Decreasing Infection Rates with Chlorhexidine Baths in Intensive Care Units

Abstract

Clinical Problem: Patients in intensive care units are very ill and susceptible to infection. Patients in intensive care units often have medical devices inserted into their bodies (Foley catheters, central lines, ventilation tubes, etc.) which are access points for infection. If a patient acquires an infection while in the hospital, it can result in increased costs, increased length of stay, and possibly death.

Objective: The purpose of this paper is to discuss the most effective bathing method in reducing infection rates in intensive care units, whether it be with chlorhexidine antimicrobial methods, or with plain soap and water. PubMed, CINAHL, and the Agency for Healthcare Research and Quality (AHRQ) were accessed to find three randomized controlled trials (RCTs) and a clinical practice guideline regarding reduction in hospital-acquired infections. Key search terms that were used include intensive care unit, chlorhexidine, hospital-acquired infection, catheter-associated urinary tract infection, central-line associated blood stream infection, infection prevention, and infection risk. The publication years searched were 2015 to 2019.

Results: The literature reviewed for this paper and the three randomized controlled trials demonstrated a reduction in infection rates in intensive care units with the use of chlorhexidine for bathing compared to alternative methods such as soap and water. The clinical practice guideline from the Centers for Disease Control and Prevention (2011) also recommends daily use of chlorhexidine wash for bathing to reduce infection rates.

Conclusion: Patients in intensive care units, who are at an increased risk of infection that received baths with antimicrobial chlorhexidine, compared to those who received non-antimicrobial baths, experienced lower infection rates. Some studies showed a significant difference between the two bathing methods, while others only showed minor differences. More extensive research is needed in order to determine if chlorhexidine significantly decreases the rate of infections in intensive care units.

Decreasing Infection Rates with Chlorhexidine Baths in Intensive Care Units

According to The Centers for Disease Control and Prevention, close to 1.7 million patients acquire hospital-acquired infection (HAIs) annually, and greater than 98,000 patients die from these HAIs (Haque, Sartelli, McKimm & Abu Bakar, 2018). Patients in intensive care units are more susceptible to infection because of underlying illness, impaired immunity, risk of aseptic mistakes during invasive monitoring, and because these patients often have medical devices inserted into the body (Foley catheters, central lines, breathing tubes, etc), which are access points for infection (Kolpa, Walaszek, Gniadek, Wolak & Dobros, 2015). With infection and mortality rates rising, it is essential to determine the most effective bathing method for patients in intensive care units. Common bathing methods include antimicrobial solutions such as chlorhexidine, and non-antimicrobial solutions, such as plain soap and water.

The purpose of this paper is to determine, among intensive care unit patients requiring nursing-delivered baths, how does bathing with chlorhexidine compared to non-chlorhexidine (ex. soap and water) decrease the rate of hospital-acquired infections.

Literature Search

PubMed, CINAHL and the Agency for Healthcare Research and Quality (AHRQ) were accessed to find three randomized controlled trials (RCTs) and one clinical practice guideline regarding reduction in hospital-acquired infections. Key search terms that were used include intensive care unit, chlorhexidine, hospital-acquired infection, catheter-associated urinary tract infection, central-line associated blood stream infection, infection prevention, and infection risk. The publication years searched were 2015 to 2019.

Literature Review

Three randomized controlled trials (RCTs) and one clinical guideline were used to evaluate how chlorhexidine bathing compares to non-chlorhexidine bathing when it comes to reducing infection rates in intensive care units (see Table 1). The purpose of the RCT by Pallotto et al. (2019) was to evaluate whether daily bathing with 4% chlorhexidine gluconate (CHG) was more effective than washing with standard soap in preventing hospital-acquired infections (HAIs). The trial included individuals who were admitted to the intensive care unit (N=446), who were then randomly divided into two groups. Patients in the intervention group (n=226) received daily bathing with 4% CHG. The patients in the control group (n=223) received daily bathing with standard soap. All patients were evaluated for the incidence of bloodstream infections (BSI), central-line associated BSI (CLASBI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI). The results of the study showed that 15% of the individuals in the intervention group and 25.6% of the individuals in the control group suffered from at least one hospital-acquired infection. Results also showed that the incidence of bloodstream infections was significantly reduced (p=0.027) in the intervention group. Strengths of this study include the use of randomized assignment and the fact that infectious disease specialists were blinded to the intervention status. One weakness of this study is that it does not directly state what other interventions are being used to prevent infection; for example, are the nurses using proper sterile technique when accessing central-lines, etc.

