Chlorhexidine Bathing and Health Care-Associated Infections

Diana Lee, Mercer University College of Pharmacy 2015

Recently, there has been a substantial concern for health care-associated infections with support for universal decolonization strategies, especially in high-risk patients.1  Chlorhexidine baths are a standard in many intensive care units (ICU) today to address this increasing concern with its use being recommended by some expert guidelines.2  This new study may provide some new insight into its use and effectiveness in the ICU setting.

Title:  Chlorhexidine Bathing and Health Care-Associated Infections3
Design Single-center, muIti-ICU, cluster randomized, crossover controlled clinical study
Objective To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections
Inclusion Criteria All patients admitted to the cardiovascular, medical, neurological, surgical, and trauma ICUs at the tertiary medical center during the study period
Exclusion Criteria Patients with known allergy to chlorhexidine, admitted with burns or toxic epidermal necrolysis or Stevens-Johnson syndrome, or if the treating physician thought it unsafe to bathe
Study Groups 2% chlorhexidine cloths once-daily bathing or disposable nonantimicrobial cloths (placebo) once-daily bathing
Methods Units were randomized to either a 2% chlorhexidine bathing (n=4,488) or a control bathing (n=4,852) protocol.  Bathing treatments were performed for a 10-week period followed by a 2-week washout period, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times during the study.
Duration One year
Primary Outcome Measure Composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections
Baseline Characteristics Median age of 56.5 years old; approximately 60% male; about 80% white and 13% black
Results  A total of 55 infections occurred during the chlorhexidine bathing period (4 CLABSI, 21 CAUTI, 17 VAP, and 13 C. difficile) and 60 infections during the control bathing period (4 CLABSI, 32 CAUTI, 8 VAP, and 16 C. difficile).  The primary outcome rate was 2.86 infectious episodes per 1000 patient-days during chlorhexidine bathing and 2.90 per 1000 patient-days during the control bathing period (rate difference, -0.04; 95% confidence interval (CI), -1.10 to 1.01; P=0.95).
Study Author Conclusions In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C. difficile.  These findings do not support daily bathing of critically ill patients with chlorhexidine.

This study challenges the notable clinical trials previously supporting the use of chlorhexidine baths to prevent health-care associated infections.4,5  Publishing bias has been a concern, so it’s nice to see some research that presents ‘negative’ results and tests the reproducibility of existing clinical trials. However, this study did have some limitations including the ICU staff not being blinded to the bathing regimen, the adherence for the regimens were not monitored, the study was at a single center, and the study was not prospectively registered at the clinical trial registration site. This clinical study warrants future curiosity and research to support the present arena for the use of chlorhexidine in the ICU setting.

References:

  1. Pittet D, Derec AC. Daily chlorhexidine bathing for critically ill patients. JAMA. 2015;313(4):365-366.
  2. Calfee DP, Salgado CD, Milstone AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmisison and infection in acute care hospitals. 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):772-796.
  3. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care-associated infections. JAMA. 2015;313(4):369-378.
  4. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-542.
  5. Huang SS, Septimus E, Kleinman K. et al; CDC 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(24):2255-2265.
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