Bathing with wipes impregnated with chlorhexidine gluconate to prevent central line-associated bloodstream infection in critically ill patients: A systematic review with meta-analysis

BACKGROUND

Recommendations for different types of bathing to prevent central line-associated bloodstream infections (CLABSI) are still divergent. The objective of this study was to verify whether bed bathing with wipes impregnated with 2% chlorhexidine (CHG) compared to conventional bed bathing is more effective in preventing CLABSI.

METHODS

Systematic review of the literature by consulting the electronic databases PubMed/Medline, Embase, CINAHL, Scopus, and Web of Science from the date of inception until July 1, 2023, with no language or time restrictions.

RESULTS

A total of 84,462 studies were examined, of which 6 were included in the meta-analysis. Data from 20,188 critical care patients included in primary studies were analyzed. The meta-analysis found that bed bathing with wipes impregnated with 2% CHG reduced the risk of CLABSI by 48% compared to conventional bed bathing (risk ratio 0.52; 95% confidence interval, 0.37-0.73), and this is moderate-quality evidence. The reduction in length of stay in the intensive care unit and length of hospital stay as well as the risk of death were not significantly different between the study groups. Whether bed bathing with 2% CHG-impregnated wipes increases the occurrence of skin reactions is unclear.

CONCLUSIONS

This meta-analysis provides moderate-quality evidence that daily bathing with 2% CHG-impregnated wipes is safe and helps prevent CLABSI among adult intensive care unit patients.

Best products for skin antisepsis

BACKGROUND

Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections.

METHODS

A PubMed search was performed to update the evidence on skin antiseptic products and practices.

RESULTS

Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs.

CONCLUSIONS

Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.

Central-line associated bloodstream infections in intensive care units before and after implementation of daily antiseptic bathing with chlorhexidine or octenidine: a post-hoc analysis of a cluster-randomised controlled trial

BACKGROUNDS

Antiseptic bathing did not reduce central-line (CL) associated bloodstream infection (CLABSI) rates in intensive care units (ICU) according to a recent cluster randomised controlled trial (cRCT). However, this analysis did not consider baseline infection rates. Our post-hoc analysis of this cRCT aimed to use a before-after comparison to examine the effect of daily bathing with chlorhexidine, octenidine or water and soap (control) on ICU-attributable CLABSI rates.

METHODS

A post-hoc analysis of a multi-center cRCT was done. ICUs that did not yet perform routine antiseptic bathing were randomly assigned to one of three study groups applying daily bathing with 2% chlorhexidine-impregnated cloths, 0.08% octenidine wash mitts or water and soap (control) for 12 months. Baseline data was assessed 12 months before the intervention started when all ICUs routinely used water and soap. Poisson regression and generalised estimating equation models were applied to identify changes of CLABSI rates per 1000 CL days between intervention and baseline periods in each study group.

RESULTS

The cRCT was conducted in 72 ICUs (24 per study group) including 76,139 patients in the baseline and 76,815 patients in the intervention period. In the chlorhexidine group, incidence density of CLABSI was reduced from 1.48 to 0.90 CLABSI per 1000 CL days comparing baseline versus intervention period (P = 0.0085). No reduction was observed in the octenidine group (1.26 versus 1.47 CLABSI per 1000 CL days, P = 0.8735) and the control group (1.20 versus 1.17, P = 0.3298). Adjusted incidence rate ratios (intervention versus baseline) were 0.63 (95%CI 0.46-0.87, P = 0.0172) in the chlorhexidine, 1.17 (95% CI 0.79-1.72, P = 0.5111) in the octenidine and 0.98 (95% CI 0.60-1.58, P = 0.9190) in the control group. Chlorhexidine bathing reduced CLABSI with gram-positive bacteria, mainly coagulase-negative staphylococci (CoNS).

CONCLUSIONS

In this post-hoc analysis of a cRCT, the application of 2% chlorhexidine-impregnated cloths reduced ICU-attributable CLABSI. This preventive effect of chlorhexidine was restricted to CLABSI caused by gram-positive pathogens (CoNS). In contrast, 0.08% octenidine wash mitts did not reduce CLABSI rates in ICUs. Trial registration Registration number DRKS00010475, registration date August 18, 2016.

One population, multiple lifestyles: Commensalism and pathogenesis in the human mycobiome

Candida auris and Candida albicans can result in invasive fungal diseases. And yet, these species can stably and asymptomatically colonize human skin and gastrointestinal tracts. To consider these disparate microbial lifestyles, we first review factors shown to influence the underlying microbiome. Structured by the damage response framework, we then consider the molecular mechanisms deployed by C. albicans to switch between commensal and pathogenic lifestyles. Next, we explore this framework with C. auris to highlight how host physiology, immunity, and/or antibiotic receipt are associated with progression from colonization to infection. While treatment with antibiotics increases the risk that an individual will succumb to invasive candidiasis, the underlying mechanisms remain unclear. Here, we describe several hypotheses that may explain this phenomenon. We conclude by highlighting future directions integrating genomics with immunology to advance our understanding of invasive candidiasis and human fungal disease.

Chlorhexidine and octenidine susceptibility of bacterial isolates from clinical samples in a three-armed cluster randomised decolonisation trial

BACKGROUND

Routine use of chlorhexidine or octenidine for antiseptic bathing may have unintended consequences. Our analysis aimed to assess the phenotypic susceptibility of bacterial isolates from clinical samples to chlorhexidine and octenidine collected from intensive care units (ICU) that routinely used 2% chlorhexidine-impregnated wash cloths or 0.08% octenidine wash mitts (intervention) or water and soap (control) for daily patient care.

