Running head: REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Reducing Hospital-acquired Infections Using Chlorhexidine Bathing

Garrett Mongelluzzo
University of South Florida

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Abstract
Clinical problem: Critically ill patients are at increased risk of acquiring a hospital-acquired
infection (HAI) and subsequent increased risk of mortality, longer hospital stays, and additional
medical care costs.
Objective: To discuss whether chlorhexidine gluconate (CHG) bathing reduces the incidence of
HAI in critically ill patients. PubMed, CINAHL, and The Centers for Disease Control and
Prevention (CDC) website were used to obtain three randomized control trials (RCT) and a
guideline about reducing HAI using CHG. Key search terms that were used were hospitalacquired infection, HAI, bloodstream infection, chlorhexidine bathing, and CHG bathing.
Results: The literature demonstrated a decreased incidence of HAI when patients received daily
CHG bathing. The CDC (2011) recommended daily 2% CHG bathing to reduce central-line
blood stream infections. When participants were bathed daily using CHG, there was a reduced
incidence of HAI.
Conclusion: The literature supports clinical practice that includes bathing patients with CHG to
reduce the incidence of HAI. The efficacy of CHG bathing should be researched further to
provide further evidence that CHG bathing can reduce the incidence of HAI, length of stay, and
reduce health care costs.

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Reducing Hospital-acquired Infections Using Chlorhexidine Bathing

A hospital-acquired infection (HAI) is a bacterial, viral, or fungal infection that is
acquired in a health care setting. According to the Agency for Healthcare Research and Quality
(AHRQ) (2014), HAIs are the most common complication of hospital care, and are responsible
for 1.7 million infections, 99,000 deaths, and $28 - $33 billion in healthcare costs annually.
Standard bathing practices using soap and water have been shown to be ineffective at reducing
the incidence of HAI. Among other reasons, hospitals are striving to reduce the incidence of HAI
due to non-reimbursement by the Centers for Medicaid and Medicare Services (CMS) and other
insurance companies. There are recommended guidelines that aim to reduce the incidence of
certain HAI. The Centers for Disease Control and Prevention (CDC) (2011) recommend daily
chlorhexidine (CHG) bathing to aid in the prevention of HAIs such as catheter-related blood
stream infections (CRBSI). The purpose of this paper is to examine the efficacy of daily CHG
bathing in reducing the incidence of HAI. In patients who are critically ill (P), does CHG bathing
(I), compared to soap and water bathing (C), affect the incidence of HAI (O), over six months
(T)?
Literature Search
PubMed, CINAHL, and the CDC website were used to obtain three randomized,
controlled trials (RCT) and one guideline associated with the use of CHG to reduce the incidence
of HAI. The key words that were used in the search were hospital-acquired infection,
bloodstream infection, chlorhexidine, chlorhexidine bathing, and CHG bathing. Search
parameters were used to only include RCTs and guidelines between 2011 and 2016.

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Literature Review
Three RCTs were reviewed to determine the effectiveness of CHG bathing to reduce the
incidence of HAI in critically ill patients when compared to standard bathing practices. Climo et
al. (2013) used a multicenter, cluster-randomized (CR), crossover study involving 7,727
participants from eight ICUs, and one bone marrow transplant unit (BMT). The study was
conducted to assess the effect of daily bathing with 2% CHG on the incidence of multidrugresistant organisms (MDRO) and the incidence of bloodstream infections (BSI). The intervention
for this study was daily bathing with 2% CHG washcloths and non-antimicrobial washcloths
were used as the control for this study. The nine units were randomized and categorized into two
groups. CHG washcloths were received by group one for the first six months, followed by nonantimicrobial washcloths for the following six months. The second group received nonantimicrobial washcloths for the first six months and CHG washcloths for the next six months.
The findings support this evidenced-based practice (EBP) proposal, as there was a reduction of a
reduction of Vancomycin-resistant enterococcus (VRE) by 25% (p=.05), a 28% reduction of HAI
(p=.007), a reduced incidence of MDRO (p=.03), and a reduced incidence of Central Lineassociated Blood Stream Infection (CLASBI) (p=.004). A study weakness was that researchers
were not blinded to the intervention, as they knew which participants received the CHG
intervention and non-antimicrobial wipes. The SAGE CHG washcloths also had to be recalled
during the study and units using CHG had to use non-antimicrobial wipes. The randomization of
participant units, large sample size, multi-center study sites, and crossover design were strengths
of the study.
Huang et al. (2013) completed a multicenter, three group, (CR), controlled trial to assess
whether CHG would reduce bacteremia in critically ill children. The study included 74,256