Swan et al. (2016) conducted a RCT to evaluate whether bathing every other day with chlorhexidine compared to daily bathing with soap and water decreases the risk of hospital-acquired infection. The trial included all patients in a surgical ICU from July 2012 to May 2013 with an anticipated stay of 48 hours or more (N=325). These patients were randomized using Microsoft Excel into two groups, the intervention group who were bathed every other day with chlorhexidine, and the control group, who were bathed every day with soap and water. The results of the study showed that 35 patients in the control group developed HAIs, while only 18 in the intervention group developed HAIs (p=0.049). Strengths of this study include the large sample size (N=325), randomized assignment into either the intervention or control group, description of eligibility criteria, blind investigators, and explanation of why some participants did not complete the study. The major weakness of this study is that it was a single-center, meaning it only included the surgical ICU at a single hospital.

Noto et al. (2015) designed a RCT to determine if daily bathing with chlorhexidine decreased the incidence of healthcare-associated infections (HAIs) compared to bathing with non-antimicrobial cloths. This trial included 9,340 patients in 5 intensive care units from July 2012-Juy 2013. The intervention group (n=4488) received daily chlorhexidine baths, while the control group (n=4852) received baths with non-antimicrobial cloths. Bathing treatments were performed for 10 weeks, followed by a 2-week washout period, before crossing over to the alternate bathing treatment. Each group crossed over 3 times during the length of the study. The results of this study showed that during the chlorhexidine period, 55 infections occurred (4 central line associated, 21 catheter associated, 17 ventilator associated pneumonia, and 13 c. difficile), and during the control period, 60 infections occurred (4 central line associated, 32 catheter associated, 8 ventilator associated, and 16 c. difficile). The rate of the primary outcome was 2.86 per 1000 days during chlorhexidine bathing and 2.90 per 1000 days during control bathing (

P

=.95). What these results show is that daily bathing with chlorhexidine did not necessarily reduce the incidence of healthcare-associated infections. What can be concluded from this study, is that the use of chlorhexidine might help prevent certain type of HAIs, such as catheter-associated (21 vs 32). The main strength of this study is the very large sample size. Weaknesses of this study include the inability to blind staff administering the baths and also the fact that it is a single-center study.

The clinical practice guideline published by The Centers for Disease Control and Prevention is concordant with the literature search performed. The guideline states that daily skin cleansing with chlorhexidine is recommended and supported. Even though there is evidence that chlorhexidine reduces infection rates, it is still not ranked as a Category IC recommendation, meaning that it is required by state or federal regulations, rules, or standards and it is not standard practice among all healthcare institutions.

Synthesis

Pallotto et al. (2019) demonstrated that the incidence of hospital-acquired infections was significantly reduced using daily chlorhexidine bathing methods (p=0.027). Additionally, Swan et al. (2016) reported a reduction in the development of hospital-acquired infections (p=0.049) with the use of bathing every other day with chlorhexidine compared to daily bathing with soap and water. Noto et al. (2015) demonstrated reduced infection rates in certain categories of hospital-acquired infections with the use of chlorhexidine bathing, but did not demonstrate a significant difference in overall occurrence of hospital-acquired infections (P=0.95).

The research shows that, in general, bathing with chlorhexidine does reduce the incidence of hospital-acquired infections in intensive care units. Because there are other considerations when it comes to infection prevention (ex. hand washing, sterile instruments, proper sterile technique, etc.), it is extremely difficult to pinpoint which interventions are causing and preventing infections. For example, a patient might develop an infection while receiving chlorhexidine baths, but there is no way to ensure that the infection was not caused by poor practice. What needs to be known is that bathing with chlorhexidine does not replace other modes of preventing infection. Because of this, additional research is needed to determine best bathing practice for not only intensive care unit patients, but for all hospitalized patients.

Clinical Recommendations

The clinical guideline published by the Centers for Disease Control and Prevention states that patients in intensive care units should be bathed daily with chlorhexidine, especially those patients who have central lines. The guideline also states that chlorhexidine bathing cannot be the only method of infection prevention; it must be used in conjunction with other precautions (ex. hand washing, sterile technique, proper skin preparation, protocols for insertion and removal of central lines, etc.). Most research is supportive that chlorhexidine does reduce hospital-acquired infection rates in intensive care units, but supplemental research is needed to rule out why some patients are still developing infections while receiving the chlorhexidine baths, maybe there is a better method? Overall, research demonstrates that chlorhexidine bathing is still a developing idea in order to improve patient outcomes, reduce healthcare costs, reduce length of stay, and decrease mortality rates from hospital-acquired infections.

