure. Among the 35 genes upregulated ≥10-fold after 15 min of exposure to the MIC of chlorhexidine gluconate were those encoding VanA-type vancomycin resistance (vanHAX) and those associated with reduced daptomycin susceptibility (liaXYZ). We confirmed thatvanAupregulation was not strain or species specific by querying other VanA-type VRE. VanB-type genes were not induced. ThevanHpromoter was found to be responsive to subinhibitory chlorhexidine gluconate in VREfm, as was production of the VanX protein. UsingvanHreporter experiments withBacillus subtilisand deletion analysis in VREfm, we found that this phenomenon is VanR dependent. Deletion ofvanRdid not result in increased chlorhexidine susceptibility, demonstrating thatvanHAXinduction is not protective against chlorhexidine. As expected, VanA-type VRE is more susceptible to ceftriaxone in the presence of sub-MIC chlorhexidine. Unexpectedly, VREfm is also more susceptible to vancomycin in the presence of subinhibitory chlorhexidine, suggesting that chlorhexidine-induced gene expression changes lead to additional alterations in cell wall synthesis. We conclude that chlorhexidine induces expression of VanA-type vancomycin resistance genes and genes associated with daptomycin nonsusceptibility. Overall, our results indicate that the impacts of subinhibitory chlorhexidine exposure on hospital-associated pathogens should be further investigated in laboratory studies.

Management of a hospital outbreak of extensively drug-resistant Acinetobacter baumannii using a multimodal intervention including daily chlorhexidine baths

Extensively drug-resistant Acinetobacter baumannii (XDR-Ab) is an increasingly important cause of healthcare-associated infection. Uncertainties remain concerning optimal control measures for healthcare-associated outbreaks. To describe the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large hospital from March 2012 to January 2014. Case-finding included screening of rectum, groin, throat, nose, wounds, iatrogenic portals of entry, and catheterized sites. Antimicrobial susceptibility was evaluated by disc diffusion and E-test. Resistance genes were detected by polymerase chain reaction. Clonality was assessed by pulsed-field gel electrophoresis. Charts of cases were reviewed to identify risk factors for invasive infection. Control measures included isolation and cohorting of cases, hand hygiene reinforcement, environmental decontamination, and source control with daily baths using wipes pre-impregnated with chlorhexidine gluconate. A single clonal strain of XDR-Ab colonized or infected 29 patients. Five patients died of XDR-Ab bacteraemia. Transmission occurred primarily on two wards. Colonization was detected at all anatomical screening sites; only 57% (16/28) of cases were rectal carriers. Advanced malignancy was a risk factor for bacteraemia (relative risk: 5.8; 95% confidence interval: 1.2-27.0). Transmission ended following implementation of the multimodal control strategy. No additional nosocomial cases occurred during the following 20 months. Our study highlights the need to screen multiple anatomic sites to diagnose carriage and identifies risk factors for XDR-Ab bacteraemia. A multimodal intervention that included daily chlorhexidine baths for cases was rapidly followed by the termination of the outbreak. Hospitals should consider similar interventions when managing future XDR-Ab outbreaks.

The Evidence Base for Prophylactic Antibiotics in Patients Receiving Extracorporeal Membrane Oxygenation.

The aim of this review was to evaluate evidence for the use of antibiotic prophylaxis in patients receiving extracorporeal membrane oxygenation (ECMO) therapy. We systematically reviewed MEDLINE, EMBASE, Scopus, and other major databases and included any study that reported rates of infection and whether antibiotic prophylaxis was a part of therapy for patients receiving ECMO. We abstracted rates of infection, microbiology of isolates, prophylactic practices, and individual study inclusion and exclusion criteria. Among 11 studies identified, rates of infection were fairly uniform regardless of prophylaxis use, and the only two studies that directly compared outcomes with and without prophylaxis found no benefit. The causative infectious organisms were heterogeneous, which gives no clear rationale for any particular prophylactic strategy. Although infections during ECMO are serious complications that must be prevented, there is no good evidence to support routine use of prophylactic antibiotics in most patients. Certain subpopulations, such as those with open chests, may have an indication for prophylaxis, but evidence is poor. Future studies should investigate the role of other approaches to infection prevention, such as chlorhexidine bathing and preferential elective cannulation.

