Cleansing Patients with Chlorhexidine Promotes Infection Control

Abstract & Commentary

By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: Cleansing patients with chlorhexidine-saturated cloths reduced VRE contamination of patients’ skin, the environment, and health care workers’ hands, and also decreased VRE acquisition.

Source: Vernon MO, et al. Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med. 2006;166:306-312.

Infection control practices often target clinician behaviors, eg, improving adherence to hand washing hygiene and other infection control practices. This study tested an alternative approach: source control. Over a 15-month period, all patients (n = 1787) admitted to a medical intensive care unit (MICU) were bathed during three sequential periods with soap and water (Phase 1), single-use, no rinse disposable cloths saturated with 2% chlorhexidine gluconate (Phase 2), and single-use, no rinse disposable cloths without chlorhexidine (Phase 3). Each study phase lasted for approximately 5 months. The study used a standard set of bathing procedures and products, eg, Dial soap (Phase 1), packets containing 2 non-medicated cloths for face and neck cleansing and 6 medicated cloths for body cleansing (Phase 2) and packets containing a similar number of non-medicated cloths (Phase 3). Vancomycin-resistant enterococci (VRE) acquisition was defined as a positive finding for VRE on a rectal culture specimen > 3 days after MICU admission with at least 1 prior negative culture.

Compared with soap and water, bathing patients with chlorhexidine-saturated cloths resulted in 2.5 log10 less colonies of VRE on patients’ skin and less VRE contamination of health care workers’ hands (risk ratio [RR], 0.6; 95% confidence interval [CI], 0.4-0.8) and environmental surfaces (RR, 0.3; 95% CI, 0.2-0.5). The incidence of VRE acquisition decreased from 26 colonizations per 1,000 patient-days to 9 per 1,000 patient-days (RR, 0.4; 95% CI, 0.1-0.9). For all measures, the effectiveness of cleansing with non-medicated cloths was similar to that of soap and water baths. Skin condition was assessed daily. More patients had deterioration in skin condition during soap and water bathing compared to chlorhexidine (P = .02) or nonmedicated cloth (P = .001) bathing.

Commentary

Today, we are facing an ever-increasing number of pathogenic bacteria with diminishing susceptibility to antibiotics. Commonly, approaches to reducing cross-contamination with resistant bacteria such as VRE have focused on improving adherence to infection control recommendations. This study evaluated a different approach—source control. The goal was to reduce microbial skin density and, thereby, patient-to-patient transmission. Chlorhexidine was selected because of its low toxicity and known effectiveness against a broad range of pathogens. To detect VRE hand carriage, culture specimens were obtained from a convenience sample of individuals exiting rooms of patients with VRE colonization and from individuals in common MICU areas. To detect environmental contamination, specimens were obtained from the bed rail, pull sheet, and overbed table.

Daily bathing with chlorhexidine produced lower bacterial counts on patients’ skin, hands, and surfaces. With such an intervention, there are always concerns about development of resistant organisms and skin reactions. Resistance, evaluated using median chlorhexidine inhibitory concentrations for strains of VRE (11 strains of Enterococcus faecalis and 52 strains of Enterococcus faecium) was similar during each phase. Also, there were no adverse reactions in the 642 patients enrolled in the phase with chlorhexidine bathing. To avoid the potential of allergic reactions, the bathing procedure did not involve use of chlorhexidine on the patients’ faces. Skin condition for most patients (89%) was unchanged and deterioration was more common during soap and water bathing and bathing with nonmedicated cloths. However, mean MICU stay was only 3.4 days and findings might have differed if the intervention was applied to long-stay ICU patients.

Findings of this study provide strong initial support for bathing with 2% chlorhexidine gluconate as a measure to reduce the transmission of VRE in high-risk settings such as the ICU. Studies involving a longer observation period are needed to evaluate safety and efficacy in long-stay ICU patients.