METHODS

This study was conducted within the context of a three armed cluster-randomised controlled decolonisation trial (Registration number DRKS00010475, registration date August 18, 2016). Bacterial isolates were collected prior to and at the end of a 12-month-intervention period from patients with ≥ 3 days length of stay at an ICU assigned to one of two intervention groups or the control group. Phenotypic susceptibility to chlorhexidine and octenidine was assessed by an accredited contract research laboratory determining minimal inhibitory concentrations (MIC) as percentage of extraction solutions used. MIC were reported as estimated concentrations in μg/ml derived from the chlorhexidine and octenidine extraction solutions. Statistical analyses including generalized estimating equation models were applied.

RESULTS

In total, 790 ICU-attributable bacterial isolates from clinical samples (e.g. blood, urine, tracheal aspirate) were eligible for all analyses. Pathogens included were Staphylococcus aureus (n = 155), coagulase-negative staphylococci (CoNS, n = 122), Escherichia coli (n = 227), Klebsiella spp. (n = 150) and Pseudomonas aeruginosa (n = 136). For all species, chlorhexidine and octenidine MIC did not increase from baseline to intervention period in the antiseptic bathing groups. For proportions of bacterial isolates with elevated chlorhexidine / octenidine MIC (≥ species-specific chlorhexidine / octenidine MIC50), adjusted incidence rate ratios (aIRR) showed no differences between the intervention groups and the control group (intervention period).

CONCLUSION

We found no evidence for reduced phenotypic susceptibilities of bacterial isolates from clinical samples to chlorhexidine or octenidine in ICUs 12 months after implementation of routine antiseptic bathing with the respective substances.

[Update of the recommendations of the Bacteraemia Zero Project]

El proyecto Bacteriemia Zero (BZ) fue el primero de los Proyectos Zero que se implementó en las Unidades de Cuidados Intensivos (UCI), consiguiendo una disminución de las tasas de infección relacionadas con catéter por debajo de las recomendadas por los estándares de calidad de las sociedades científicas. A raíz de la pandemia causada por el SARS-CoV-2 en las UCI, se ha observado un incremento importante de estas tasas de infección. El incremento de las tasas de infección y la necesidad de incorporar en la práctica clínica la mejor evidencia disponible, justifica la necesidad de actualizar las recomendaciones del proyecto BZ. Se constituyó un grupo de trabajo formado por miembros de las diferentes sociedades científicas que consideró que el paquete de medidas obligatorias del proyecto no debía modificarse debido a su eficacia demostrada y decidió incorporar, después de su revisión, las siguientes medidas opcionales: uso de catéteres impregnados con antimicrobianos, uso de apósitos impregnados con clorhexidina, uso de tapones con solución antiséptica en los conectores e higiene corporal diaria con clorhexidina.

Effect of didecyl dimethyl ammonium chloride (DDAC)-impregnated washcloth wipe whole-body bathing on catheter-related bloodstream infections and central venous line-associated infections in adult intensive care units

OBJECTIVE

To investigate the effect of daily whole-body bathing (WBB) using disposable washcloth wipes/caps impregnated with an antiseptic solution containing the quaternary ammonium base compound didecyl dimethyl ammonium chloride (DDAC).

METHODS

A prospective double-blind randomized crossover trial was conducted to compare WBB of adult intensive care unit (ICU) patients with washcloth wipes/caps impregnated with either regular cleanser/shampoo or the antiseptic DDAC. The clinical trial was performed in a medical ICU (MICU) and a surgical ICU (SICU). The study period was divided into two 6-month intervals with alternating treatment regimens.

RESULTS

A total of 1540 ICU patients (total length of ICU stay 10 470 days) were included in the trial. Compared to controls, DDAC bathing was found to be associated with reduced incidence rates per 1000 patient days for central-venous-line-associated infections (CLAIs) caused by Gram-positive bacteria (GPB) from 16.39 (95%CI 13.1-20.3) in the control group to 7.28 (95%CI 5.2-9.9) in the intervention group (p 0.01). A stratified analysis by unit showed that the incidence rates of CLAI due to GPB were reduced by the intervention in both the MICU and the SICU from 21.2 (95%CI 15.8-27.7) to 9.3 (95%CI 5.8-14.1) (p < 0.01) and from 12.1 (95%CI 8.3-17.0) to 5.7 (95%CI 3.4-9.1) (p 0.01), respectively. There was a trend towards reduction in catheter-related bloodstream infections (CRBSIs) and bloodstream infections (BSIs); however, this did not reach statistical significance due to carry-over effects and small numbers.

CONCLUSIONS

Given the growing need for new concepts to prevent and control healthcare-associated infections, DDAC may be a new and promising agent for WBB of ICU patients.

Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support

Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.

Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

BACKGROUND

Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration.

METHODS

Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations.

RESULTS

Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap.

DISCUSSION

Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change.

CONCLUSIONS

Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Chlorhexidine bathing of the exposed circuits in extracorporeal membrane oxygenation: an uncontrolled before-and-after study

BACKGROUND

Although the prevention of extracorporeal membrane oxygenation (ECMO) catheter-related infection is crucial, scientific evidence regarding best practices are still lacking.

METHODS

We conducted an uncontrolled before-and-after study to test whether the introduction of disinfection with 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA) of the exposed circuits and hub in patients treated with ECMO would affect the rate of blood stream infection (BSI) and microbial colonization of the ECMO catheter. We compared the microbiological and clinical data before and after the intervention.

