Steady as She Goes: The Case for Daily Patient Bathing as Part of a Bundled Intervention Protocol

<p>In a recent study published in the Journal of the American Medical Association (JAMA)1, Noto et al. found that in a &ldquo;single-center, multi-ICU, cluster randomized, crossover study, once daily bathing with chlorhexidine did not reduce the rate of the composite primary outcome of infections including central-line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), possible or probable ventilator-associated pneumonia (VAP), or infection with C difficile.&rdquo;&nbsp;The authors further concluded that these findings do not support daily bathing of critically ill patients with chlorhexidine.</p>

By Kimberly LaFreniere, PhD, and Rosie Lyles MD, MHA, MSc

In a recent study published in the Journal of the American Medical Association (JAMA)(1), Noto et al. found that in a “single-center, multi-ICU, cluster randomized, crossover study, once daily bathing with chlorhexidine did not reduce the rate of the composite primary outcome of infections including central-line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), possible or probable ventilator-associated pneumonia (VAP), or infection with C difficile.”  The authors further concluded that these findings do not support daily bathing of critically ill patients with chlorhexidine.

The results of the JAMA study are in conflict with two notable studies published in the New England Journal of Medicine, Climo et al.(2) and Huang et al.(3)  Further, because of this new JAMA publication, clinicians are once again left wondering, “Now what do we do”?  This paper briefly summarizes the limitations of the JAMA study, the evidence-based support for daily bathing of critically ill patients with chlorhexidine gluconate (CHG), and the argument for bundled interventions. The prudent answer is “steady as she goes.”

Limitations of the JAMA Study

• Single-center study(1,4)

• Staff administering baths were not blinded to the treatment groups(1)

• Infection rates were relatively low in this facility(5)

• The study was under-powered for CLABSI(1,4) and these results may not translate to facilities with higher infection rates, where the benefit of daily bathing may have emerged

• No active surveillance for MRSA VRE was performed, so ICU acquisition could not be accurately measured(1,4)

• The frequency of training of the staff administering the baths over the course of the study was not stated

• Bathing adherence [to protocol] was not monitored(1)

• Bathing with CHG cloths would not be expected to reduce CAUTI, VAP, or C. difficile infection rates(4)

Evidence-based Support for Daily Bathing of Critically Ill Patients with CHG

• This is a single study; several studies have shown a reduction of CLABSI infection rates with daily bathing of ICU patients with CHG(2,3, 6-13) 

• Further, when bottled, liquid CHG products were used, an unexpected reduction of C. difficile infections rates was observed(14)

The Argument for Bundled Interventions

Multiple studies have demonstrated the importance of bundled interventions to reduce CLABSI, VAP, and SSIs(15-19). As an example, a Johns Hopkins University School of Medicine research team from the Quality and Safety Research Group (QSRG) partnered with the Michigan Health and Hospital Association, Keystone Center for Patient Safety and Quality and conducted a statewide collaborative cohort study(15) to determine the extent to which the incidence of catheter-related bloodstream infections (CR-BSIs) could be reduced using a bundle of interventions, which included:

• Washing hands
• Using full barrier precautions during the insertion of central venous catheters
• Cleaning the skin with chlorhexidine
• Avoiding the femoral site when possible because of its potential infectious and mechanical complications
• Removing unnecessary catheters

Researchers reported the analysis of data that included 1981 ICU-months and 375,757 catheter-days. “The regression model showed a significant decrease in CR-BSI rates from baseline, with incidence-rate ratios decreasing from 0.62 at zero to 3 months after implementing the intervention to 0.34 at 16 to 18 months. Preliminary analysis suggested CR-BSI rates were sustained 4 years after implementation of the intervention.”

Steady as She Goes

To summarize, there were several limitations to the current JAMA study(1).  The JAMA study also conflicts with many published, evidence-based, peer-reviewed studies(2,3, 6-14). Bundled interventions are also important, as demonstrated in the literature(15-19). Clinicians are challenged daily to interpret conflicting reports in the literature and are left asking “How do I know which interventions are best for my patients?” 

Patient outcomes are the sum of the interventions that were executed well.  Each intervention taken may lead to improved patient outcomes. If your facility is experiencing average or higher infection rates, daily bathing of your critically ill patients with CHG may reduce your infection rates when used as part of a bundled intervention protocol or a horizontal approach to reduce healthcare-associated infection (HAI)(20). If your infections rates are lower than average, daily bathing of your critically ill patients with CHG may help you maintain or even further reduce your infection rates when used as part of a bundled intervention protocol. 