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

participants in 74 ICUs. Group one received the standard of care methicillin-resistant

Staphyloccocus aureus (MRSA) screening and contact precautions. Group two received targeted
decolonization, contact precautions, and MRSA-positive participants received nasal mupirocin
five times daily, with daily CHG bathing. Group three received universal decolonization, no
MRSA screening, and all MRSA participants received nasal mupirocin five times daily, with
daily CHG bathing. Universal decolonization reduced MRSA-positive cultures by 37% (p=.01)
and BSIs were reduced (p=<.001). A weakness of the study was that researchers and medical
staff were not blind to the intervention group. The crossover design, randomization of groups,
and large sample size were strengths of the study.
Milstone et al. (2013) used an unmasked, (CR), two-period, crossover trial to determine
whether daily CHG bathing would reduce bacteremia in critically ill children. This study
involved 4,947 participants at ten pediatric intensive care units (ICU), at five hospitals. The
intervention was daily bathing with 2% CHG impregnated washcloths, and the control was
standard bathing practices using soap and water. Participants were randomly assigned a daily
bathing routine that consisted of a six-month period of bathing with CHG and a six-month period
of standard practice bathing. The rate of bacteremia decreased in participants receiving daily
CHG bathing (p=.044). A weakness of this study was that the researchers and medical staff were
not blinded in that they knew which participants were assigned to the intervention and control
groups. Some participants also did not receive CHG bathing due to lack of consent and were
excluded before participating in the study, which is a strength of the study. The crossover design,
randomization of participants, and large sample size were also strengths of the study.

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Synthesis
Climo et al. (2013) reported a reduction of VRE by 25% (p=.05), a 28% reduction of HAI
(p=.007), a reduced rate of MDRO (p=.03), and a reduced rate of CLASBI (p=.004). Huang et al.
(2013) reported that universal decolonization reduced MRSA-positive cultures by 37% (p=.01)
and reduced BSI (p=<.001). Milstone et al. (2013) stated that the rate of bacteremia was reduced
in participants receiving daily CHG bathing (p=.044). The results are significant and provide
support for the implementation of CHG bathing to decrease the incidence of HAIs in critically ill
patients.
Clinical Recommendation
The CDC guidelines (2011) recommend using 2% CHG wash for daily patient cleansing
to reduce CRBSI. The guidelines also recommend using sterile barrier precautions, aseptic skin
prep, antimicrobial impregnated catheter and cuff use, antibiotic prophylaxis, proper hand
hygiene, and aseptic technique (Centers for Disease Control and Prevention [CDC], 2011).
Research provides evidence that CHG bathing can be implemented in hospitals to reduce the
incidence of HAI. This is potentially an evidenced-based, simple, cost-effective, solution to
implement that could reduce the incidence of HAI. The efficacy of CHG bathing should be
researched further to provide further evidence that CHG bathing can reduce the incidence of
HAI, length of stay, and reduce overall health care costs.

REDUCING HOSPITAL-ACQUIRED INFECTIONS WITH CHLORHEXIDINE

Resources
Agency for Healthcare Research and Quality. (2014). AHRQs efforts to prevent and reduce
health care-associated infections. Retrieved from
http://www.ahrq.gov/research/findings/factsheets/errors-safety/haiflyer/index.html
Centers for Disease Control and Prevention. (2011). Guidelines for the prevention of
intravascular catheter-related infections. Retrieved from
http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html
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. The New
England Journal of Medicine, 368(6), 533-542.
Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T., Platt, R. (2013).
Targeted versus universal decolonization to prevent ICU infection. The New England
Journal of Medicine, 368(24), 2555-2265.
Milstone, A. M., Elward, A., Song, X., Zerr, D. M., Orscheln, R., Speck, K., Perl, T. M.
(2013). Daily chlorhexidine bathing to reduce bacteremia in critically ill children: A
multicenter, cluster randomized, two-period crossover trial. Lancet, 381(9872), 10991106.