Running head: INTEGRATIVE REVIEW 1

Chlorhexidine Bathing in ICUs: An Integrative Review

Kirsten Larson

NUR 4122

Bon Secours Memorial College of Nursing

March 28, 2017

I pledge.
INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate studies on the use of chlorhexidine bathing

in adult intensive care units (ICUs) to prevent hospital acquired infections (HAI). HAI cause

significant morbidity and mortality to patients each year in the US. The study design is an

integrative review. Literature for this review was found using the search databases EBSCO

Discover, PubMed, and Google Scholar. The search resulted in 1,440 articles, five of which met

the inclusion criteria. In order to be included, the articles must contain chlorhexidine bathing,

adult ICU, effect on hospital acquired infections, and prevention of hospital acquired infections.

Four of the five articles found that chlorhexidine bathing in adult ICUs prevent hospital acquired

infections. The studies also found that chlorhexidine bathing does not increase the risk of adverse

skin reactions in patients. The integrative review was limited by the researchers inexperience in

conducting research, time constraints, and the requirement of using only five articles. The results

implicate that chlorhexidine bathing should be used in ICUs to prevent hospital acquired

infections. Further research on the use of chlorhexidine bathing in preventing hospital acquired

infections in other settings, such as non-critical care units, and in other populations should be

conducted.
INTEGRATIVE REVIEW 3

Chlorhexidine Bathing in ICUs: An Integrative Review

The purpose of this integrative review is to study the research conducted on the

effectiveness of bathing with chlorhexidine gluconate in adult ICU on the prevention of hospital

acquired infections. HAI pose a major concern due to their high mortality rates and cost to the

healthcare system. Around 1.7 million hospital acquired infections happen each year in the U.S.,

costing up to 147 billion dollars (Swan, et al., 2016). In 2011 Methicillin-resistant

Staphylococcus aureus (MRSA) alone was responsible for over 11,000 deaths (Petlin et al.,

2014). ICU patients are especially susceptible due to the severity of their condition and the

prevalence of drug resistant organisms in hospitals. Recently, researchers have scrutinized the

effectiveness of chlorhexidine based soap in preventing infections. This topic is of interest to the

researcher because of the morbidity, mortality, and cost of hospital acquired infections. The

proposed PICO question is: For ICU patients, does the use of chlorhexidine baths reduce the risk

of hospital acquired infections compared with soap and water baths?

Design/Search Methods

The research was conducted as an integrative review. The articles included in this review

were found using the search engine databases PubMed, EBSCO Discovery, and Google Scholar.

The researcher used the words chlorhexidine gluconate, bathing, adult, ICU,

prevention, and healthcare associated infection as search terms. The search was limited to

sources published between the years 2012 and 2017, peer reviewed articles in academic journals,

full text availability, and inclusion in the colleges library collection. Sources had to be written in

English and relate to the PICO question. The search resulted in 28 articles in EBSCO Discovery,

12 results in PubMed, and 1,400 articles in Google Scholar. Out of these results, five total

articles were chosen, two from Google Scholar, two from EBSCO Discover, and one from
INTEGRATIVE REVIEW 4

PubMed. The researcher included the articles based on chlorhexidine bathing, adult ICU, effect

on hospital acquired infections, and prevention of hospital acquired infections. The articles were

excluded if they did not meet the inclusion criteria, and were not qualitative or quantitative.

Findings/Results

All of the studies evaluate the use of chlorhexidine gluconate soap or washcloths in the

prevention of various hospital acquired infections (Climo et al., 2013; Noto et al., 2015; Petlin et

al., 2014; Swan et al., 2016; Viray et al., 2014). One study reported a slight decrease in hospital

acquired infection rates but it was not statistically significant. More in depth information on all

five articles used in this integrative review can be found in the Appendix 1. After analyzing the

data presented in the articles, two major similarities were found. The themes of the articles

include chlorhexidine bathings effectiveness against various hospital acquired infections

(including organisms that cause HAI), and the safety of using chlorhexidine soap.