Bathing With 2% Chlorhexidine Gluconate: Evidence and Costs Associated With Central Line-Associated Bloodstream Infections.

In a coordinated national effort reported by the Agency for Healthcare Research and Quality, the use of 2% chlorhexidine gluconate (CHG) has reduced the central line-associated bloodstream infection (CLABSI) rate by 40%. Conversely, a recent randomized clinical trial determined that chlorhexidine bathing did not reduce the CLABSI rate. The objectives of this study were to conduct meta-analysis and clarify the effectiveness of 2% CHG bathing by nurses on CLABSIs in adult intensive care unit patients and to determine the contributing costs attributable to CLABSIs and 2% CHG bathing. Eligible studies that included the outcome of bloodstream infection rate for central lines were considered. A rigorous systematic review protocol and software tools available from the Joanna Briggs Institute via OvidSP were used. Agency for Healthcare Research and Quality tools assisted with identifiable CHG bathing costs. Four studies were included in the meta-analysis for the outcome of primary bloodstream infections, and 2 studies narratively supported the meta-analysis. A relative risk of 0.46 with 95% confidence interval (0.34-0.63) was determined. This significant effect is seen in an overall z-score of 4.84 (P < .0001). This meta-analysis supports that 2% CHG reduces CLABSIs. The estimated cost increase of 2% CHG-impregnated cloths is $4.10 versus nonmedicated bathing cloths. The cost associated with a single CLABSI is 10 times more than the cost of using 2% CHG-impregnated cloths. Nursing provides significant influence for the prevention of CLABSIs in critical care via evidence-based best practices.

Decolonization of Methicillin resistantStaphylococcus aureus: Role in the Neonatal Intensive Care Unit

Purpose: We aimed to assess the incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a neonatal intensive care unit (NICU) by using various decolonization methods and to evaluate their efficacy. Methods: Medical records of all neonates who were admitted to the NICU of Seoul National University Children's Hospital were retrospectively reviewed. Surveillance culture were obtained for all neonates in the NICU 48 hours after admission. Three periods with different decolonization methods were compared; Period 1 was without any decolonization measures (July 1, 2009 to August 26, 2010). In period 2, intranasal mupirocin and chlorhexidine gluconate bathing were administered to MRSA-colonized neonates (August 27, 2010 to September 6, 2011). In period 3, only chlorhexidine bathing was performed for MRSA-colonized infants (September 7, 2011 to August 31, 2012). Results: A total of 1,378 infants were admitted to the NICU during the study period. Baseline demographic and clinical characteristics were similar among the 3 periods. The incidence of MRSA colonization per 1,000 patient-days was 6.27 for period 1, 7.02 for period 2, and 6.29 for period 3; however, these values were not significantly different. The incidence of MRSA infection was highest in period 3, with 0.69 cases per 1,000 patient-days; however, this finding was not significant. The MRSA infection/ colonization ratio also did not differ significantly among the 3 study periods. Conclusion: Decolonization of MRSA in the NICU with the application of chlorhexidine gluconate bathing alone or in combination with intranasal mupirocin were not effective in decreasing the incidence of MRSA colonization and infection.

The Impact of a Universal Decolonization Protocol on Hospital-Acquired Methicillin-Resistant Staphylococcus aureus in a Burn Population.