RESULTS

A total of 1740 ECMO catheter days in 192 patients were studied. These were divided into 855 ECMO catheter days in 96 patients before and 885 ECMO catheter days in 96 patients during the intervention. The rates of BSI were significantly decreased during the intervention period at 11.7/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during (difference 9.4, 95% confidence interval (CI) 1.5-17.3, p = 0.019). Furthermore, the colonization of the ECMO catheter was similarly significantly reduced during the intervention period at 10.5/1000 ECMO catheter days before vs. 2.3/1000 ECMO catheter days during intervention (difference 8.3, 95% CI 0.7-15.8, p = 0.032). Hospital mortality (41.7% vs. 24%, p = 0.009) and sepsis-related death (17.7% vs. 6.3%, p = 0.014) were also significantly decreased during intervention.

CONCLUSION

Extensive disinfection of exposed ECMO circuits and hub with 2% CHG/IPA was associated with a reduction in both BSI and microbial colonization of ECMO catheters. A further randomized controlled study is required to verify these results.

TRIAL REGISTRATION

KCT 0004431.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis

Introduction

Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention.

Materials and methods

This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs.

Results

We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences.

Conclusion

Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

You get back what you give: Decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis

BACKGROUND

Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs.

METHODS

Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates.

RESULTS

At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost.

CONCLUSIONS

As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

Association between chlorhexidine gluconate concentrations and resistant bacterial bioburden on skin

We studied the association between chlorhexidine gluconate (CHG) concentration on skin and resistant bacterial bioburden. CHG was almost always detected on the skin, and detection of methicillin-resistant Staphylococcus aureus, carbapenem-resistant Enterobacteriaceae, and vancomycin-resistant Enterococcus on skin sites was infrequent. However, we found no correlation between CHG concentration and bacterial bioburden.

Chlorhexidine bathing of the critically ill for the prevention of hospital-acquired infection

BACKGROUND

Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications, permanent disability or death. Whilst all hospital-based patients are susceptible to infections, prevalence is particularly high in the ICU, where people who are critically ill have suppressed immunity and are subject to increased invasive monitoring. People who are mechanically-ventilated are at infection risk due to tracheostomy and reintubation and use of multiple central venous catheters, where lines and tubes may act as vectors for the transmission of bacteria and may increase bloodstream infections and ventilator-associated pneumonia (VAP). Chlorhexidine is a low-cost product, widely used as a disinfectant and antiseptic, which may be used to bathe people who are critically ill with the aim of killing bacteria and reducing the spread of hospital-acquired infections.

OBJECTIVES

To assess the effects of chlorhexidine bathing on the number of hospital-acquired infections in people who are critically ill.

SEARCH METHODS

In December 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared chlorhexidine bathing with soap-and-water bathing of patients in the ICU.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and undertook risk of bias and GRADE assessment of the certainty of the evidence .

MAIN RESULTS

We included eight studies in this review. Four RCTs included a total of 1537 individually randomised participants, and four cluster-randomised cross-over studies included 23 randomised ICUs with 22,935 participants. We identified one study awaiting classification, for which we were unable to assess eligibility.The studies compared bathing using 2% chlorhexidine-impregnated washcloths or dilute solutions of 4% chlorhexidine versus soap-and-water bathing or bathing with non-antimicrobial washcloths.Eight studies reported data for participants who had a hospital-acquired infection during the ICU stay. We are uncertain whether using chlorhexidine for bathing of critically ill people reduces the rate of hospital-acquired infection, because the certainty of the evidence is very low (rate difference 1.70, 95% confidence interval (CI) 0.12 to 3.29; 21,924 participants). Six studies reported mortality (in hospital, in the ICU, and at 48 hours). We cannot be sure whether using chlorhexidine for bathing of critically-ill people reduces mortality, because the certainty of the evidence is very low (odds ratio 0.87, 95% CI 0.76 to 0.99; 15,798 participants). Six studies reported length of stay in the ICU. We noted that individual studies found no evidence of a difference in length of stay; we did not conduct meta-analysis because data were skewed. It is not clear whether using chlorhexidine for bathing of critically ill people reduced length of stay in the ICU, because the certainty of the evidence is very low. Seven studies reported skin reactions as an adverse event, and five of these reported skin reactions which were thought to be attributable to the bathing solution. Data in these studies were reported inconsistently and we were unable to conduct meta-analysis; we cannot tell whether using chlorhexidine for bathing of critically ill people reduced adverse events, because the certainty of the evidence is very low.We used the GRADE approach to downgrade the certainty of the evidence of each outcome to very low. For all outcomes, we downgraded evidence because of study limitations (most studies had a high risk of performance bias, and we noted high risks of other bias in some studies). We downgraded evidence due to indirectness, because some participants in studies may have had hospital-acquired infections before recruitment. We noted that one small study had a large influence on the effect for hospital-acquired infections, and we assessed decisions made in analysis of some cluster-randomised cross-over studies on the effect for hospital-acquired infections and for mortality; we downgraded the evidence for these outcomes due to inconsistency. We also downgraded the evidence on length of stay in the ICU, because of imprecision. Data for adverse events were limited by few events and so we downgraded for imprecision.

AUTHORS' CONCLUSIONS

Due to the very low-certainty evidence available, it is not clear whether bathing with chlorhexidine reduces hospital-acquired infections, mortality, or length of stay in the ICU, or whether the use of chlorhexidine results in more skin reactions.

