Chlorhexidine Gluconate Bathing Research Articles

Implementing a Compliance Monitoring Process to Promote Chlorhexidine Gluconate Bathing and Hand Hygiene: An Initiative to Decrease Central Line–Associated Bloodstream Infections

Background Chlorhexidine gluconate (CHG) bathing has proven to reduce central line–associated bloodstream infections (CLABSI) in hospitalized patients. The aim of this study is to evaluate whether the implementation of a compliance monitoring process for CHG bathing and strict hand hygiene as part of the traditional CLABSI prevention bundle will reduce the overall hospital CLABSI standardized infection ratio (SIR). Methods A quasi-experimental study was conducted in intensive care and non-intensive care inpatient hospital units in an urban 361-bed teaching hospital in Western Pennsylvania. The pre-intervention period consisted of January–August 2021, the intervention period consisted of September–November 2021, and the post-intervention and sustainability period consisted of December 2021–June 2022. A compliance monitoring process for the initiation of a daily bath using a 4% CHG solution and strict hand hygiene surveillance was implemented as part of the standard CLABSI prevention bundle (which includes standardized insertion checklists and processes, daily necessity assessment, dressing change and integrity standards, five moments hand hygiene standards, CHG disk [Biopatch], end caps [Curos], and care of tubing). Outcomes A statistically significant increase in hand hygiene (p=<0.001) and in CHG bathing compliance (p=0.014) helped reduce the overall hospital CLABSI SIR from 1.45 to 0.82, standing for an overall 43.4% decrease. Cost reduction was statistically significant (p=0.011) and was an estimated $1.4 million dollars in savings for the hospital. Next Steps Incorporate the compliance monitoring component for CHG bathing and hand hygiene as part of the best strategy for CLABSI bundle prevention within the healthcare system.

Quantity versus Quality: Chlorhexidine Bathing Adequacy Assessments in 3 High-Risk Units

Background: Chlorhexidine gluconate bathing (CHGB) prevents healthcare associated infections (HAIs). CHGB quality is rarely assessed; prior studies identified that concentrations of CHG can be suboptimal, particularly at the neck, and if rinsed after application. In the setting of increased HAI rates on 3 high-risk units, we evaluated CHG skin concentrations, comparing results to bathing documentation and patient reports as part of a quality improvement initiative. Methods: All patients admitted to 3 high-risk units were swabbed for CHG concentration testing at the neck, bilateral upper arms, and groin. Swabs were processed using a semi-quantitative colorimetric CHG assay. A threshold of 0.001875% CHG was used to determine adequacy based on prior studies. Adequacy was assessed by body site, timing of bath, and patient-reported skin care activities using Chi-square tests in SAS 9.4. Per hospital policy, all admitted patients are bathed daily with 2% CHG pre-packed wipes. Patients without a documented CHGB for the duration of the admission were excluded. Results: CHG testing was completed on 63 patients: 23 on medical ICU, 18 surgical ICU, 22 oncology ward, yielding 249 samples. Only ward patients could report the time of last CHGB, which agreed with nursing documentation for 12/21(57%) Adequacy by sample was no different across units: 59/88(67%) Oncology, 68/90(76%) MICU, 56/71(79%) SICU, p=0.2091. Site adequacy was different by site: neck 36/63(57%), left arm 49/62(79%), right arm 50/62(81%), groin 48/62(77%), p=0.0083. Samples taken from the 11 patients with > = 24 hours since last CHGB were more likely to be below threshold concentration: 19/47(40%) versus 47/202(23%) not adequate in the recent treatment grouping. Three patients reported showering soon after the CHGB and 8 patients used moisturizing lotion. The percent of samples below threshold for the showering patients (6/12, 50%) and lotion-users (11/32, 34%) were not significantly different from the non-showering or non-lotion using patient samples (p=0.0588 and 0.2800 respectively). Conclusion: In a facility with longstanding daily CHGB policies in place, 66/249 samples from 63 patients lacked adequate concentrations of CHG for optimal HAI prevention. Even in patients with recent CHGB, 23% of sites tested revealed inadequate levels of CHG, while 60% of those overdue for CHGB kept adequate concentrations. Reliable implementation strategies are required for CHGB so as to ensure maximal infection prevention impact.