Hospital-acquired (HA) methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of HA infections and a significant concern for burn centers. The use of 2% chlorhexidine-impregnated wipes and nasal mupirocin significantly decreases the rate of HA-MRSA in adult intensive care units. The aim of this study was to examine the impact of universal decolonization on the rate of MRSA conversion in an American Burn Association verified adult and pediatric burn center. Universal decolonization protocol consisting of daily chlorhexidine baths and a 5-day course of nasal mupirocin was implemented in the burn unit. MRSA screening both on admission and weekly and contact isolation practices were in place in pre-decolonization and post-decolonization periods. Patient data were analyzed 2 years before and 1 year after implementation of the protocol. The incidence rate of MRSA was significantly decreased after the implementation of the decolonization protocol (11.8 vs 1.0 per 1000 patient days, P < .001). Secondary to the loss of the skin barrier and suppressed immune systems, burn patients are at greater risk for invasive infection leading to severe complications and death. The prevalence of HA-MRSA at our institution's burn center was significantly decreased after the implementation of a universal decolonization protocol.

The Effect of Chlorhexidine Bathing on Rates of Nosocomial Infections Among the Critically Ill Population: An Analysis of Current Clinical Research and Recommendations for Practice.

This literature review examined the current research of evidence-based standards to evaluate the effectiveness of daily bathing with 2% chlorhexidine gluconate (CHG; manufactured by Sage Products Inc) compared with traditional non-antimicrobial bathing on reducing the incidence of nosocomial infections in the critically ill population. The objective of this article is 3-fold: first, to provide a background on the increased susceptibility to pathogens that have become endemic in many intensive care units; second, to challenge health care providers to question current practice and consider additional ways to ensure safety and better outcomes in the critically ill population; and third, to provide health care providers with clinical evidence to avoid infection control failures. To determine whether published standards for daily patient bathing exist, a search was conducted of bibliographic databases for articles published within the last 5 years (2010-2015). Ultimately, 3 large multicenter cluster randomized controlled studies were chosen to compare the outcomes of daily bathing with 2% CHG cloths with those of daily bathing with non-antimicrobial cloths. The side-by-side comparison of the studies revealed similar outcomes, but with variations in study design. Climo et al (2013) and Milestone et al (2013) recommended the implementation of daily bathing with 2% CHG washcloths as a strategy to decrease nosocomial infections in the critically ill population. Huang et al (2013) recommended universal decolonization as the most effective method to decrease nosocomial infections. The analysis of the 3 primary studies revealed similar findings that support the recommendation for the implementation of daily bathing with 2% CHG in the critically ill population. Further research will inform clinicians on the susceptibility of bacteria to CHG and the probability of creating microbial resistance.

Research in Review: Driving Critical Care Practice Change.

During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.

The effect of daily chlorhexidine baths on nosocomial meticillin-resistant Staphylococcus aureus infection in MRSA-colonized patients admitted to general wards

Compared to the Intensive Care Unit setting, relatively little data has been published on the benefits of daily Chlorhexidine gluconate (CHG) baths in infection prevention on general wards. To contribute to our knowledge of this infection prevention strategy we report three years of cumulative data from a 550-bed general hospital in Singapore. Our hospital infection control policy mandates Methicillin-resistant Staphylococcus aureus (MRSA) entry-screening for all cases admitted to hospital. Positive cases are isolated or cohorted with appropriate contact precautions. In addition positive cases receive daily 4% CHG baths throughout their stay. We compare the rates of hospital-acquired MRSA (HA-MRSA) infection in the cohort that screened MRSA-positive (and hence received daily CHG baths) with the cohort in whom MRSA was not detected and hence did not receive CHG baths. Of 4598 screen-positive cases only 4 developed HA-MRSA infection. This compares to 36 cases of HA-MRSA infection among 5391 patients who we estimate were undetected MRSA-carriers, either because they missed screening, or screened false-negative, or acquired MRSA during their hospital stay. MRSA-colonized patients receiving daily CHG baths while in hospital were significantly less likely to develop HA-MRSA infection (OR = 0.129; P = 0.0001; 95% CI 0.046-0.36; NNT = 172)). We conclude that General Ward patients who screen MRSA-positive on admission and who receive daily CHG baths throughout hospitalization have a significantly lower rate of HA-MRSA infection compared to patients who screen MRSA-negative and who do not receive such CHG baths.

