Chlorhexidine Gluconate Cloths Research Articles

A Quality Improvement Initiative on Reducing Blood Culture Contamination in the Emergency Department

IntroductionContaminated blood cultures may have detrimental effects on patients, the organization, and antimicrobial stewardship. Patients in the emergency department may need blood cultures collected before antimicrobial therapy. Contaminated blood culture samples may contribute to prolonged hospital stay and also are associated with delayed or unnecessary antimicrobial therapy. This initiative aims to improve the emergency department’s blood culture contamination rate that will eventually benefit the patients who will receive timely and proper antimicrobial therapy, and benefit the organization fiscally. MethodsThis quality improvement initiative used the Define–Measure–Analyze–Improve–Control (DMAIC) process. The organization targets blood culture contamination rate of ≤2.5%. Control charts were used to study how blood culture contamination rate changed over time. In 2018, a workgroup was formed to work on this initiative. Improved site disinfection using 2% Chlorhexidine gluconate cloth before the standard procedure of blood culture sample collection was initiated. Chi squared test of significance was used to compare blood culture contamination rates 6 months before and during feedback intervention as well as contamination rate from source of blood draw. ResultsBlood culture contamination rates 6 months before and during feedback intervention showed significant decrease (3.52% before intervention and 2.95% after intervention; P < .05). Contamination rates differed significantly based on the source of blood culture draw (7.64% via line, 3.05% via percutaneous venipuncture, and 4.53% via other; P < .01). DiscussionBlood culture contamination rate continued to decrease with the use of a predisinfection process with 2% Chlorhexidine gluconate cloth before blood sample collection process. Practice improvement also was evident with effective feedback mechanism.

Study To Reduce Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized clinical trial of chlorhexidine

Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora. To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo. In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery. From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis. Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.

70 Chlorhexidine Gluconate for Burn Wound Cleansing: Reduction in Multi-drug Resistant Organism Acquisition

Abstract Introduction Daily wound care is an important part of burn wound management to help prevent infection. Literature suggests that daily Chlorhexidine Gluconate (CHG) bathing can reduce the risk of acquiring Multi-Drug Resistant Organisms (MDRO). The purpose of this study was to identify change in overall MDRO acquisition in the Burn Unit with the addition of a 1% CHG solution for wound care to the CHG bathing protocol for burn patients. Methods Prior to March 2018, routine bathing and wound care involved use of CHG-incompatible antibacterial soap and water followed by 2% chlorhexidine gluconate cloths to intact skin. In March 2018, the bathing protocol changed, in consultation with the hospital’s infection prevention program, to involve a 1% CHG solution for burn wounds followed by 2% CHG cloths to intact skin in order to prevent the loss of protective residual CHG due to rinsing with CHG-incompatible soap and water. A solution of 1% CHG was chosen by staff as an acceptable concentration for wound bathing. Adherence was measured through review of daily documentation of bathing in the electronic medical record. Incidences of burn unit-attributable hospital-onset MDRO cultures were reviewed for the following periods: Baseline (Aug 2016-Aug 2017), Phase-In (Sept 2017 – Aug 2018) and Post-Implementation (Sept 2018 – Aug 2019). Results Adherence was &amp;gt;85% throughout the intervention period. No adverse events were noted. Incidences of hospital-onset burn unit MDROs during the following time periods were: 22 cases (Baseline), 15 cases (Phase-In), and 10 cases (Post-Implementation). The most common organisms in the baseline period were Extended-Spectrum b-Lactamase (ESBL) Escherichia coli, MRSA, and Multi Drug Resistant Pseudomonas; and post-implementation, the most common organisms were: MRSA and MDR-Pseudomonas. Conclusions A change to a 1% CHG solution for rinsing burn wounds in the setting of 2% CHG cloths to intact skin was well tolerated and associated with a decline in MDRO acquisition attributable to the burn ICU in the one-year post implementation. Applicability of Research to Practice The use of a 1% CHG solution for burn wounds may help prevent MDRO acquisition in the highly susceptible and unique burn population.

A Multifaceted Surgical Site Infection Prevention Bundle for Cesarean Delivery.

