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Review
. 2016 Nov 23;20(1):379.
doi: 10.1186/s13054-016-1553-5.

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis

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Free PMC article
Review

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis

Steven A Frost et al. Crit Care. .
Free PMC article

Abstract

Background: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35, 2010; Warren and Quadir, Crit Care Med 34(8):2084-9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039-46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1-70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes. This meta-analysis aims to summarise the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce infection.

Methods: A systematic literature search was undertaken to identify trials assessing the effectiveness of CHG bathing to reduce risk of infection, among adult intensive care patients. Infections included were: bloodstream infections; central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections; ventilator-associated pneumonia; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile. Summary estimates were calculated as incidence rate ratios (IRRs) and 95% confidence/credible intervals. Variation in study designs was addressed using hierarchical Bayesian random-effects models.

Results: Seventeen trials were included in our final analysis: seven of the studies were cluster-randomised crossover trials, and the remaining studies were before-and-after trials. CHG bathing was estimated to reduce the risk of CLABSI by 56% (Bayesian random effects IRR = 0.44 (95% credible interval (CrI), 0.26, 0.75)), and MRSA colonisation and bacteraemia in the ICU by 41% and 36%, respectively (IRR = 0.59 (95% CrI, 0.36, 0.94); and IRR = 0.64 (95% CrI, 0.43, 0.91)). The numbers needed to treat for these specific ICU infections ranged from 360 (CLABSI) to 2780 (MRSA bacteraemia).

Conclusion: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

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Review
. 2017 Mar;19(2):123-136.
doi: 10.1177/1099800416654013. Epub 2016 Jul 26.

Chlorhexidine Bathing Effects on Health-Care-Associated Infections

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Review

Chlorhexidine Bathing Effects on Health-Care-Associated Infections

Janette Denny et al. Biol Res Nurs. 2017 Mar.

Abstract

Background: Health-care-associated infections (HAIs), infections that patients contract during the course of their hospitalization, are receiving a growing amount of attention. Heavy skin bacterial colonization aids in the transmission and development of HAIs. Nurses frequently use bathing with chlorhexidine gluconate (CHG) to reduce patients' cutaneous microbial burden. This intervention has been shown to have promising but mixed results in the prevention of HAIs.

Purpose: This article reviews the literature for evidence on the impact of CHG bathing on HAIs.

Method: A literature search was conducted to identify peer-reviewed studies and meta-analyses that examined the impact of CHG bathing on HAIs using PubMed and CINAHL with the following search terms: CHG bathing AND healthcare associated infections, surgical site infections ( SSIs), central line associated bloodstream infections ( CLABSIs), ventilator-associated pneumonias ( VAP), catheter-associated urinary-tract infections ( CAUTIs), and Clostridium difficile-associated disease. The initial search identified 23 articles for review. Additional studies were identified by searching references used in original studies or review articles on this topic.

Principle findings: There is good evidence to support incorporating a CHG bathing regimen to reduce the incidence of CLABSIs, SSIs, vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) HAIs.

Conclusion: As CHG becomes a standard practice to prevent HAIs, it is important to monitor for adverse reactions and evidence of resistance/susceptibility.

Keywords: bathing; chlorhexidine gluconate; health-care-associated infections.

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Randomized Controlled Trial
. 2015 Jan 27;313(4):369-78.
doi: 10.1001/jama.2014.18400.

Chlorhexidine bathing and health care-associated infections: a randomized clinical trial

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Free PMC article
Randomized Controlled Trial

Chlorhexidine bathing and health care-associated infections: a randomized clinical trial

Michael J Noto et al. JAMA. .
Free PMC article

Abstract

Importance: Daily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections.

Objective: To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections.

Design, setting, and participants: A pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013.

Interventions: Units performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study.

Main outcomes and measures: The primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU.

Results: During the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit.

Conclusion and relevance: In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine.

