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.
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