Running head: PREVENTING METHICILLIN-RESISTANT STAPHYLOCCUS AUREUS

Preventing Methicillin-resistant Staphylococcus aureus Using Bathing Techniques

Krista Caprio
University of South Florida

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Abstract
Clinical problem: Methicillin-resistant Staphylococcus aureus (MRSA) is one of many hospital
acquired infections that pose a threat to all hospitalized patients. Acquiring MRSA in a
healthcare setting can lead to additional problems such as bloodstream infections, pneumonia,
and surgical site infections; these unexpected complications will prolong a patients stay in the
hospital and increase the risk of mortality (Center for Disease Control and Prevention, 2014).
Objective: To determine if the use of chlorhexidine gluconate for daily bathing will decrease the
incidence of MRSA in critical care patients. CINAHL and the National Guideline Clearinghouse
were the search engines used to find clinical trials and guidelines to support the objective. The
key search terms used were MRSA and bathing, chlorhexidine bathing, and MRSA prevention.
Results: Climo et al. (2013) reported that patients receiving daily chlorhexidine baths had a 23%
lower incidence of MRSA (P= 0.03) than patients bathed with non-antimicrobial soap. Ferrara,
Courson, & Paulson (2011) reported that a smaller amount of MRSA colonized in areas treated
with chlorhexidine (mean=1.67 log10, P< 0.0001) than areas treated with non-medicated soap
(mean=3.23 [log.sub.10)]. Septimus et al. (2014) reported that daily chlorhexidine bathing had
the lowest rate of blood culture contamination (95% confidence interval, 0.43-0.71). Cincinnati
Children's Hospital Medical Center (2013) recommends using 2% chlorhexidine gluconate for
daily baths in critical care settings to decrease the risk of blood stream infections.
Conclusion: Critical care patients that receive daily chlorhexidine baths will have a decreased
incidence of MRSA. This will prevent complications that increase the risk of morbidity and
mortality. Additionally, healthcare costs should decrease because of the lessened length of
hospitalization.

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Preventing Methicillin-resistant Staphylococcus aureus Using Bathing Techniques

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant
to methicillin or other commonly used antibiotics such as Penicillin (Lopez et al., 2015). It is
recognized as one of the most common antibiotic resistant pathogens in a hospital setting.
MRSA colonizes on the skin. For this reason, contaminated hands, clothes, or equipment can
easily transfer it from one patient to another. Upon admission to an intensive care unit (ICU),
patient incidence of MRSA rises from 1.5% to 5.8% - 8.3% (Lopez et al., 2015). Eighteen to
thirty-three percent of adult patients with colonized MRSA will develop a MRSA infection such
as pneumonia or blood stream infection (Lopez et al., 2015). These complications will increase
morbidity, mortality, and medical costs significantly (Center for Disease Control and Prevention,
2014). In critical care patients, how does using chlorhexidine (CHG) cloths and water for daily
bathing compared with non-antimicrobial soap and water prevent the incidence of MRSA in the
course of three months?
Literature Search
CINAHL and National Guideline Clearinghouse were used to obtain clinical trials and
guidelines about preventing the incidence of MRSA in critical care patients by using CHG for
daily bathing. The key search terms used were MRSA and bathing, chlorhexidine bathing, and
MRSA prevention.
Literature Review
Cincinnati Children's Hospital Medical Center (2013) strongly recommends that in order
to reduce blood stream infections patients in critical care settings should receive daily baths with
2% CHG. Climo et al. (2013) assessed the use of CHG washcloths and non-medicated soap on
the incidence of MRSA. Patients were screened for MRSA up to 48 hours after admission and
upon discharge from the hospital. Overall, there was a 23% lower incidence of MRSA when
using chlorhexidine cloths (5.10 vs. 6.60 cases per 1,000 patient days, P=0.03). The strengths of
this study were that the nine ICUs were randomly assigned to use either the intervention or the

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

control product. Reasons why patients/hospitals did not complete the study were given. Followup assessments were conducted long enough to fully study the effects of the intervention. The
subjects were analyzed in the groups to which they were assigned. The control group was
appropriate. Instruments used to measure the occurrence of MRSA and VRE in ICU patients
were valid. Patients in both groups were similar in regards to baseline variables. The weaknesses
of this study were that the random assignment was not concealed from the individuals who were
first enrolling subjects into the study. In addition, the clinical staff was aware of the use of the
control or intervention product.
Ferrara, Courson, & Paulson (2011) examined the preventative effects of CHG against
MRSA using twenty volunteers. One of the participants forearms was washed for two minutes
with the control product and the other with the test product. Three test sites were designated to
each arm. One site was exposed to MRSA for 1 hour, another for 2 hours, and the last site was
exposed to MRSA for 4 hours. The number of bacteria after exposure to forearms treated with
chlorhexidine (mean= 1.67 log10) were fewer (P< 0.0001) than the control product (mean= 3.23
[log.sub.10]). The number of bacteria recovered from forearms treated with chlorhexidine did
not differ when cultured at 1-4hrs (P=0.236). Strengths of this study were that the test and
control product were randomly assigned to the subjects. Reasons why volunteers did not
complete the study were given. Volunteers in this study were similar in regards to baseline
variables. The control group was appropriate. The instruments used to measure the colonization
of MRSA were valid. The subjects were analyzed in the group to which they were assigned.
Weaknesses of this study were that the random assignment was not concealed from the
individuals who were first enrolling subjects. The subjects were not blind to the study. Lastly,
follow-up assessments were not conducted long enough to fully study the effects of the
intervention.