Effectiveness against Bacteria that Cause HAI

Four of the five quantitative studies found that daily bathing of chlorhexidine and every

other day bathing with chlorhexidine is effective against various hospital acquired infections

including those caused by MRSA compared with non-antimicrobial soap (Climo et al., 2013;

Petlin et al., 2014; Swan et al., 2016; Viray et al., 2014). Two of these four studies also showed

that bathing with chlorhexidine reduces the number of infections of Vancomycin-resistant

enterococci (Climo et al., 2013; Swan et al., 2016). The studies discovered that chlorhexidine

bathing reduces the transmission and infection rates of catheter-associated urinary tract

infections, surgical site infections, ventilator-associated pneumonia, and bloodstream infections.

All the studies took place in adult Intensive Care Units.

INTEGRATIVE REVIEW 5

Climo et al. (2013) conducted a multicenter, cluster-randomized, non-blinded crossover

study to determine the effect of daily chlorhexidine bathing on hospital acquired bloodstream

infections and the acquisition of multidrug resistant organisms. The study was set in nine

intensive care and bone marrow transplantation units in six different hospitals. In total, 7,727

patients were involved in the study. For six months each unit was randomly selected to bathe

patients with a 2% chlorhexidine impregnated washcloths or with washcloths that were not

antimicrobial. The unit staff conducted active surveillance for MRSA, and VRE colonization and

bloodstream infection. The average rates of MRSA and VRE acquisition and bloodstream

infections were analyzed using PROC GENMOD procedure in SAS software in order to fit a

Poisson regression model. The Cox proportional hazards regression model was also used to

evaluate the length of time from admission until the first primary bloodstream infection (2013,

p. 536). The study found a 23% lower rate of transmission of multidrug resistant organisms and a

28% lower rate of hospital acquired bloodstream infections compared with non-antimicrobial

soap.

In response to the study conducted by Climo et al. (2013), Petlin et al. performed a study

focusing on the effect of a chlorhexidine bathing protocol specifically on MRSA acquisition in

adult intensive care units (2014). The study also evaluated what method of chlorhexidine bathing

was the most affordable. The study was conducted with a pre and post intervention design. Five

adult ICUs participated in the study. Three of the ICUs performed active surveillance for MRSA.

Patients received nasal swabs at admission, weekly, and then at discharge. The two other ICUs

performed incident surveillance to detect MRSA acquisition. Patients in these units were

considered to have acquired MRSA if they had a new culture that was positive for MRSA forty-

eight hours after admission. The rate of MRSA acquisition of all five ICUs were obtained and
INTEGRATIVE REVIEW 6

compared with the rates before the chlorhexidine bathing was instituted. Patients received baths

with 4% chlorhexidine gluconate mixed with six quarts of water. Petlin et al. used OpenEpi to

calculate MRSA acquisition rates. Before chlorhexidine bathing was instituted in the ICUs, 132

patients acquired MRSA in 34333 patient days and a total of 109 patients in 41376 patient days

acquired MRSA (Petlin et al., 2014, p. 17). The resulting ratio difference was 1.46, showing a

decrease in MRSA acquisition.

The study by Swan et al. (2016) evaluates the use of 2% chlorhexidine gluconate

bathings effectiveness in decreasing the acquisition of hospital acquired catheter-associated

urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and

primary blood stream infection in adult surgical ICU patients compared with soap and water

bathing. The study is a single center, pragmatic, randomized trial. Although patients and

clinicians knew who was in the treatment group, those who investigated the outcomes did not.

The study took place in a twenty-four bed surgical ICU at a quaternary academic medical

center (Swan et al., 2016, p. 1823). A total of 325 patients participated in the study. Hospital

acquired infections were identified using cultures, blood tests, urine analysis, and imaging. Data

was analyzed by blinded investigators using Cox regression analysis and chi-square tests. The

study found that the absolute risk reduction for acquiring hospital acquired infections was 9.0%.