Effect of chlorhexidine bathing on colonization or infection with Acinetobacter baumannii: a systematic review and meta-analysis

Healthcare-associated infections (HAIs) caused by multi-drug-resistant Gram-negative bacteria (MDRGNB) have increased prevalence in intensive care units (ICUs). A common strategy to prevent HAIs is bathing patients with chlorhexidine gluconate (CHG). However, the effectiveness of CHG bathing against multidrug-resistant Acinetobacter baumannii (MDRAB) is still controversial. The aim of this study was to perform a systematic review and meta-analysis of the effectiveness of CHG bathing on Acinetobacter baumannii colonization and infection in the ICU setting. A systematic literature search of PubMed, EMBASE, Web of Science and CINAHL was performed from inception through to June 2018. Randomized controlled trials (RCTs), pre-post studies, or interrupted time series (ITS) studies were included. The numbers of patients with/without colonization or infection of A. baumannii in the experimental or control groups were extracted from each study. Quality assessment was performed by the related instruments of National Institute of Health. Pooled risk ratios (RRs) were calculated using the random-effects model. One RCT and 12 pre-post or ITS studies comprising 18,217 patients were included, of which 8069 were in the CHG bathing arm and 9051 in the control arm. CHG bathing was associated with a reduced colonization of A. baumannii (RR, 0.66; 95% confidence interval: 0.57-0.77; P<0.001). Chlorhexidine at 4% showed a better effect than 2% chlorhexidine (meta-regression P=0.044). CHG bathing was associated with a non-significant reduction of infection (pooled RR 0.41, 95% CI: 0.13-1.25). This study suggests that CHG bathing significantly reduces colonization of A. baumannii in the ICU setting. However, more trials are needed to confirm whether CHG bathing can reduce infections with A. baumannii.

Best products for skin antisepsis

Application of antiseptic products to the skin plays an important role in prevention of a variety of health care-associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care-associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted. Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.

The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a systematic review and meta-analysis

Background

Chlorhexidine gluconate (CHG) bathing of hospitalized patients may have benefit in reducing hospital-acquired bloodstream infections (HABSIs). However, the magnitude of effect, implementation fidelity, and patient-centered outcomes are unclear. In this meta-analysis, we examined the effect of CHG bathing on prevention of HABSIs and assessed fidelity to implementation of this behavioral intervention.

Methods

We undertook a meta-analysis by searching Medline, EMBASE, CINAHL, Scopus, and Cochrane’s CENTRAL registry from database inception through January 4, 2019 without language restrictions. We included randomized controlled trials, cluster randomized trials and quasi-experimental studies that evaluated the effect of CHG bathing versus a non-CHG comparator for prevention of HABSIs in any adult healthcare setting. Studies of pediatric patients, of pre-surgical CHG use, or without a non-CHG comparison arm were excluded. Outcomes of this study were HABSIs, patient-centered outcomes, such as patient comfort during the bath, and implementation fidelity assessed through five elements: adherence, exposure or dose, quality of the delivery, participant responsiveness, and program differentiation. Three authors independently extracted data and assessed study quality; a random-effects model was used.

Results

We included 26 studies with 861,546 patient-days and 5259 HABSIs. CHG bathing markedly reduced the risk of HABSIs (IRR = 0.59, 95% confidence interval [CI]: 0.52–0.68). The effect of CHG bathing was consistent within subgroups: randomized (0.67, 95% CI: 0.53–0.85) vs. non-randomized studies (0.54, 95% CI: 0.44–0.65), bundled (0.66, 95% CI: 0.62–0.70) vs. non-bundled interventions (0.51, 95% CI: 0.39–0.68), CHG impregnated wipes (0.63, 95% CI: 0.55–0.73) vs. CHG solution (0.41, 95% CI: 0.26–0.64), and intensive care unit (ICU) (0.58, 95% CI: 0.49–0.68) vs. non-ICU settings (0.56, 95% CI: 0.38–0.83). Only three studies reported all five measures of fidelity, and ten studies did not report any patient-centered outcomes.

Conclusions

Patient bathing with CHG significantly reduced the incidence of HABSIs in both ICU and non-ICU settings. Many studies did not report fidelity to the intervention or patient-centered outcomes. For sustainability and replicability essential for effective implementation, fidelity assessment that goes beyond whether a patient received an intervention or not should be standard practice particularly for complex behavioral interventions such as CHG bathing.

Trial registration

Study registration with PROSPERO CRD42015032523.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4002-7) contains supplementary material, which is available to authorized users.

Implementation Strategies to Improve Evidence-Based Bathing Practices in a Neuro ICU

BACKGROUND

Evidence supports daily bathing using chlorhexidine gluconate (CHG) cloths to decrease preventable hospital-acquired central line-associated bloodstream infections (CLABSIs). However, implementation of this practice is inconsistent. Using multifaceted strategies to promote implementation is supported in the literature, yet there is a gap in knowing which strategies are most successful.

PURPOSE

Using the Grol and Wensing Model of Implementation as a guide, the purpose of this study was to determine whether using tailored, multifaceted strategies would improve implementation of daily CHG bathing and decrease CLABSIs in a large neuro ICU.

METHODS

An observational pre-/postdesign was used.

RESULTS

Following implementation, infection rates decreased (P = .031). Statistically significant improvements were also seen across all process measures: bathing documentation, nursing knowledge, and perceived importance of CHG bathing.

CONCLUSIONS

This study assists in closing the research-practice gap by using tailored, multifaceted implementation strategies to increase use of evidence-based nursing care for infection prevention practices.

Patient perceptions of chlorhexidine bathing: A pilot study using the health belief model

BACKGROUND

Many studies investigating daily chlorhexidine gluconate (CHG) bathing as an infection control intervention to decrease health care-associated infections have focused on reduction of infection and colonization; few studies have assessed CHG bathing compliance, work system factors, facilitators, and barriers to implementation.

METHODS

This is a combination retrospective/prospective pilot study conducted at a large academic teaching hospital that implemented daily CHG bathing across all inpatient units. CHG compliance and patient refusal were calculated on the basis of documentation in the electronic medical record. We used the health belief model to guide semistructured interviews with patients about knowledge and barriers related to CHG bathing.

