Reducing the risk or development of HAIs of Critical Care ICU patients

Abstract

Clinical Problem: Patient’s admitted to Intensive Care Units (ICUs) are critically compromised and have higher risk of Healthcare Associate Infections (HAIs).  HAIs can affect length of stay (LOS), increase rate of mortality and directly affect patient outcome.

Objective: This paper will discuss if routine bathing with chlorhexidine-based products in Critical Care ICU patients will reduce risk or development of a HAI.  RCTs were obtained using the CINAHL database to search for literature involving the use of chlorhexidine-based products to reduce HAIs.  Key search terms were intensive care unit, chlorhexidine or CHG or chlorhexidine gluconate, bathing, healthcare associated infection or HAI or nosocomial infection.  The publication years searched were 2009 through 2019.

Results:  Growing evidence continues to support that CHG bathing reduces colonization of pathogens that cause HAIs.  The literature showed a statistically significant reduction of HAIs compared to traditional bathing methods when receiving CHG baths daily or every other day.

Conclusion: Critical Care patients in the ICU receiving CHG baths had a lower percentage of HAI development than patients receiving traditional baths with bath wipes or soap and water. Further research is warranted into investigation of chlorhexidine resistant pathogens, and CHG bathing in non-critical care ICU patients.

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Annually there is an estimated 1.7 million Healthcare Associated Infections (HAI) occurring in the United States, reaching an annual cost of 147 billion dollars (Swan et al., 2016).  Healthcare organizations continue to search for new methods and guidelines to reduce HAIs to improve patient outcomes.  Researchers found that in addition to effecting patient outcome, the length of stay among patients diagnosed with a HAI was prolonged for an additional 10.4 days, reducing medical income of the hospital and affecting throughput of patients (Jia et al., 2019).  To suppress the development of HAIs, hospitals are implementing chlorhexidine gluconate (CHG) bathing versus traditional bathing methods.  This paper will discuss if CHG is a viable alternative to reduce HAIs among Critical Care Intensive Care Unit (ICU) patients.  In critical care ICU patients, does bathing with CHG based products compared to non-CHG based products reduce the risk of acquiring a HAI? 

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Literature Search

CINAHL was the primary database accessed to acquire RCTs and journal articles regarding the reduction of HAI in the ICU using CHG based products.  Key search terms used were intensive care unit or ICU, chlorhexidine or CHG or chlorhexidine gluconate, bathing, healthcare associated infection or HAI or nosocomial infection.  The publication years of the literature ranged from 2009 to 2019. 

Literature Review

The literature consisted of three RCTs and one clinical protocol from the United States Department of Health and Services (see table 1).  In a multicenter, before-after study, Climo et al. (2009) investigated if bathing using chlorhexidine gluconate-based products would reduce HAIs including blood stream infections.  The organisms cultured for were Vancomycin Resistant Enterococci (VRE) and Methicillin Resistant Staphylococcus Aureus (MRSA).  The study was conducted over 12 months and included 5,293 patients.  The control group (n=2670) received routine daily baths with soap and water using non-medicated, non-antimicrobial cloths.  The intervention group (n=2650) received the same daily bed bath as the control group with 4% CHG solution mixed with warm water in place of soap and water.  Patients were tested on admission and weekly thereafter for presence of MRSA and VRE.  There was a 32% decrease (p=.046) of MRSA and 50% decrease of VRE (p=.008) vs the control group.  Weaknesses of the study are the absence of randomization, using a before-after design, and incomplete patient data collection.  Strengths of the study included utilizing a diverse population across multiple facilities and a large sample size.

Researchers conducted a study to evaluate daily bathing with CHG based pre-packaged wipes on reduction of Multi-Drug Resistant Organism (MDRO) acquisition and HAIs (Climo et al., 2013).  Data was collecting using a randomized multi-center nonblinded crossover design.  The study involved six hospitals, nine ICUs and a bone marrow transplantation, and 7727 patients.  The study consisted of six hospitals and lasted for 12 months.  The intervention group (n=3970) was bathed with CHG wipes.  The control group (n=3842) was bathed with nonantimicrobial wash cloths and unidentified alternative solution.  The data from the intervention group showed statistically significant reduction of 28% in HAIs (p=.03), and 23% in acquisition of MDROs (p=.007).  The weaknesses of the study include lack of blinding in which medical staff knew which treatment was given to each patient, and a recall on contaminated CHG wipes used in the study.  Strengths of the study were a large sample size, exclusion of compromised data, and feasibility of replicating methods.

