Can We Discard the Traditional Soap-and-Basin Bath?

Ruth M. Kleinpell, PhD, RN

Disclosures

April 08, 2010

Question

I see a trend where chlorhexidine is being used for routine bathing in critical care. Is there a downside to discarding the traditional soap-and-basin bath?

Response from Ruth M. Kleinpell, PhD, RN
Professor, Rush University College of Nursing, Chicago, Illinois; Director, Center for Clinical Research, Rush University Medical Center, Chicago, Illinois

Your question is pertinent to clinical care for acutely ill and critically ill patients. A growing body of literature supports the use of chlorhexidine (CHG) bathing to decrease colonization rates of potentially harmful pathogens, especially for patients in the intensive care unit (ICU). CHG is an antiseptic solution that has been used worldwide since the 1950s; because it has broad antiseptic activity, CHG is used for a variety of infection-prevention measures, including general skin cleansing, skin decolonization, preoperative showering and bathing, vascular catheter-site preparation, impregnated catheter-site dressings, impregnated catheters, and oral decontamination.[1] The antimicrobial properties of CHG bind strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery, and placement of intravascular access catheters.[2]

Several studies have specifically examined the use of CHG baths and the effect on skin colonization rates. Vernon and colleagues[3] conducted a prospective study of 2% CHG baths compared with soap-and-water baths in a medical ICU over 1 year and assessed the effect on vancomycin-resistant enterococci (VRE) colonization rates in 1787 patients. They also studied 86 patients with VRE colonization and obtained culture specimens from 758 environmental surfaces and 529 healthcare workers' hands. Compared with soap-and-water baths, cleansing patients with CHG cloths resulted in significantly fewer VRE colonies on patients' skin and reduced VRE contamination of healthcare 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 to 9 colonizations per 1000 patient-days (RR, 0.4; 95% CI, 0.1-0.9).

In another study, Bleasdale and colleagues[4] assessed the effect of CHG baths on catheter-related bloodstream infections (BSI) in 836 medical ICU patients over 1 year. The use of CHG-impregnated cloths for bathing was effective in decreasing the rates of BSI. A similar decrease in BSI was seen by Popovich and associates,[5] who examined the effect of bathing ICU patients with 2% CHG-impregnated cloths on the rate of central venous catheter (CVC)-associated BSI over 2 years. The results indicated a statistically significant decrease in the rate of CVC-associated BSI (from 5.31 to 0.69 cases per 1000 CVC-days; P = .006) and the rate of blood culture contamination (from 6.99 to 4.1 cases per 1000 patient-days; P = .04). These findings were supported by another study of 2% CHG baths vs daily soap-and-water baths in terms of CVC-associated BSI rates for patients in a long-term acute care hospital.[6] The rates of CVC-associated BSI were 9.5, 3.8, and 6.4 cases per 1000 CVC-days during the preintervention, intervention, and postintervention periods, respectively. By the end of the intervention period, a net reduction of 99% in the CVC-associated BSI rate was seen, demonstrating that daily CHG baths were effective in reducing these infections.

The effect of daily bathing with CHG compared with soap and water on BSI caused by methicillin-resistant Staphylococcus aureus (MRSA) and VRE was explored in a study conducted at 6 ICUs in 4 hospitals.[7] After introduction of daily CHG bathing, rates of MRSA decreased by 32% (5.04 vs 3.44 cases per 1000 patient-days, P = .046) and acquisition of VRE decreased by 50% (4.35 vs 2.19 cases per 1000 patient-days, P = .008). Significant reductions in VRE bacteremia were also documented (P = .02).

Aside from daily bathing, CHG is widely used for oral care of intubated patients in the ICU.[8,9,10,11] CHG effectively decontaminates the oropharynx,[12] and its use in oral care has been associated with decreased dental plaque[13] and incidence of ventilator-associated pneumonia.[14,15,16]

Although the use of CHG to decrease both skin and oral colonization in critically ill patients has expanded, an ongoing concern is the need for long-term monitoring to ensure that decreasing the growth of gram-positive bacteria, such as S aureus and enterococci, does not promote the growth of gram-negative bacteria or fungal infections.

In conclusion, the evidence confirms the advantages of CHG bathing over soap-and-water bathing in reducing skin colonization rates for MRSA and VRE and rates of CVC-associated BSI in critically ill patients, but data on the possible disadvantages of CHG bathing are lacking. As evidence of the benefits of CHG bathing continues to mount, the need to change the long-standing clinical practice of traditional soap-and-water daily baths may be evident.

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