Heterogeneity in Pre-operative Staphylococcus aureus Screening and Decolonization Strategies among Healthcare Institutions

Background: Staphylococcus aureus (SA) is the most common pathogen causing surgical site infections (SSIs). In the past decade, strategies incorporating new SA decolonization products have been implemented to prevent SSIs in surgical patients. The objective of this cross-sectional study was to determine which pre-operative screening and decolonization strategies are currently utilized in healthcare institutions. Methods: A survey was programmed in REDCap and emailed to members of the Society for Healthcare Epidemiology of America Research Network, the Minnesota chapter of the Association of Practitioners in Infection Control and Epidemiology, and the Minnesota Hospital Association between May-August 2023. We report the prevalence of institutional screening and decolonization strategies and decolonization products used for the prevention of SA SSIs. Results: A total of 153 unique institutions initiated the survey and 111 provided complete data on their institutional screening and decolonization strategies. The most commonly reported strategies included universal decolonization (decolonization of pre-operative patients without screening for carrier status) (n=31, 27.9%), no screening or decolonization (n=24, 21.6%), targeted screening for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA) and decolonization based on carrier status (n=24, 21.6%), or MRSA only screening and decolonization (n=11, 9.9%) (Figure 1). Institutions that utilized targeted screening and decolonization strategies frequently reported using nasal mupirocin (n=18, 66.7%MSSA, n=29, 60.4%MRSA), chlorhexidine gluconate (CHG) bathing (n=16, 59.3%MSSA, n=28, 58.3%MRSA), and CHG cloths (n=7, 25.9%MSSA, n=14, 29.2%MRSA) (Figure 2). Among the 31 institutions that reported implementing the universal decolonization strategy, CHG bathing (n=18, 58.1%), CHG cloths (n=15, 48.4%), and nasal povidone iodine (n=14, 45.2%) were the most prevalent decolonization products. Additionally, a smaller percentage of institutions used nasal alcohol gel (n=5, 16.1%) for universal decolonization. Conclusion: Compared to the survey we conducted in 2012, we report a new shift towards universal decolonization and a small increase in targeted SA screening and decolonization.1 In the 2012 survey we reported 37% of respondents’ institutions screened pre-operative patients for SA carriage and the majority of those institutions decolonized carriers.1 Universal decolonization was not reported in the 2012 survey.1 We highlight the continued heterogeneity in practice at this time, which may reflect the ongoing uncertainty in optimal decolonization practices and emphasizes the need for future research.

Antimicrobial bathing of the critically ill for the prevention of healthcare-associated infection at a hospital in California

Background: Patients in the intensive care unit (ICU) have invasive lines increasing their risk for healthcare-associated infections (HAIs). Our objective was to determine if antimicrobial bathing with 2% chlorhexidine gluconate (CHG) compared to the colloidal silver-based antimicrobial product would reduce the incidents of central line–associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Methods: We performed a before-and-after study in four adult ICUs at a two-hospital facility in California. Prospective surveillance of CLABSI and CAUTI prevention bundles monitoring was established. The intervention consisted of daily bathing with CHG for all patients in the ICUs. A baseline period of one year was followed by an intervention period of one year. The incidence rates of CLABSIs and CAUTIs were compared between the baseline and intervention periods utilizing a t-test analysis. Results: A total of 10103 patients were included. At Facility A, a mean CLABSI rate of 2.43/1000 central line catheter days (CL) with 2149 patients days (Mean differences 95% CI -0.5–3.1; P>0.0975), during the baseline period followed by 1.11/1000 CL days with 2193 patient days in the intervention period. At Facility B, the mean CLABSI rate of 1.82/1000 CL days with 2976 patient days (Mean differences 95% CI -0.6–2.31; P>0.161) during the baseline period was followed by 1.01/1000 CL days with 2785 patient days in the intervention period. At Facility A, the mean CAUTI rate of 1.37/1000 indwelling catheter days (IUC) with 2149 ICU patient days (Mean difference 95% CI is 0.28–1.97; P 0.2160) was noted in the baseline period, followed by 0.45/1000 IUC days with 2785 in the intervention period. Conclusion: Daily bathing with CHG significantly reduced the incidence of CAUTI at Facility A. It is unclear why Facility A saw a statistically significant reduction in CAUTI, but Facility B did not. The difference in outcomes may be related to hospital size, service lines, supply constraints, and discrepancies in staffing. CHG bathing was not directly associated with a reduced risk of CLABSI at Facility A and B during our limited study, but it was encouraging enough that our organization will continue this intervention to obtain additional data to determine if bathing with CHG will reduce CLABSI and CAUTI.

