Chlorhexidine gluconate bathing to reduce methicillin-resistant Staphylococcus aureus acquisition

Chlorhexidine Gluconate Bathing Program to Reduce Health Care-Associated Infections in Both Critically Ill and Non-Critically Ill Patients

BACKGROUND

Critical care nurses take care of patients with complicated, comorbid, and compromised conditions. These patients are at risk for health care-associated infections, which affect patients' lives and health care systems in various ways.

OBJECTIVE

To gauge the impact of routinely bathing patients with 4% chlorhexidine gluconate solution on the incidence of health care-associated infections in a medical-surgical intensive care unit and a postoperative telemetry unit; to outline the framework for a hospital-wide presurgical chlorhexidine gluconate bathing program and share the results.

METHODS

A standard bathing protocol using a 4% chlorhexidine gluconate solution was developed. The protocol included time studies, training, monitoring, and surveillance of health care-associated infections.

RESULTS

Consistent patient bathing with 4% chlorhexidine gluconate was associated with a 52% reduction in health care-associated infections in a medical-surgical intensive care unit. The same program in a postoperative telemetry unit yielded a 45% reduction in health care-associated infections.

CONCLUSION

A comprehensive daily 4% chlorhexidine gluconate bathing program can be implemented with standardized protocols and detailed instructions and can significantly reduce the incidence of health care-associated infections in intensive care unit and non-intensive care unit hospital settings.

Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region

IMPORTANCE

Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement.

OBJECTIVE

To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California.

DESIGN, SETTING, AND PARTICIPANTS

An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses.

EXPOSURES

Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities.

MAIN OUTCOMES AND MEASURES

MRSA and CRE prevalence and number of new carriers (ie, transmission events).

RESULTS

Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events).

CONCLUSIONS AND RELEVANCE

The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.

In Vitro Efficacy of Bacterial Cellulose Dressings Chemisorbed with Antiseptics against Biofilm Formed by Pathogens Isolated from Chronic Wounds

Local administration of antiseptics is required to prevent and fight against biofilm-based infections of chronic wounds. One of the methods used for delivering antiseptics to infected wounds is the application of dressings chemisorbed with antimicrobials. Dressings made of bacterial cellulose (BC) display several features, making them suitable for such a purpose. This work aimed to compare the activity of commonly used antiseptic molecules: octenidine, polyhexanide, povidone-iodine, chlorhexidine, ethacridine lactate, and hypochlorous solutions and to evaluate their usefulness as active substances of BC dressings against 48 bacterial strains (8 species) and 6 yeast strains (1 species). A silver dressing was applied as a control material of proven antimicrobial activity. The methodology applied included the assessment of minimal inhibitory concentrations (MIC) and minimal biofilm eradication concentration (MBEC), the modified disc-diffusion method, and the modified antibiofilm dressing activity measurement (A.D.A.M.) method. While in 96-well plate-based methods (MIC and MBEC assessment), the highest antimicrobial activity was recorded for chlorhexidine, in the modified disc-diffusion method and in the modified A.D.A.M test, povidone-iodine performed the best. In an in vitro setting simulating chronic wound conditions, BC dressings chemisorbed with polyhexanide, octenidine, or povidone-iodine displayed a similar or even higher antibiofilm activity than the control dressing containing silver molecules. If translated into clinical conditions, the obtained results suggest high applicability of BC dressings chemisorbed with antiseptics to eradicate biofilm from chronic wounds.

Effective elimination of Staphylococcal contamination from hospital surfaces by a bacteriophage-probiotic sanitation strategy: a monocentric study

Persistent contamination of hospital surfaces and antimicrobial resistance (AMR) is recognized as major causes of healthcare‐associated infections (HAI). We recently showed that probiotic‐based sanitation (PCHS) can stably decrease surface pathogens and reduce AMR and HAIs. However, PCHS action is slow and non‐specific. By contrast, bacteriophages have been proposed as a decontamination method as they can rapidly attack specific targets, but their routine application has never been tested. Here, we analysed the feasibility and effectiveness of phage addition to PCHS sanitation, aiming to obtain a rapid and stable abatement of specific pathogens in the hospital environment. Staphylococcal contamination in the bathrooms of General Medicine wards was analysed, being those areas the most contaminated and Staphylococci the most prevalent bacteria in such settings. Results showed that a daily phage application by nebulization induced a rapid and significant decrease in Staphylococcus spp. load on treated surfaces, up to 97% more than PCHS alone (P < 0.001), suggesting that such a system might be considered as a part of prevention and control strategies, to counteract outbreaks of specific pathogens and prevent associated infections.

