Is Chlorhexidine Bathing Really Better Than Soap and Water?

Ruth M. Kleinpell, PhD, RN

Disclosures

November 06, 2012

Editor's Note: To submit a question for future consideration, write to the editor at syox@medscape.net

Question

Our institution is considering using chlorhexidine for bathing patients instead of soap and water. Is there any recent evidence that this practice is better for patients?

Response from Ruth M. Kleinpell, PhD, RN
Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing; Nurse Practitioner, Mercy Hospital & Medical Center, Chicago, Illinois

Your question is timely, because a recently published study evaluated the use of chlorhexidine gluconate (CHG) solution in place of standard soap and water for patient bathing.[1] CHG is an antiseptic that has been shown to reduce the risk for infection in hospitalized patients, but it has predominantly been studied in the form of CHG-impregnated bathing cloths.

In a study published in the September 2012 issue of the American Journal of Critical Care, the impact of CHG solution (2 fluid ounces CHG to 3 quarts water in bath basins) on bacterial growth was evaluated with bath-basin cultures. Specimens from 90 bath basins used for 5 days or more for daily bathing of patients in the intensive care unit (ICU) at 1 hospital were cultured for bacterial growth to assess contamination of basins when CHG was used, and this was compared with recent data from another study using soap and water bathing.[2]

Of the 90 basins cultured, only 4 were positive for microbial growth. Three of the 4 organisms were identified as coagulase-negative Staphylococcus, which is frequently found on the skin. The results of this study indicated that compared with the findings of the previous study using soap and water, CHG bathing is associated with a 95.5% reduction in bacterial growth, which translates into reduced risk for hospital-acquired infection. (In the previous study, 98% of basins used for soap and water bathing grew bacteria.[2])

According to Jan Powers RN, PhD, lead author of the CHG study and a clinical nurse specialist in the trauma intensive care unit at St. Vincent Hospital in Indianapolis, Indiana, where the study was conducted, "Patients' hospital bath basins are a known source of microbial contamination. This is supported by the literature, which has shown that soap-and-water bath basins were found to be reservoirs for bacteria and potentially associated with the development of hospital-acquired infection. One of the nurses on our quality committee wanted to assess whether we saw the same contamination with CHG-solution bathing, because there is a lack of research on this."

Powers explained that before the study was conducted, the team reinforced the use of consistent bathing practices. Bath basins were wiped with a paper towel to eliminate standing water and placed upside down on a storage table to air-dry after use. Basins were labeled and designated solely for CHG bathing and were assigned a unique identification number to ensure that basin duplication did not occur. A culture swab for each study basin was obtained from the hospital laboratory and a culture was obtained using a standardized method.

The results of the study demonstrated a significant reduction in bacterial growth when CHG solution was used for patient bathing compared with soap and water.

Powers comments that the results of the study reinforced practices that were currently being used in the ICU, and the results were rolled out hospital-wide. "The study demonstrated the positive aspects of CHG bathing and reinforced to the nursing staff that we were implementing best care practices for our patients."

When asked about concerns related to the impact of CHG on resistant infections, Powers said, "We have not seen any change in infection rates. Although CHG can alter the pH of the skin, it is still maintained in the normal acidic range for skin flora." She added, "Our next study will focus on comparing the use of CHG cloths compared with CHG solution for use in bath basins. This will give us information not only on the cost effectiveness but also on whether there is a difference in skin irritation."

The use of chlorhexidine bathing cloths has been predominantly studied in the ICU patient population. In this setting, use of daily CHG bathing has been demonstrated to result in reduced environmental and skin contamination with vancomycin-resistant enterococci (VRE), reduced central venous catheter-associated bloodstream infections, and reduced blood culture contamination.[3,4,5,6]

In addition, a study last year from a Rhode Island hospital conducted on 4 medical floors with more than 7000 patients found a reduced risk for hospital-acquired infections when 2% CHG cloths were used for daily bathing instead of soap and water. The study found a 64% reduction in the risk of acquiring infection with methicillin-resistant S aureus (MRSA) or VRE.[7]

Powers concludes, "I would definitely say that the literature supports the use of CHG bathing for hospitalized patients and that changing practice to incorporate CHG bathing is not difficult." The use of CHG bathing may be a beneficial intervention for infection control and prevention in hospitalized patients, yet additional research is warranted. Resistance to CHG was observed among gram-negative bacilli in one study,[7] and in another setting, MRSA susceptibility was found to be associated with prolonged CHG use for daily bathing and application to mucous membranes.[8]

The focus on infection prevention for hospitalized patients warrants the consideration of CHG bathing practices. Additional evidence from ongoing studies will help to establish the role of CHG bathing as a strategy for infection prevention in hospitalized patients.

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