Swan et al. (2016) researched the effectiveness of every other day bathing with CHG based wipes in reducing HAIs including urinary tract infections, blood stream infections, ventilator associated pneumonia, and surgical site infections.  The sample size consisted of 325 patients.  Patients were randomized into the control group (n=164), and an intervention group (n=161).  Patients in the control group were bathed with soap and water.  Patients in the intervention group were first bathed with BedsideCare® Easicleanse™️ bath wipes.  Patients were then cleansed with CHG water-based solution and air dried.  Both groups received baths in-between scheduled bathing for hygiene to remove feces, urine and bodily fluids, however, only the contaminated area was cleansed.  Results demonstrated a statistically significant reduction of 44.5% when bathing with CHG based wipes (p=.049) compared to washing with soap and water.  Weaknesses of the study included being a relatively small population size at a single surgical ICU.  Another weakness was the lack of blinding on two of eight adjudicators due to providing direct care with patients. There also might have been the risk of contaminated water basins due to compliance with discarding single-use water basins not being tracked.  The strengths of the study were using medical staff not involved in collection of data to bathe patients, feasibility of reproducing the study, and independent blind review of data by an adjucation committee to reduce bias.

The U.S. Department of Health and Human Services (HHS) (2013) clinical guideline on ICU decolonization is consistent with the literature.  The HHS (2013) recommends routine CHG bathing while admitted to the ICU as a standard of decolonization protocol.  Research continues to support implementing CHG based protocols for the prevention of HAI and other complications while patients are admitted to the ICU.  

Climo et al. (2009) showed a significant reduction in HAI when analyzing MRSA (p=.046) and VRE (p=.008) incidence when using daily CHG bathing.  Additionally, Climo et al. (2013) again demonstrated a statistically significant reduction in HAIs (p=.03) and MDROs (p=.007) among patients bathed with chlorhexidine-based solution.   Swan et al. (2016) reported a statistically significant reduction of HAIs in patients bathed every other day with CHG wipes when compared to soap and water (p=.049).  In addition, the HHS (2013) clinical guideline recommends utilizing CHG based bathing products for routine bathing.

The data illustrates that daily bathing using CHG based product or solution over soap and water or bath wipes reduces incidence of HAIs.  Research has that HAIs can be associated with increased LOS, financial implications, reduction in optimal patient outcome, and can lead to costly medical disputes (Jia et al., 2019).  Additional research is warranted into complications of CHG bathing, CHG resistant organisms, and efficacy of CHG bathing in non-critical care ICU environments (Climo et al., 2009).

Clinical Recommendations

The HHS (2013) recommends that for patients highly susceptible to infection, such as those admitted to an ICU, routine use of special soaps such as CHG impregnated soap or CHG based products should be utilized to reduce risk of infection.  Research supports proper screening and isolation of infected patients, targeted decolonization in site specific infected areas, and universal decolonization using CHG bathing and mupirocin for prevention of MRSA and other blood stream infections.  CHG bathing has effectively demonstrated a significant reduction in HAIs in numerous multi-center trials involving critical-care ICU patients.  CHG bathing provides an inexpensive, safe, and effective alternative to traditional bathing methods especially in high-risk patients.

Table 1

Literature Review

References

• Climo, M. W., Sepkowitz, K. A., Zuccotti, G., Fraser, V. J., Warren, D. K., Perl, T. M., . . . Wong, E. S. (2009). The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: Results of a quasi-experimental multicenter trial*. Critical Care Medicine,37(6), 1858-1865. doi:10.1097/ccm.0b013e31819ffe6d
• Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . . Wong, E. S. (2013). Effect of Daily Chlorhexidine Bathing on Hospital-Acquired Infection. New England Journal of Medicine,368(6), 533-542. doi:10.1056/nejmoa1113849
• Jia, H., Li, L., Li, W., Hou, T., Ma, H., Yang, Y., . . . Chen, M. (2019). Impact of Healthcare-Associated Infections on Length of Stay: A Study in 68 Hospitals in China. BioMed Research International,2019, 1-7. doi:10.1155/2019/2590563
• Swan, J. T., Ashton, C. M., Bui, L. N., Pham, V. P., Shirkey, B. A., Blackshear, J. E., . . . Wray, N. P. (2016). Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU. Critical Care Medicine,44(10), 1822-1832. doi:10.1097/ccm.0000000000001820
• U.S. Department of Health and Human Services. (2013). Universal ICU Decolonization: An Enhanced Protocol. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/universal_icu_decolonization/universal-icu-rationale.html