RESULTS

Of the 31 patients interviewed, 74% reported using CHG soap during their stay. Average compliance documented in the electronic medical record was 78% with a range of 57%-91% among all hospital units. Sixteen percent of patients declined CHG bathing, and refusal ranged from 3%-29% among all units. Major themes about CHG bathing from patient interviews include low perceived susceptibility to infection, high degree of trust in medical professionals, low knowledge of benefits of CHG, and low perceived self-efficacy in preventing HAIs.

CONCLUSIONS

Educating patients about CHG bathing appears to be a critical factor in decreasing patient refusal of CHG bathing.

Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis

Background

Health care associated infections (HAI) among adults admitted to the intensive care unit (ICU) have been shown to increase length of stay, the cost of care, and in some cases increased the risk of hospital death (Kaye et al., J Am Geriatr Soc 62:306-11, 2014; Roberts et al., Med Care 48:1026-35, 2010; Warren et al., Crit Care Med 34:2084-9, 2006; Zimlichman et al., JAMA Intern Med 173:2039-46, 2013). Daily bathing with chlorhexidine gluconate (CHG) has been shown to decrease the risk of infection in the ICU (Loveday et al., J Hosp Infect 86:S1-S70, 2014). However, due to varying quality of published studies, and varying estimates of effectiveness, CHG bathing is not universally practiced. As a result, current opinion of the merit of CHG bathing to reduce hospital acquired infections in the ICU, is divergent, suggesting a state of ‘clinical equipoise’.

This trial sequential meta-analysis aims to explore the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections, and address the question: do we need more trials?

Methods

A systematic literature search was undertaken to identify trials assessing the effectiveness of chlorhexidine bathing to reduce risk of infection, among adult intensive care patients. With particular focus on: (1) Blood stream infections (BSI); (2) Central Line Associated Blood Stream Infections (CLABSI); (3) Multi-Resistant Drug Organism (MRDO); (4) Ventilator Associated Pneumonia; and, Catheter Associated Urinary Tract Infections (CAUTI). Only randomised-control or cluster randomised cross-over trials, were include in our analysis. A Trial Sequential Analysis (TSA) was used to describe the current status of evidence for the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce hospital acquired infections.

Results

Five trials were included in our final analysis - two trials were individual patient randomised-controlled, and the remaining cluster-randomised-crossover trials. Daily bathing with CHG was estimated to reduce BSI in the ICU by approximately 29% (Der-Simonian and Laird, Random-Effects.

(DL-RE) Incidence Rate Ratio (IRR) = 0.71, 95% confidence interval (CI) 0.51, 0.98); reduce CLABSI in the ICU by approximately 40% (DL-RE IRR = 0.60, 95% CI 0.34, 1.04); reduce MDRO in the ICU by approximately 18% (DL-RE IRR = 0.82, 95% CI 0.69, 0.98); no effect in reducing VAP in the ICU (DL-RE IRR = 1.33, 95% CI 0.81, 2.18); and, no effect in reducing CAUTI in the ICU (DL-RE IRR = 0.77, 95% CI 0.52, 1.15). Upper (superiority) monitoring boundaries from TSA were not crossed for all five specific infections in the ICU.

Conclusion

Routine bathing with CHG does not occur in the ICU setting, and TSA suggests that more trials are needed to address the current state of ‘clinical equipoise’. Ideally these studies would be conducted among a diverse group of ICU patients, and to the highest standard to ensure generalisability of results.

Chlorhexidine-based body washing for colonization and infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: an updated meta-analysis

Background

The effects of chlorhexidine-based body washing (CHW) on health care-associated infections have been reported in numerous studies, while their findings remain conflicting. This study aims to update the evidence for the effects of CHW on the risk of colonization or infection with hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

Methods

Two independent authors searched PubMed, Embase, and Cochrane Library from inception through February 2018. We selected all observational studies or clinical trials for the effect of CHW on the risk of colonization and infection with hospital-acquired MRSA or VRE. Random-effects models were applied to calculate summary incidence rate ratios (IRRs) for the related associations.

Results

Of 140 records identified, we obtained data from 17 relevant articles for meta-analysis. Compared with patients without antiseptic bathing, patients with CHW had a significantly lower risk of MRSA colonization (IRR 0.61, 95% CI 0.48–0.77) and VRE colonization (IRR 0.58, 95% CI 0.42–0.80). Similarly, we also noted that patients with CHW had a significantly lower risk of MRSA infection (IRR 0.65, 95% CI 0.52–0.81). However, no significantly lower risk of VRE infection (IRR 0.61, 95% CI 0.30–1.25) was noted in patients with CHW. Sensitivity analyses or trim-and-fill method confirmed the robustness of the findings.

Conclusion

Current evidence supports that patients with CHW had a significantly lower risk of MRSA or VRE colonization and a lower risk of MRSA infection. More evidence should be accumulated to reinforce these findings, especially on the effect of CHW on the risk of VRE infection.

Infections in Neurocritical Care

Neurointensive care (NICU) patients experience complex infectious disease challenges. Central nervous system (CNS) infections are difficult to diagnose and treat, and post-neurosurgical patients are vulnerable to a unique set of healthcare-acquired infections (HAI) in addition to those typical of critically ill patients. The purpose of this review is to summarize the approach to suspected infection in the NICU and discuss management of several infectious syndromes in the NICU setting.

Emergence of carbapenem-resistant Enterobacteriaceae in Orange County, California, and support for early regional strategies to limit spread

BACKGROUND

The east-to-west spread of carbapenem-resistant Enterobacteriaceae (CRE) represents an opportunity to explore strategies to limit spread in nonendemic areas. We evaluated CRE emergence and regional support for containment strategies.

METHODS

A 17-question cross-sectional survey was administered to infection prevention programs in Orange County, CA (31 hospitals serving 3 million residents), between January and September 2014. Questions addressed newly detected hospital- and community-onset CRE cultures (2008-2013), current CRE control strategies, and support for prevention strategies for a hypothetical regional intervention.

