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Running Head: REDUCING HAIS USING CHG

Using Chlorhexidine Gluconate Wipes to Reduce Hospital Acquired Infections in the Intensive

Care Unit

Victoria Arriaga (words: 610)

Tiffany Timmons (words: 612)

Malak Saleh (words: 646)

University of South Florida

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Abstract

Clinical Problem: Patients admitted to the intensive care unit (ICU) are 2 to 5 times more likely

to develop a hospital acquired infection (HAI) (Dasgupta, Das, & Chawan, 2015). A HAI can

increase a patient's length of stay and mortality rate (Glance, Stone, Mukamel & Dick, 2011).

Objective: The objective of this synthesis is to determine if bathing with chlorhexidine gluconate

(CHG) wipes reduces the risk of HAI in the ICU as compared to non-antimicrobial bathing. The

database CINAHL was used to search the literature for nursing intervention randomized control

trials (RCT).

Results: Patients who received CHG baths had a statistically significant reduction of HAIs as

compared to patients who received non-antimicrobial bathing. Climo et al. (2015) demonstrated

a decrease in the acquisition of MRSA and VREs amongst the CHG intervention group (p=0.03),

and the rates of bloodstream infections were lower as well (p=0.007). Derde et al. (2013)

showed the acquisition of infections significantly decreased while combining the use of CHG

baths and improving hand hygiene (p=0.04). Swan et al. (2016) showed that CHG baths

decreased acquisition of HAIs (p=0.049).

Conclusion: Current research supports the hypothesis that chlorhexidine bathing may be an

effective intervention to reduce the various forms of HAIs amongst intensive care patients as

compared to non-antimicrobial bathing options. Additional research is needed to determine the

best way to implement chlorhexidine bathing into hospital practice in order to maximize the

effectiveness in reducing HAIs. Further research may be difficult considering the fragility of ICU

patients and the ethical situations that can emerge with an immunocompromised population.
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Using Chlorhexidine Gluconate (CHG) Wipes to Reduce Hospital Acquired Infections (HAIS)

in the ICU

Hospital acquired infections (HAIs) are considered nosocomial infections, meaning they

are infections that are acquired after admission to the hospital (Dasgupta, Das, & Chawan, 2015).

A nosocomial infection can increase morbidity in any hospitalized patient. The risk of acquiring

a HAI in the intensive care unit (ICU) is about 2 to 5 times more likely than other hospital units

due to the severely immunocompromised patient population (Dasgupta, Das, & Chawan, 2015).

Even in high-income countries, at least 30% of all ICU patients are affected by a nosocomial

infection (World Health Organization, n.d.). In 2011 there were 722,000 hospital acquired

infections in the US that consisted of pneumonia, urinary tract infections, blood stream

infections, and surgical site infections (Centers for Disease Control, 2016). Of the 722,000

cases, 75,000 patients died at the hospital (Centers for Disease Control, 2016). Patients with

hospital acquired infections are at increased risk for longer hospital stays and mortality (Glance,

Stone, Mukamel & Dick, 2011). Limiting the spread of HAIs has therefore been a major area of

study. Guidelines have already been developed for healthcare personnel involved in the care of

patients, which include screening and monitoring protocols to catch signs of infections early

(Mehta et al., 2014). Chlorhexidine bathing has also been incorporated into various health care

practices to try and reduce infections. Chlorhexidine gluconate (CHG) is normally used to clean

and prepare skin for surgery since it helps to reduce bacteria that can cause infection (FDA,

2017). Therefore, bathing patients with 2% chlorhexidine wipes as compared to other non-

antimicrobial wipes may be a viable intervention to decrease the chances of infection in ICU

patients. This synthesis paper will explore if chlorhexidine gluconate bathing, compared to non-

antimicrobial bathing, reduce hospital acquired infections, over a 3-month period?

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Literature Search

CINAHL was used to access randomized controlled trials (RCT) in nursing pertaining to

usage of chlorhexidine gluconate bathing for reduction of HAIs. Key search terms included

hospital acquired infections, CHG, chlorhexidine gluconate, bathing, and infection reduction.

The publication years searched were within 2012 to 2017.