A Randomized Controlled Study to Evaluate the Effectiveness of 2 Treatment Methods in Reducing Incidence of Short Peripheral Catheter-Related Phlebitis

Short peripheral catheter (SPC)-related phlebitis can lead to bloodstream infections and affect patients' quality of life. A randomized trial was carried out to evaluate the effectiveness of 2 treatment methods in reducing the incidence of SPC-related phlebitis. The 2 treatment methods differed in terms of the cleansing solution used before insertion and dressing material used after removal. The results demonstrated that the type of cleansing solution and postremoval dressing material did not make a difference in the incidence of phlebitis. Strict adherence to aseptic techniques and prompt removal of the SPC remained the cornerstone in the prevention of phlebitis.

Use of a chlorhexidine-impregnated dressing reduced catheter-related bloodstream infections caused by Gram-positive microorganisms

Objective:

We compared the protective effects of secure Chlorhexidine Gluconate (CHG)-containing dressings with those of non-antimicrobial transparent dressings.

Methods:

This prospective, comparative, single-center clinical study was conducted in a tertiary pediatric intensive care unit from October 2014 to March 2017. The inclusion criterion was catheterization of the jugular vein for ≥48 hour. The study was conducted in two phases. Non-antimicrobial standard dressings were applied both before and after the CHG- dressing phase to negate any coincidental temporal effect. During the standard-dressing phases, the dressings did not include any antimicrobial; transparent CHG-impregnated dressings were applied during the test phase. All patients were divided into two groups by the type of dressing applied (standard and CHG-containing dressings).

Results:

The standard- and CHG-dressing groups contained 68 and 63 patients, respectively. The median durations of catheterization were 13 (8–22) and 14 (2–28) days, respectively (p>0.05). The Catheter-Related Bloodstream Infection (CRBSI) rate was somewhat lower in the CHG-dressing group (20.6 vs. 26.5%), but the difference was not statistically significant (p>0.05). In the CHG-dressing group, CRBSIs caused by Gram-positive microorganisms totaled 0%, but the figure was 8.8% in the control group (p=0.028).

Conclusions:

CHG dressings reduced CRBSIs caused by Gram-positive microorganisms.

Differential Effects of Chlorhexidine Skin Cleansing Methods on Residual Chlorhexidine Skin Concentrations and Bacterial Recovery

BACKGROUND Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)-impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results. OBJECTIVE To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin. DESIGN Prospective, randomized 2-center study with blinded assessment. PARTICIPANTS AND SETTING Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016. INTERVENTION Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non-antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C). RESULTS In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001). CONCLUSION In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined. Infect Control Hosp Epidemiol 2018;39:405-411.

Nursing Care of the Patient Undergoing an Anterior Approach to Total Hip Arthroplasty

The anterior, anterolateral, direct lateral, transtrochanteric, and posterior techniques have historically been the surgical approach to a total hip arthroplasty; however, a forthcoming technique called the direct anterior approach has been demonstrated to produce many patient and physician quality outcomes. These favorable outcomes can include shorter hospital stay, earlier mobility and functionality, decreased medical costs, and increased patient satisfaction scores. Appropriate nursing care during the preoperative, intraoperative, and postoperative phases is essential. The purpose of this article is to describe the nursing care for a patient undergoing a direct anterior approach to hip arthroplasty.

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 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.

Research in Review: Driving Critical Care Practice Change

During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.

Economic features of antibiotic resistance: the case of methicillin-resistant Staphylococcus aureus

This paper analyses and updates the economic information regarding methicillin-resistant Staphylococcus aureus (MRSA), including information that has been previously reviewed by other authors, and new information, for the purpose of facilitating health management and clinical decisions. The analysed articles reveal great disparity in the economic burden on MRSA patients; this is mainly due to the diversity of the designs of the studies, as well as the variability of the patients and the differences in health care systems. Regarding prophylactic strategies, the studies do not provide conclusive results that could unambiguously orientate health management. The studies addressing treatments noted that linezolid seems to be a cost-effective treatment for MRSA, mostly because it is associated with a shorter length of stay (LOS) in hospital. However, important variables such as antimicrobial susceptibility, infection type and resistance emergence should be included in these analyses before a conclusion is reached regarding which treatment is the best (most efficient). The reviewed studies found that rapid MRSA detection, using molecular techniques, is an efficient technique to control MRSA. As a general conclusion, the management of MRSA infections implicates important economic costs for hospitals, as they result in higher direct costs and longer LOS than those related to methicillin-susceptible S. aureus (MSSA) patients or MRSA-free patients; there is wide variability in those increased costs, depending on different variables. Moreover, the research reveals a lack of studies on other related topics, such as the economic implications of changes in MRSA epidemiology (community patients and lineages associated with farm animals).