Trial registration: clinicaltrials.gov Identifier: NCT02033187.

Conflict of interest statement

No other authors have conflicts to disclose.

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Randomized Controlled Trial
. 2019 Jun;25(6):705-710.
doi: 10.1016/j.cmi.2018.09.012. Epub 2018 Sep 26.

Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial

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Free article
Randomized Controlled Trial

Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial

C Pallotto et al. Clin Microbiol Infect. 2019 Jun.
Free article

Abstract

Objectives: To investigate whether daily bathing with a soap-like solution of 4% chlorhexidine (CHG) followed by water rinsing (CHGwr) would decrease the incidence of hospital-acquired infections (HAI) in intensive care settings.

Methods: Randomized, controlled trial; infectious diseases specialists were blinded to the intervention status. All patients admitted to the Intensive Care Unit (ICU) and to the Post-operative Cardiosurgical Intensive Care Unit (PC-ICU) of the University Hospital of Perugia were enrolled and randomized to the intervention arm (daily bathing with 4% CHGwr) or to the control arm (daily bathing with standard soap). The incidence rate of acquisition of HAI was compared between the two arms as primary outcome. We also evaluated the incidence of bloodstream infections (BSI), central-line-associated BSI (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI), and 4% CHGwr safety.

Results: In all, 449 individuals were enrolled, 226 in treatment arm and 223 in control arm. Thirty-four individuals of the 226 (15%) and 57 (25.6%) suffered from at least an HAI in the intervention and control arms, respectively (p 0.008); 23.2 and 40.9 infections/1000 patient-days were detected in the intervention arm and control arm, respectively (p 0.037). The incidence of all bloodstream infections (BSI plus CABSI) was significantly reduced in the intervention arm (9.2 versus 22.6 infections/1000 patient-days, p 0.027); no differences were observed in the mortality between the two arms.

Conclusions: Daily bathing with 4% CHGwr significantly reduced HAI incidence in intensive care settings. CLINICALTRIAL.

Gov registration: NCT03639363.

Keywords: 4% chlorhexidine gluconate; Daily bathing; Hospital-acquired infections; Infection control; Intensive care.

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Review
. 2018 Dec 19;18(1):679.
doi: 10.1186/s12879-018-3521-y.

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis

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Free PMC article
Review

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis

Steven A Frost et al. BMC Infect Dis. .
Free PMC article

Abstract

Background: Health care associated infections (HAI) among adults admitted to the intensive care unit (ICU) have been shown to increase length of stay, the cost of care, and in some cases increased the risk of hospital death (Kaye et al., J Am Geriatr Soc 62:306-11, 2014; Roberts et al., Med Care 48:1026-35, 2010; Warren et al., Crit Care Med 34:2084-9, 2006; Zimlichman et al., JAMA Intern Med 173:2039-46, 2013). Daily bathing with chlorhexidine gluconate (CHG) has been shown to decrease the risk of infection in the ICU (Loveday et al., J Hosp Infect 86:S1-S70, 2014). However, due to varying quality of published studies, and varying estimates of effectiveness, CHG bathing is not universally practiced. As a result, current opinion of the merit of CHG bathing to reduce hospital acquired infections in the ICU, is divergent, suggesting a state of 'clinical equipoise'. This trial sequential meta-analysis aims to explore the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections, and address the question: do we need more trials?

Methods: A systematic literature search was undertaken to identify trials assessing the effectiveness of chlorhexidine bathing to reduce risk of infection, among adult intensive care patients. With particular focus on: (1) Blood stream infections (BSI); (2) Central Line Associated Blood Stream Infections (CLABSI); (3) Multi-Resistant Drug Organism (MRDO); (4) Ventilator Associated Pneumonia; and, Catheter Associated Urinary Tract Infections (CAUTI). Only randomised-control or cluster randomised cross-over trials, were include in our analysis. A Trial Sequential Analysis (TSA) was used to describe the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections.

