The prevention of hospital-acquired infections (HAIs)—particularly bloodstream infections (BSIs) and ventilator-associated pneumonia (VAP)—has become a focus of critical care and a marker for quality among ICUs due to their significant burden. Under rules created by the CMS, a catheter-related BSI (CR-BSI) is now considered one of the preventable complications that will not be incrementally reimbursed. As a result, hospitals are more closely scrutinizing rates of HAIs and increasingly making efforts to reduce their impact.
Assessing Potential Strategies
In the March 2010 Archives of Surgery, my colleagues and I published a retrospective analysis of data collected 6 months before and after institution of a chlorhexidine gluconate bathing protocol in a trauma ICU. Chlorhexidine is an antiseptic preparation that has demonstrated broad activity against yeasts, viruses, and bacteria (including multi-drug resistant organisms, such as MRSA and Acinetobacter baumannii). The study compared the efficacy of daily bathing with washcloths impregnated with 2% chlorhexidine with that of disposable washcloths without this substance to determine the effect on HAI rates as well as its effect on the rate of isolation of multidrug-resistant organisms.
“Using routine decontamination bathing regimens may help decrease the potential for organism transmission.”
We observed that introduction of 2% chlorhexidine gluconate to routine, daily whole-body bathing of trauma ICU patients was associated with a significant reduction in the incidence of CR-BSIs. While the incidence of VAP was not significantly affected by chlorhexidine baths, patients who received these baths were less likely to develop MRSA VAP. The rate of colonization with MRSA and Acinetobacter was significantly lower in the chlorhexidine group than in the comparison group. The intervention also appeared to change the microbiology of HAIs, shifting the key pathogens from being Gram positive to Gram negative. Furthermore, feedback on the intervention was positive, and we expanded the use of the chlorhexidine bathing to all of our ICUs after the trial period. We have continued to observe further declines in nosocomial MRSA rates since the study was completed.
While our findings are encouraging, it should be noted that chlorhexidine bathing is not a replacement for other current infection-control efforts such as contact precautions. Rather, this novel intervention may be used together with other efforts such as handwashing programs, central line insertion protocols, and the ventilator bundle to further reduce HAI rates. Using routine decontamination bathing regimens may help decrease the potential for organism transmission. Chlorhexidine bathing may be particularly effective in critically ill trauma patients who arrive in the ICU with a significant bioburden, even after visiting the operating room. The key is to ensure that providers administer chlorhexidine appropriately and not use it on mucous membranes or in wounds. The chlorhexidine bathings are not intended to clean wounds; the intent is to reduce bacteria counts on intact skin to reduce transmission of bacteria from patients to providers.
In the future, it would be beneficial to perform cost-effective analyses and investigations into the possible emergence of resistance to chlorhexidine. It should also be noted that, at the time of the study, our institution was not practicing isolation strategies for MRSA patients. Even in the absence of barrier precautions, it appears that chlorhexidine bathing decreased the rate of colonization by MRSA and Acinetobacter and lowered rates of CR-BSIs and MRSA VAP. As more pressure is put on hospitals to reduce the transmission of antibiotic-resistant bacteria, it will be imperative to continue using current infection control practices as well as novel interventions to further reduce the burden of HAIs.
Evans HL, Dellit TH, Chan J, Nathens AB, Maier RV, Cuschieri J. Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients. Arch Surg. 2010;145:240-246. Available at: http://archsurg.ama-assn.org/cgi/content/full/145/3/240#AUTHINFO.
Davis KA, Stewart JJ, Crouch HK, Florez CE, Hospenthal DR. Methicillin-resistant Staphylococcus aureus (MRSA) nares colonization at hospital admission and its effect on subsequent MRSA infection. Clin Infect Dis. 2004;39:776-782.
Ridenour G, Lampen R, Federspiel J, Kritchevsky S, Wong E, Climo M. Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol. 2007;28:1155-1161.
Sandri AM, Dalarosa MG, Ruschel de Alcantara L, da Silva Elias L, Zavascki AP. Reduction in incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in an intensive care unit: role of treatment with mupirocin ointment and chlorhexidine baths for nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27:185-187.
Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167:2073-2079.