Literature Review

To evaluate the effectiveness of CHG wipes reducing HAIs in the ICU, three RCTs were

assessed. Climo et al. (2015) conducted a study which supported the implementation of CHG

bathing in order to reduce the incidence of HAIs in the ICU. This study included 7,727 patients

from nine units which including medical, coronary care, surgical, and cardiac surgery ICUs, and

one bone marrow transplantation unit, spread throughout six hospitals. The control consisted of

four units and the intervention group consisted five units. The patients randomized to the control

group bathed daily with non-antimicrobial washcloths (n=3,842), while the intervention group

(n=3,970) were bathed with 2% CHG washcloths. The HAIs were determined by presence of

methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE),

and bloodstream infections. Serum blood samples to test for HAIs were collected on a monthly

basis for six months. The decrease in the acquisition of MRSA and VREs were found to be

significant amongst the intervention group (p=0.03). The rates of bloodstream infections were

significantly lower as well (p=0.007). The study possessed several strengths including random

assignment to either group, not disclosing the random assignment to the study recruiter, and

revealing why patients chose to not participate in the study. Additionally, the study was

comprised of multiple units from geographic locations throughout the United States. The study’s
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weaknesses included not having follow-up assessments, and the patients and providers were

aware of intervention group assignment.

Derde et al. (2013) conducted an RCT to study the effect of combing CHG baths and

proper handwashing to reduce the rates of transmitting antimicrobial-resistant bacteria in ICUs.

The groups were split with one being rapid screening and the other with conventional screening.

The design of this study was held in three phases, with a total of 8,976 patients. Phase one lasted

six months to establish a baseline. Phase two introduced the CHG baths and handwashing for an

interrupted time series lasting six months. The RCT was implemented in phase three was

comprised of 4,861 patients from 13 ICUs spread across 8 European countries lasting 12-15

months. Rapid and conventional cultures were screened from patients admitted for at least three

days. Cultures were obtained from wounds, nasally and from the perineum within two days. The

results showed the acquisition of HAIs significantly decreased while combining the use of CHG

baths and improving hand hygiene (p=0.04). The study’s strengths were random assignment to

control and intervention groups, providing reasons patients did not participate, and only allowing

patients with a stay of more than three days to participate in the study. Weaknesses include the

lack of follow-up assessments, and the patients and providers were aware of intervention group

assignment.

Swan et al. (2016) performed an RCT to determine whether 2% CHG bathing every other

day decreases HAIs in adult ICU patients when compared to non-antimicrobial bathing. The

sample size was 325 adults, with 161 in the intervention group. The intervention group received

CHG baths every other day, receiving soap and water baths on the off days. CHG baths were

performed for a maximum 28 days over a 10 month period. The control group (n=164) received

daily baths with soap and water. HAIs were measured by the rates of surgical infection,
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bloodstream infection, ventilator-associated pneumonia (VAP), and catheter-associated urinary

tract infection (CAUTI). It was found that CHG baths decreased acquisition of HAIs (p=0.049).

Strengths were random assignment of patients to intervention or control groups, and the patients

enrolled in the study were from a comparable demographic. Study weaknesses were the total

sample size. In comparison to similar studies, sample sizes were significantly larger.

Additionally, the study was conducted within one center, and patients and providers were aware

of intervention group assignment.

Synthesis

Climo et al. (2013) demonstrated that throughout a multicentered, cluster-randomized

study, the intervention group that had chlorhexidine implemented into care routines had a

significantly lower chance of acquiring nosocomial infections during intensive care unit

hospitalization (p=0.03). Derde et al. (2014) demonstrated that throughout an interrupted time

series study and cluster randomized trial, the intervention group that had chlorhexidine body

washing implemented into care, as well as improved hand hygiene practices, had an overall

reduced rate of antimicrobial-resistant bacteria infections, particularly methicillin-resistant

Staphylococcus aureus (MRSA) (p=0.06). Swan et al. (2016) demonstrated that throughout a

single-centered, pragmatic, randomized trial, the intervention group had a significant reduction in

infection rates by nearly 44.5% (p=0.049). All the studies indicate that the implementation of

chlorhexidine bathing into the care routines of critical care patients leads to a lower probability

of acquiring nosocomial infections during hospitalization. All the studies reach this conclusion

with different study designs and methods, strengthening the support for chlorhexidine bathing.

