Running head: CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 1

Chlorhexidine to Reduce Hospital Acquired Infections

Stacy D. Dunham

University of South Florida

CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 2

Abstract

Clinical Problem: ICU patients are much more susceptible to healthcare-associated infections

(HAIs), such as Staphylococcus aureus, bacteremia, VRE, and MRSA then other hospitalized

patient due to a lengthier hospital stay. The acquisition of a nosocomial infection in the ICU

patient population also increases cost, risk, and morbidity.

Objective: To determine if performing daily chlorhexidine (CHX) baths, compared to standard

nonantimicrobial baths, will decrease the prevalence of HAIs in ICU patients. PubMed, Oxford

Journals, American Journal of Infection Control, Elsevier, and the National Guideline

Clearinghouse were all used to research various clinical trials, nursing practices, and hospital

guidelines to reduce infection. The key search terms used were hospital acquired infections,

nosocomial infections, MRSA, VRE, bacteremia, risks to ICU patients, chlorhexidine baths,

bathing practices, and infection control.

Results: The Centers for Disease Control and Prevention published strategies to prevent infection

with the use of CHX baths to decolonize MRSA carriers (2010). Multiple studies performed

have shown the use of daily CHX baths in ICU populations decrease MRSA and multiple other

HAIs.

Conclusion: The data showed ICU patients who received daily CHX baths have shown to have a

lower rate of prevalence of various HAIs, which cuts down cost, risk, and morbidity. However,

there is no significant data showing whether or not daily bathing decreased death. There are also

no data regarding proper training or compliance of CHX bathing standards.

CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 3

Chlorhexidine to Reduce Hospital Acquired Infections

Healthcare-associated infections are a widespread problem throughout hospitals and pose

a lethal threat to a patients health. According to the World Health Organization (2002), HAIs

are An infection acquired in hospital by a patient who was admitted for a reason other than that

infection. This includes infections acquired in the hospital but appearing after discharge (p.9).

The CDC reports one in twenty-five hospitalized patients will have a HAI during hospitalization

(2016). While statistics show the overall rate of incidence of HAIs down nationwide, in the state

of Florida MRSA bacteremia is up by 4% compared to the national average (CDC, 2016). In

2012, there were 36.5 million hospital stays in the United States, with an average length of stay

of 4.5 day, reports the Agency for Healthcare Research and Quality (p.1). If there are 36.5

million hospitalized patients and one in twenty-five of them acquire a nosocomial infection, it

equates to 1,460,000 HAIs annually. With numbers like this it emphasizes the importance of

implementing and enforcing policies to reduce infection. The use of antiseptic agents like

chlorhexidine can provide patients a safeguard in preventing transmission of disease, reduce

nosocomial infections, and have better outcomes in the hospitalized patient. This paper assesses

the efficacy of daily CHX baths in ICU patients to reduce HAIs. Among ICU patients with a

length of stay greater than two days, how does receiving daily CHX baths, compared to

nonantimicrobial baths, decrease the frequency of nosocomial infections throughout their

hospital admission?

Literature Search

PubMed, Oxford Journals, American Journal of Infection Control, Elsevier, and the

National Guideline Clearinghouse were all used to research various clinical trials, nursing
CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 4

practices, and hospital guidelines to reduce infection. The key search terms used were hospital

acquired infections, nosocomial infections, MRSA, VRE, bacteremia, risks to ICU patients,

chlorhexidine baths, bathing practices, and infection control practices.

Literature Review

One guideline and three randomized controlled trials were used to assess the efficacy of

daily CHX baths in ICU patients to reduce HAIs. In a cluster-randomized crossover study, Climo

et al. (2013) investigated how incorporating daily CHX baths would reduce the number of

multidrug-resistant organisms (MDRO) and the overall number of HAIs when compared to

nonantimicrobial agents. Seven thousand seven hundred twenty-seven patients participated from

nine different units in six hospitals. Participants were randomly assigned into two groups, either

to be bathed daily by nurses with CHX washcloths or nonantimicrobial cloths. Participants were

bathed by either product for six months, and at the end of the six month trial they switched to the

alternative treatment for an additional six months. Results reported a significant decrease in the

number of VRE and MRSA infections with the utilization of CHX cloths verses the alternative

(P=0.03), a 23% lower rate of infection. In addition, there was also a 28% decrease in all

bloodstream infections acquired in the hospital with the use of CHX (P=0.007), but the greatest

promise shown was in ICU patients with a 40% decrease in bloodstream HAIs. There were

several weaknesses in this study, the first being investigators and nurses were aware of the study

group and associated interventions. In addition, there was no analysis of the clinical staffs

collection of the specimens. It is also unknown whether or not the chlorhexidine cloths were kept

in a warmer according to the manufacturers recommendations or how many cloths were used

per patient. The strengths of the study were having a large patient population from multiple
CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 5

hospital ICUs. Subjects were also randomly assigned to the respective groups. Sage Products

was also on hand to give the clinical staff training on how to properly use both the CHX and

nonantimicrobial washcloths, as well as provide support throughout the study.

