Running head: CHLORHEXIDINE BATHING IN INFECTION PREVENTION

Effects of Bathing with Chlorhexidine Versus Soap and Water in Reducing Healthcare-Associated Methicillin-resistant Staphylococcus aureus Infections Among Intensive Care Unit Patients

Raya Lilley Washington State University, College of Nursing

CHLORHEXIDINE BATHING IN INFECTION PREVENTION Abstract

The spread of Methicillin-resistant Staphylococcus aureus within intensive care units considerably increases patient morbidity and mortality. Interventions are needed to reduce the acquisition of Methicillin-resistant Staphylococcus aureus within intensive care units. The purpose of this article evaluated the practice of bathing intensive care unit patients with chlorhexidine compared to bathing with soap and water to reduce the spread of Methicillin-resistant Staphylococcus aureus infections. Using the keywords, MRSA, transmission, bathing, and chlorhexidine, Cochrane, PubMed, and CINAHL were searched. Five evidenced-based publications were found. The author presented the result that chlorhexidine bathing is more effective at reducing Methicillin-resistance Staphylococcus aureus infections within intensive care units and should be adopted as best practice.

CHLORHEXIDINE BATHING IN INFECTION PREVENTION

Effects of Bathing with Chlorhexidine Versus Soap and Water in Reducing Healthcare-Associated Methicillin-resistant Staphylococcus aureus Infections Among Intensive Care Unit Patients The spread of Methicillin-resistant Staphylococcus aureus (MRSA) within intensive care units (ICUs) considerably increases patient morbidity and mortality (Climo et al., 2009). Healthcare-associated infections (HAIs) affect up to 20% of ICU patients, many of which are caused by MRSA (Climo et al., 2009). Interventions are needed to reduce the acquisition of MRSA within the ICU. The purpose of this article is to evaluate the practice of bathing ICU patients with chlorhexidine (CHG) compared to bathing with soap and water to reduce the spread of MRSA infections. Using the keywords, MRSA, transmission, bathing, and chlorhexidine, Cochrane, PubMed, and CINAHL were searched. Five evidenced based articles were retrieved. Of the five articles one was a level I systematic review and meta-analysis (OHoro, Silva, Munoz-Price, & Safdar, 2012), two were level III controlled trials without randomization (Climo et al., 2009; Ridenour et al., 2007), one was a level IV case-controlled trial without randomization (Evans et al., 2010) and one was a level V descriptive systematic review (Sievert, Armola, & Halm, 2011). Each article appeared to follow a standardized format for publication with the exception of the article by Sievert et al. (2011) which did not contain an abstract. All of the five articles contained information directly relating the effects of CHG bathing to reducing HAIs and therefore were all utilized throughout this paper. The systematic review and meta-analysis conducted by OHoro et al. (2012) was to determine if daily bathing with CHG was more effective in preventing HAIs versus soap and water. They determined that CHG bathing reduced the incidence of HAIs by an odds ratio (OR) of 0.44 (95% confidence interval [CI], 0.32-0.59; P < 0.00001). The information was validated using ran-

CHLORHEXIDINE BATHING IN INFECTION PREVENTION

dom-effects model and inverse variance random effects. OHoro et al. (2012) concluded that the data convincingly supported the practice of daily bathing with CHG to decrease HAIs. Climo et al. (2009) conducted a controlled trail without randomization to analyze the effect of bathing with CHG on the acquisition of MRSA and HAIs. They determined that the acquisition of MRSA decreased 32% (P = 0.046) following the introduction of this intervention. The data was validated using Poisson, Cox proportional-hazards and segmented regression models. They concluded that CHG bathing may reduce the acquisition of MRSA among ICU patients. The research of Ridenour et al. (2007) looked at whether CHG bathing and intranasal muprocin therapy among MRSA colonized ICU patients would decrease the incidence of MRSA. The findings showed that after the intervention, cases of MRSA colonization/infection decreased 52% (P = .048). They used the 2-sample t test, the 2-sided Mann-Whitney U test, and the X2 test with Yates correction to validate the statistics. After analysis they concluded that the intervention did reduce the incidence of MRSA colonization and infection. Evans et al. (2010) also examined the effect of CHG bathing on HAIs among trauma patients in a case-controlled trial without randomization. They determined patients who received CHG baths were less likely to develop MRSA (P=0.03) and the rate of colonization (P < .001) was significantly lower in the CHG group than in the comparison group. They validated the data using an intention-to-treat analysis, the t test for continuous variables and the X2 test for categorical variables, and a multiple logistic regression analysis. Evans et al. (2010) concluded CHG bathing is associated with a decreased rate of colonization by MRSA. Sievert et al. (2011) conducted a descriptive systematic review exploring whether bathing patients with CHG decreases HAIs in the ICU. The analysis of CHG versus soap and water showed significant reduction in MRSA (P < 0.5) in all but one study. The article does not include the