Results: Five trials were included in our final analysis - two trials were individual patient randomised-controlled, and the remaining cluster-randomised-crossover trials. Daily bathing with CHG was estimated to reduce BSI in the ICU by approximately 29% (Der-Simonian and Laird, Random-Effects. (DL-RE) Incidence Rate Ratio (IRR) = 0.71, 95% confidence interval (CI) 0.51, 0.98); reduce CLABSI in the ICU by approximately 40% (DL-RE IRR = 0.60, 95% CI 0.34, 1.04); reduce MDRO in the ICU by approximately 18% (DL-RE IRR = 0.82, 95% CI 0.69, 0.98); no effect in reducing VAP in the ICU (DL-RE IRR = 1.33, 95% CI 0.81, 2.18); and, no effect in reducing CAUTI in the ICU (DL-RE IRR = 0.77, 95% CI 0.52, 1.15). Upper (superiority) monitoring boundaries from TSA were not crossed for all five specific infections in the ICU.

Conclusion: Routine bathing with CHG does not occur in the ICU setting, and TSA suggests that more trials are needed to address the current state of 'clinical equipoise'. Ideally these studies would be conducted among a diverse group of ICU patients, and to the highest standard to ensure generalisability of results.

Keywords: Chlorhexidine bathing; Intensive care; Meta-analysis; Preventing hospital acquired infection; Trial sequential analysis.

Conflict of interest statement

Authors’ information

Not applicable.

Ethics approval and consent to participate

Not applicable (review of published literature).

Consent for publication

Not applicable.

Competing interests

All authors have no competing interests to declared.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Review
. 2016 Nov;31(6):1159-1170.
doi: 10.3904/kjim.2015.240. Epub 2016 Apr 6.

The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units

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Free PMC article
Review

The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units

Hua-Ping Huang et al. Korean J Intern Med. 2016 Nov.
Free PMC article

Abstract

Background/aims: Healthcare-associated infections (HAIs) in critically ill patients with prolonged length of hospital stay and increased medical costs. The aim of this study is to assess whether daily chlorhexidine gluconate (CHG) bathing will significantly reduce the rates of HAIs in adult intensive care units (ICUs).

Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched until December 31, 2014 to identify relevant studies. Two authors independently reviewed and extracted data from included studies. All data was analyzed by Review Manager version 5.3.

Results: Fifteen studies including three randomized controlled trials and 12 quasi-experimental studies were available in this study. The outcomes showed that daily CHG bathing were associated with significant reduction in the rates of primary outcomes: catheter-related bloodstream infection (risk ratio [RR], 0.44; 95% confidence interval [CI], 0.32 to 0.63; p < 0.00001), catheter-associated urinary tract infection (RR, 0.68; 95% CI, 0.52 to 0.88; p = 0.004), ventilator-associated pneumonia (RR, 0.73; 95% CI, 0.57 to 0.93; p = 0.01), acquisition of methicillin-resistant Staphylococcus aureus (RR, 0.78; 95% CI, 0.68 to 0.91; p = 0.001) and vancomycin-resistant Enterococcus (RR, 0.56; 95% CI, 0.31 to 0.99; p = 0.05).

Conclusions: Our study suggests that the use of daily CHG bathing can significantly prevent HAIs in ICUs. However, more well-designed studies are needed to confirm these findings.

Keywords: Bathing; Chlorhexidine gluconate; Infection; Intensive care units.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

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. 2018 Jun;36(6):305-313.
doi: 10.1097/CIN.0000000000000429.

A Technology Intervention for Nurses Engaged in Preventing Catheter-Associated Urinary Tract Infections

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A Technology Intervention for Nurses Engaged in Preventing Catheter-Associated Urinary Tract Infections

Kathleen Rea et al. Comput Inform Nurs. 2018 Jun.

