You are on page 1of 14

1

Running head: DECREASING BLOODSTREAM INFECTIONS

Decreasing Health Care-Associated Bloodstream Infections in Patients in the Intensive Care Unit
Christina Weyant
University of South Florida

Abstract

DECREASING BLOODSTREAM INFECTIONS


Clinical Problem: Health care-associated bloodstream infections lead to increased lengths of
hospital stay, increased healthcare costs, and greater morbidity and mortality in patients in the
intensive care setting.
Objectives: To determine the effectiveness of daily bathing with 2 percent chlorhexidine wipes in
decreasing health care-associated bloodstream infections in patients in intensive care units (ICU).
PubMed, CINHAL, and National Guidelines Clearinghouse were used to find randomized
controlled trials, and national guidelines related to the effectiveness of chlorhexidine bathing on
decreasing bloodstream infections. Key words involved in the search were chlorhexidine,
chlorhexidine bathing, bloodstream infections, health care-associated infection, and infection
prevention.
Results: The Cincinnati Childrens Hospital Medical Center (CCHMC) (2013) strongly
recommends the use of chlorhexidine baths on a daily basis in order to prevent bloodstream
infections in children in the critical care setting. The literature also demonstrates a significant
decrease in bloodstream infections in patients bathed with chlorhexidine wipes compared to
patients bathed with nonantibacterial wipes, or with soap and water. It was also determined that
universal decolonization with chlorhexidine leads to greater decreases in bloodstream infections
than screening, or targeted decolonization.
Conclusion: Patients bathed daily with 2 percent chlorhexidine have decreased rates of
bloodstream infections. This suggests that bathing each day with chlorhexidine is an effective
way to decrease bloodstream infections in the ICU. Further research is needed to investigate
adverse skin reactions, and chlorhexidine resistance associated with the use of chlorhexidine
bathing.
Decreasing Health Care-Associated Bloodstream Infections in Patients in the Intensive Care Unit

DECREASING BLOODSTREAM INFECTIONS


Health care-associated bloodstream infections pose a substantial problem to patients in
intensive care units. They are correlated with increased length of stay, greater health care costs,
and greater morbidity and mortality among patients. One study by Kaye et al. (2014) found that
bloodstream infections lead to an average increase in length of stay of 10 days, increased health
care costs of $43,208, and significantly greater mortality rates in older patients in an acute care
setting. Another study linked hospital acquired bloodstream infections to greater time in the
intensive care unit (ICU), longer hospital stays in general, as well as an increased likelihood of
dying in the hospital (Laupland, Lee, Gregson & Manns, 2006). Bloodstream infections are a
significant burden causing patients both physical aliment, and financial strain. Reducing health
care-associated bloodstream infections will lead to decreased health care costs, more favorable
patient outcomes, and will reduce unnecessary harm to patients and their families. The goal of
this paper is to determine if daily bathing with chlorhexidine wipes is an effective way to reduce
hospital-acquired bloodstream infections in patients in a critical care setting. In patients in the
intensive care unit, how does daily bathing with 2% chlorhexidine cloths compared to daily
bathing with nonantibacterial cloths affect the incidence of health care-associated bloodstream
infections within a one year time frame?
Literature Search
PubMed, CINHAL, and National Guidelines Clearinghouse were used to find
randomized controlled trials, and national guidelines for preventing health care-associated
bloodstream infections in patients in ICUs. Key words used were chlorhexidine, chlorhexidine
bathing, bloodstream infections, health care-associated infection, and infection prevention.
Literature Review

