Chlorhexidine Impregnated Washcloths—Chlorhexidine Bath

Chlorhexidine Impregnated Washcloths—Chlorhexidine Bath

PEP Topic 
Prevention of Infection: Transplant
Description 

Chlorhexidine is an antiseptic that has a broad spectrum effect against both gram-positive and gram-negative bacteria.  Bathing patients with chlorhexidine or with washcloths impregnated with chlorhexidine has been examined for the prevention of infection in patients with cancer.

Likely to Be Effective

Research Evidence Summaries

Bass, P., Karki, S., Rhodes, D., Gonelli, S., Land, G., Watson, K., . . . Cheng, A. C. (2013). Impact of chlorhexidine-impregnated washcloths on reducing incidence of vancomycin-resistant enterococci colonization in hematology-oncology patients. American Journal of Infection Control, 41, 345–348.

doi: 10.1016/j.ajic.2012.04.324
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Study Purpose:

To evaluate the impact of daily use of 2% chlorhexidine washcloths on the incidence of vancomycin-resistant enterococci (VRE) colonization.

Intervention Characteristics/Basic Study Process:

The incidence of VRE colonization among oncology inpatients was examined before and after the introduction of daily use of chlorhexidine-impregnated washcloths. Each day, patients were given four impregnated washcloths, which were used individually for cleaning different parts of the body. Rectal swabs were taken on all new admissions and weekly during the inpatient stay. The baseline period was March to June 2010, and the experimental period was July to October 2010. Patients were in single rooms, although patients colonized with resistant organisms were roomed together. Prior bed occupancy with a patient colonized with VRE was used as a covariate in analysis.

Sample Characteristics:

  • The study examined 439 total patients (229 at baseline and 210 experimental).
  • Males comprised 63.5% of the sample, and females comprised 35.5%.
  • Key disease characteristics were not stated.
  • Preliminary data showed that 12% of patients became colonized with VRE during the hospital stay.

Setting:

  • Single site
  • Inpatient
  • Australia

Phase of Care and Clinical Applications:

Patients were undergoing the active antitumor treatment phase of care. 

Study Design:

This was an observational study with a historical control. 

Measurement Instruments/Methods:

  • VRE isolates
  • Methicillin-resistant Staphylococcus aureus (MRSA) isolates

Results:

During the baseline period, 7.8% of the previously uncolonized patients acquired VRE, compared to 3.8% during the experimental period (relatve risk [RR] = 0.48; 95% confidence interval [CI] [0.21, 1.09]). There was no significant effect of prior bed occupants with VRE on VRE acquisition. Patients who shared a room with a VRE-positive patient had significantly higher VRE rates (p < 0.001). There were no significant differences in central line-associated bloodstream infection rates, and few MRSA isolates were found.

Conclusions:

The findings do not support the effectiveness of using chlorhexidine-imgregnated washcloths for the reduction of VRE colonization.

Limitations:

  • Risk of bias (no control group, no blinding, no random assignment)
  • No information was available regarding treatments, tumor types, and aspects associated with risk of infection or use of any prophylaxis for infection prevention.  
  • At one point, the researchers stated that patients had private rooms unless colonized, and then they reported that sharing a room with a colonized patient increased the risk, which does not make sense.

Nursing Implications:

The findings from this study do not support the effectiveness of using chlorhexidine-impregnated washcloths to prevent VRE colonization.

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. New England Journal of Medicine, 368, 533–542.

doi: 10.1056/NEJMoa1113849
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Study Purpose:

The purpose of the study was to evaluate the usefulness of bathing with chlorhexidine to reduce the acquisition of multiple drug-resistant organisms and hospital-acquired infections among high-risk patients.

Intervention Characteristics/Basic Study Process:

Six intensive care units or bone marrow transplantation units were randomly assigned to perform daily patient bathing with either nonantimicrobial washcloths (control) or washcloths impregnated with 2% chlorhexidine gluconate for six months. After six months, units were crossed over to use of the alternative approach. Infections and resistant-organism acquisition was monitored for two days after the transition in bathing treatment if the infection or organism was contracted during the bathing assignment time period. Before the study, nurses were instructed on the proper use of both washcloths. All units performed active surveillance testing for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) throughout the study period, including staff and patient swabbing for evidence of colonization.