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Septimus et al. (2014) compared three strategies to determine which produced the lowest
blood culture contamination rate. Forty-three hospitals were involved in this study. In strategy
one, all ICU patients received a MRSA nares screening. In strategy two, all patients were
screened and a positive diagnosis resulted in twice-daily intranasal mupirocin and chlorhexidine
baths for five days. In strategy three, patients were not screened for MRSA; however, contact
precautions were enabled for patients with a history. Additionally, all ICU patients received
intranasal ointment for 5 days and daily chlorhexidine baths. Strategy three showed the greatest
reduction in blood culture contamination (95% confidence interval, 0.43-0.71). It avoided an
additional 26.8 contaminations per 1,000 admissions compared to strategy two and 12.2
compared to strategy one. Strengths of this study were that the hospitals were randomly assigned
one of three strategies. Participants in this study were similar in regards to baseline clinical
variables. Subjects were analyzed in the groups to which they were randomly assigned. The
control group was appropriate. The instruments used to measure the rate of blood culture
contamination were valid. Follow-up assessments were conducted long enough to fully study the
effects of the intervention. Weaknesses of this study were that it is unknown if the random
assignment was concealed from the individuals who were first enrolling subjects into the study.
In addition, reasons why patients did not complete the study were not given, and it is unknown
whether the providers and subjects were blind to the study group.
Synthesis
Climo et al. (2013) demonstrated that bathing patients with CHG produced a 23% lower
incidence of MRSA (P= 0.03). Ferrara, Courson, & Paulson (2011) demonstrated that areas
treated with chlorhexidine had a smaller colonization of MRSA (P< 0.0001). Septimus et al.
(2014) demonstrated that daily chlorhexidine bathing produced the lowest rate of blood culture

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

contamination (95% confidence interval, 0.43-0.71). The Cincinnati Childrens Hospital

Medical Center (2013) guideline recommends the use of 2% chlorhexidine gluconate for daily
baths in critical care settings to decrease the risk of blood stream infections.
A strong similarity between all studies shows the significance of decreasing skin
bacterial load with CHG to decrease the incidence of MRSA. Climo et al. (2013) and Ferrara,
Courson, & Paulson (2011) focused specifically on comparing the use of non-medicated soap to
CHG and their effects on MRSA. However, Ferrara, Courson, & Paulson (2011) also tested the
bactericidal residual effect of chlorhexidine. Septimus et al. (2014) measured blood culture
contamination rates rather than skin bacterial load of MRSA. However, decreasing skin bacterial
load is how blood culture contamination can be prevented. Research has shown that using CHG
for daily bathing can reduce the incidence of MRSA. This will prevent complications (blood
stream infections) that increase the risk for morbidity and mortality. Due to the reduction in
MRSA, healthcare costs should decrease because of the lessened length of hospitalization. Since
only two non-antimicrobial soaps were tested, additional research is needed to determine if other
non-medicated soaps would produce the same results. Further studies needs to be implemented
to determine the length of time chlorhexidine can prevent the colonization of MRSA on the skin.
Clinical Recommendation
Cincinnati Children's Hospital Medical Centers (2013) guideline recommends the use of
2% CHG for daily bathing to reduce the rate of bloodstream infections in an inpatient critical
care setting. Research confirms that the use of CHG for daily bathing reduced the incidence of
MRSA. Based on these findings, daily CHG baths can be used in combination with screening,
contact precautions, and hand hygiene in order to reduce the spread of MRSA in critical care
settings. Taking precautions to prevent the spread of MRSA is crucial in order to keep patients
healthy and improve client outcomes.

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

References
Center for Disease Control and Prevention (2014). Methicillin-resistant staphylococcus aureus
infections. Retrieved from http://www.cdc.gov/mrsa/healthcare/#q1
Cincinnati Childrens Hospital Medical Center. (2013). Daily bathing of children in critical care
settings with chlorhexidine gluconate. Retrieved from
http://www.guideline.gov/content.aspx?id=47066&search=chlorhexidine+bathing
Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . . Wong,
E. S. (2013). Effects of daily chlorhexidine bathing on hospital-acquired infection. The
New England Journal of Medicine, 368(6), 533-542. doi: 10.1056/NEJMoa1113849
Ferrara, M. S., Courson, R. W., & Paulson, D. S. (2011). Evaluation of persistent antimicrobial
effects of an antimicrobial formulation. Journal of Athletic Training, 46(6), 629-633. doi:
10.4085/1062-6050-46.6.629
Lopez, A. J., Mateos, M. M., Guevara. M., Conterno, L., Sola, I., Cabir, N. S., Bonfill, C. X.
(2015). Gloves, gowns and masks for reducing the transmission of methicillin-resistant

PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Staphylococcus aureus (MRSA) in the hospital setting. Cochrane Database of Systematic

Reviews. 7, N.PAG. doi: 10.1002/14651858.CD007087.pub2
Septimus, E. J., Hayden, M. K., Kleinman, K., Avery, T. R., Moody, J,.Weinstein, R. A., . . .
Huang, S. S. (2014). Does chlorhexidine bathing in adult intensive care units reduce
blood culture contamination? A pragmatic cluster-randomized trial. Infection Control &
Hospital Epidemiology, 35, 17-22. doi: 10.1086/677822