This included infections caused by MRSA and VRE.

In their study, Viray et al. (2014) performed a prospective pre and post intervention study

with the use of a control unit from January 2005 to December 2007. Previously, active

surveillance of MRSA had been conducted on the intervention unit beginning in January 2002

and the control unit beginning January 2005. They conducted the study at a 1,250 bed tertiary

care teaching hospital. The study itself was conducted on patients from a surgical ICU that
INTEGRATIVE REVIEW 7

contained twenty-four beds and a medical ICU with 19 beds. The intervention ICU (Surgical

ICU) implemented the intervention of daily bathing with chlorhexidine based soap. The patients

were bathed once upon admission and then daily with 4% chlorhexidine based soap added to

four quarts of water. The mixture resulted in a final concentration of 0.125%. Nose swabs were

cultured to determine the presence of MRSA and variables such as presence of central venous

catheters, use of ventilators, issues in skin integrity, patient length of stay, tracheostomy

presence, enteral tube feedings, and presence of MRSA upon admission. The results of the study

were analyzed with a time series model, Durbin-Watson statistic, and Box-Ljung test. The study

detected a decrease of ICU acquired MRSA infections of 41.37% in the intervention ICU.

In the article by Noto et al. (2015), the researchers conducted a study to identify if

chlorhexidine bathing reduces the occurrence of HAI in critical care patients. The study

consisted of a pragmatic, cluster randomized, crossover study of 9,340 patients in five adult

ICUs a year in length. Units alternated using chlorhexidine soap and antimicrobial soap. Blinded

infection control personal collected data on the occurrence of bloodstream infections, ventilator-

associated pneumonia, catheter-associated urinary tract infections, and Clostridium difficile

infections during the intervention and the comparison treatment. The researchers analyzed the

data using a Poisson regression model to compare the rate of infection. The primary outcome rate

for the chlorhexidine bathing was 2.86 per 1000 patient days and 2.90 per 1000 patient days

during the control period. However, the authors noted that compliance with chlorhexidine

bathing was not assessed.

The Safety of Chlorhexidine Soap

Each of the five studies conducted education to the nurses and other staff members prior

to implementing bathing with chlorhexidine (Climo et al., 2013; Noto et al., 2015; Petlin et al.,
INTEGRATIVE REVIEW 8

2014; Swan et al., 2016; Viray et al., 2014). The staff was educated on proper bathing technique

with chlorhexidine, signs and symptoms of skin reaction to the chemical, and areas on the skin

that should not be cleaned with chlorhexidine gluconate. Several of the studies evaluated the

risks of using chlorhexidine soap in daily baths along with the main objective of the study. The

studies found that there is no increased risk of harm by using chlorhexidine soap bathing

compared with non-antimicrobial soap and water baths.

During the study conducted by Climo et al. (2013), nursing staff were instructed to assess

the skin of all patients receiving chlorhexidine baths and report any adverse skin reactions. The

investigators then determined the severity of the reaction and whether it was caused directly by

the use of chlorhexidine soap. Only 78 of the 3,970 patients receiving chlorhexidine baths

developed any skin reactions. In comparison, 130 patients out of 3,842 who were bathed with

non-antimicrobial washcloths developed skin reactions. The investigators found that all of these

skin reactions were mild to moderate and not associated with the method of bathing. Climo et al.

concluded that chlorhexidine baths posed little risk of harm for patients (2013).

Swan et al. also compared the incidence of skin reactions with chlorhexidine bathing with

soap and water bathing (2016). The study analyzed the proportion of patients with adverse skin

reactions using chi-square tests. According to Swan et al., the incidence of skin occurrences was

18.9% with soap and water bathing and 18.6% with chlorhexidine bathing (2016, p. 1826).