DECREASING BLOODSTREAM INFECTIONS


The effect of daily bathing with chlorhexidine wipes on health care-associated
bloodstream infections was evaluated based on three randomized controlled trials, and one
national guideline. The first of the randomized controlled trials was Bleasdale et al. (2007) which
compared primary bloodstream infections in patients bathed with 2 percent chlorhexidine to
patients bathed with soap and water. This was a crossover study where one group received the
intervention, daily bathing with chlorhexidine, and the other group served as the control, bathing
with soap and water. The first interval of the study lasted 28 weeks, followed by a two week
period where only bathing with soap and water occurred, then followed by another 24 week
interval where the units switched which group they were assigned to. There were a total of 391
patients in the chlorhexidine group, and 445 patients in the soap and water group. These
participants were patients in the medical ICUs at John H. Stroger Jr Hospital. These patients had
similar demographics, and a high percentage of them were male. The participants electronic
medical records were monitored for new antibiotic prescriptions, and results from clinical
cultures to determine if a bloodstream infection or other health care-associated infection was
present. A statistical analysis was conducted using a 95 percent confidence interval. Initial
analysis did not reveal a statistical significance between groups bathed with chlorhexidine versus
groups bathed with soap and water, however after controlling for the number of days that a
person had a central venous catheter in place, it was determined that the chlorhexidine group was
at significantly reduced risk for primary bloodstream infections (p=0.01). Some of the
weaknesses of the study were that it was not a double blinded study, and a few of the participants
were analyzed outside of the group that they were randomly assigned, however this only
involved 3 participants in the intention to treat group. Another weakness was that the majority of
the study participants were male. Some strengths of the study were that it was a crossover

DECREASING BLOODSTREAM INFECTIONS


randomized controlled study with a wash out period, it had an appropriate control group, and it
occurred over a one year period of time.
A study by Climo et al. (2013) was done to determine the effect of 2 percent
chlorhexidine wipes on hospital-acquired bloodstream infections, and multidrug resistant
organisms. This was a cluster randomized crossover study where participants were either
assigned to receive daily bathing with 2 percent chlorhexidine wipes, the intervention group, or
daily bathing with nonantibacterial cloths, the control group. The study occurred over a period of
a year, and after an initial 6 month period, the groups switched which intervention they were
receiving. Participants were monitored for vancomycin-resistant enterococcus (VRE),
methicillin-resistant staphylococcus aureus (MRSA), and hospital-acquired bloodstream
infections. Nine ICUs and bone marrow transplant units participated in the study, and data from
7727 patients was collected. Results showed a significant reduction in MRSA or VRE (p=0.03),
hospital-acquired bloodstream infections (p=0.007), primary bloodstream infections (p=0.006),
and central-catheter-associated bloodstream infections (p=0.004) in the chlorhexidine group
compared to the nonantimicrobial group. Some of the drawbacks of this study were that it was
not a double blind study, and there was an interruption in the study when the chlorhexidine wipes
being used were recalled for a period of four months. The strengths of the study were that it was
a randomized controlled crossover study, its large sample size, and its involvement of multiple
hospital units.
Huang et al. (2013) conducted a three group cluster randomized controlled trial
comparing screening, targeted decolonization, and universal decolonization and their
effectiveness in reducing bloodstream infections from MRSA, and other pathogens. The
screening group involved swabbing of the nares for MRSA, and placing patients on contact
5

DECREASING BLOODSTREAM INFECTIONS


precautions if the results were positive. The targeted decolonization group involved screening,
and contact precautions, but also involved daily bathing with 2 percent chlorhexidine, and
intranasal mupirocin for a five day period. In the universal decolonization group there was no
screening process, and everyone received daily bathing with chlorhexidine and intranasal
mupirocin for a five day period. A total of 74 intensive care units from 43 hospital participated in
the study and it lasted for a 12 month baseline period and an 18 month intervention period.
Participants were monitored for MRSA associated bloodstream infections, and bloodstream
infections associated with other pathogens. The clinical cultures were collected at the discretion
of the clinician. Statistical analysis showed that universal decolonization significantly reduced
incidence of MRSA compared with screening (p=0.003), and had significantly reduced incidence
of bloodstream infections from any pathogens compared to screening and isolation (p<0.001)
and targeted decolonization (p=0.04). The major drawbacks of the study were that it was not a
double blind study, and the cultures were collected at the discretion of the healthcare providers.
The major strengths of the study were that it was a randomized controlled trial, and there was a
large sample.
A national guideline from Cincinnati Childrens Hospital Medical Center (CCHMC)
(2013) was retrieved from the national guidelines clearinghouse, and recommends daily bathing
with chlorhexidine to prevent bloodstream infections for patients in intensive care units. The
intended population for this guideline is children in intensive care units, and this data may or
may not be generalizable to an adult population. This guideline is strongly recommended,
implicating that the benefits strongly outweigh the risks for this particular intervention. The
evidence used to support this recommendation comes mostly from level one and level two
research.
6

