Leslie A. Hoffman, RN, PhD
Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh
Dr. Hoffman reports no financial relationships relevant to this field of study.
SYNOPSIS: In a randomized, crossover study of 9340 patients, daily chlorhexidine bathing did not reduce ventilator-associated pneumonia, central line-associated bloodstream infections, Clostridium difficile, or catheter-associated urinary tract infections.
SOURCE: Noto MJ, et al. Chlorhexidine bathing and health care-associated infections: A randomized clinical trial. JAMA 2015;313:369-378.
The goal of this study was to determine if daily bathing with chlorhexidine decreased the incidence of healthcare-associated infections. Subjects were 9340 patients enrolled between July 2012 and July 2013 who were admitted to one of five ICUs (cardiovascular, neurological, surgical, trauma, medical) in a single academic teaching institution. The units performed once-daily bathing of all patients with cloths impregnated with 2% chlorhexidine or disposable non-antimicrobial cloths as a control. Physicians performed each treatment for a 10-week period followed by a 2-week washout period during which patients bathed with non-antimicrobial cloths before crossing over to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times during the study. The primary study outcome was a composite of ventilator-associated pneumonia (VAP), central line-associated bloodstream infections (CLABSI), C. difficile, or catheter-associated urinary tract infections (CAUTI). Trained infection control personnel blinded to group assignment determined the infections. During chlorhexidine bathing, 55 infections occurred (4 CLABSI, 21 CAUTI, 17 VAP, and 13 C. difficile) vs 60 infections during the control bathing period (4 CLABSI, 21 CAUTI, 8 VAP, 16 C. difficile), a rate of 2.86 per 1000 patient days with chlorhexidine vs 2.90 per 1000 patients during the control period, a non-significant difference (P = 0.95). There were also no significant between-group differences after adjusting for baseline values or difference in outcomes in any of the five ICUs.
COMMENTARY
The emergence of multidrug-resistant organisms and adverse effects of hospital-acquired infections on patient outcomes, including increased length of stay, morbidity, and costs, has prompted an extensive search for better ways to prevent such events. One proposed approach has focused on decolonization as a means to decrease exposure in high-risk patients, such as those admitted to an ICU. Findings of the present study, designed to test benefits of daily chlorhexidine bathing, did not support a benefit of this strategy. This outcome contrasts with findings of two prior studies, one of which used a similar crossover design.1,2
There are several differences between these prior studies and the present study, which may explain the discrepant findings. Similar to the present study, Climo et al used a multicenter, non-blinded, cluster, randomized design and enrolled a large patient sample (n = 7727).1 However, they included both ICUs and units that admitted bone marrow transplant patients and employed chlorhexidine bathing for 24 weeks compared to 10 weeks in this study. Moreover, the reduction in bloodstream infections primarily appeared to result from a decrease in positive blood culture results caused by skin contamination bacteria. In addition, infection rates were lower initially in this study, whereas Climo et al reported a high prevalence of multi-drug resistant organisms in the control period.1 The second study by Huang et al tested a multi-component, decolonization intervention (of which chlorhexidine bathing was one component) and, therefore, is not directly comparable.2
Taken together, findings from this and prior studies suggest that chlorhexidine bathing can be successful, but success may vary depending on the characteristics of the patient population and infection rates in the targeted units. This study came about as a quality improvement project to determine if findings of prior studies could be replicated in the data collection institution. Findings indicated no benefit, suggesting that this approach (situation specific testing) might be the best option before universal adoption. There are also concerns about costs and emergence of resistant organisms, which were not explored but should be considered when decontamination is implemented on a long-term basis.
REFERENCES
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Climo MW, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 2013;368:533-542.
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Huang SS, et al. Prevention Epicenters Program: AHRQ DECIDE Network and Healthcare-Associated Infections Program. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013;368:2255-2265.
