Major Article
Implementation of daily chlorhexidine bathing to reduce colonization by multidrug-resistant organisms in a critical care unit

https://doi.org/10.1016/j.ajic.2017.02.038Get rights and content

Highlights

  • Prevalence decreased in the immediate aftermath of daily CHG bathing and for the most part remained at that level over the observation period.

  • Low rates of incidence of MDRO colonization was observed with VRE>FQRGNB>MRSA.

  • Absence of efforts to sustain the initial momentum observed in the immediate aftermath of the daily CHG bathing intervention will likely affect its successful implementation.

Background

Colonized patients are a reservoir for transmission of multidrug-resistant organisms (MDROs). Not many studies have examined the effectiveness of daily chlorhexidine gluconate (CHG) bathing under routine care conditions. We present a descriptive analysis of the trends of MDRO colonization following implementation of daily CHG bathing under routine clinical conditions in an intensive care unit (ICU).

Methods

From May 2010-January 2011, we screened patients admitted to a 24-bed ICU for and methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and fluoroquinolone-resistant gram-negative bacilli (FQRGNB). We calculated and plotted monthly incidence and prevalence of colonization of these MDROs.

Results

Prevalence decreased in the immediate aftermath of daily CHG bathing implementation and generally remained at that level throughout the observation period. We observed low rates of incidence of MDRO colonization with VRE>FQRGNB>MRSA. Monthly prevalence of colonization and incidence for the composite of MRSA, VRE, and/or FQRGNB was 1.9%-27.9% and 0-1.1/100 patient-days, respectively.

Conclusions

Following the implementation of daily CHG bathing, the incidence of MDROs remained low and constant over time, whereas the prevalence decreased immediately after the implementation.

Section snippets

Study design

Between May 2010 and January 2011, a quasiexperimental, pretest–posttest study was carried out as a quality improvement project. On June 14, 2010, our hospital began daily CHG bathing of all patients in the critical care unit. We collected samples for microbiologic testing (nasal, skin, oral, and stool) pre- and postimplementation of daily CHG bathing. During both the pre- and post-implementation periods, we collected admission and discharge surveillance samples, stored them, and later (April

Results

Of the 619 patients in this study, 463 (74.8%) were admitted during the postintervention period and contributed 5,608 patient days compared with 882 for the preintervention period. The median age, median length of stay, and race did not differ between the pre- and postimplementation periods, but there were more men in the postimplementation period (Table 1).

The prevalence of VRE, FQRGNB, and that of a composite outcome (MRSA, VRE, and/or FQRGNB) at the first admission to the ICU was higher

Discussion

Here, we provide a descriptive analysis of MDRO colonization following real-world application of daily CHG bathing.

With the exception of MRSA, we observed an initial decrease in the trend of the prevalence and incidence of MDROs immediately following implementation of daily CHG bathing. The prevalence was higher than the incidence during most months after the intervention, but this was not consistent throughout the entire postimplementation period.

The initial decrease in the incidence and

Conclusions

Prevalence of MDROs decreased during the immediate aftermath, but generally remained at that level throughout the postimplementation period. The incidence of MDROs remained low and constant over the observation period. Health care facilities need to identify and address factors that might influence the long-term sustainability of the effects of daily CHG bathing. Moreover, in light of the recent Food and Drug Administration warning about rare but serious allergic reactions to CHG,22 health care

References (22)

  • P. Eggimann et al.

    Nonantibibiotic measures for the prevention of Gram-positive infections

    Clin Microbiol Infect

    (2001)
  • N.T. Holland et al.

    Biological sample collection and processing for molecular epidemiological studies

    Mutat Res

    (2003)
  • E. Zimlichman et al.

    Health care–associated infections: a meta-analysis of costs and financial impact on the us health care system

    JAMA Intern Med

    (2013)
  • S.S. Magill et al.

    Multistate point-prevalence survey of health care-associated infections

    N Engl J Med

    (2014)
  • R.R. Roberts et al.

    Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods

    Med Care

    (2010)
  • N. Safdar et al.

    Educational interventions for prevention of healthcare-associated infection: a systematic review

    Crit Care Med

    (2008)
  • M.W. Climo et al.

    Effect of daily chlorhexidine bathing on hospital-acquired infection

    N Engl J Med

    (2013)
  • HuangS.S. et al.

    Targeted versus universal decolonization to prevent ICU infection

    N Engl J Med

    (2013)
  • J.C. O'Horo et al.

    The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: a meta-analysis

    Infect Control Hosp Epidemiol

    (2012)
  • A.M. Milstone et al.

    Chlorhexidine: expanding the armamentarium for infection control and prevention

    Clin Infect Dis

    (2008)
  • Y. Cetinkaya et al.

    Vancomycin-resistant enterococci

    Clin Microbiol Rev

    (2000)
  • Cited by (15)

    • Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities

      2021, Journal of Hospital Infection
      Citation Excerpt :

      Further evidence came from eighteen UBA studies [117–134] which used CHG either in combination or alone. These other studies showed heterogenous results with 11 studies reporting a benefit [118,120–124,128,130–132,134] and seven reporting no significant change. [117,119,125–127,129,133]. There was inconsistent evidence from two RCTs [86,95] which assessed the effectiveness of CHG mouth rinse on the presence of MRSA in the oral cavity in patients admitted to ICUs.

    • Chlorhexidine bathing to prevent healthcare-associated vancomycin-resistant Enterococcus infections: A cluster quasi-experimental controlled study at intensive care units

      2021, Journal of the Formosan Medical Association
      Citation Excerpt :

      Daily bathing with 2% CHG is a simple and highly effective intervention to decolonize the skin and prevent catheter-associated bloodstream infections at ICUs or hematological units.10–15 CHG bathing has been shown to decrease VRE acquisition.13,14,16 However, its effect on VRE-HAIs has not been assessed in prospective studies at ICUs.17,18

    • Is it cost effective to use a 2% chlorhexidine wipes bath to reduce central-line associated blood stream infection? A quasi-experimental study

      2021, Brazilian Journal of Infectious Diseases
      Citation Excerpt :

      Studies indicate an attributed mortality of CLABSI to be 2.27–2.75%,3,4 reaching up to 34% if the infection is caused by carbapenem resistant Klebsiella pneumoniae.5 Several studies have shown that bathing with 2% chlorhexidine (CHG) wipes is an important preventive measure of infection in critically ill patients, mainly of CLABSI.6–11 Previous studies also support the use of CHG bathing as a cost-saving practice.

    • Response to Aho Glele et al.

      2018, Journal of Hospital Infection
    View all citing articles on Scopus

    Supported by grant No. R18HS024039 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

    Conflicts of interest: None to report.

    View full text