Sample Characteristics:

  • The total sample size was 7,727 patients.
  • Age and gender information was not provided.
  • Patients were in intensive care settings, including one bone marrow transplantation unit.

Setting:

  • Multi-site
  • Inpatient
  • United States

Phase of Care and Clinical Applications:

Active antitumor treatment

Study Design:

This was a cluster, randomized, non-blinded crossover trial.

Measurement Instruments/Methods:

  • MRSA and VRE prevalence and incidence per 1,000 patient days
  • Central venous catheter (CVC)-associated bloodstream infection (BSI) prevalence and incidence per 1,000 patient days
  • Hospital-acquired BSIs
  • Secondary BSIs

Results:

The incidence of overall drug-resistant organism acquisition was significantly lower in the intervention period (5.1 versus 6.6 per 1,000 patient days; p = 0.03). Vancomycin-resistant enterococci acquisitions were significantly lower during the intervention period (3.21 versus 4.38 per 1,000 patient days; p = 0.05). Hospital-acquired BSIs were lower with the intervention (7.48 versus 6.6 per 1,000 patient days; p = 0.007), as were primary BSIs (3.61 versus 5.24; p = 0.006) and central line-associated bloodstream infections (CLABSIs) (1.44 versus 3.3; p = 0.004). There were no significant differences in length of stay or central catheter days between study periods. Incidence of skin reactions among patients assigned to chlorhexidine was 2%, compared to 3.4% of those bathed with the control product. There were no differences associated with unit type, size, mean length of stay, median patient age, or gender distributions. Declines during the intervention period were seen for primary BSIs due to coagulase-negative staphylococci (p = 0.006), enterobacter (p = 0.06), and fungi (p = 0.06).

Conclusions:

Bathing with chlorhexidine-impregnated washcloths was associated with a significant reduction in the incidence of VRE acquisition, reduction in lower rates of CVC, and general hospital-acquired BSIs. Daily chlorhexidine bathing was not associated with any serious adverse effects.

Limitations:

  • Risk of bias (no blinding)
  • The overall study design was such that there is potential that other practice changes could have also occurred that affected the findings, such as increased attention for various care processes due to training and study implementation. 
  • During the relatively short timeframe of the study, there was no evidence of resistance of organisms to chlorhexidine; however, this can be a concern and would require ongoing monitoring. 
  • Relatively few patients undergoing bone marrow transplantation were included; it was unknown if other intensive care unit settings included patients with cancers or neutropenia.

Nursing Implications:

Daily bathing with chlorhexidine may prevent some BSIs and reduce the acquisition of drug-resistant organisms among hospitalized patients at high risk for infection.

Guideline/Expert Opinion

O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger, E.P., Garland, J., Heard, S.O., . . . Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

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Purpose & Patient Population:

To provide evidence-based recommendations for the prevention of intravascular catheter-related infections for healthcare personnel who insert and care for intravascular catheters and for those responsible for surveillance and infection control in hospital, outpatient, and home health settings. Patients addressed in the guidelines were adult and pediatric patients with intravascular catheters.

Type of Resource/Evidence-Based Process:

The resource is comprised of evidence-based guidelines. For the development process, evidence was categorized as category 1A to category 2 based on strength of recommendation and support from clinical or epidemiological studies.

Phase of Care and Clinical Applications:

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for pediatrics. 

Results Provided in the Reference:

The results were not summarized.

Guidelines & Recommendations:

The guidelines provided extensive recommendations regarding the education and training of staff; selection of catheters and sites, including avoidance of the femoral vein for central venous access and use of the central venous catheter with the minimum number of ports needed; hand hygiene; use of maximal sterile barrier precautions for insertion; skin preparation with alcohol, iodine, or chlorhexidine; use of standard catheter site dressing regimens; specific aspects of care for umbilical and dialysis catheters; and use of piggybacks, stopcocks, and catheter flushing. Guideline recommendations include a bundling of multiple recommendations:  antimicrobial-impregnated catheters and cuffs are recommended in patients with long-term use if the organizational central line-associated blood stream infection (CLABSI) rate is not decreasing despite the implementation of comprehensive strategies for improvement. Lower-level (category II) recommendations include the use of prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of CLABSIs despite optimal aseptic technique as well as daily cleansing of patients in the intensive care unit with 2% chlorhexidine-impregnated washcloths.


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