The effect of daily chlorhexidine baths on nosocomial meticillin-resistant Staphylococcus aureus infection in MRSA-colonized patients admitted to general wards

Compared to the Intensive Care Unit setting, relatively little data has been published on the benefits of daily Chlorhexidine gluconate (CHG) baths in infection prevention on general wards. To contribute to our knowledge of this infection prevention strategy we report three years of cumulative data from a 550-bed general hospital in Singapore. Our hospital infection control policy mandates Methicillin-resistant Staphylococcus aureus (MRSA) entry-screening for all cases admitted to hospital. Positive cases are isolated or cohorted with appropriate contact precautions. In addition positive cases receive daily 4% CHG baths throughout their stay. We compare the rates of hospital-acquired MRSA (HA-MRSA) infection in the cohort that screened MRSA-positive (and hence received daily CHG baths) with the cohort in whom MRSA was not detected and hence did not receive CHG baths. Of 4598 screen-positive cases only 4 developed HA-MRSA infection. This compares to 36 cases of HA-MRSA infection among 5391 patients who we estimate were undetected MRSA-carriers, either because they missed screening, or screened false-negative, or acquired MRSA during their hospital stay. MRSA-colonized patients receiving daily CHG baths while in hospital were significantly less likely to develop HA-MRSA infection (OR = 0.129; P = 0.0001; 95% CI 0.046-0.36; NNT = 172)). We conclude that General Ward patients who screen MRSA-positive on admission and who receive daily CHG baths throughout hospitalization have a significantly lower rate of HA-MRSA infection compared to patients who screen MRSA-negative and who do not receive such CHG baths.

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Bathing in Community Hospital Intensive Care Units

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Bathing in Community Hospital Intensive Care Units

Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial

Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs. We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period. 122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88-1·18) for screening or isolation, 0·88 (0·76-1·02) for targeted decolonisation, and 0·87 (0·77-1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85-1·40] for screening or isolation, 1·01 [0·79-1·29] for targeted decolonisation, and 0·78 [0·63-0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80-1·17] for screening and isolation, 0·83 [0·70-1·00] for targeted decolonisation, and 0·93 [0·79-1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95-1·37) for screening and isolation, 0·99 (0·83-1·18) for targeted decolonisation, and 0·83 (0·70-0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88-1·68] for screening or isolation, 1·01 [0·73-1·39] for targeted decolonisation, and 0·63 [0·45-0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81-1·25] for screening or isolation, 1·04 [0·83-1·30] for targeted decolonisation, and 0·74 [0·61-0·90] for universal decolonisation, p=0·04). Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women. HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.

Efficacy of chlorhexidine bathing for reducing healthcare associated bloodstream infections: a meta-analysis.

BackgroundWe performed a meta-analysis of randomized controlled trials (RCTs) to determine if daily bathing with chlorhexidine decreased hospital-acquired BSIs in critically ill patients.MethodsWe searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases to identify randomized controlled trials that compared daily bathing with chlorhexidine and a control in critically ill patients.ResultsThis meta-analysis included five RCTs. The overall incidence of measured hospital-acquired BSIs was significantly lower in the chlorhexidine group compared to the controls 0.69 (95 % CI 0.55–0.85; P < 0.001; I2 = 57.7 %). Gram-positive-induced (RR = 0.49, 95 % CI 0.41–0.58; P = 0.000; I2 = 0.0 %) bacteremias were significantly less common in the chlorhexidine group. The incidence of MRSA bacteremias (RR 0.63; 95 % CI 0.44–0.91; P = 0.006; I2 = 30.3 %) was significantly lower among patients who received mupirocin in addition to chlorhexidine bathing than among those who did not routinely receive mupirocin.ConclusionsDaily bathing with chlorhexidine may be effective to reduce the incidence of hospital-acquired BSIs. However, chlorhexidine bathing alone may be of limited utility in reduction of MRSA bacteremia; intranasal mupirocin may also be required. This meta-analysis has several limitations. Future large-scale international multicenter studies are needed.