RESULTS

Among 31 hospitals, 21 (68%, representing 17 infection prevention programs) completed the survey. CRE was scarcely detected between 2009-2010; within 4 years, 90% of hospitals reported CRE, with 2.5-fold higher community-onset than hospital-onset CRE. Between 2011 and 2013, annual CRE incidence increased 4.7-fold (1.4-6.3 cases/10,000 admissions). Support for a regional CRE prevention bundle was unanimous. Although 22% bathed patients positive for CRE with chlorhexidine gluconate and 11% actively screened for CRE, 86% and 57%, respectively, would consider these strategies in a regional intervention.

CONCLUSIONS

CRE epidemiology in Orange County parallels early progression previously seen in now-endemic areas, representing an opportunity to consider interventions to prevent endemic spread. Many facilities would consider proactive strategies, such as chlorhexidine bathing, in the setting of a regional collaborative.

Implementation of daily chlorhexidine bathing to reduce colonization by multidrug-resistant organisms in a critical care unit

BACKGROUND

Colonized patients are a reservoir for transmission of multidrug-resistant organisms (MDROs). Not many studies have examined the effectiveness of daily chlorhexidine gluconate (CHG) bathing under routine care conditions. We present a descriptive analysis of the trends of MDRO colonization following implementation of daily CHG bathing under routine clinical conditions in an intensive care unit (ICU).

METHODS

From May 2010-January 2011, we screened patients admitted to a 24-bed ICU for and methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and fluoroquinolone-resistant gram-negative bacilli (FQRGNB). We calculated and plotted monthly incidence and prevalence of colonization of these MDROs.

RESULTS

Prevalence decreased in the immediate aftermath of daily CHG bathing implementation and generally remained at that level throughout the observation period. We observed low rates of incidence of MDRO colonization with VRE>FQRGNB>MRSA. Monthly prevalence of colonization and incidence for the composite of MRSA, VRE, and/or FQRGNB was 1.9%-27.9% and 0-1.1/100 patient-days, respectively.

CONCLUSIONS

Following the implementation of daily CHG bathing, the incidence of MDROs remained low and constant over time, whereas the prevalence decreased immediately after the implementation.

Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial

OBJECTIVE

To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.

DESIGN

This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.

SETTING

Twenty-four-bed surgical ICU at a quaternary academic medical center.

PATIENTS

Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.

INTERVENTIONS

Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309-0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5-16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).

CONCLUSIONS

Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

Hospital-wide chlorhexidine gluconate bed bathing protocol: A cross-sectional study in a single hospital

The objective of this study was to determine understanding of bed bathing practices over time after the implementation of a standardized bed bathing protocol. An online survey addressing bathing practices was administered preintervention and 6 and 18 months postintervention to all nurses and technicians caring for adult patients. Survey responses suggested that the intervention resulted in sustained understanding of the standardized bed bathing protocol.

Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomised crossover trials

We assessed the impact of 2% daily patient bathing with chlorhexidine gluconate (CHG) washcloths on the incidence of hospital-acquired (HA) and central line-associated (CLA) bloodstream infections (BSI) in intensive care units (ICUs). We searched randomised studies in Medline, EMBASE, Cochrane Library (CENTRAL) and Web of Science databases up to April 2015. Primary outcomes were total HABSI, central line, and non-central line-associated BSI rates per patient-days. Secondary outcomes included Gram-negative and Gram-positive BSI rates and adverse events. Four randomised crossover trials involved 25 ICUs and 22,850 patients. Meta-analysis identified a total HABSI rate reduction (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.60–0.90; p = 0.002) with moderate heterogeneity (I² = 36%). Subgroup analysis identified significantly stronger rate reductions (p = 0.01) for CLABSI (OR: 0.50; 95% CI: 0.35–0.71; p < 0.001) than other HABSI (OR: 0.82; 95% CI: 0.70–0.97; p = 0.02) with low heterogeneity (I² = 0%). This effect was evident in the Gram-positive subgroup (OR: 0.55; 95% CI: 0.31–0.99; p = 0.05), but became non-significant after removal of a high-risk-of-bias study. Sensitivity analysis revealed that the intervention effect remained significant for total and central line-associated HABSI. We suggest that use of CHG washcloths prevents HABSI and CLABSI in ICUs, possibly due to the reduction in Gram-positive skin commensals.

Reduction in hospital-associated methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus with daily chlorhexidine gluconate bathing for medical inpatients

BACKGROUND

Daily bathing with chlorhexidine gluconate (CHG) is increasingly used in intensive care units to prevent hospital-associated infections, but limited evidence exists for noncritical care settings.

METHODS

A prospective crossover study was conducted on 4 medical inpatient units in an urban, academic Canadian hospital from May 1, 2014-August 10, 2015. Intervention units used CHG over a 7-month period, including a 1-month wash-in phase, while control units used nonmedicated soap and water bathing. Rates of hospital-associated methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) colonization or infection were the primary end point. Hospital-associated S. aureus were investigated for CHG resistance with a qacA/B and smr polymerase chain reaction (PCR) and agar dilution.

RESULTS

Compliance with daily CHG bathing was 58%. Hospital-associated MRSA and VRE was decreased by 55% (5.1 vs 11.4 cases per 10,000 inpatient days, P = .04) and 36% (23.2 vs 36.0 cases per 10,000 inpatient days, P = .03), respectively, compared with control cohorts. There was no significant difference in rates of hospital-associated Clostridium difficile. Chlorhexidine resistance testing identified 1 isolate with an elevated minimum inhibitory concentration (8 µg/mL), but it was PCR negative.