Case-Control Study Design to Identify Attributable Risk Factors for Rare Yet Trending Healthcare-Associated Infections

Introduction: There are a number of tools available to healthcare epidemiologists for identification and investigation of healthcare-associated infections. For example, root cause analysis (RCA) is an evidence-based strategy for identifying process failures that resulted in infection. However, RCA is most valuable on a case-by-case basis. It is not an efficient tool for investigating numerous events that trend over time. Healthcare epidemiologists must use different strategies that are both efficient and powerful. A case-control study is a valuable option to investigate rare but recurrent infection events. The objective of this study was to demonstrate the utility of a case-control study design to detect attributable risk factors of cesarean section surgical site infections (SSI). Methods: We conducted a case-control study at a Level III childbirth center with data timeframe of January 1, 2021 to May 31, 2023. The project was approved by the institutions’ Quality Improvement Review Board prior to implementation. Cases were identified using the National Healthcare Safety Network (NHSN) SSI event criteria and included all levels of SSI. Controls were selected from the NHSN surgical denominator and were matched randomly without replacement by age at a 1:4 ratio. Variables were identified in collaboration with stakeholders based on known risk factors for SSI and abstracted manually. Analyses were conducted in Stata/MP version 17.0, and we performed multivariable conditional logistic regression with an alpha of 0.05 as threshold for statistical significance. The model was built according to a priori hypotheses and results from bivariate analysis of individual risk factors. Results: There were 32 SSI among 1709 cesarean deliveries, and all cases successfully matched with 4 controls for an analytic sample of 128. Bivariate analyses identified 7 relevant variables for inclusion in the multivariable model which narrowed down significant risk factors to 3: operative time (in minutes), post-operative chlorhexidine gluconate (CHG) bathing, and number of people in the operating room. Assessment of fit indices suggested an excellent fit with pseudo R-square of 0.526. Conclusions: This study demonstrated the utility of a case-control study design to identify attributable risk factors for relatively rare but significantly trending infection events. Not only is the design more efficient (e.g., time needed to abstract 50 data points for each patient), but it also employs statistical analyses that are often lacking in case-by-case investigations or RCA. It also has the power to narrow down risk factors for focused prevention efforts to get “the most bang for the buck.”

Horizontal versus vertical strategies for infection prevention: current practices and controversies.

Healthcare-associated infections (HAIs) represent a major burden on healthcare facilities. Effective infection prevention strategies are essential to prevent the spread of HAIs. These can be broadly classified as vertical and horizontal interventions. Through this review, we aim to assess the merits of these strategies. Vertical strategies include active surveillance testing and isolation for patients infected or colonized with a particular organism. These strategies are beneficial to curb the spread of emerging pathogens and during outbreaks. However, the routine use of contact precautions for organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus remains controversial. Horizontal interventions are larger-scale and reduce HAIs by targeting a common mode of transmission shared by multiple organisms. Among these, hand hygiene, chlorhexidine gluconate bathing of select patients and environmental decontamination are the most high-yield and must be incorporated into infection prevention programs. As antimicrobial stewardship is also an effective horizontal strategy, antimicrobial stewardship programs must operate in synergy with infection prevention programs for maximal impact. Overall, horizontal interventions are considered more cost-effective and have a broader impact. Infection control programs may opt for a combination of vertical and horizontal strategies based on local epidemiology and available resources.

Relationship between chlorhexidine gluconate concentration and microbial colonization of patients' skin.

