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Abstract & Commentary
Should ICU Patients Be Bathed Daily with Chlorhexidine?
By Saadia R. Akhtar, MD, MSc, St. Luke's Idaho Pulmonary Associates, Boise, is Associate Editor for Critical Care Alert.
Dr. Akhtar reports no financial relationship to this field of study.
Synopsis: This observational study found a large reduction in central line-associated bloodstream infections compared to historical controls for surgical ICU patients bathed daily with chlorhexidine gluconate-impregnated cloths.
Source: Dixon JM, Carver RL. Daily chlorhexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. Am J Infect Control 2010;38:817-821.
The authors set out to determine whether daily bathing of patients with 2% chlorhexidine gluconate (CHG)-impregnated cloths could reduce central line-associated bloodstream infection (CLABSI) rate by at least 30% in a surgical ICU where CLABSI rates were above National Healthcare Safety Network averages. The study took place at a single, nine-bed surgical ICU in the United States; usual interventions for reduction of CLABSI (maximal sterile barrier precautions, appropriate protocols for dressing and tubing changes, daily review for necessity of lines, etc.) were already in place.
All patients admitted to this ICU during the study period and without a known sensitivity to CHG were included. A well-defined protocol was used by nursing staff for CHG bathing and the CHG-impregnated cloths were used after incontinence clean-up as well. The authors performed an initial 3-month observational study to determine effectiveness of their intervention and then extended the observational period and data-gathering for another 14 months. Historical control data (from the 17 months preceding the start of this study) were used for comparison. Any adverse reaction to CHG (such as rash) was recorded and data were collected on CLABSI rates (number of CLABSIs per number of central line days × 1000). Usual statistical methods were employed.
During the initial 3-month observational period, 144 patients were included and the CLABSI rate was found to be 3.17 compared to a historical control of 12.07 per 1000 central line days. (This historical control rate may have been derived from the 3 months immediately preceding the study, but this is not clear from the article.) Based on this statistically and clinically significant reduction, CHG bathing was continued with data collection and observation for another 14 months. For the entire 17-month study period, CLABSI rate was 2.1 compared to 8.6 per 1000 central line days for the 17 months immediately preceding the study, a statistically significant reduction of 76%. Inclusion and compliance were 100% and there were no adverse events.
Prevention of CLABSIs remains a key goal and initiative in most ICUs. The recommendation to consider bathing patients daily with CHG in areas with unacceptably high CLABSI rates, despite use of other preventive strategies, has been a part of recent national guidelines for prevention of hospital-acquired infections. Daily bathing with CHG is not yet advised as a first-line measure; the current study adds some credence to the idea that perhaps it should be in the future.
Bathing with CHG has been investigated as a means of reducing colonization with resistant organisms, postoperative/surgical wound infections, and other hospital-acquired infections. Available studies are, like the current one, usually small, single-center and often with design limitations such as absence of concurrent controls, though they generally have shown promising results. A 1-year long crossover trial of daily bathing with CHG with concurrent controls in two medical ICUs at a single hospital in 2007 found an approximately 60% reduction in bloodstream infections.1 A more recent 6-month cohort study using historical controls in a trauma ICU found a 75% reduction in CLABSI and a large decrease in rates of colonization with methacillin-resistant Staphylococcus aureus (MRSA) or Acinetobacter species.2 Other studies of bathing patients with CHG also suggest reduced colonization with MRSA and vancomycin-resistant enterococcus (VRE) in surgical and medical ICUs and perioperative settings and lower rates of CLABSIs in patients at long-term acute care hospitals.
As the authors of this investigation discuss, daily bathing of patients with CHG is a simple, benign, and likely cost-effective strategy. It is easily incorporated into current nursing care practices (perhaps even reducing bathing time since a rinse is not indicated). Even if "real-life" reduction of bloodstream infections is lower than that seen in the study, the cost-savings and potential decreases in morbidity and mortality could be considerable.
Thus, I agree with the authors' recommendation to consider implementation of daily bathing of ICU patients with CHG as an addition to other usual measures for placement and management of central lines such as: use of appropriate central line kits and checklists for insertion and care, maximal sterile barrier precautions for insertion, avoiding femoral site whenever possible, dressing and tubing changes, and cleaning/access of the ports and line per usual national guidelines, daily assessment of the need for the line and routine monitoring/audits of compliance, infection rates, and local resistance patterns.