Kimberly LaFreniere, PhD, is associate research fellow for R&D, Clorox Healthcare.

Rosie Lyles, MD, MHA, MSc, is head of clinical affairs, Clorox Healthcare.

References:
1. Noto, MJ, et al., “Chlorhexidine Bathing and Health Care-Associated Infections  A Randomized Trial,” JAMA. doi:10.1001/jama.2014.18400 Published online January 20, 2015.
2. Climo MW, et al. “Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-542.
3. Huang SS, Septimus E, Kleinman K, et al.; CDC Prevention Epicenters Program; AHRQ DECIDE Network and Healthcare-Associated Infections Program. “Targeted versus universal decolonization to prevent ICU infection.” N Engl J Med. 2013;368(24):2255-2265.
4. Controversies in Hospital Infection Prevention, “Falling out of love with chlorhexidine?”  http://haicontroversies.blogspot.com/2015/01/falling-out-of-love-with-chlorhexidine.html
5. Pittet, D, Angus, DC, “Daily Chlorhexidine Bathing for Critically Ill Patients  A Note of Caution,” JAMA, http://jama.jamanetwork.com/ on 01/21/2015  Published online January 20, 2015.
6. D. Armellino et al.  “Modifying the risk: Once-a-day bathing “at risk” patients in the intensive care unit with chlorhexidine gluconate,”  AJIC  42 (2014) 571-3.
7. J.A. Popp et al.  “Hospital-acquired infections and thermally injured patients:  Chlorhexidine gluconate baths work,” AJIC  42 (2014) 129-32.
8. Montecalvo, MA et al. “Chlorhexidine Bathing to Reduce Central Venous Catheter associated Bloodstream Infection: Impact and Sustainability,” The American Journal of Medicine (2012) 125, 505-511.
9. Bleasdale, SC, et al. “Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients,” Arch Intern Med/Vol 167 (No. 19), Oct 22, 2007, 2073-2079.
10. Chen, W., et al. “Effects of daily bathing with chlorhexidine and acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a meta-analysis,” Journal of Thoracic Disease, Vol 5, No 4 August 2013 :518-524.
11. Kassakian, SZ, et al. “Impact of Chlorhexidine Bathing on Hospital-Acquired Infections among General Medical Patients,” Infect Control Hosp Epidemiol 2011;32(3):238-243.
12. Popovich, KJ, et al. “Effectiveness of Routine Patient Cleansing with Chlorhexidine Gluconate
for Infection Prevention in the Medical Intensive Care Unit ,” Infect Control Hosp Epidemiol 2009;30(10):959–963.
13. O’Horo, JC, et al. “The Efficacy of Daily Bathing with Chlorhexidine for Reducing
Healthcare-Associated Bloodstream Infections: A Meta-analysis,” Infect Control Hosp Epidemiol 2012;33(3):257-267.
14. Rupp, ME et al. “Effect of Hospital-Wide Chlorhexidine Patient Bathing on Healthcare-Associated Infections,” Infect Control Hosp Epidemiol 2012;33(11):1094-1100.
15. Pronovost . P. “Interventions to decrease catheter-related bloodstream infections in the ICU: The Keystone Intensive Care Unit Project,” AJIC  2008;36:S171.e1-S171.e5.
16. Berenholtz, SM, et al. “Eliminating catheter-related bloodstream infections in the intensive care unit,”  Critical Care Med 2004;32:2014-20.
17. Resar, R. et al. “Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia,” Jt Comm J Qual Pateint Saf 2005;31:243-8.
18. Waits, SA, et al. “Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery,” Surgery, 2014 155(4), 602-606.
19. Keenan, JE, et al. “The Preventative Surgical Site Infection Bundle in Colorectal Surgery:  An Effective Approach to Surgical Site Infection Reduction and Health Care Cost Savings,”  JAMA Surg, JAMA Surg. doi:10.1001/jamasurg.2014.346.  Published online August 27, 2014.
20. Septimus, Edward, et al. “Approaches for Preventing Healthcare-Associated Infections: Go Long or Go Wide,” Infection Control and Hospital Epidemiology, 2014; 35(7):797-801.

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