Surgical site infections (SSI, including wound infections, endometritis, pelvic abscess, and sepsis) may complicate cesarean section (C/S). We report outcomes before and after the introduction of an SSI prevention bundle that did not include antibiotics beyond routine prophylaxis (cefazolin, or gentamicin/clindamycin for penicillin-allergic patients). The prevention bundle was introduced following an increase in C/S-associated SSI, which itself was associated with an institutional switch in preoperative scrub from povidone-iodine to chlorhexidine gluconate (CHG)/isopropanol. Components of the bundle included: (1) full-body preoperative wash with 4% CHG cloths; (2) retraining on surgeon hand scrub; (3) retraining for surgical prep; and (4) patient education regarding wound care. Patients delivered by C/S at ≥24 weeks of gestation were segregated into four epochs over 7 years: (1) baseline (18 months when povidone-iodine was used); (2) CHG scrub (18 months after skin prep was switched to CHG); (3) bundle implementation (24 months); and (4) maintenance (24 months following implementation). A total of 3,637 patients were included (n = 667, 796, 1098, and 1076, respectively, in epochs 1-4). A rise in SSI occurred with the institutional switch from povidone-iodine to CHG (i.e., from baseline to the CHG scrub epoch, 8.4-13.3%, p < 0.01). Following the intervention (maintenance epoch), this rate decreased to below baseline values (to 4.5%, p < 0.01), attributable to a decline in wound infection (rates in the above three epochs 6.9, 12.9, and 3.5%, respectively, p < 0.01), with no change in endometritis. In multivariable analysis, only epoch and body mass index (BMI) were independently associated with SSI. The improvement associated with the prevention bundle held for stratified analysis of specific risk factors such as chorioamnionitis, prior C/S, obesity, labor induction, and diabetes. Implementation of a prevention bundle was associated with a reduction in post-C/S SSI. This improvement was achieved without the use of antibiotics beyond standard preoperative dosing.

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

895. Impact of Measurement and Results Feedback of Chlorhexidine Gluconate (CHG) Skin Concentrations in Medical Intensive Care Unit (MICU) Patients Receiving CHG Bathing

BackgroundHigher CHG skin levels may be needed to adequately control infection and transmission of pathogens in the ICU. We assessed whether measurement and feedback of patient CHG skin concentrations could improve CHG bathing quality and identified factors associated with higher CHG skin concentrations.MethodsWe conducted 6 one-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established daily CHG bathing. Adults admitted >1 day were assessed for CHG skin levels with a semi-quantitative colorimetric assay using swabbed 25 cm2 areas of anterior neck, axilla, and inguinal skin. Prior to survey 4, results from the first 3 surveys (baseline) were reported to ICU leadership and front-line staff to retrain and reeducate on bathing technique. Feedback of results from prior surveys also occurred before surveys 5 and 6. For statistical analysis, mixed-effects models accounted for clustering of CHG measurements within patients and ICUs. We categorized CHG product type as “cloth” for no-rinse 2% CHG-impregnated cloth and “liquid” for 4% CHG liquid or foam.ResultsIn total, 681 of 704 (97%) patients were enrolled. Three ICUs used CHG cloth, 3 ICUs used CHG liquid, and 1 ICU switched from liquid to cloth after the second survey. Median CHG skin concentrations were higher in both the baseline and feedback period for institutions using CHG cloth, as compared with liquid (table). Across all time points, axillary and inguinal regions had higher skin CHG concentrations than the neck (median 39.1, 78.1, 19.5 µg/mL, respectively, P < 0.001). After controlling for age, mechanical ventilation, presence of a central venous catheter, body site, and hours since last CHG bath, institutions that used CHG cloth had a 3-fold increase in adjusted CHG skin concentrations in the feedback period compared with the baseline period (P = 0.001, Figure). There was no significant change in CHG skin concentrations from baseline to feedback period for institutions that used liquid CHG.ConclusionCHG skin concentrations on MICU patients receiving daily CHG bathing varied by body site and CHG product type. The use of CHG cloth was associated with higher CHG skin levels, compared with CHG liquid. For ICUs using CHG cloth, feedback of CHG skin concentration results to ICU staff improved CHG bathing quality. Disclosures All Authors: No reported Disclosures.

