For patients in intensive care units and bone marrow transplantation units, daily bathing with chlorhexidine-impregnated washcloths significantly reduced the incidence of bloodstream infections and decreased the acquisition of multidrug-resistant organisms in a randomized controlled trial reported online Feb. 7 in the New England Journal of Medicine.
The multicenter study, which included nine medical, coronary care, surgical, cardiac surgery, and bone marrow transplantation units in several geographic regions of the United States, confirms the results of previous single-center studies and demonstrates that the benefit of daily chlorhexidine bathing is widely generalizable, said Dr. Michael W. Climo of the Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Va., and his associates.
Courtesy Janice Haney Carr/CDC
Magnified 20,000X, this colorized scanning electron micrograph (SEM) depicts a grouping of methicillin resistant Staphylococcus aureus (MRSA) bacteria.
Each hospital unit participating in the trial was randomized to perform daily bathing of patients using either washcloths impregnated with 2% chlorhexidine gluconate (intervention) or washcloths with no impregnated antimicrobial (control) for 6 months, followed by a crossover period in which patients were bathed daily with the alternate product for another 6 months. A total of 7,727 patients were included in the study.
Nurses were trained in the manufacturer’s instructions for bathing, which involved using the cloths in a sequential order to rinse all body surfaces except the face (to avoid getting chlorhexidine in the patient’s eyes and mouth). Implementing this cost-effective strategy was "relatively straightforward" because it did not require much of a change from current routine patient-bathing practices, the investigators said.
All the hospital units performed active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) throughout the study.
There were 119 hospital-acquired bloodstream infections during the intervention and 165 during the control period, representing a 28% reduction with chlorhexidine bathing. The rate of primary bloodstream infections was 31% lower and the rate of central catheter–associated bloodstream infections was 53% lower with the intervention, Dr. Climo and his associates reported (N. Engl. J. Med. 2013 Feb. 6 [doi: 10.1056/NEJMoa1113849]).
This benefit was greatest among patients who had longer lengths of stay in the hospital units.
One "unanticipated" finding was that rates of fungal infection in particular were dramatically reduced with chlorhexidine bathing. The incidence of primary bloodstream infection caused by fungi was 53% lower and the incidence of central catheter–associated fungal bloodstream infection was 90% lower during the intervention period than during the control period.
This antifungal effect has not been reported previously. "If our results are confirmed, topical use of chlorhexidine could be added to strategies to prevent fungal infection," the researchers noted.
The rate of MRSA or VRE acquisition was 23% lower during the intervention period (5.10 cases per 1,000 patient-days) than during the control period (6.60 cases per 1,000 patient-days). However, reductions in the incidence of MRSA and VRE bacteremia did not reach statistical significance, most likely because the overall number of cases was so low, Dr. Climo and his colleagues said.
No serious adverse effects were observed. The incidence of skin reactions was higher with the control washcloths (3.4%) than with the chlorhexidine washcloths (2.0%), and none of the skin reactions were considered to be related to the bathing intervention.
It was reassuring that none of the MRSA or VRE isolates that were detected in this study showed resistance to chlorhexidine. However, the development of resistance to biocides and disinfectants among nosocomial organisms remains "a substantial concern" and should continue to be monitored, they added.
This study was supported by the Centers for Disease Control and Prevention and Sage Products. Sage Products supplied the washcloths, provided technical and educational support, and participated in weekly teleconferences with the research group but was not involved in the study design, data analysis, or reporting of the study results. Dr. Climo and his associates reported ties to Sage Products, Centene, and other companies.