DECREASING BLOODSTREAM INFECTIONS


Synthesis
Bleasdale et al. (2007) found a significantly lower frequency of primary bloodstream
infections once adjusted for catheter days in patients bathed with chlorhexidine versus patients
bathed with soap and water (p=0.01). Climo et al. (2013) observed a reduction in MRSA or VRE
(p=0.03), hospital-acquired bloodstream infections (p=0.007), primary bloodstream infections
(p=0.006), and central-catheter-associated bloodstream infections (p=0.004) in patients receiving
daily baths with 2 percent chlorhexidine compared with patients being bathed with
nonantimicrobial cloths. Huang et al. (2013) determined that universal decolonization with
chlorhexidine and intranasal mupirocin significantly reduced the incidence of bloodstream
infections associated with MRSA compared to screening and isolation (p=0.003), and a reduction
in bloodstream infections caused by other pathogens compared with both screening and isolation
(p<0.001), and targeted decolonization (p=0.04). Finally, a national guideline from Cincinnati
Childrens Hospital Medical Center (2013) strongly recommends using daily chlorhexidine baths
to reduce bloodstream infections in children in the critical care setting. This set of research
receives a grade B recommendation owing to the fact that none of the randomized controlled
trials were double blind studies.
Research supports using daily bathing with chlorhexidine wipes to decrease the incidence
of health care-associated bloodstream infections. However, there are a few areas in which
additional research needs to be done. In each of the three articles there were some reported
adverse skin reactions associated with the use of chlorhexidine wipes. These reactions were a
mild to moderate rash, and warrant further investigation (Bleasdale et al., 2007; Climo et al.,
2013; Huang et al., 2013). There is also some concern that the overuse of chlorhexidine could
lead to resistance in pathogens. More long term studies are needed to determine if daily use of
7

DECREASING BLOODSTREAM INFECTIONS


chlorhexidine for all patients in intensive care units could lead to greater antibacterial resistance
in organisms. One final gap in the research is that the national guideline is intended for children,
and may not be generalizable to the adult population.
Clinical Recommendations
Research supports the use of daily bathing with chlorhexidine to reduce the incidence of
bloodstream infections in patients in the ICU. Several studies show a significant reduction in
bloodstream infections in patients bathed with chlorhexidine, compared with soap and water or
other nonantimicrobial wipes (Bleasdale et al., 2007; Climo et al., 2013). And that universal use
of chlorhexidine is more effective than screening or targeted isolation (Huang et al., 2013).
Finally, a national guideline from the CCHMC (2013) recommend daily bathing with
chlorhexidine as a means to reduce bloodstream infections. Further investigation needs to be
done in relation to adverse skin reactions, and possible chlorhexidine resistance in organisms.
Chlorhexidine bathing appears to be an effective way to reduce health care-associated
bloodstream infections in the critical care setting.

References
Bleasdale, S., Trick, W., Gonzalez, I., Lyles, R., Hayden, M., & Weinstein, R. (2007).

DECREASING BLOODSTREAM INFECTIONS


Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream
infections in medical intensive care unit patients. Archives of Internal Medicine, 167(19),
2073-2079.
Cincinnati Children's Hospital Medical Center (2013). Best evidence statement (BEST). Daily
bathing of children in critical care settings with chlorhexidine gluconate. Retrieved from
http://www.guideline.gov/content.aspx?id=47066&search=chlorhexidine
Climo, M., Yokoe, D., Warren, D., Perl, T., Bolon, M., Herwaldt, L., . . . Wong, E.
(2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New
England Journal of Medicine, 368(6), 533-542. doi:10.1056/NEJMoa1113849
Huang, S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T., . . . Platt, R. (2013).
Targeted versus universal decolonization to prevent ICU infection. New England Journal
of Medicine, 368(24), 2255-2265. doi: 10.1056/NEJMoa1207290
Kaye, K., Marchaim, D., Chen, T., Baures, T., Anderson, D., Choi, Y., . . . Schmader, K. (2014).
Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital
costs in older adults. Journal of the American Geriatrics Society, 62(2), 306-311.
doi:10.1111/jgs.12634
Laupland, K., Lee, H., Gregson, D., & Manns, B. (2006). Cost of intensive care unit-acquired
bloodstream infections. Journal of Hospital Infection, 63(2), 124-132.
doi:10.1016/j.jhin.2005.12.016