563. Association Between Chlorhexidine Gluconate Concentrations and Resistant Bacterial Bioburden on Skin

BackgroundLittle research exists to guide optimal Chlorhexidine gluconate (CHG) bathing practices. We examined the association between CHG concentrations and methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacteriaceae (CRE), and vancomycin-resistant Enterococcus (VRE) on the skin. Also, we studied whether bioburden is affected by bathing method (2% CHG cloth vs. 4% liquid CHG soap) and time since last CHG bath.MethodsPatients with MRSA, CRE and VRE at 4 US hospitals were enrolled. Skin swabs (arm, chest) were collected to quantify bioburden and CHG concentrations. Information on bathing method and time since last CHG bath was collected. χ 2 test, Spearman’s correlation, and linear regression were performed.Results253 patients were enrolled. On arm skin, MRSA was detected in 17 (19%), CRE on 16 (12%), and VRE on 12 (21%) patients. Detectable CHG levels were observed in 82 (93%) MRSA, 81 (79%) CRE, and 44 (79%) VRE patients. A negative correlation was observed between bioburden and CHG concentration for MRSA (rs = −0.11, P = 0.28) and CRE (rs = −0.02, P = 0.82) while a positive correlation was observed for VRE (rs = 0.15, P = 0.28). On chest skin, MRSA was detected in 25 (28%), CRE on 18 (12%), and VRE on 7 (13%) patients. Detectable CHG levels were observed in 83 (95.4%) MRSA, 78 (72%) CRE, and 43 (77%) VRE patients. MRSA bioburden was negatively correlated with CHG concentration (rs = −0.16, P = 0.12), while a positive correlation was noted for CRE (rs = 0.18, P = 0.06) and VRE (rs =0.24, P = 0.06). There was no significant difference in bacterial bioburden between CHG concentrations (>20 ppm vs. ≤20 ppm) at both skin sites (Table 1). The bioburden did not differ by method of CHG bath. The mean estimates of bacterial bioburden on both skin sites did not show a significant decrease with increase in CHG concentrations and were not affected by time since last bath (Table 2).ConclusionDetection of MRSA, CRE and VRE was infrequent irrespective of CHG bathing method and time since last bath. We found inconsistent associations between increasing CHG concentrations and bacterial bioburden. CHG bathing frequency may be optimized for individual patient populations to augment the reduction of bacteria. Additional research to understand the association of CHG skin concentrations and resistant bacterial burden is required. Disclosures All authors: No reported disclosures.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations.

Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG). Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites. Preadmission application of chlorhexidine gluconate, 2% Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively). The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Perioperative Skin Preparation

Liaison: Anthony T Tokarski BS Leaders: David Blaha MD (US), Michael A. Mont MD (US), Parag Sancheti MS, DNB, MCh (International) Delegates: Lyssette Cardona MD, MPH, MHA, AAHIVS, FIDSA, Gilberto Lara Cotacio MD, Mark Froimson MD, Bhaveen Kapadia MD, James Kuderna MD, PhD, Juan Carlos Lopez MD, Wadih Y Matar MD, MSc, FRCSC, Joseph McCarthy MD, Rhidian Morgan-Jones MB BCh, FRCS, Michael Patzakis MD, Ran Schwarzkopf MD, Gholam Hossain Shahcheraghi MD, Xifu Shang MD, Petri Virolainen MD, PhD, Montri D. Wongworawat MD, Adolph Yates Jr, MD

Effectiveness of 2% CHG Cloth Bathing for Reducing Surgical Site Infections

We conducted a prospective cohort study on the effectiveness of preoperative bathing with chlorhexidine gluconate (CHG) cloths for reducing surgical site infections. We hypothesized that use of CHG cloths as an adjunct to surgical prep would significantly reduce the endogenous flora of surgical patients and therefore reduce surgical site infections. Data from a control group of patients who had undergone general, vascular, and orthopedic surgery were used for comparison. Results indicated an overall reduction of infection in the group that received a 2% CHG bath before surgery. There also was a possible reduction in postoperative organ space infection, although the sample numbers were extremely small. To reduce surgical site infections, we suggest a nursing protocol of preoperative bathing with a 2% CHG cloth for patients undergoing general and vascular surgery, and an additional trial to investigate the use of preoperative CHG cloth baths in all surgical patient populations.

Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin

Surgical site infections (SSIs) associated with methicillin-resistant Staphylococcus aureus (MRSA) are a major complication of surgery. This study is part of a large infection control quality improvement effort to eliminate MRSA SSIs. This is an Institutional Review Board-approved, case-control study examining MRSA SSI rates before and after implementation of a facility-wide MRSA SSI prevention protocol in 2007. The protocol involved a 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths. In 2006, a total of 39 MRSA SSIs occurred after 9,976 procedures in patients who underwent orthopedic, vascular, cardiac, or neurosurgical procedures (rate=0.39 per 100 procedures). The highest incidence occurred after cardiac surgery (rate=1.24/100 procedures), and the lowest occurred after orthopedic surgery (rate=0.28/100 procedures). In 2007, the MRSA SSI rate decreased to 20 of 9,818 procedures (rate=0.20/100 procedures) in the 4 categories (P=.016; odds ratio, 1.92). In 2008, the MRSA SSI rate dropped again to 13 of 10,068 procedures (rate=0.13/100 procedures) in the 4 categories (P=.0003; odds ratio, 3.04). A 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths may be beneficial in preventing MRSA SSIs in the non-general surgery population.