Discussion/Implications

The articles all evaluate the effectiveness of chlorhexidine bathing compared with

bathing with non-antimicrobial soap in preventing hospital acquired infections in adult intensive

care units. Thus, the findings and results directly relate to the PICO question which looks to

evaluate the use of chlorhexidine bathing in preventing all kinds of hospital acquired infections.
INTEGRATIVE REVIEW 9

Four out of the five articles clearly found that daily or every other day chlorhexidine bathing

prevents numerous hospital acquired infections (Climo et al., 2013; Petlin et al., 2014; Swan et

al., 2016; Viray et al., 2014). The studies found that chlorhexidine bathing is effective in the

prevention of catheter-associated urinary tract infections, ventilator-associated pneumonia,

surgical site infections, and bloodstream infections even when these infections were caused by

drug resistant microbes. The study by Noto et al. (2015) did not show any significant reduction

in hospital acquired infections when using chlorhexidine bathing compared with bathing with

non-antimicrobial soap. However, unlike the other studies, Noto et al. (2017) did not ensure

compliance in using the chlorhexidine soap.

Chlorhexidine bathing is a safe and effective method of reducing hospital acquired

infections in adult intensive care units. Further research needs to be conducted on the

effectiveness of chlorhexidine bathing in reducing hospital acquired infections on general

medical/surgical units. More research is needed to determine whether basin baths with

chlorhexidine soap is less effective than using chlorhexidine wipes.

Limitations

This integrative review was limited by many different factors. The sole researcher is an

undergraduate nursing student and has never conducted an integrative review before. The

researcher was required to use only five articles that were published within the last five years.

The researcher had a limited amount of time to conduct the integrative review.

Conclusion

Hospital acquired infections continue to cause serious illnesses throughout the country.

The findings of this integrative review answers the PICO question in that the use of

chlorhexidine bathing in adult intensive care units prevents HAI as opposed to using non-
INTEGRATIVE REVIEW 10

antimicrobial soap. Chlorhexidine bathing does not pose a greater risk of adverse skin reactions

than bathing with non-antimicrobial soap. Further research is needed to determine the

effectiveness of chlorhexidine bathing in settings other than the adult intensive care units. Due to

their role at the bedside, nurses are at the forefront in implementing chlorhexidine bathing for the

prevention of HAI. Chlorhexidine bathing can easily be implemented by educating the nursing

staff on its use and substituting non-antimicrobial soap with chlorhexidine soap.
INTEGRATIVE REVIEW 11

References

Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . . Wong,

E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. The

New England Journal of Medicine, 368(6), 533-542. doi: 10.1056/NEJMoa1113849

Noto, M. J., Domenico, H. J., Byrne, D. W., Talbot, T., Rice, T. W., Bernard, G. R., & Wheeler,

A. P. (2015). Chlorhexidine bathing and health care-associated infections: A randomized

clinical trial. The Journal of the American Medical Association, 313(4), 369-378. doi:

10.1001/jama.2014.18400

Petlin, A., Schallom, M., Prentice, D., Sona, C., Mantia, P., McMullen, K., & Landholt, C.

(2014). Chlorhexidine gluconate bathing to reduce methicillin-resistant staphylococcus

aureus acquisition. Critical Care Nurse, 34(5), 17-24. doi:

http://dx.doi.org/10.4037/ccn2014943

Swan, J. T., Ashton, C. M., Bui, L. N., Pham, V. P., Skirkey, B. A., Blackshear, J. E., . . . Wray,

N. P. (2016). Effect of chlorhexidine bathing every other day on prevention of hospital-

acquired infections in the surgical ICU: A single-center, randomized control trial. Critical

Care Medicine, 44(10), 1822-1832. doi: 10.1097/CCM.0000000000001820

Viray, M. A., Morley, J. C., Coopersmith, C. M., Kollef, M. H., Fraser, V. J., & Warren, D. K.