References

• Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheter-related infections. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html
• Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections – an overview.
  
  Infection and Drug Resistance, 11
  
  , 2321-2333. doi:10.2147/IDR.S177247
• Kolpa, M., Walaszek, M., Gniadek, A., Wolak, Z., & Dobros, W. (2015). Incidence, microbiological profile and risk factors of healthcare-associated infections in intensive care units: A 10 year observation in a provincial hospital in southern Poland.
  
  Int J Environ Res Public Health, 15
  
  (1), 112. doi:3390/ijerph15010112
• Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, C., Quondam Girolamo, L., Volpi, F., Iorio, P., Francisci, D., Tascini, C., & Baldelli, F. (2019). Daily bathing with 4% chlorhexidine gluconate in the intensive care settings: a randomized controlled trial.
  
  Clinical Microbiology and Infection, 25
  
  (6), 705-710. doi:10.1016/j.cmi.2018.09.012
• Swan, J.T., Ashton, C.M., Bui, L.N., Pham, V.P., Shirkey, B.A., Blackshear, J.E., Bersamin, J.B., Pomer, R.M., Johnson, M.L., Magtoto, A.D., Butler, M.O., Tran, S.K., Sanchez, L.R., Patel, J.G., Ochoa, R.A., Hai, S.A., Denison, K.I., Graviss, E.A., & Wray, N.P. (2016). Effect of chlorhexidine bathing every other day on prevention of hospital-acquired infections in the surgical ICU: A single-center, randomized controlled trial.
  
  Critical Care Medicine, 44
  
  (10), 1822-1832. doi:10.1097/CCM.0000000000001820
• Noto, M.J., Domenico, H.J., Byrne, D.W., Talbot, T., Rice, T.W., Bernard, G.R., & Wheeler, A.P. (2015). Chlorhexidine bathing and healthcare-associated infections: A randomized clinical trial.
  
  JAMA, 313
  
  (4), 369-378. doi:10.1001/jama.2014.18400

Table 1

Literature Review

Reference (in APA without indention)	Purpose	Design and Measures (relevant to project topic)	Sample (total size (N=?), control/intervention size (n=?), demographics relevant to project topic)	Outcomes / statistics (include significant findings related to the PICOT topic & include p -values or confidence intervals)
Pallotto et al. (2019)	To determine whether daily bathing with chlorhexidine compared to bathing with soap and water would decrease hospital-acquired infection rates in intensive care units.	Design:  RCT Measures: Number of patients who developed HAIs	Total size (N=449) Control group (n=223) Intervention group (n=226)	Thirty-four of the 226 individuals (15%) in the intervention group suffered from at least one HAI, while 57 (25.6%) individuals in the control group suffered from at least one HAI (p=0.008). The incidence of all bloodstream infections was significantly reduced in the intervention group (9.2 vs 22.6), (p=0.027)
Swan et al. (2016)	To evaluate whether bathing every other day with chlorhexidine compared to daily bathing with soap and water decreases the rate of hospital-acquired infections.	Design:  RCT Measures: Number of patients who developed HAIs	Total size (N=325) Adults >18 admitted to ICU expected to stay for 48 hours or longer; Braden Scale Score >9	Thirty-five patients in the control group (soap and water) developed HAIs, while 18 in the intervention group developed HAIs (p=0.049)
Noto et al. (2015)	Determine if daily bathing with chlorhexidine decreased incidence of HAIs compared to non-antimicrobial methods.	Design: RCT Measures: Number of patients who developed HAIs	Total size (N=9,340) Intervention group (n=4488) Control group (n=4852) All patients admitted to cardiovascular, neurological, surgical, and trauma ICUs were included Patients were excluded if they had an allergy to chlorhexidine, were admitted with burns, or if the physician thought bathing would be unsafe.	During the chlorhexidine period, 55 infections occurred (4 central line associated, 21 catheter associated, 17 ventilator associated, 13 c. diff). During the control period, 60 infections occurred (4 central line, 32 catheter associated, 8 ventilator associated, 16 c. diff). Rate of primary outcome was 2.86 per 1000 days during chlorhexidine bathing and 2.90 per 1000 days during control bathing (P=0.95)