ReviewEffect of chlorhexidine bathing on colonization or infection with Acinetobacter baumannii: a systematic review and meta-analysis
Introduction
Healthcare-associated infections (HAIs) caused by multi-drug-resistant Gram-negative bacteria (MDRGNB) continue to increase in frequency and to become a serious threat in intensive care units (ICUs) globally [1], [2], [3]. Among Gram-negative bacteria, multi-drug-resistant (MDR) strains of Pseudomonas aeruginosa and Acinetobacter baumannii have emerged as being of particularly serious concern due to their high mortality rate and treatment difficulties [4], [5], [6], [7]. According to a previous study, A. baumannii related HAIs have been estimated to cost hospitals more than 30,000 USD per infection on average [8].
A. baumannii is a common cause of bloodstream infections in ICUs. The pathogen can live on the skin of humans, especially at tracheostomy sites and on open wounds [9]. Skin colonization with A. baumannii may then be related to contamination of vascular catheters such as central venous or arterial origin [10]. Studies have also reported lower respiratory tract infections and urinary tract infections as possible sources of A. baumannii bloodstream infections [11]. Risk factors for A. baumannii infection include previous use of broad-spectrum antibiotics, catheter insertion, longer duration of ventilation, and longer periods of hospitalization [12], [13], [14].
Cross-transmission between ICU patients is also a major determinant of MDR A. baumannii (MDRAB) acquisition [15]. In order to reduce MDR bacterial colonization and infection, a plethora of strategies have been developed, including hand hygiene among healthcare personnel, contact precautions, antimicrobial stewardship, environmental cleaning, decolonizing bathing and source control. It has been shown that a multi-modal strategy is more effective in reducing MDRGNB spread compared with a single strategy alone [16].
Chlorhexidine gluconate (CHG) bathing in ICU settings has been proven to be beneficial in preventing catheter colonization and catheter-related bloodstream infections [17]. The efficacy of daily CHG bathing among ICU patients in reducing the acquisition of drug-resistant Gram-positive cocci, such as meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), has been demonstrated in a multi-centre trial [18]. However, the effectiveness of CHG bathing against A. baumannii, and especially MDRAB, is still controversial. To solve this ongoing issue, this study aimed to conduct a systematic review and meta-analysis to assess the benefit of CHG bathing on reducing A. baumannii, and especially MDRAB, colonization and infection rates, especially those with multi-drug resistance. This study investigated whether CHG bathing, compared with usual care, significantly decreases the rates of HAIs in adult ICUs.
Section snippets
Data sources and search strategy
A systematic literature search was performed through medical literature databases including PubMed, EMBASE, Web of Science and CINAHL, published up until July 2018. PubMed was searched by combining four separate queries composed of medical subject heading (MeSH) terms and title/abstract keywords for the three topics described above, along with a query starting with ‘NOT’ to exclude inappropriate studies and article types. A similar search strategy was repeated in EMBASE, Web of Science and
Inclusion and exclusion criteria
Two authors (C.Y.F., C.H.L.) independently screened articles for inclusion. Studies were included if all of the following conditions were met: adults comprised over 50% of the enrolled patients in the study; the study was conducted in at least one ICU; the study applied CHG bathing as one of the interventions; the outcome(s) were either colonization or infection rates; and the study was a randomized controlled trial, an interrupted time series study, or a pre-post comparative study analysis.
Study selection
Our search criteria identified 113 studies. After excluding 46 overlapping citations, 67 articles were included for title and abstract screening. An additional three articles were included from related systematic reviews and meta-analyses. After title and abstract screening, 20 articles were deemed eligible for full-text review. After full-text review, 13 articles remained eligible for final analysis, including one randomized control trial, seven interrupted time series studies, and five
Discussion
This meta-analysis comprising 13 studies with 18,217 patients presented a summary of the estimated benefits of CHG bathing to prevent A. baumannii colonization and infection in ICUs. The results show that CHG bathing decreases the risk of A. baumannii colonization, regardless of different study designs, medium of CHG bathing, types of ICU settings, or whether implemented in the MDRAB outbreak periods or not. Compared with patients who did not received CHG bathing, patients receiving CHG bathing
Author contributions
C.C.L. had full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis. C.C.L. was responsible for study concept and design, analysis and interpretation of data. C.Y.F., S.P.W. and C.H.H. were responsible for acquisition of data. C.C.L., W.T.L. and T.C.H. performed the statistical analysis. C.Y.F. and C.C.L. were responsible for drafting of the manuscript. W.T.L., C.H.L., S.P.W., S.C.C. and C.C.L. were responsible for
References (46)
- et al.
Presence, distribution and molecular epidemiology of multi-drug-resistant Gram-negative bacilli from medical personnel of intensive care units in Tianjin, China, 2007–2015
J Hosp Infect
(2017) - et al.
Co-colonization with multiple different species of multidrug-resistant gram-negative bacteria
Am J Infect Control
(2011) - et al.
Impact of 4% chlorhexidine whole-body washing on multidrug-resistant Acinetobacter baumannii skin colonisation among patients in a medical intensive care unit
J Hosp Infect
(2007) - et al.
