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Chlorhexidine Gluconate
Bathing to Reduce
Methicillin-Resistant
Staphylococcus aureus
Acquisition
ANN PETLIN, RN, MSN, CCRN-CSC, CCNS, PCCN, ACNS-BC
MARILYN SCHALLOM, RN, PhD, CCRN, CCNS
DONNA PRENTICE, RN, MSN(R), CCRN, ACNS-BC
CARRIE SONA, RN, MSN, CCRN, CCNS, ACNS-BC
PAULA MANTIA, RN, MSN, ANP-BC
KATHLEEN McMULLEN, MPH, CIC
CASSANDRA LANDHOLT, BS
Authors
Ann Petlin is a clinical nurse specialist in the cardiothoracic intensive care unit at Barnes-Jewish Hospital, St Louis, Missouri.
Marilyn (Lynn) Schallom is a clinical nurse specialist and research scientist in the Department of Research for Patient Care Services at
Barnes-Jewish Hospital.
Donna Prentice is a clinical nurse specialist in a medical intensive care unit at Barnes-Jewish Hospital.
Carrie Sona is a clinical nurse specialist in the surgery/burns/trauma intensive care unit at Barnes-Jewish Hospital.
Paula Mantia is the advanced practice nurse in a medical intensive care unit at Barnes-Jewish Hospital.
Kathleen McMullen is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at Barnes-Jewish
Hospital.
Cassandra (Casey) Landholt is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at
Barnes-Jewish Hospital.
Corresponding author: Ann Petlin, RN, MSN, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Mail stop 90-00-056, St Louis, MO 63110 (e-mail: amp2645@bjc.org).
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The 2 other ICUs in our study, the coronary care unit We did not collect a final nasal swab on patients who
and a second medical ICU, did not have protocols for died or were already found to be MRSA positive via the
active surveillance. They used incident surveillance active surveillance. We defined hand hygiene compli-
instead. We defined MRSA acquisition in these 2 units ance as the percentage of staff members who were
as any patient with a new culture positive for MRSA at observed performing hand hygiene upon entering or
any site 48 hours after admission. exiting a patients room.
The ICU physicians in all the study units were informed
of swabs and cultures that were positive for MRSA by a Results
telephone call from the microbiology laboratory. Patients In the preintervention period (July 2008-December
went on contact isolation precautions immediately upon 2009) when soap-and-water bathing was the routine,
the report of a culture positive for MRSA. Infection pre- there were 132 MRSA acquisitions in 34333 patient days
vention staff (see Table). This equaled a MRSA acquisition rate of
Patients bathed with soap and water monitored the 3.84 per 1000 patient days. In the postintervention period,
were 1.5 times more likely than patients MRSA acqui- (January 2010-April 2011) with the CHG bathing proto-
bathed with CHG to acquire MRSA. sition rates col, there were 109 MRSA acquisitions in 41376 patient
and compli- days. This equaled a MRSA acquisition rate of 2.63 per
ance with admission, weekly, and discharge surveillance 1000 patient days. The MRSA rate ratio difference is
swabs, and they reported the data monthly to the 3 ICUs 1.46 (95% CI=1.12-1.90, P=.003; Figure 1). Patients in
in the study that were performing active surveillance. the preintervention period were almost 1.5 times more
They also observed hand hygiene compliance monthly likely to acquire MRSA than patients who received the
in all ICUs by using secret shoppers as data collectors CHG bathing protocol.
during both study periods. No significant differences in compliance were found
with nasal swabbing or with hand hygiene between
Data Analysis the study periods. Compliance rates with nasal swab-
We used OpenEpi30 software to calculate MRSA bing for MRSA were 87% to 90% in the preinterven-
acquisition rate ratios in the preintervention and postin- tion period and 86% to 92% after the intervention.
tervention periods. We defined the MRSA acquisition The patients in the medical ICU showed the greatest
rate as the number of patients with nasal swabs negative decline in MRSA acquisition rates from 6.8 per 1000
for MRSA upon admission, or no nasal swab performed patient days before the intervention to 3.8 per 1000
on admission, in whom MRSA from any source developed patient days after the intervention. They also had the
more than 48 hours after their ICU admission, divided highest compliance (92%) with nasal swabbing. The
by the number of patient days per month times 1000. surgical/burn/trauma ICU had been one of the units
Patients who were known to be positive for MRSA on in the multi-institutional study by Climo et al.11 Their
ICU admission were excluded from the calculations. We MRSA acquisition rate returned to the multisite study
defined MRSA nasal swab compliance as the percentage level when the CHG bathing protocol resumed with
of admission, weekly, and discharge nasal swabs obtained. our study.
Petlin A, Schallom M, Prentice D, Sona C, Mantia P, McMullen K, Landholt C. Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureus
Acquisition. Critical Care Nurse. 2014;34(5):17-26.
1. Which of the following statements is true regarding colonization with 7. Essential measures to analyze the impact of CHG bathing include which
Staphylococcus aureus? of the following?
a. The Centers for Disease Control and Prevention estimates that more than a. Staff satisfaction with the protocol
11 000 deaths occurred due to colonization with methicillin-resistant b. Survey of patient comfort
S aureus (MRSA) in 2011. c. Compliance with nasal swab screening
b. Patients may be colonized with S aureus without signs of infection. d. Utilization rate of the CHG soap
c. Culture swabs of the nares are the only reliable method to diagnose MRSA.
d. Microbes in bath basins may lead to contamination of the lungs. 8. According to the AACN evidence-based leveling system, publications on
multidrug-resistant organisms provide what level of evidence for CHG
2. Which of the following describes CHGs mechanism of action? bathing?
a. Washing microbes off the skin a. Class IA
b. Killing all gram-negative bacteria b. Class 2
c. Altering integrity of bacterial cell walls c. Class A
d. Interacting with mupirocin d. Class B
3. Patient characteristics of the AACNs Synergy Model applicable to this 9. The decision to use prepackaged clothes versus bath basin bathing
study are which of the following? should include consideration of which of the following?
a. Available resources and costs a. The method that provides best reduction in MRSA
b. Complexity and collaboration b. Time requirements
c. Resiliency and predictability c. Increase of bacterial resistance
d. Complexity and vulnerability d. Availability of a clinical nurse specialist to support compliance
4. The bathing protocol used in this study included which of the following? 10. Limitations of this study include which of the following?
a. Use of a new dedicated wash basin daily a. Small sample size
b. Complete bathing from the neck down b. The study used a different bathing protocol than the study on which it was
c. 4-ounce bottle of 2% CHG with warm water in a 4-quart basin based on.
d. Use of 1 washcloth per body area c. Active surveillance only took place in the coronary care unit.
d. It relied on the nurses report that the bath was provided per the protocol.
5. Which of the following are adverse effects of CHG bathing?
a. Serious rashes 11. Which of the following describes the design of this study?
b. Contact dermatitis a. Retrospective design
c. Allergic reactions b. Randomized control group design
d. Should not be a cause for concern c. Pre/post-intervention design
d. Experimental crossover design
6. In this study, which of the following is true regarding using washcloths
impregnated with 2% CHG? 12. Results of previous studies on bath basins include which of the following?
a. Provided benefits that justify the cost a. Soap and tap water and CHG techniques both had residual effects on bacterial
b. Cost the hospital approximately $131000 contamination.
c. Is more expensive than the CHG soap and basin method b. Ninety-eight percent of basins grow potentially pathogenic microbes.
d. Cost $5.52 more than the bath-basin method c. Over time CHG use may result in loss of antibiotic effectiveness.
d. Bacterial growth in bath basins is eliminated when bathing with CHG soap
in the bath water.
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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