(2014). Infection Control and Hospital Epidemiology, 35(3), 243-250. doi:

10.1086/675292
 Running head: INTEGRATIVE REVIEW 12

NUR 4122: Nursing Research

Appendix 1: Table of Evidence

First Author Climo, MD. (2013). Professor in the department of Internal Medicine Division of
(Year)/Qualifications Infectious Diseases, Virginia Commonwealth University School of Medicine
Background/Problem The authors state results of previous single-center, observational studies suggest that
Statement daily bathing of patients with chlorhexidine may prevent hospital acquired bloodstream
infections and the acquisition of multidrug-resistant organisms (MDROs). The purpose of
the study was to evaluate the effect of daily bathing with chlorhexidine impregnated
washcloths on the acquisition of MDROs and the incidence of hospital acquired
bloodstream infections. (2013, p. 533)
Conceptual/theoretical Chlorhexidine gluconate is an antiseptic agent that has broad-spectrum activity against
Framework many organisms, including S. aureus and enterococcus species.
Design/ The authors state a multi-center, cluster-randomized, non-blinded crossover trial to
Method/Philosophical evaluate the effect of daily bathing with chlorhexidine impregnated washcloths on the
Underpinnings acquisition of MDROs and the incidence of hospital acquired bloodstream infections.
(2013, p. 533)
Sample/ Setting/Ethical A total of 7,727 patients from nine intensive care and bone marrow transplantation units
Considerations in six hospitals were enrolled in the study. Approval of the study protocol was obtained
from institutional review boards at the study centers and the Center for Disease Control
and Prevention.
Major Variables Studied The authors state bloodstream infections were identified with the use of National
(and their definition), if Healthcare Safety Network definitions. Hospital acquired bloodstream infections were
appropriate defined as bloodstream infections detected more than 48 hours after admission to the
unit without an attributable secondary source of infection. Central-catheter-associated
bloodstream infections were defined as primary bloodstream infections in patients with at
least one central venous catheter in place within 48 hours before detection of the
infection. (2013, p. 535). MRSA and VRE infections were detected by positive results on
swabs from patients up to 48 hours after admission to the unit and on discharge from the
unit.
 INTEGRATIVE REVIEW 13

Measurement Tool/Data The incidence rates of acquisition of MDROs and the rates of hospital acquired
Collection Method bloodstream infections were obtained through swabs and blood cultures and signs and
symptoms of infection.
Data Analysis The incidence rates of acquisition of MDROs and the rates of hospital acquired
bloodstream infections were compared between the two periods (6 months bathing with
chlorhexidine and 6 months bathing with antimicrobial soap) by means of Poisson
regression analysis (Climo et al., 2013).
Findings/Discussion The rate of MDROs acquisition decreased 23% with chlorhexidine bathing. The overall
rate of hospital acquired bloodstream infections was reduced by 28% with chlorhexidine
bathing. No serious skin reactions were noticed during either study period. Not only did
bacterial bloodstream infections decreased but fungal bloodstream infections were also
reduced.
Appraisal/Worth to This study supports the growing evidence that chlorhexidine bathing can reduce hospital
practice acquired infections. It is a relatively straightforward strategy and is easy to sustain
because it does not require a substantial change of bathing protocols.
 INTEGRATIVE REVIEW 14