To characterize the relationship between chlorhexidine gluconate (CHG) skin concentration and skin microbial colonization. Serial cross-sectional study. Adult patients in medical intensive care units (ICUs) from 7 hospitals; from 1 hospital, additional patients colonized with carbapenemase-producing Enterobacterales (CPE) from both ICU and non-ICU settings. All hospitals performed routine CHG bathing in the ICU. Skin swab samples were collected from adjacent areas of the neck, axilla, and inguinal region for microbial culture and CHG skin concentration measurement using a semiquantitative colorimetric assay. We used linear mixed effects multilevel models to analyze the relationship between CHG concentration and microbial detection. We explored threshold effects using additional models. We collected samples from 736 of 759 (97%) eligible ICU patients and 68 patients colonized with CPE. On skin, gram-positive bacteria were cultured most frequently (93% of patients), followed by Candida species (26%) and gram-negative bacteria (20%). The adjusted odds of microbial recovery for every twofold increase in CHG skin concentration were 0.84 (95% CI, 0.80-0.87; P < .001) for gram-positive bacteria, 0.93 (95% CI, 0.89-0.98; P = .008) for Candida species, 0.96 (95% CI, 0.91-1.02; P = .17) for gram-negative bacteria, and 0.94 (95% CI, 0.84-1.06; P = .33) for CPE. A threshold CHG skin concentration for reduced microbial detection was not observed. On a cross-sectional basis, higher CHG skin concentrations were associated with less detection of gram-positive bacteria and Candida species on the skin, but not gram-negative bacteria, including CPE. For infection prevention, targeting higher CHG skin concentrations may improve control of certain pathogens.

Octenidine exposure was not associated with reduced octenidine susceptibility of meticillin-resistant Staphylococcus aureus in an extended-care facility in Singapore

Antiseptics such as chlorhexidine gluconate (CHG) and octenidine dihydrochloride (OCT) are frequently used in hospitals to prevent and control the transmission of meticillin-resistant Staphylococcus aureus (MRSA). Given the increasing prevalence of reduced CHG susceptibility of MRSA, there are concerns about the possibility of reduced OCT susceptibility. This study evaluated the prevalence of reduced CHG and OCT susceptibility over 3 years, and assessed the association between OCT exposure and reduced OCT susceptibility in MRSA. MRSA isolates from inpatients who acquired MRSA in an extended-care facility between 2019 and 2021 were included in antiseptic susceptibility testing. Inpatients were exposed to universal daily CHG bathing from January to September 2019, and universal daily OCT bathing after October 2019. The minimum inhibitory concentrations (MICs) of CHG and OCT were determined using the broth microdilution method. Multi-variable logistic regression was used to assess if OCT exposure was independently associated with reduced OCT susceptibility. Of 186 isolates, 179 (96%) had reduced CHG susceptibility (MIC ≥4mg/L) and 46 (25%) had reduced OCT susceptibility (MIC ≥2mg/L). Reduced OCT susceptibility rates were 26.9%, 13.8% and 14.3% in 2019, 2020 and 2021, respectively. Reduced CHG susceptibility rates were 95.4%, 100% and 95.9% in 2019, 2020 and 2021, respectively. OCT exposure was not associated with reduced OCT susceptibility (adjusted odds ratio 0.23, 95% confidence interval 0.08-0.75; P=0.014), after adjusting for age, gender, race, year of sample collection, days at risk in facility, hospitalization in preceding year, and MRSA colonization/infection in preceding year. The prevalence of reduced OCT susceptibility has remained low, despite universal OCT bathing for extended inpatient care. However, the rate of reduced CHG susceptibility was high. OCT exposure was not associated with reduced OCT susceptibility in MRSA.

Misuse of the P Value: Using Quality Improvement Analyses to Identify Clinically Significant Improvements.

Quantitative research and quality improvement (QI) both seek to improve care provided to patients. However, clinicians often blur the lines between how to appropriately analyze data from these methodologies. Clinicians may inappropriately use statistical analyses for QI initiatives, rather than using run and statistical process control (SPC) charts to analyze improvements in outcomes. The purpose of this article was to address the analytic methods used for QI initiatives in the clinical setting in an effort to show clinicians how to identify meaningful improvements in clinical practice. In this article, we provide an example comparing the same evidence-based practice/QI initiative (chlorhexidine gluconate bathing in a medical intensive care unit) using a quasi-experimental pretest/posttest research design with statistical analyses completed with t tests with analyses using run and SPC charts to show the data trended over time. Using a pretest/posttest design, chlorhexidine gluconate bathing compliance improved from 63% to 65%, a nonsignificant change, P = .075. These same data plotted on run and SPC charts, however, show a shift and a trend, indicating clinically significant improvements per QI methodologies. The example in this article highlights the pitfall of relying only on statistical analyses and P values to determine the importance of a clinical project, and provides a practical example for how run or SPC charts can be used to identify improvements over time.