Milestone et al. (2013) performed a cluster-randomized trial analyzing the efficiency of

daily CHX baths in pediatric patients to decrease the number of HAIs when compared to

nonantimicrobial baths. The study incorporated five hospitals and ten ICUs within the U.S. The

population of the study included 4,072 patients over the age of two months who were

hospitalized more than two days. Patients were divided into two groups, those who received

CHX baths and those who were bathed with nonantimicrobial cloths. For six months each group

used their assigned bathing practices and then switched to the alternative for an additional six

months. The study showed patients who were receiving daily CHX baths did have a lower

incident of bacteremia or HAIs. The findings showed a lower incident rate of bacteremia

(p=0.044). A weakness of the study was investigators and hospital staff was aware of the study

group and associated intervention. There was no analysis of the accuracy of the clinical staffs

collection of specimens. It is unknown whether staff received proper training on bathing

practices for each product prior to performing such duties. It is also unknown whether or not the

chlorhexidine cloths were kept in a warmer according to the manufacturers recommendations or

how many cloths were used per patient. Strengths of the study were a large patient population

from multiple hospitals and ICUs, and subjects were randomly assigned to their respective

groups. The length of the study was long.

Viray et al (2014) performed a randomized clinical trial to test the effectiveness of daily

CHX baths verses nonantimicrobial baths in the reduction of S. aureus and MRSA among ICU
CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 6

patients. Participants in the study had a hospital stay greater than two days; they were assigned

based on what ICU they were admitted into. Patients on the twenty-four bed surgical ICU floor

were assigned to the CHX intervention group to be bathed daily using a 4 ounce bottle of CHX

soap in 4 quarts of water. Patients in the 19 bed medical ICU floor were assigned to be bathed

with soap and water. The duration of the study was 61 months in a surgical ICU and 24 months

for the medical ICU. The study also compared the mutual study period performed from June

2005 to December 2007. There was a reported decrease of MRSA infections in CHX

intervention group (P=.001), as well as a decrease in S. aureus also in the CHX intervention

group (P=0.012). Weaknesses of this study were investigators and staff were aware of the study

groups. There was no analysis of the clinical staffs collection of the specimens, nor are there

data reporting how many cultures were taken and how often. Lastly, it is unknown if staff

performing bathing practices received proper training prior to performing such duties. Strengths

of the study were all participants were randomly assigned to either group, and the timeframe of

the study was lengthy.

The CDC (2010) published strategies to prevent infection with Active Surveillance

Testing (AST) and supplemental CHX baths to decolonize MRSA carriers. In addition, it

recommends daily CHX baths in high risk populations, such as ICU patients, for an overall

reduction of MRSA and other HAIs (CDC, 2010).

Synthesis

Climo et al. (2013) reported the overall rate of HAIs with the use of CHX compared to

nonantimicrobial agents were significantly reduced (P=0.007), and the number of MRSA or VRE

infections also saw a reduction (P=0.03). In addition, Milestone et al. (2013) reported children
CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 7

bathed with CHX had a 36% decreased possibility of bacteremia then children bathed using

standard practices (aIRR 064, 95% CI 042098). Viray et al. (2014) reported a decrease in

MRSA infections in the surgical ICU population who were receiving daily CHX baths (P=.001),

as well as a decrease in S. aureus in the surgical ICU (P=0.012). Lastly, the CDC published

guidelines (2010) recommending decolonization of MRSA patients with CHX baths, as well as

universal daily chlorhexidine bathing in high risk patient populations, such as ICU patients.

Research shows by administering CHX baths, either with washcloths or in the liquid

form, to ICU patients it will result in an overall decrease of HAIs, such as Staphylococcus

aureus, bacteremia, VRE, and MRSA. Significant progress has been made in the reduction of

HAIs, risks, morbidity, and cost; however, there are no significant data to support a notable

reduction in length of hospital stays or deaths. Additional studies will need to be performed to

assess if incorporating daily CHX bathing as a standardized practice in ICUs will have any

impact on those.

Clinical Recommendations

The CDC published guidelines (2010) recommending decolonization of MRSA patients

with CHX baths, as well as universal daily chlorhexidine bathing in high risk patient populations,

such as ICU patients, to reduce HAIs. Other ways to reduce infection are better and more

frequent patient assessments, incorporating appropriate contact precautions based on infection

with the use of gloves, masks, and gowns, proper hand hygiene using either antimicrobial or

antiseptic products, getting cultures and beginning a regimen of antibiotics earlier, and

performing ACT. Additional research needs to be performed to assess if incorporating daily

CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 8

CHX bathing as a standardized practice in ICUs will have any impact on the duration of hospital

stay and associated deaths.

CHLORHEXIDINE TO REDUCE HOSPTIAL AQUIRED INFECTIONS 9

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