CONCLUSIONS

This prospective pragmatic study to assess daily bathing for CHG on inpatient medical units was effective in reducing hospital-associated MRSA and VRE. A critical component of CHG bathing on medical units is sustained and appropriate application, which can be a challenge to accurately assess and needs to be considered before systematic implementation.

Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences

BACKGROUND

Daily bathing with chlorhexidine gluconate (CHG) of intensive care unit (ICU) patients has been shown to reduce healthcare-associated infections and colonization by multidrug resistant organisms. The objective of this project was to describe the process of daily CHG bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital.

METHODS

We conducted 26 semi-structured interviews with a convenience sample of 4 nurse managers (NMs), 13 registered nurses (RNs) and 9 health care technicians (HCTs) working in the ICU. We used qualitative content analysis to code and analyze the data. Dedoose software was used to facilitate data management and coding. Trustworthiness and scientific integrity of the data were ensured by having two authors corroborate the coding process, conducting member checks and keeping an audit trail of all the decisions made.

RESULTS

Duration of the interviews was 15 to 39 min (average = 26 min). Five steps of bathing were identified: 1) decision to give a bath; 2) ability to give a bath; 3) decision about which soap to use; 4) delegation of a bath; and 5) getting assistance to do a bath. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. The outcome was influenced by a combination of barriers and facilitators at each step. Most barriers were related to perceived workload, patient factors, and scheduling. Facilitators were mainly organizational factors such as the policy of daily CHG bathing, the consistent supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers.

CONCLUSIONS

Patient bathing in ICUs is a complex process that can be hindered and interrupted by numerous factors. The decision to use CHG soap for bathing was only one of 5 steps of bathing and was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene. Interventions that address the organizational, provider, and patient barriers to bathing could improve adherence to a daily CHG bathing protocol.

Bathing With 2% Chlorhexidine Gluconate: Evidence and Costs Associated With Central Line-Associated Bloodstream Infections

In a coordinated national effort reported by the Agency for Healthcare Research and Quality, the use of 2% chlorhexidine gluconate (CHG) has reduced the central line-associated bloodstream infection (CLABSI) rate by 40%. Conversely, a recent randomized clinical trial determined that chlorhexidine bathing did not reduce the CLABSI rate. The objectives of this study were to conduct meta-analysis and clarify the effectiveness of 2% CHG bathing by nurses on CLABSIs in adult intensive care unit patients and to determine the contributing costs attributable to CLABSIs and 2% CHG bathing. Eligible studies that included the outcome of bloodstream infection rate for central lines were considered. A rigorous systematic review protocol and software tools available from the Joanna Briggs Institute via OvidSP were used. Agency for Healthcare Research and Quality tools assisted with identifiable CHG bathing costs. Four studies were included in the meta-analysis for the outcome of primary bloodstream infections, and 2 studies narratively supported the meta-analysis. A relative risk of 0.46 with 95% confidence interval (0.34-0.63) was determined. This significant effect is seen in an overall z-score of 4.84 (P < .0001). This meta-analysis supports that 2% CHG reduces CLABSIs. The estimated cost increase of 2% CHG-impregnated cloths is $4.10 versus nonmedicated bathing cloths. The cost associated with a single CLABSI is 10 times more than the cost of using 2% CHG-impregnated cloths. Nursing provides significant influence for the prevention of CLABSIs in critical care via evidence-based best practices.

Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis

Background

Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306–11, 2014; Roberts and Scott, Med Care 48(11):1026–35, 2010; Warren and Quadir, Crit Care Med 34(8):2084–9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039–46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1–70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes. This meta-analysis aims to summarise the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce infection.

Methods

A systematic literature search was undertaken to identify trials assessing the effectiveness of CHG bathing to reduce risk of infection, among adult intensive care patients. Infections included were: bloodstream infections; central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections; ventilator-associated pneumonia; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile. Summary estimates were calculated as incidence rate ratios (IRRs) and 95% confidence/credible intervals. Variation in study designs was addressed using hierarchical Bayesian random-effects models.

Results

Seventeen trials were included in our final analysis: seven of the studies were cluster-randomised crossover trials, and the remaining studies were before-and-after trials. CHG bathing was estimated to reduce the risk of CLABSI by 56% (Bayesian random effects IRR = 0.44 (95% credible interval (CrI), 0.26, 0.75)), and MRSA colonisation and bacteraemia in the ICU by 41% and 36%, respectively (IRR = 0.59 (95% CrI, 0.36, 0.94); and IRR = 0.64 (95% CrI, 0.43, 0.91)). The numbers needed to treat for these specific ICU infections ranged from 360 (CLABSI) to 2780 (MRSA bacteraemia).

Conclusion

This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1553-5) contains supplementary material, which is available to authorized users.

The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units

BACKGROUND/AIMS

Healthcare-associated infections (HAIs) in critically ill patients with prolonged length of hospital stay and increased medical costs. The aim of this study is to assess whether daily chlorhexidine gluconate (CHG) bathing will significantly reduce the rates of HAIs in adult intensive care units (ICUs).

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched until December 31, 2014 to identify relevant studies. Two authors independently reviewed and extracted data from included studies. All data was analyzed by Review Manager version 5.3.

RESULTS

Fifteen studies including three randomized controlled trials and 12 quasi-experimental studies were available in this study. The outcomes showed that daily CHG bathing were associated with significant reduction in the rates of primary outcomes: catheter-related bloodstream infection (risk ratio [RR], 0.44; 95% confidence interval [CI], 0.32 to 0.63; p < 0.00001), catheter-associated urinary tract infection (RR, 0.68; 95% CI, 0.52 to 0.88; p = 0.004), ventilator-associated pneumonia (RR, 0.73; 95% CI, 0.57 to 0.93; p = 0.01), acquisition of methicillin-resistant Staphylococcus aureus (RR, 0.78; 95% CI, 0.68 to 0.91; p = 0.001) and vancomycin-resistant Enterococcus (RR, 0.56; 95% CI, 0.31 to 0.99; p = 0.05).