Sustained Reduction in Methicillin-Resistant Staphylococcus aureus Incidence in a Geriatric Setting by Implementing Daily Bathing with 2% Chlorhexidine Gluconate Cloths

Sustained Reduction in Methicillin-Resistant Staphylococcus aureus Incidence in a Geriatric Setting by Implementing Daily Bathing with 2% Chlorhexidine Gluconate Cloths

Chlorhexidine Bathing to Reduce Central Venous Catheter-associated Bloodstream Infection: Impact and Sustainability

BackgroundChlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infection. To determine the impact and sustainability of the effect of chlorhexidine bathing on central venous catheter-associated bloodstream infection, we performed a prospective, 3-phase, multiple-hospital study. MethodsIn the medical intensive care unit and the respiratory care unit of a tertiary care hospital and the medical-surgical intensive care units of 4 community hospitals, rates of central venous catheter-associated bloodstream infection were collected prospectively for each period. Pre-intervention (phase 1) patients were bathed with soap and water or nonmedicated bathing cloths; active intervention (phase 2) patients were bathed with 2% chlorhexidine gluconate cloths with the number of baths administered and skin tolerability assessed; post-intervention (phase 3) chlorhexidine bathing was continued but without oversight by research personnel. Central venous catheter-associated bloodstream infection rates were compared over study periods using Poisson regression. ResultsCompared with pre-intervention, during active intervention there were significantly fewer central venous catheter-associated bloodstream infections (6.4/1000 central venous catheter days vs 2.6/1000 central venous catheter days, relative risk, 0.42; 95% confidence interval, 0.25-0.68; P<.001), and this reduction was sustained during post-intervention (2.9/1000 central venous catheter days; relative risk, 0.46; 95% confidence interval, 0.30-0.70; P<.001). During the active intervention period, compliance with chlorhexidine bathing was 82%. Few adverse events were observed. ConclusionIn this multiple-hospital study, chlorhexidine bathing was associated with significant reductions in central venous catheter-associated bloodstream infection, and these reductions were sustained post-intervention when chlorhexidine bathing was unmonitored. Chlorhexidine bathing was well tolerated and is a useful adjunct to reduce central venous catheter-associated bloodstream infection.

Reduction of surgical site infections in low transverse cesarean section at a university hospital

We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS). An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings. Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P= .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period. A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.

Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery

Deep infection after shoulder surgery is a rare but devastating problem. This study tested the hypothesis that the home application of a 2% chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a standard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder. This randomized, prospective study evaluated 100 consecutive patients undergoing shoulder surgery. Patients were randomly assigned to use 2% chlorhexidine gluconate-impregnated cloths (treatment group) or to shower with soap and water before surgery (control group). Cutaneous cultures were taken from the patients'shoulders in the preoperative holding area. Patients were monitored for 2 months postoperatively for clinical signs of infection. In the treatment group vs the control group, the overall positive culture rate was 66% vs 94% (P= .0008), and the positive culture rate for coagulase-negative Staphylococcus was 30% vs 70% (P=.0001). The positive culture rate for Propionibacterium acnes was 46% in the treatment group vs 58% in the control group (P = .32). No infections occurred in any patients at a minimum of 2-months after surgery. The use of the 2% chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus, a known causative agent of postoperative shoulder infections. Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies.

Lessons from a Community-Based Infection Prevention Study

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

Reducing Surgical Site Infections by Bundling Multiple Risk Reduction Strategies and Active Surveillance

Postoperative surgical site infections (SSIs) are serious health care-associated infections that contribute to higher rates of mortality. Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of SSIs. A quality improvement intervention was developed to identify surgical patients with nasal colonization of MRSA, treat them with mupirocin, and introduce a new preoperative skin antisepsis protocol using 2% chlorhexidine gluconate cloths. The total number of SSIs was reduced by 63%, and MRSA SSIs decreased by 78%. Preoperative MRSA screening and treatment and the preoperative skin antisepsis protocol were smoothly integrated into the facility workflow and well accepted by patients. This intervention saved two community hospitals an estimated $240,000.