NUR 4122: Nursing Research

Appendix 1: Table of Evidence

First Author Noto, MD, PhD, department of Medicine, Vanderbilt University, Nashville, TN. (2015)
(Year)/Qualifications
Background/Problem Noto et al. states Daily bathing of critically ill patients with the broad spectrum, topical
Statement antimicrobial agent chlorhexidine is widely performed and may reduce health care
associated infections and the purpose of the study is to determine if daily bathing of
critically ill patients with chlorhexidine decreases the incidence of healthcare associated
infections (2015, p. 369)
Conceptual/theoretical Chlorhexidine gluconate is a broad spectrum antimicrobial agent and can kill the
Framework microbes responsible for hospital acquired infections.
Design/ The researchers used a pragmatic cluster randomized, crossover study. Cultures and
Method/Philosophical swabs were used to detect hospital acquired infections during the study.
Underpinnings
Sample/ Setting/Ethical The authors state The study involved 9,340 patients admitted to five adult intensive care
Considerations units of a tertiary medical center in Nashville, TN, from July 2012 to July 2013 (2015, p.
369). The researchers received approval by the Vanderbilt University Institutional Review
Board and obtained waivers of consent from the patients participating.
Major Variables Studied Variables studied included central line associated bloodstream infections, catheter
(and their definition), if associated urinary tract infections, ventilator associated pneumonia, and C. difficile
appropriate infections. Infections were determined using the Centers for Disease Control and
Prevention National Healthcare Safety Network definitions by infection control personnel.
Measurement Tool/Data Infections were determined using the Centers for Disease Control and Prevention
Collection Method National Healthcare Safety Network definitions by blinded infection control personnel.
Data Analysis The primary analysis performed was a comparison of the infection rate between groups
using a Poisson regression model. Repeated infections from an individual patient were
included as events in the analysis.
Findings/Discussion Chlorhexidine bathing did not significantly reduce the rate of hospital acquired infection
during the study period. The findings did not support the use of daily bathing with
chlorhexidine in critical care patients.
 INTEGRATIVE REVIEW 15

Appraisal/Worth to The study contradicts numerous studies on the use of chlorhexidine bathing in intensive
practice care units. The authors admit that this could be due to the fact that adherence to the use
of chlorhexidine bathing was not assessed at all.
 INTEGRATIVE REVIEW 16

NUR 4122: Nursing Research

Appendix 1: Table of Evidence

First Author Petlin, RN, MSN, CCR-CSC, CCNS, PCCN, ACNS-BC. (2014). Petlin is a clinical
(Year)/Qualifications nurse specialist in the cardiothoracic intensive care unit at Barnes-Jewish Hospital
in St. Louis, MO.
Background/Problem Methicillin-resistant Staphylococcus aureus (MRSA) is behind a large amount of
Statement morbidity and mortality in intensive care units. Chlorhexidine gluconate is an antiseptic
substance that can kill both gam positive and gram negative bacteria. According to the
authors, The purpose of this study is to research the impact of a bathing protocol using
chlorhexidine gluconate and bath basin management on MRSA acquisition and to
examine the cost differences between chlorhexidine bathing by using the bath-basin
method versus using prepackaged chlorhexidine impregnated washcloths (2014, p. 17).
Conceptual/theoretical The researchers use the Synergy Model from the American Association of Critical-Care
Framework Nurses that promotes a holistic view of the patients and nurses special contribution to
patient care and outcomes.
Design/ The study used a pre-post intervention design. Clinical nurse specialists worked with their
Method/Philosophical unit-based physician leadership and infection prevention staff. A clinical nurse specialist
Underpinnings in the hospitals research department collaborated with each clinical nurse specialist to
implement the protocol. A nurse champion(s) and the clinical nurse specialists provided
education about the protocol and monitored for implementation progress and supply
needs.
Sample/ Setting/Ethical Patients in three ICUs went through active surveillance for MRSA acquisition. Patients in
Considerations two other units were monitored for a new positive culture for MRSA at any site forty eight
hours after admission. The study collected data from 41,376 patient days.
Major Variables Studied 4% chlorhexidine gluconate was used to bathe patients. MRSA acquisition was defined
(and their definition), if as a nasal swab or clinical culture that was positive for MRSA 48 hours after admission in
appropriate any patient who had a negative result or no nasal swab at admission.
Measurement Tool/Data Data was collected through nasal swabs and cultures in three of the ICUs. Two other
Collection Method ICUs used incident surveillance. Infection prevention staff monitored the MRSA
acquisition rates and compliance with admission, weekly, and discharge surveillance
 INTEGRATIVE REVIEW 17