A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery.

This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients. A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery. About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients. An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rateof infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.

Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey.

To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014. Cross-sectional survey. Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology. In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014. Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place. Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.

Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children?

National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11years undergoing any surgical procedure with the use of an incision in the OR (N=1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.

273. Chlorhexidine Gluconate (CHG) Bathing in Nursing Homes (NHs) and Hospitals: Impact on the Nose &amp; Skin Microbiome and Multidrug Resistant Organism (MDRO) Prevalence

Abstract Background Widespread CHG bathing to prevent infection has raised concerns about potential skin microbiome perturbations and depletion of commensal microbiota. Methods A prospective repeated measures cross-over study in NH residents/hospital patients evaluated the impact of CHG vs routine soap bathing on the nose/skin microbiome. Participants underwent serial visits during distinct CHG and routine soap phases (Figure) involving nares, axilla, groin, and finger/hand swabs processed for MDROs, CHG concentration (skin sites only), and bacterial 16S rRNA V1-3 gene sequencing (Illumina MiSeq). Sequences were processed with DADA2 and analyzed with PhyloSeq and Vegan packages in R to calculate microbial diversity and composition. Results We enrolled 30 participants (20 NH, 10 hospital). Mean age was 62y, 52% female. Mean CHG concentration was 1736 µg/mL (range: 0-20000) during CHG visits vs 17.5 µg/mL (range: 0-1250) during routine soap visits. MDRO prevalence was lower during CHG visits (NH: 19%, hospital: 9%) vs routine soap visits (NH: 47%, hospital: 23%). 555 samples from 30 participants were adequate for microbiome analyses. CHG did not affect overall alpha diversity of microbial communities on skin (Figure), but proteobacteria were notably higher in NH vs hospital participants (P&amp;lt; 0.001). Because gram-negative bacteria often exhibit higher MICs to CHG than gram-positive bacteria, we assessed whether CHG concentration in NHs was associated with greater relative abundance of proteobacteria using generalized linear mixed models clustered by person. In NHs, CHG concentration was not associated with relative abundance of skin proteobacteria, although body mass index ≥30 (14% higher abundance, P=0.01) and stool/urine incontinence were (13% higher, P=0.01). Compared to the axilla, the groin had 35% higher relative abundance of proteobacteria (P&amp;lt; 0.001); fingers/hand samples had 9% lower (P=0.01). Nose/Skin Taxonomic Diversity Not Impacted by CHG Bathing Timeline and alpha diversity using the Shannon Diversity Index of axilla, groin, finger/hand, and nares samples during CHG versus routine soap bathing phases. Each dot represents a sample. There were no significant differences in alpha diversity between CHG and routine soap phases. Conclusion CHG bathing reduced MDRO prevalence but did not impact skin or nasal microbial alpha diversity in hospital or NH participants. Overall, NH residents had notably higher relative abundance of skin proteobacteria vs hospital patients. This finding was not associated with CHG concentration. Rather, proteobacteria appeared enriched in NH residents with obesity or incontinence. Disclosures Gabrielle Gussin, MS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning &amp; antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals &amp; nursing homes received antiseptic bathing product Raveena D. Singh, MA, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning &amp; antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals &amp; nursing homes received antiseptic bathing product Raheeb Saavedra, AS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning &amp; antiseptic product|Xttrium Laboratories: Conducted studies where participating hospitals &amp; nursing homes received antiseptic bathing product Connie Nguyen, n/a, Xttrium Laboratories: Conducted studies where participating hospitals &amp; nursing homes received antiseptic bathing product Robert Pedroza, BS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning &amp; antiseptic product Chase Berman, BS, Medline Industries, Inc: Conducted studies where participating hospitals/nursing homes received cleaning &amp; antiseptic product Susan S. Huang, MD MPH, Medline Industries, Inc: Conducted studies whereby participating nursing homes and hospital patients received cleaning &amp; antiseptic products|Xttrium Laboratories: Conducted studies where participating nursing homes and hospital patients received antiseptic products

739. Impact of Alcohol-based Nasal Decolonization’s Method of Documentation in Reducing Methicillin-resistant Staphylococcus aureus Hospital-associated Infections