Presurgical Skin Preparation With a Novel 2% Chlorhexidine Gluconate Cloth Reduces Rates of Surgical Site Infection in Orthopaedic Surgical Patients

Postoperative surgical site infections (SSIs) are a common complication of joint surgery. Prevention depends on adequate preoperative skin antisepsis. In previous studies, use of a 2% chlorhexidine gluconate (CHG) no-rinse cloth reduced SSI rates in general surgery patients. Patients admitted for a total joint procedure used a skin antisepsis protocol incorporating 2% CHG no-rinse cloths to do a site-specific wash on the night before surgery and in the holding area just before surgery. In the 3 quarters before implementation of the protocol, the SSI rate was 3.19%. In the 3 quarters after the 2% CHG cloth was introduced, the SSI rate decreased to 1.59%, representing a 50.16% reduction in SSIs. The rate of SSI was cut in half after the introduction of 2% CHG no-rinse cloths in the place of a povidone-iodine (Betadine) skin antiseptic in orthopaedic patients undergoing total joint procedures. Further testing using randomization comparative protocols are required to conclude that the decreased SSI was in fact a direct result of the 2% CHG protocol.

Preoperative Shower Revisited: Can High Topical Antiseptic Levels Be Achieved on the Skin Surface Before Surgical Admission?

Skin asepsis is a sentinel strategy for reducing risk of surgical site infections. In this study, chlorhexidine gluconate (CHG) skin concentrations were determined after preoperative showering/skin cleansing using 4% CHG soap or 2% CHG-impregnated polyester cloth. Subjects were randomized to one of three shower (4% soap)/skin cleansing (2% cloth) groups (n = 20 per group): (group 1 A/B) evening, (group 2 A/B) morning, or (group 3 A/B) evening and morning. After showering or skin cleansing, volunteers returned to the investigator's laboratory where CHG skin surface concentrations were determined at five separate skin sites. CHG concentrations were compared with CHG minimal inhibitory concentration that inhibits 90% (MIC(90)) of staphylococcal skin isolates. CHG MIC(90) for 61 skin isolates was 4.8 parts per million (ppm). In group 1A, 4% CHG skin concentrations ranged from 17.2 to 31.6 ppm, and CHG concentrations were 361.5 to 589.5 ppm (p < 0.0001) in group 1B (2%). In group 2A (4%), CHG levels ranged from 51.6 to 119.6 ppm and 848.1 to 1,049.6 ppm in group 2B (2%), respectively (p < 0.0001). CHG levels ranged from 101.4 to 149.4 ppm in the 4% CHG group (group 3A) compared with 1,484.6 to 2,031.3 ppm in 2% CHG cloth (group 3B) group (p < 0.0001). Effective CHG levels were not detected in the 4% CHG group in selected sites in seven (35%) subjects in group 1A, three (15%) in group 2A, and five (25%) in group 3A. Effective CHG levels were achieved on most skin sites after using 4% CHG; gaps in antiseptic coverage were noted at selective sites even after repeated application. Use of the 2% CHG polyester cloth resulted in considerably higher skin concentrations with no gaps in antiseptic coverage. Effective decolonization of the skin before hospital admission can play an important role in reducing risk of surgical site infections.

Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients

To determine whether patients bathed daily with chlorhexidine gluconate (CHG) have a lower incidence of primary bloodstream infections (BSIs) compared with patients bathed with soap and water. The study design was a 52-week, 2-arm, crossover (ie, concurrent control group) clinical trial with intention-to-treat analysis. The study setting was the 22-bed medical intensive care unit (MICU), which comprises 2 geographically separate, similar 11-bed units, of the John H. Stroger Jr (Cook County) Hospital, a 464-bed public teaching hospital in Chicago, Illinois. The study population comprised 836 MICU patients. During the first of 2 study periods (28 weeks), 1 hospital unit was randomly selected to serve as the intervention unit in which patients were bathed daily with 2% CHG-impregnated washcloths (Sage 2% CHG cloths; Sage Products Inc, Cary, Illinois); patients in the concurrent control unit were bathed daily with soap and water. After a 2-week wash-out period at the end of the first period, cleansing methods were crossed over for 24 more weeks. Main outcome measures included incidences of primary BSIs and clinical (culture-negative) sepsis (primary outcomes) and incidences of other infections (secondary outcomes). Patients in the CHG intervention arm were significantly less likely to acquire a primary BSI (4.1 vs 10.4 infections per 1000 patient days; incidence difference, 6.3 [95% confidence interval, 1.2-11.0). The incidences of other infections, including clinical sepsis, were similar between the units. Protection against primary BSI by CHG cleansing was apparent after 5 or more days in the MICU. Daily cleansing of MICU patients with CHG-impregnated cloths is a simple, effective strategy to decrease the rate of primary BSIs.