Table 1
Literature review

10

DECREASING BLOODSTREAM INFECTIONS


Reference

Aims

Design and

Sample

Outcomes/statistics

Bleasdale, S., Trick, W., The purpose of

Measures
Randomized

N=391 in the

After controlling for

Gonzalez, I., Lyles, R.,

the study was to

crossover

chlorhexidine

central venous

Hayden, M., &

discover if

clinical trial

group

catheter days the

Weinstein, R. (2007).

patients bathed

consisting of

N= 445 in the

occurrence of

Effectiveness of

daily with

a 28 week

soap and

bloodstream

chlorhexidine bathing

chlorhexidine

intervention

water group.

infections was

to reduce catheter-

had lower rates

period,

N=3

significantly lower

associated bloodstream

of primary

flowed by a

excluded

in the chlorhexidine

infections in medical

bloodstream

2 week wash

from the

group compared to

intensive care unit

infections

out period,

chlorhexidine

the soap and water

patients. Archives of

compared to

and then a 24

group due to

group (p=0.01)

Internal Medicine,

patients bathed

week

adverse skin

167(19), 2073-2079.

daily with soap

crossover

reaction.

and water.

intervention

All

period.

participants
were patients

Primary

in the

measure was

medical ICUs

primary

at John H.

bloodstream

Stroger Jr

infections

(Cook

and clinical

County)
10

11

DECREASING BLOODSTREAM INFECTIONS


sepsis.

Hospital.

The

Groups of

secondary

participants

measures

were similar.

were other
nosocomial
infections.
Climo, M., Yokoe, D.,

To ascertain the

A cluster-

N= 7727 total There was a

Warren, D., Perl, T.,

effect of

randomized

participants

Bolon, M., Herwaldt,

bathing with 2

crossover

L., . . . Wong, E.

percent

clinical trial

9 intensive

(p=0.03), hospital-

(2013). Effect of daily

chlorhexidine

with a 6

care units and

acquired

chlorhexidine bathing

each day on

month

1 bone

bloodstream

on hospital-acquired

multidrug

intervention

marrow

infections

infection. New England

resistant

period, and a

transplant

(p=0.007), primary

Journal of Medicine,

organisms and

6 month

clinic

bloodstream

368(6), 533-542.

health care-

crossover

participated.

infections

significant reduction
in MRSA or VRE

doi:10.1056/NEJMoa11 associated

intervention

(p=0.006), and

13849

period.

central-catheter-

bloodstream
infections

associated

compared to

Measures

bloodstream

daily bathing

used were

infections (p=0.004)
11

12

DECREASING BLOODSTREAM INFECTIONS


with

National

in the chlorhexidine

nonantibacterial

Healthcare

group compared to

cloths.

Safety

the

Network

nonantimicrobial

definitions

group

for, hospitalacquired
bloodstream
infection,
primary
bloodstream
infections,
and central
catheterassociated
bloodstream
Huang, S., Septimus,

To compare

infections.
Cluster-

E., Kleinman, K.,

screening and

randomized

A total of

decolonization

Moody, J., Hickok, J.,

isolation,

clinical trial

43hospitals

significantly

Avery, T., . . . Platt, R.

targeted

involving a

and 74

reduced incidence

(2013).

decolonization

12 month

intensive care

of MRSA compared

Targeted versus

with

baseline

units

with screening

universal

chlorhexidine

period and an participated.

Universal

(p=0.003), and had


12

13

DECREASING BLOODSTREAM INFECTIONS


decolonization to

and intranasal

18 month

Two hospitals significantly

prevent ICU infection.

mupirocin, and

intervention

were

reduced incidence

New England Journal

universal

period.

excluded due

of bloodstream

of Medicine, 368(24),

decolonization

to exclusion

infections from any

2255-2265. doi:

with

Primary

criteria, and

pathogens compared

10.1056/NEJMoa12072 chlorhexidine

outcome was

one hospital

to screening and

90

and intranasal

ICU

withdrew and

isolation (p<0.001)

mupirocin as

associated

was analyzed

and targeted

interventions

clinical

in the as-

decolonization

for bloodstream

cultures

assigned

(p=0.04).

infections

positive for

analysis

associated with

MRSA.

MRSA, and
bloodstream

Secondary

infections

outcome was

associated with

ICU

other

associated

pathogens.

bloodstream
infections
associated
with MRSA
or other
pathogens.

13

14

DECREASING BLOODSTREAM INFECTIONS

Center of
Disease
Control
criteria was
used.

14

You might also like