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.

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.

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.

• 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.

• Multi-site
• Inpatient
• United States

Active antitumor treatment

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

• 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

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).

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.

• 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.

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