Review
Effect of chlorhexidine bathing on colonization or infection with Acinetobacter baumannii: a systematic review and meta-analysis

https://doi.org/10.1016/j.jhin.2019.08.004Get rights and content

Summary

Healthcare-associated infections (HAIs) caused by multi-drug-resistant Gram-negative bacteria (MDRGNB) have increased prevalence in intensive care units (ICUs). A common strategy to prevent HAIs is bathing patients with chlorhexidine gluconate (CHG). However, the effectiveness of CHG bathing against multidrug-resistant Acinetobacter baumannii (MDRAB) is still controversial. The aim of this study was to perform a systematic review and meta-analysis of the effectiveness of CHG bathing on Acinetobacter baumannii colonization and infection in the ICU setting. A systematic literature search of PubMed, EMBASE, Web of Science and CINAHL was performed from inception through to June 2018. Randomized controlled trials (RCTs), pre-post studies, or interrupted time series (ITS) studies were included. The numbers of patients with/without colonization or infection of A. baumannii in the experimental or control groups were extracted from each study. Quality assessment was performed by the related instruments of National Institute of Health. Pooled risk ratios (RRs) were calculated using the random-effects model. One RCT and 12 pre-post or ITS studies comprising 18,217 patients were included, of which 8069 were in the CHG bathing arm and 9051 in the control arm. CHG bathing was associated with a reduced colonization of A. baumannii (RR, 0.66; 95% confidence interval: 0.57–0.77; P<0.001). Chlorhexidine at 4% showed a better effect than 2% chlorhexidine (meta-regression P=0.044). CHG bathing was associated with a non-significant reduction of infection (pooled RR 0.41, 95% CI: 0.13–1.25). This study suggests that CHG bathing significantly reduces colonization of A. baumannii in the ICU setting. However, more trials are needed to confirm whether CHG bathing can reduce infections with A. baumannii.

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

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