The purpose of evidenced-based practice is to provide clear support for gaps in patient care and

in this case, that gap is the issue of nosocomial infection rates in critical care patient populations.
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These findings impact patient care by providing supporting evidence on a practice that will

improve patient outcomes, increase patient safety, and promote wellness through a higher quality

of life. The application of evidence obtained from the studies conducted will be applied to the

clinical setting with the aim of improving patient outcomes.

According to Mehta et. al (2014), it is a fact that the issue of hospital-acquired infections

is a major safety concern for both patients and healthcare providers, therefore guidelines have

been developed for healthcare personnel involved in the care of patients in critical care settings

(p.1). These guidelines include screening and monitoring protocols as well as the implementation

of chlorhexidine bathing into practice. The gap in this field concerning reducing nosocomial

infections has not only been a major area of focus for researchers, but it has been addressed

through clinical practices based on the evidence of numerous studies. What is not fully known is

if there is a better solution to reducing infection rates with the use of other techniques besides

chlorhexidine bathing. This would require further studies focused on comparing a new practice

to current practices. Comparing practices would result in stronger support for the most effective

intervention to reduce infection rates. The evidence clearly supports the use of chlorhexidine to

reduce nosocomial infections, however, further research focused on the study of the most

effective techniques in the application of chlorhexidine into care routines is critical to clinical

application. More research on how the chlorhexidine should be applied to patients including a

specification of the timing, frequency, and methods of application would further fill the gaps in

this field.

Clinical Recommendations

Research suggests that chlorhexidine bathing may be an effective intervention to

implement into care in order to reduce the various forms of hospital-acquired infection rates
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amongst intensive care unit patients. Implementing evidenced based safety practices requires

strategic planning and an approach that not only addresses the focused issue but the overarching

complexity of systems of care, individual clinicians, and changing health care cultures. Based on

current trial findings, health care providers should accept and implement the practice of

chlorhexidine bathing into care routines while using hospital protocols and guidelines as a

framework for practice. Health care providers must understand that the implementation of this

practice must also recognize that evidence-based practice is not a static model, rather it is a

constantly changing field that will be regularly updated with research. Therefore, it is critical to

be educated and aware of research and clinical practice changes, while also remaining within the

scopes of institutional parameters on the practice. The practice of chlorhexidine bathing will

improve patient outcomes, but it is critical to respect each patient’s unique situation, preferences,

and values.
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References

Centers for Disease Control. (2016). Healthcare- associated infections: Data and statistics.

Retrieved from https://www.cdc.gov/hai/surveillance/index.html

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, (6), 533.

Dasgupta, S., Das, S., & Chawan. (2015). Nosocomial infections in the intensive care unit:

Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching

hospital of Eastern India. Indian Journal of Critical Care Medicine, 19(1), 14-20.

Derde, L., Cooper, B., Goosens, H., Malhotra-Kumar, S., Willems, R., Gniadkowski, M., & …

Bonten, M. (2014). Interventions to reduce colonization and transmission of

antimicrobial-resistant bacteria in intensive care units: An interrupted time series study

and cluster randomized trial. The Lancet: Infectious Diseases, 14(1), 31-39.

FDA. (2017). Chlorhexidine gluconate: Drug safety communication. Retrieved from

https://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalpro

ducts/ucm539575.htm

Glance, L. G., Stone, P. W., Mukamel, D. B., & Dick, A. W. (2011). Increases in mortality,

length of stay, and cost associated with hospital-acquired infections in trauma patients.

Archives Of Surgery, 146(7), 794. doi:10.1001/archsurg.2011.41

Mehta, Y., Gupta, A., Todi, S., Myatra, S., Samaddar, D. P., Patil, V., … Ramasubban, S.

(2014). Guidelines for prevention of hospital acquired infections. Indian Journal of

Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of

Critical Care Medicine, 18(3), 149–163. http://doi.org/10.4103/0972-5229.128705

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

Ochoa, R. J. (2016). Effect of chlorhexidine bathing every other day on prevention of

hospital-acquired infections in the surgical ICU: A single-center, randomized controlled

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

World Health Organization. (n.d.). Healthcare- associated infections: Fact sheet [PDF

document]. Retrieved from

http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf