By Kelly M. Pyrek
One of the most talked-about issues at last year's IDWeek conference was patient bathing with chlorhexidine gluconate (CHG). The topic was included in a session called "Thorny Issues in Infection Prevention" in which panelists described practical solutions to real-world problems in infection prevention, compared the strengths and weaknesses of the solutions discussed, and debated strategies to assist in the implementation of the solutions presented. Moderated by Charles Huskins, MD, MSc, FIDSA, FSHEA, FPIDS, of Mayo Clinic and Thomas Talbot, MD, MPH, of Vanderbilt University, the panel included Loreen Herwaldt, MD, FIDSA, FSHEA; Susan Ray, MD, FIDSA; Stephen Parodi, MD, FIDSA; Edward Septimus, MD, FIDSA, FSHEA; and Danielle Zerr, MD, MPH, FPIDS.
In an informal audience-participation survey conducted during the session, attendees were asked if their healthcare institution engaged in CHG bathing. Thirty-four percent said their facility did not participate in CHG bathing; 27 percent said CHG bathing was administered to all ICU patients; 24 percent reported that it was used for ICU patients and select non-ICU patients; and 12 percent said CHG bathing was administered to select ICU patients.
Septimus pointed out that CHG bathing of patients has seen renewed interest in the wake of publication of several recent studies indicating it as a successful intervention against HAIs. "In our study we saw a 44 percent reduction in all-cause bacteremias," Septimus said. "We implemented it in all adult ICUs and saw a 23 percent reduction in CLABSIs."
In this cluster-randomized trial, Septimus, et al. (2014) sought to determine rates of blood culture contamination comparing three strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization. The trial involved 43 hospitals with 74 ICUs and was conducted from July 1, 2009 to Sept. 30, 2011. After a six-month baseline period, hospitals were randomly assigned to one of the three aforementioned strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all three arms.
During the baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. The researchers reported that among all individual draws, for arms 1, 2, and 3, the contamination rates were 4.1 percent, 3.9 percent, and 3.8 percent for the baseline period and 3.3 percent, 3.2 percent, and 2.4 percent for the intervention period, respectively.
When the researchers evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8 percent (N = 108 sets) in the baseline period and 7.5 percent (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4 percent (N = 78) compared to 7.5 percent (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7 percent (N = 119) contaminated blood cultures during the baseline period to 5.1 percent (N = 184) during the intervention period. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 and an adjusted OR of 0.55. The authors say their study demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.
The panelists addressed their experiences with their facilities' CHG bathing policies, reporting varying degrees of success and detailing the inherent challenges, such as the need for establishing the business case for CHG bathing. As several panelists pointed out, in some hospitals there has been pushback from nurses and administrators regarding cost and the need for the C-suite to provide the resources necessary for these types of interventions that show demonstrable impact on infection rates.
Panelists also addressed clinician concerns about patients' skin sensitivities and their reactions to CHG's tendency toward stickiness until it dries. As Parodi observed, "You definitely need to achieve consensus on the use of CHG, get nursing's buy-in and address competencies in terms of providing education and training about its use. For example, if you have a patient needing an occlusive dressing, it needs to be put on after the CHG has been applied and the CHG absolutely has to have dried first or you will get skin reactions. It requires education and checking competencies regularly. Because unfortunately, just one reaction tends to derail things quickly."
Addressing challenges to implementation, Septimus noted, "It's important to look at compliance and make sure the CHG bathing is performed correctly regardless of the preparation used. We found a lot of variation when we first implemented this across our organization. Another barrier is convincing your frontline healthcare workers that this is a smart intervention. The updated Compendium says it is a good practice." Septimus also addressed many of the common mistakes observed, including using the right amount of wipes or solution per the manufacturer's directions; looking at other products such as soaps and lotions currently used on units that can interfere with CHG's activity or inactivate it; and ensuring that the CHG dries thoroughly.
Septimus noted that the Agency for Healthcare Quality and Research (AHRQ) offers a toolkit, Universal ICU Decolonization: An Enhanced Protocol, which offers step-by-step instructions for proper decolonization using mupirocin and CHG.
In the Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update, a collaborative effort led by the Society for Healthcare Epidemiology of America (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, CHG bathing is highlighted in the recommended practice of "Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. In long-term acute care hospitals, daily chlorhexidine bathing may also be considered as a preventive measure. The role of chlorhexidine bathing in non-ICU patients remains to be determined. The optimal choice of antiseptic agents is unresolved for children under 2 months of age. However, chlorhexidine is widely used in children under 2 months of age."
According to the Compendium, "For chlorhexidine gluconate (CHG)–based topical antiseptic products, the Food and Drug Administration recommends 'use with care in premature infants or infants under 2 months of age; these products may cause irritation or chemical burns.' The American Pediatric Surgical Association recommends CHG use but states that 'care should be taken in using chlorhexidine in neonates and premature infants because of increased risk of skin irritation and risk of systemic absorption.' Concerns in children under 2 months have been noted elsewhere. Cutaneous reactions to CHG have also been reported in extremely-low-birth-weight neonates under 48 hours of age; however, in a small pilot trial of neonates under 1,000 grams and at least 7 days of age, severe contact dermatitis did not occur, although CHG was cutaneously absorbed. These findings have not been replicated in a recent trial in neonates weighing more than or equal to 1,500 grams. Some institutions have used chlorhexidine-containing sponge dressings for CVCs and chlorhexidine for cleaning CVC insertion sites in children in this age group with minimal risk of such reactions. Providers must carefully weigh the potential benefit in preventing CLABSI in children under 2 months and the risks of CHG, recognizing that term and preterm infants may have different risks. Alternative agents, such as povidone-iodine or alcohol, can be used in this age group."
Regarding the impact of the use of chlorhexidine-based products on bacterial resistance to chlorhexidine, the Compendium states, "Widespread use of chlorhexidine-based products (e.g., use of chlorhexidine bathing, antisepsis, and dressings) may promote reduced chlorhexidine susceptibility in bacterial strains. However, testing for chlorhexidine susceptibility is not standardized. The clinical impact of reduced chlorhexidine susceptibility in gram-negative bacteria is unknown."
Bacteria responsible for dangerous bloodstream infections may be growing less susceptible to this common antiseptic, according to a recent study led by investigators at Johns Hopkins. The study was published in the September 2014 issue of Infection Control and Hospital Epidemiology. As we have seen, CHG has been increasingly used in hospitals in light of recent evidence that daily antiseptic baths for patients in ICUs may prevent infections and stop the spread of healthcare-associated infections. The impact of this expanded use on the effectiveness of the disinfectant is not yet known.
"Hospitals are appropriately using chlorhexidine to reduce infections and control the spread of antibiotic-resistant organisms," says study lead author Nuntra Suwantarat, MD. "However, our findings are a clear signal that we must continue to monitor bacteria for emerging antiseptic resistance as these antibacterial washes become more widely used in hospitals."
In the study, investigators compared bacterial resistance between cultures from patients in eight ICUs receiving daily antiseptic washes to patients in 30 non-ICUs who did not bathe daily with CHG. Bacterial cultures obtained from patients with regular antiseptic baths showed reduced susceptibility to CHG when compared with those from patients who did not have antiseptic baths. Regardless of unit protocol, 69 percent of all bacteria showed reduced CHG susceptibility, a trend that requires vigilant monitoring.
"The good news is that most bacteria remain vulnerable to CHG, despite the reduced susceptibility. Daily baths with a CHG solution remain effective against life-threatening bloodstream infections," says Suwantarat.
The investigators caution that the clinical implications of their findings remain unclear. For example, antibiotic susceptibility tests are commonly used to determine whether patients will respond to antibiotic treatment. A similar correlation between antiseptic susceptibility and response to an antiseptic are not as well defined. Identifying particular bacteria and settings in which these bacteria will not respond to antiseptic agents used in hospitals is an important next step.
Agency for Healthcare Quality and Research (AHRQ). Universal ICU Decolonization: An Enhanced Protocol. September 2013. Available at: http://www.ahrq.gov/professionals/systems/hospital/universal_icu_decolonization/universal-icu-ape4.html
Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL and Yokoe DS. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidem. June 2014.
Septimus EJ, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, Hickok J, Lankiewicz J, Gombosev A, Haffenreffer K, Kaganov RE, Jernigan JA, Perlin JB, Platt R, Huang SS. Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infect Control Hosp Epidemiol. 2014 Oct;35 Suppl 3:S17-22.
Suwantarat N, Carroll KC, Tekle T, Ross T, Maragakis LL, Cosgrove S and Milstone AM. High Prevalence of Reduced Chlorhexidine Susceptibility in Organisms Causing Central Line-Associated Bloodstream Infections. Infect Control Hosp Epidem. September 2014.