Abstract Background Infections related to multi-drug resistant organisms (MDRO) are increasingly difficult to treat and contribute to elevated mortality, prolonged length of stay and financial burden. At a 382-bed academic medical center, universal decolonization using an alcohol-based nasal decolonizing agent is performed twice daily on all inpatients, as well as chlorhexidine gluconate (CHG) bathing on select populations. Numerous studies cite decolonization as an effective reduction method for MDRO such as methicillin-resistant Staphylococcus aureus (MRSA). Unfortunately, documentation method is a seldomly considered variable. The purpose of this review was to evaluate the impact of documentation method for an alcohol-based nasal decolonization agent in reducing MRSA hospital-associated infections. Methods The study included all National Healthcare Safety Network (NHSN) defined hospital associated laboratory identified (Lab ID) MRSA blood infections from July 2019 through March 2023. Data was divided into descriptive categories with number of infections noted. The baseline period included population specific decolonization (n=35), followed by universal decolonization documentation via nursing task list (n=13), and concluded with electronic medication administration record (EMAR) implementation (n=7). The Kruskal Wallace Test was utilized for evaluation due to non-normative distribution. Results A Kruskal Wallace H Test indicated a statistical significance in medians between the task list and EMAR H(1) =5.10, p=0.024. There was no significance noted between the baseline and task list H(1 =0.04), p=0.841. Medians between baseline and EMAR approached significance but did not meet for this study H(1) =3.24, p=0.072. Clinically, there was a reduction in MRSA Lab ID of 48% between baseline and task list, followed by a 46% reduction between task list and EMAR. Overall reduction from baseline to EMAR was 80%. Conclusion Reduction of infection is crucial for patient safety and quality outcomes. Documentation is not typically highlighted as a risk reduction method. This study noted a significant decrease in hospital-associated MRSA Lab ID events after transition of documentation from the nursing task list to the EMAR. Disclosures All Authors: No reported disclosures

1703. Pseudo-Outbreak of Methicillin-Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit: Implications for Surveillance

Abstract Background We conduct weekly surveillance screening for methicillin-resistant Staphylococcus aureus (MRSA) in our neonatal intensive care unit (NICU). In September 2021, we noted an increase in positive MRSA screening results and identified 2 patients with MRSA wound infection. We conducted an investigation to explore the possibility of in-unit transmission. Methods We launched a multi-pronged investigation that included additional patient screening. Surveillance isolates were assessed for the presence of MRSA using chromogenic agar. Additional antimicrobial sensitivity testing was performed on an automated bacterial identification system if chromogenic agar results were inconclusive, fig 1 &amp; 2. We also conducted audits of staff hand hygiene, enhanced cleaning and disinfection of shared patient-care equipment, implemented standardized chlorhexidine gluconate (CHG) scrub use for NICU staff upon unit entry, and added new CHG bathing for certain patients. Positive control chromogenic agar plate Ambiguous chromogenic agar results Results Over the course of a 6-week long investigation, 18 neonates were found to be MRSA-positive on surveillance swabs using chromogenic agar. In the first 2 weeks of the investigation, PFGE showed that 9 MRSA isolates were genetically distinct. Over the next weeks, additional MRSA-positive surveillance swabs were collected and ultimately 15 isolates underwent whole genome sequencing at the Mass. State Public Health Laboratory. Only 2 pairs of isolates appeared related. Antimicrobial resistance genes were identified and revealed only 6 of the 15 isolates contained the mecA gene consistent with MRSA. As a result, all 18 positive surveillance swabs obtained during the investigation underwent full identification and sensitivity testing confirming only 6 samples contained MRSA and 12 contained methicillin-sensitive Staphylococcus aureus (MSSA). Testing discordance with breakthrough MSSA growth was reported to the chromogenic agar manufacturer. Conclusion Our investigation identified that an increase in MRSA-positive surveillance swabs was a pseudo-outbreak due to false-positive MSSA growth on MRSA selective media. At the conclusion of this investigation, the need for ongoing surveillance swabs was re-evaluated and ultimately discontinued. Clinical NICU specimens are now monitored in real-time by Infection Control. Disclosures James Kirby, MD, D(ABMM), Abbott Molecular: Educational Grant

Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs

Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. ClinicalTrials.gov Identifier: NCT03140423.