CONCLUSIONS

Our study suggests that the use of daily CHG bathing can significantly prevent HAIs in ICUs. However, more well-designed studies are needed to confirm these findings.

Chlorhexidine bathing for the prevention of colonization and infection with multidrug-resistant microorganisms in a hematopoietic stem cell transplantation unit over a 9-year period: Impact on chlorhexidine susceptibility

Health care associated infections (HAIs) are currently among the major challenges to the care of hematopoietic stem cell transplantation (HSCT) patients. The objective of the present study was to evaluate the impact of 2% chlorhexidine (CHG) bathing on the incidence of colonization and infection with vancomycin-resistant Enterococcus (VRE), multidrug-resistant (MDR) gram-negative pathogens, and to evaluate their CHG minimum inhibitory concentration (MIC) after the intervention.A quasi-experimental study with duration of 9 years was conducted. VRE colonization and infection, HAI rates, and MDR gram-negative infection were evaluated by interrupted time series analysis. The antibacterial susceptibility profile and mechanism of resistance to CHG were analyzed in both periods by the agar dilution method in the presence or absence of the efflux pump inhibitor carbonyl cyanide-m-chlorophenyl hydrazone (CCCP) and presence of efflux pumps (qacA/E, qacA, qacE, cepA, AdeA, AdeB, and AdeC) by polymerase chain reaction (PCR).The VRE colonization and infection rates were significantly reduced in the postintervention period (P = 0.001). However, gram-negative MDR rates in the unit increased in the last years of the study. The CHG MICs for VRE increased during the period of exposure to the antiseptic. A higher MIC at baseline period was observed in MDR gram-negative strains. The emergence of a monoclonal Pseudomonas aeruginosa clone was observed in the second period.Concluding, CHG bathing was efficient regarding VRE colonization and infection, whereas no similar results were found with MDR gram-negative bacteria.

Chlorhexidine Bathing Effects on Health-Care-Associated Infections

BACKGROUND

Health-care-associated infections (HAIs), infections that patients contract during the course of their hospitalization, are receiving a growing amount of attention. Heavy skin bacterial colonization aids in the transmission and development of HAIs. Nurses frequently use bathing with chlorhexidine gluconate (CHG) to reduce patients' cutaneous microbial burden. This intervention has been shown to have promising but mixed results in the prevention of HAIs.

PURPOSE

This article reviews the literature for evidence on the impact of CHG bathing on HAIs.

METHOD

A literature search was conducted to identify peer-reviewed studies and meta-analyses that examined the impact of CHG bathing on HAIs using PubMed and CINAHL with the following search terms: CHG bathing AND healthcare associated infections, surgical site infections ( SSIs), central line associated bloodstream infections ( CLABSIs), ventilator-associated pneumonias ( VAP), catheter-associated urinary-tract infections ( CAUTIs), and Clostridium difficile-associated disease. The initial search identified 23 articles for review. Additional studies were identified by searching references used in original studies or review articles on this topic.

PRINCIPLE FINDINGS

There is good evidence to support incorporating a CHG bathing regimen to reduce the incidence of CLABSIs, SSIs, vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) HAIs.

CONCLUSION

As CHG becomes a standard practice to prevent HAIs, it is important to monitor for adverse reactions and evidence of resistance/susceptibility.

An observational study of the universal use of octenidine to decrease nosocomial bloodstream infections and MDR organisms

OBJECTIVES

To investigate the effect of universal decolonization with octenidine on the incidence of ICU-acquired bloodstream infections (BSI) and MDR organisms (MDRO).

METHODS

A system-wide change in practice was performed in the ICUs of a university hospital with three campuses (eight medical ICUs and nine surgical ICUs). All ICUs had a general admission screening strategy for MRSA with subsequent isolation in the 12 month baseline period, which was stopped. After a wash-in period of 1 month, decolonization of the nose with octenidine nasal gel and octenidine wash cloths was introduced. The endpoints were ICU-acquired BSI and ICU-acquired MDRO isolates from clinical cultures. Segmented regression analysis of interrupted time series was used to assess the effect of intervention.

RESULTS

A total of 29 532 ICU patients (16 677 surgical and 12 855 medical) were included in the study. The baseline incidence density of ICU-acquired BSI was 5.1 per 1000 patient days and the baseline ICU-acquired MRSA rate was 0.97 per 1000 patient days. Whereas no significant effect on either outcome was found in surgical ICUs, we identified a significant effect on ICU-acquired BSI for the intervention in medical ICUs by means of multivariate analysis (incidence rate ratio 0.78; 95% CI 0.65-0.94). In addition, the intervention was also effective in decreasing ICU-acquired MRSA in medical ICUs (incidence rate ratio 0.58; 95% CI 0.41-0.82). No effect on ICU-acquired VRE and Gram-negative MDRO was found.

CONCLUSIONS

System change was successful by decreasing infection rates in medical ICUs and improving the management in all ICUs.

Using a Systems Engineering Initiative for Patient Safety to Evaluate a Hospital-wide Daily Chlorhexidine Bathing Intervention

We undertook a systems engineering approach to evaluate housewide implementation of daily chlorhexidine bathing. We performed direct observations of the bathing process and conducted provider and patient surveys. The main outcome was compliance with bathing using a checklist. Fifty-seven percent of baths had full compliance with the chlorhexidine bathing protocol. Additional time was the main barrier. Institutions undertaking daily chlorhexidine bathing should perform a rigorous assessment of implementation to optimize the benefits of this intervention.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.