swabs and they reported the data monthly to the three ICUs that were performing active
surveillance.
Data Analysis Data was analyzed using OpenEpi software to calculate MRSA acquisition rate ratios.
Patients who were positive for MRSA on admission were excluded from the calculations.
Findings/Discussion Patients in the pre-intervention period were almost 1.5 times more likely to acquire MRSA
than patients who received the CHG bathing protocol. The chlorhexidine soap and bath
basin method cost much less than chlorhexidine impregnated cloths.
Appraisal/Worth to The study found that soap and bath basin bathing with chlorhexidine is an effective and
practice affordable method to decrease MRSA acquisition in ICUs. Although there were some
flaws in the study, the results reflect other research that supports the conclusion.
 INTEGRATIVE REVIEW 18

NUR 4122: Nursing Research

Appendix 1: Table of Evidence

First Author Swan (2016), PharmD, MPH, BCPS, Department of Pharmacy Practice and Clinical
(Year)/Qualifications Health Sciences, Texas Southern University; Allied Health Sciences, Institute for
Academic Medicine; Department of Pharmacy, Houston Methodist Hospital; Center
for Outcomes Research, Department of Surgery, Houston Methodist Research
Institute.

Background/Problem Hospital acquired infections pose a huge problems in hospitals across the United States.
Statement Hospital acquired infections in the United States each year cost billions of dollars. The
purpose of this study is to test the hypothesis that compared with daily soap and water
bathing, bathing with 2% chlorhexidine gluconate bathing every other day for up to 28
days decreases the risk of hospital acquired catheter-associated urinary tract infection,
ventilator-associated pneumonia, incisional surgical site infection, and primary blood-
stream infection in surgical ICU patients (Swan et al., 2016, p 1823).
Conceptual/theoretical Studies have shown the effectiveness of chlorhexidine gluconate bathing in killing
Framework hospital acquired infection causing pathogens. Other studies show that chlorhexidine
gluconate bathing is effective in preventing non-blood stream infections. Because of this,
the researchers hypothesized that chlorhexidine gluconate bathing will reduce blood
stream infections and other hospital acquired infections (Swan et al., 2016).
Design/ The study was a single-center, pragmatic, randomized trial. Patients and clinicians were
Method/Philosophical aware of treatment-group assignment. However, the investigators who determined
Underpinnings outcomes were blinded. One group received soap and water baths. The second group
received baths with 2% chlorhexidine gluconate (Swan et al., 2016).
Sample/ Setting/Ethical 325 adult patients were randomized and included in the study. In order to reach 80%
Considerations power, the researchers estimated that a minimum of 320 patients. Patients were
excluded if they had a Braden score less than 9, pregnant, had skin irritation that
precluded chlorhexidine bathing, had a chlorhexidine allergy, or had an SICU stay of
more than 48 hours prior to screening. The study took place in a surgical intensive care
unit with twenty-four beds at a quaternary academic medical center. The study received
support from an intramural gran and was approved by the hospitals institutional review
 INTEGRATIVE REVIEW 19

board. Participants filled out waivers of informed consent and could withdraw from the
study at any time (Swan et al., 2016).
Major Variables Studied Variables studied included catheter associated urinary tract infections, ventilator
(and their definition), if associated infections, incisional surgical site infections and primary blood stream
appropriate infections. Catheter associated urinary tract infections (CAUTI) were determined by
symptoms and urinary analysis. Pneumonia detected after 48 hours of ventilation were
classified as ventilator associated pneumonia (VAP). Surgical site infections were
determined through symptoms and cultures. Blood stream infections (BSI) were
determined by blood cultures and CBC (Swan et al., 2016).
Measurement Tool/Data Two committee members independently reviewed every patient case using standardized
Collection Method flow sheets to detect hospital acquired infections. One investigator reviewed patient data
to detect and grade skin occurrences. Both reviewers were blinded (Swan et al., 2016).

