Chlorhexidine Bathing and Health Care-associated Infections: A Randomized Clinical Trial
Noto MJ, Domenico HJ, Byrne DW, et al
Is Daily Chlorhexidine Bathing Clean Ineffective?
As hospitals strive to prevent hospital-acquired infections, the use of daily chlorhexidine bathing has grown in popularity. The wide adoption of chlorhexidine bathing has been spurred by several quasi-experimental studies showing its benefit for preventing central line-associated bloodstream infections (CLABSIs) and reducing the acquisition of multidrug-resistant organisms (MDROs).
In a multicenter randomized controlled trial conducted in intensive care units (ICUs) and bone marrow units, Climo and colleagues showed that chlorhexidine bathing reduced acquisition of vancomycin-resistant enterococci by 25% and CLABSIs by 53%. However, the reduction in bloodstream infections was driven largely by a reduction in coagulase-negative staphylococci, and the significance of this finding has been challenged.
Noto and colleagues performed a cluster-randomized crossover trial to evaluate the effect of chlorhexidine bathing on healthcare-associated infections in critically ill adults. The 12-month study was conducted in five ICUs at Vanderbilt University Medical Center, during which bathing with a 2% chlorhexidine cloth was compared with bathing with a nonantimicrobial cloth. Each ICU alternated between 10 weeks of standard chlorhexidine bathing and 10 weeks of nonantimicrobial cloth bathing, with a 2-week washout period in between, during which a nonantimicrobial bathing cloth was used. More than 9000 patients were included in the primary analysis.
Patients bathed with chlorhexidine-impregnated cloths and those bathed with nonantimicrobial cloths did not differ in the primary outcome, which was a composite of four hospital-associated infections: CLABSIs, catheter-associated urinary tract infections, possible or probable ventilator-associated pneumonia, and Clostridium difficile infection. The rate of the primary outcome was 2.86 per 1000 patient-days during chlorhexidine bathing and 2.90 per 1000 patient-days during control bathing (rate difference, -0.04; P = 0.95). chlorhexidine bathing also failed to reduce healthcare-associated bloodstream infections, blood culture contamination, and clinical cultures positive for MDROs.
Noto and colleagues' findings need to be interpreted in light of the following limitations. First, the study did not monitor adherence to the bathing protocol, so it is possible that the lack of benefit reflected inadequate bathing. Second, units were not blinded to their assignments, so the prejudgement of clinical staff may have influenced the results.
Third, clinical cultures were used to track MDRO acquisition. Active surveillance—as used by Climo and colleagues—would have provided a more sensitive marker for this metric.
Fourth, for two of the infections in the composite outcome (ventilator-associated pneumonia and C difficile infection, and arguably catheter-associated urinary tract infections as well), one would not expect reductions to result from the use of chlorhexidine.
Finally, the study was conducted at a single center. Vanderbilt's rates of hospital-acquired infections were low before the study was started, so these findings may not be relevant to institutions struggling with higher infection rates.
An accompanying editorial raises concerns about resistance developing to chlorhexidine with its widespread use. Although the incidence of chlorhexidine resistance is currently low, concerns about promoting resistance will persist.
In the end, infection preventionists find themselves in a difficult position. The uncertain benefits of chlorhexidine must be weighed against its theoretical risks. At a minimum, hospitals that have already implemented daily chlorhexidine bathing should closely evaluate the effectiveness of this intervention on their own infection rates. Hospitals that are planning to implement widespread chlorhexidine bathing should think carefully before proceeding.
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