CHLORHEXIDINE BATHING IN INFECTION PREVENTION

methods of statistical analysis, just a discussion of the results found. Sievert, Armola, and Halm (2011) concluded CHG bathing should be considered an acceptable, safe, and useful intervention in reducing MRSA. As noted previously, the purpose of this paper was to determine whether or not bathing patients in the ICU with chlorhexidine versus soap and water would reduce MRSA transmission and acquisition. All five research teams concluded that bathing with CHG contributed to an increased reduction in MRSA infections and supported CHG bathing as a useful intervention among ICU patients. ICU patients are at higher risk for developing HAIs due to multiple factors such as: increased vulnerability due to compromised immune systems, underlying disease, medical/surgical treatments, the severity of illness which can prolong hospitalization times increasing the possibility of exposure and invasive medical devices which provide a portal of entry for microorganisms (Climo et al., 2009; Evans et al., 2010; OHoro et al., 2012). Based on this authors judgement, the data collected by the above noted researchers, supports the use of CHG when bathing ICU patients, as an effective intervention in reducing healthcare-associated MRSA infections. However, CHG bathing should be used in conjunction with contact precautions, active surveillance for MRSA, and proper hand hygiene techniques as a comprehensive approach to infection control. Therefore, it is recommended that hospitals create concrete policies to adopt the practice of daily CHG bathing in ICU patients to reduce MRSA. It is also suggested that a more active approach be taken to implement surveillance programs to identify patients colonized with MRSA upon admission and throughout their stay. Further investigation is needed to examine the efficacy

CHLORHEXIDINE BATHING IN INFECTION PREVENTION

of chlorhexidine use outside of the ICU and among different age groups such as pediatrics which were not represented in the study. According to Climo et al. (2009), healthcare-associated bloodstream infections are the leading cause of morbidity among ICU patients. It is evident that the use of CHG reduces MRSA infection rates in ICUs. Thus, when responding to the issue of whether or not daily CHG bathing should be used instead of traditional soap and water, this author determined that CHG bathing is more effective at reducing MRSA infections within the ICU and should be adopted as best practice.

References Climo, M. W., Sepkowitz, K. A., Zuccotti, G., Fraser, V. J., Warren, D. K., Perl, T. M., ... Wong, E. S. (2009). The effect of daily bathing with chlorhexidine on the acquisition of cillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and methihealth-

CHLORHEXIDINE BATHING IN INFECTION PREVENTION care-associated bloodstream infections: Results of a quasi-experimental multicenter Critical Care Medicine, 37(6), 1858-1865. doi:10.1097/CCM.0b013e31819ffe6d Evans, H. L., Dellit, T. H., Chan, J., Nathens, A. B., Maier, R. V., & Cuschieri, J. (2010). Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients. Archives of Surgery, 145(3), 240-246. Retrieved from http://www.archsurg.ama-assn.org/ OHoro, J. C., Silva, G. L. M., Munoz-Price, L. S., & Safdar, N. (2012). The efficacy of daily

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bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: A meta-analysis. Infection Control & Hospital Epidemiology, 33(3), 257-267. doi: 10.1086/664496 Ridenour, G., Lampen, R., Federspiel, J., Kritchevsky, S., Wong, E., & Climo, M. (2007). Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of sistant Staphylococcus aureus colonization and infection among intensive tients. Infection Control & Hospital Epidemiology, 28(10), 1155-1161. doi:10.1086/520102 Sievert, D., Armola, R., & Halm, M. A. (2011). Chlorhexidine gluconate bathing: Does it crease hospital-acquired infections?. American Journal of Critical Care, 20(2), 170. doi:10.4037/ajcc2011841 de166methicillin-recare unit pa-