El baño en cama en pacientes adultos en cuidados críticos

Introduction: Bed bathing is an essential intervention to provide well-being and comfort to critically ill patients, as well as to protect them from risks and threats. Prolonged hospitalization in critical care units can have negative consequences, and bed bathing has been presented as a complementary intervention to improve the care provided by nursing staff. Methods: An integrative literature review was carried out in the Scopus and Scielo databases for the last 5 years, using descriptors such as "baths" and "critical care". A total of 60 articles were obtained, from which 22 relevant to the topic were selected. Results: Bed bathing with chlorhexidine gluconate (CHG) has been shown to be effective in reducing bacterial colonization, healthcare-associated infections and the incidence of bloodstream infections in critically ill patients. Although positive results were observed with regular use of CHG bathing, more research is needed to define the optimal frequency and duration of treatment, as well as to evaluate possible adverse effects. The use of music to reduce pain in ventilated patients is identified.Conclusion: Bed bathing is used more frequently in critical settings with CHG. Further research with larger samples and defined methods is needed to maximize its effectiveness and establish clear guidelines for its appropriate use.

Horizontal approaches to infection prevention: daily chlorhexidine gluconate bathing.

Healthcare-associated infections (HAIs) pose a significant challenge in hospitals. Infection control strategies have been widely employed to mitigate their incidence. In hospitals, chlorhexidine gluconate (CHG) solutions are commonly used as antiseptic skin cleansers as part of comprehensive infection prevention bundles, with daily CHG bathing being highly effective in reducing HAIs and lowering skin micro-organism density. This evidence review addresses the challenges of risk stratification in implementing CHG bathing protocols in hospitals. It highlights the benefits of a horizontal approach, where CHG bathing is implemented across the entire facility rather than being limited to specific patient populations. Evidence from systematic reviews and studies suggests that CHG bathing consistently reduces HAI rates in both intensive care unit (ICU) and non-ICU settings, supporting the adoption of a hospital-wide approach. The findings emphasise the significance of incorporating CHG bathing as part of a comprehensive approach to infection prevention in hospitals and highlight the potential for cost savings.

Chlorhexidine bathing in a tertiary care neonatal intensive care unit: A pilot study.

Concerns regarding potential risk of dermal irritation have led to the exclusion of NICU patients from the recommendation regarding the use of 2% chlorhexidine gluconate (CHG) wash for daily skin cleansing to reduce bloodstream infections. Our aim was to assess the safety of 2% CHG bathing in NICU patients. The regulator required a stepwise study enrollment to three successive groups: term infants, followed by near-term and pre-term infants. For comparison, we used a cohort of matched controls. A propensity score-adjusted regression model was used to compare the groups. Infants were bathed thrice-weekly with 2% CHG-impregnated washcloths. Participant's skin was examined daily. Over a total of 661 days of treatment: 384,129, and 148 days for the term, near-term and pre-term groups, respectively, no skin reactions were observed. The intervention group was generally sicker, however, bloodstream infections were similar between the groups. For infants >30 weeks and >3 days old, 2% CHG bathing was safe. Large multicenter studies are urgently needed to establish the effectiveness of this practice in the NICU.

Reduction in patient refusal of CHG bathing

Daily chlorhexidine gluconate (CHG) bathing is a well-supported intervention to reduce patient's risk of central line associated bloodstream infection (CLABSI); however, compliance with this practice is suboptimal. One major barrier is patient refusals of CHG bathing. The purpose of this project was to implement tailored interventions to mitigate this barrier. The specific aims were to reduce patient refusals, increase compliance with CHG bathing, and evaluate CLABSI rates and nursing staff's knowledge of CHG bathing. Iterative Plan-Do-Study-Act (PDSA) cycles were implemented over the course of 6 months. Run charts were used to identify signals of improvement. Interventions included printed educational flyers for staff and patients, educational sessions, an electronic learning module, and a "badge buddy." We saw a reduction in the median percentage of patient refusals documented, from 23% to 8% after the PDSA cycles. Documentation compliance with CHG bathing increased only slightly from 46% to 47%. CLABSI rates decreased 6% from 0.69 to 0.65. Using interventions tailored to the clinical setting can impact patient outcomes. Other health care systems should consider implementing PDSA cycles to improve evidence-based practices. Using PDSA cycles can result in a reduction in patient refusal documentation, and may slightly improve CHG bathing compliance and CLABSI rates.