Abstract

Catheter-associated urinary tract infections account for 40% of healthcare-acquired infections. This study explored the addition of cloud-based software technology to an established nursing quality improvement program to reduce catheter-associated urinary tract infections. Unit-based nurse champions evaluated peers' evidence-based catheter-associated urinary tract infection prevention practices using manual, paper-based feedback. That process achieved reduced rates of catheter-associated urinary tract infection over 18 months. However, it was resource intensive. Cloud-based software technology was introduced to replace the paper. Nurse champions' satisfaction, catheter-associated urinary tract infection and indwelling urinary catheter utilization, and prevention practices were compared before and after the technology intervention. Compliance with the provision of a chlorhexidine bath demonstrated improvement (P = .003), while other practice measures did not significantly change. The indwelling urinary catheter utilization ratio was lower (P = .01), yet the intervention yielded no change in catheter-associated urinary tract infection rates. The short time interval of the intervention was potentially a contributing factor in no significant rate change. Nurse champions (N = 14) were more satisfied with the cloud-based technology (P = .004), the clarity of improvement targets (P = .004), and the speed of sharing data (P = .001). Their time to share data decreased from 4 days or more to 1 hour or less. Nurse champions readily adopted the cloud-based technology. These findings suggest additional research on technology innovations for nursing quality improvement is needed.

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Clinical Trial
. 2016 Jul;37(7):791-7.
doi: 10.1017/ice.2016.23. Epub 2016 Feb 10.

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

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Free PMC article
Clinical Trial

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

Kristen V Dicks et al. Infect Control Hosp Epidemiol. 2016 Jul.
Free PMC article

Abstract

OBJECTIVE To determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). DESIGN Interrupted time series analysis. SETTING The study included 33 community hospitals participating in the Duke Infection Control Outreach Network from January 2008 through December 2013. PARTICIPANTS All ICU patients at study hospitals during the study period. METHODS Of the 33 hospitals, 17 hospitals implemented CHG bathing during the study period, and 16 hospitals that did not perform CHG bathing served as controls. Primary pre-specified outcomes included ICU central-line-associated bloodstream infections (CLABSIs), primary bloodstream infections (BSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs). MRSA and VRE HAIs were also evaluated. RESULTS Chlorhexidine gluconate (CHG) bathing was associated with a significant downward trend in incidence rates of ICU CLABSI (incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.93-0.99), ICU primary BSI (IRR, 0.96; 95% CI, 0.94-0.99), VRE CLABSIs (IRR, 0.97; 95% CI, 0.97-0.98), and all combined VRE infections (IRR, 0.96; 95% CI, 0.93-1.00). No significant trend in MRSA infection incidence rates was identified prior to or following the implementation of CHG bathing. CONCLUSIONS In this multicenter, real-world analysis of the impact of CHG bathing, hospitals that implemented CHG bathing attained a decrease in ICU CLABSIs, ICU primary BSIs, and VRE CLABSIs. CHG bathing did not affect rates of specific or overall infections due to MRSA. Our findings support daily CHG bathing of ICU patients. Infect Control Hosp Epidemiol 2016;37:791-797.

Conflict of interest statement

Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.

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Comment
. 2016 Jan;16(1):8-9.
doi: 10.1016/S1473-3099(15)00244-3. Epub 2015 Nov 27.

Do chlorhexidine patient baths prevent catheter-associated urinary tract infections?

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Comment

Do chlorhexidine patient baths prevent catheter-associated urinary tract infections?

Mark E Rupp. Lancet Infect Dis. 2016 Jan.
No abstract available

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. 2018 Oct;268(4):650-656.
doi: 10.1097/SLA.0000000000002932.

Impact of a Novel Preoperative Patient-centered Surgical Wellness Program

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Impact of a Novel Preoperative Patient-centered Surgical Wellness Program

Kristen E Kelley et al. Ann Surg. 2018 Oct.

Abstract

Objective: The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI).

Background: HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections.

Methods: A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression.

Results: Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90.

Conclusions: A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.

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