Data Analysis The researchers used Cox regression analysis of a multiple outcomes failure model
stratifying the baseline hazard function on infection type and providing an overall HR rate
for the four infection types. This analysis was conducted with a modified intention-to-treat
population and was not adjusted for baseline variables. All analysis was performed using
Stata version 13. Proportions of patients with incident skin occurrences or in-hospital
mortality were compared using chi-square tests. A HR rate for each infection type was
calculated using survival models, and infection rates were compared using Poisson
regression. Sensitivity analyses were conducted to test the robustness of results (Swan
et al., 2016).
Findings/Discussion Compared with soap and water, chlorhexidine bathing every other day decreased the risk
of acquiring infections by 44.5% in surgical ICU patients. Incidences of adverse skin
occurrences were similar between soap and water bathing and chlorhexidine bathing
(18.9% soap and water vs 18.6% chlorhexidine). Chlorhexidine bathing did not increase
the risk of adverse skin occurrences or pressure ulcers (Swan et al., 2016).
Appraisal/Worth to The researchers used two blinded, outside investigators to classify hospital acquired
practice infections. However, the patient population contained many patients who had received
organ transplants. The immunocompromised population effects the incidence of hospital
acquired infections and makes it more difficult to recreate the study.
 INTEGRATIVE REVIEW 20

This article not only demonstrated that chlorhexidine bathing can reduce hospital
acquired infections but also showed that adverse reactions from chlorhexidine bathing
are almost the same as that of soap and water bathing.
 INTEGRATIVE REVIEW 21

NUR 4122: Nursing Research

Appendix 1: Table of Evidence

First Author M. A. Viray, MD. (2014) Washington University School of Medicine

(Year)/Qualifications
Background/Problem The purpose of this article is to determine whether daily bathing with chlorhexidine-
Statement based soap decreased methicillin-resistant Staphylococcus aureus transmission and
intensive care unit acquired S. aureus infection among ICU patients (Viray et al., 2014,
p. 243). MRSA causes a large amount of hospital acquired infections.
Conceptual/theoretical Chlorhexidine based soap kills bacterial organisms and may reduce and prevent MRSA
Framework transmission and infections.
Design/ The design is a prospective pre-post-intervention study with control unit (Viray et al.,
Method/Philosophical 2014).
Underpinnings
Sample/ Setting/Ethical The sample consisted of medical and surgical ICU patients. The setting was in a 1,250
Considerations bed tertiary care teaching hospital. The study was approved by the Washington
University Human Research Protection Office (Viray et al., 2014).
Major Variables Studied The variables studied were daily bathing with chlorhexidine-based soap on methicillin-
(and their definition), if resistant staphylococcus aureus (MRSA) transmission and acquisition of S. aureus in the
appropriate intensive care unit. Other variables such as patients on ventilators, central venous
catheterization, enteral tube feedings, tracheostomy, and decubitus ulcers (Viray et al.,
2014).
Measurement Tool/Data Active surveillance for MRSA colonization was performed in both ICUs. In June 2005, a
Collection Method chlorhexidine bathing protocol was implemented in the surgical ICU (Viray et al., 2014).
Data Analysis Changes in S. aureus transmission and infection rate before and after implementation
were analyzed using time-series methodology. The primary outcome of the analysis was
the effect of the bathing intervention on MRSA acquisition in the intervention ICU versus
the control ICU (Viray et al., 2014).
Findings/Discussion The incidence of ICU-acquired MRSA infections decreased by 41.37% in the intervention
ICU (Viray et al., 2014).
 INTEGRATIVE REVIEW 22

Appraisal/Worth to This study supports the theory that the institution of daily chlorhexidine bathing in an ICU
practice can reduce acquisition of MRSA and S. aureus. Chlorhexidine soap is inexpensive and
has a low risk of harming patients.