Risk factors of multidrug-resistant, extensively drug-resistant and pandrug-resistant Acinetobacter baumannii ventilator-associated pneumonia in a Medical Intensive Care Unit of University Hospital in Thailand
J Infect Chemother
(2015) - et al.
Colonization pressure and risk factors for acquisition of imipenem-resistant Acinetobacter baumannii in a medical surgical intensive care unit in Brazil
Am J Infect Control
(2013) - et al.
Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability
Am J Med
(2012) - et al.
Effectiveness of infection prevention measures featuring advanced source control and environmental cleaning to limit transmission of extremely-drug resistant Acinetobacter baumannii in a Thai intensive care unit: An analysis before and after extensive flooding
Am J Infect Control
(2014) - et al.
Effect of daily chlorhexidine bathing on acquisition of carbapenem-resistant Acinetobacter baumannii (CRAB) in the medical intensive care unit with CRAB endemicity
Am J Infect Control
(2015) - et al.
Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients
Am J Infect Control
(2014) - et al.
Successful control of 2 simultaneous outbreaks of OXA-48 carbapenemase-producing Enterobacteriaceae and multidrug-resistant Acinetobacter baumannii in an intensive care unit
Am J Infect Control
(2017)
Carbapenem-resistant Acinetobacter baumannii in intensive care unit patients: risk factors for acquisition, infection and their consequences
J Hosp Infect
Multidrug-resistant Acinetobacter baumannii outbreak: an investigation of the possible routes of transmission
Public Health
Epidemiology and clinical outcomes of multidrug-resistant, gram-negative bloodstream infections in a European tertiary pediatric hospital during a 12-month period
Pediatr Infect Dis J
Multidrug-resistant Gram-negative bacterial infections in the hospital setting: overview, implications for clinical practice, and emerging treatment options
Microb Drug Resist
The increasing challenge of multidrug-resistant Gram-negative bacilli: results of a 5-year active surveillance program in a neonatal intensive care unit
Medicine (Baltimore)
Combating multidrug-resistant Gram-negative bacterial infections
Expert Opin Investig Drugs
Monitoring and control of pan-drug resistant Acinetobacter baumannii colonization and infection in a medical intensive care unit
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue
Costs and mortality associated with multidrug-resistant healthcare-associated Acinetobacter infections
Infect Control Hosp Epidemiol
Healthcare provider information sheet for multidrug-resistant acinetobacter baumannii (MDRAb)
A prospective multicenter study on the evaluation of antimicrobial resistance and molecular epidemiology of multidrug-resistant Acinetobacter baumannii infections in intensive care units with clinical and environmental features
Ann Clin Microbiol Antimicrob
The epidemiology of multidrug-resistant bacteria colonization and analysis of its risk factors in intensive care unit
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue
Risk factors and outcome analysis of acinetobacter baumannii complex bacteremia in critical patients
Crit Care Med
Prevention and Control of Multidrug-Resistant Gram-Negative Bacteria in Adult Intensive Care Units: A Systematic Review and Network Meta-analysis
Clin Infect Dis
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Contamination of healthcare environment by carbapenem-resistant Acinetobacter baumannii
2022, American Journal of the Medical SciencesCitation Excerpt :Prevention measures for dissemination of antimicrobial-resistant pathogens include cleaning techniques for environmental surfaces and antiseptic baths. The effectiveness of cleaning techniques is associated with diverse aspects, including disinfectant products (chlorhexidine, chlorine solution, aerosolized hydrogen peroxide (aHP), etc.), concentration, and action time.77–81 An 85% reduction of CRAB contamination was observed after sodium hypochlorite disinfection (24/59 sampled objects were contaminated before disinfection with sodium hypochlorite, and contamination persisted in 3/52 sampled objects after disinfection process); and a 78% reduction after aHP disinfection (59/74 sampled objects were contaminated before disinfection, and 12/68 objects remained contaminated after disinfection).82
Chlorhexidine gluconate bathing of adult patients in intensive care units in São Paulo, Brazil: Impact on the incidence of healthcare-associated infection
2022, Brazilian Journal of Infectious DiseasesCitation Excerpt :Robert A. Weinstein was the first to study daily full body CHG bathing to prevent infections in ICUs.11 It has been used in several settings to control outbreaks and infections related to MDROs including methicilin-resistant Staphylococcus aureus (MRSA)12 vancomycin-resistant Enterococcus sp (VRE)11 and Gran-negative bacteria13–16 and fungi,17,18 but has no activity against mycobacteria and bacterial spores.19,20 Few studies have accessed the impact of daily 2% CHG detergent solution bathing on the incidence of HAI among ICU patients in Brazil.
Air dispersal of multidrug-resistant Acinetobacter baumannii: implications for nosocomial transmission during the COVID-19 pandemic
2021, Journal of Hospital InfectionCitation Excerpt :Increasing the number of patients will increase the bacterial burden in the confined clinical area, as illustrated in patients with VRE colonization, where the extent of environmental contamination was associated with the number of positive body sites [40]. Chlorhexidine gluconate bathing may reduce the cutaneous colonization of MRAB [41]. In our patient cohort, the detection rates of MRAB in air and non-reachable surfaces gradually decreased after the initiation of daily chlorhexidine gluconate bathing during hospitalization for the MRAB patients.