Chlorhexidine bathing of the critically ill for the prevention of hospital‐acquired infection

This Cochrane Systematic Review by Lewis and colleagues was first published online in August 2019.

What is the aim of this review?
The aim of this review was to find out whether people who are critically ill in hospital should be bathed with the antiseptic chlorhexidine, in order to prevent them from developing infections. Researchers from Cochrane collected and analysed all relevant studies to answer this question and found eight relevant randomised trials. Randomised trials are medical studies where people are chosen at random to receive different treatments. This study design provides the most reliable evidence on whether treatments have a relationship with desired or undesired health outcomes.

Key messages
This review assesses whether using chlorhexidine (instead of soap and water) to bathe patients in an intensive care unit (ICU), or a high‐dependency or critical care unit reduces the number of hospital‐acquired infections. The evidence available from the studies we analysed was very low quality, meaning that we cannot be certain whether bathing with chlorhexidine reduces the likelihood of critically‐ill patients developing an infection, or dying. We are also uncertain whether bathing critically ill patients with chlorhexidine shortens the length of time people spend in hospital, or lowers their risk of developing skin reactions.

What was studied in the review?
People who are critically ill (in an ICU, or a high‐dependency or critical care unit) often catch infections during their time in hospital. These infections can lead to longer hospital stays, additional medical complications, permanent disability or even death. Patients in ICUs are particularly vulnerable to infections because the body’s ability to fight infection is reduced by illness or trauma. Surgical tubes and lines (for example to help with feeding or breathing) may enable bacteria to enter the body. Chlorhexidine is a low‐cost product which is used as an antiseptic and disinfectant in hospitals.

What are the main results of the review?
In December 2018 we searched for studies looking at the use of chlorhexidine for bathing critically ill patients. We found eight studies dating from 2005 to 2018, involving a total of 24,472 people across more than 20 ICUs. Seven studies included people who were adults, and one study included only children. All studies included both males and females. All studies compared bathing with chlorhexidine versus bathing with soap and water or non‐antimicrobial washcloths. Four studies received funding from independent funders (government organisations, or from hospital or university departments) or reported no external funding, and four studies received funding from companies that manufactured chlorhexidine products.

The evidence from all eight studies combined is not sufficient to allow us to be certain whether patients bathed in chlorhexidine are less likely to catch an infection during their stay in the ICU. We are also uncertain whether patients bathed in chlorhexidine are less likely to die, because the certainty of the evidence from the six studies that reported on this is very low. We did not pool the evidence from the six studies that reported how long patients had stayed in the ICU, because the results differed widely. We are also uncertain whether patients bathed in chlorhexidine are likely to be in the ICU for less time, because the certainty of the evidence is very low. Reports from five studies provided different evidence about whether chlorhexidine led to more or less skin reactions; we are uncertain whether patients bathed in chlorhexidine are likely to have more or less skin reactions, because the certainty of the evidence is very low.

How up to date is this review and Quality of evidence
We searched for studies that had been published up to December 2018.  Most studies did not use methods to conceal the type of bathing solution that staff were using, which increases the risk that staff may have treated patients differently depending on whether patients were in the chlorhexidine study group or the soap‐and‐water study group. Participants in some studies may have already caught an infection before the start of the study and we were concerned that this might have affected our results. We also noticed wide differences in some results, and some outcomes had few reported events. These were reasons to judge the quality of the evidence to be very low.

Implications for practice
It is not clear whether bathing with chlorhexidine reduces hospital‐acquired infections, mortality or length of stay in the intensive care unit, or whether chlorhexidine use results in more skin reactions, because the certainty of the evidence is very low. One study is awaiting classification and two studies are ongoing; we do not know if inclusion of these studies in future updates of this Cochrane Review will increase our certainty in the results of the review.

Implications for research
Additional research is needed to evaluate whether chlorhexidine bathing may reduce hospital‐acquired infections in the intensive care unit. We recommend that studies are sufficiently powered and methodologically robust, and that attention is paid to reduce the risk of performance bias through blinding of personnel. Cluster‐randomised studies and cross‐over trials would benefit from reporting data in more detail, including important parameters such as the intracluster correlation coefficient and interperiod correlation. Some consensus on the reporting of hospital‐acquired infection rates, for example through the adoption of a core outcome set for trials of infection prevention, would also be helpful.

The full details of this Cochrane Systematic Review are available via this link.

Microbiological colonization of healthcare workers’ mobile phones in a tertiary-level Italian intensive care unit

This article by Galazzi and colleagues was published in Intensive and Critical Care Nursing online in early February 2019.
Background:  Careful hand hygiene of healthcare workers is recommended to reduce transmission of pathogenic microorganisms to patients. Mobile phones are commonly used during work shifts and may act as vehicles of pathogens.
Objective:  To assess the colonisation rate of intensive care unit healthcare workers’ mobile phones before and after work shifts.
Methods:  Prospective observational study conducted in an academic, tertiary-level intensive care unit. Healthcare workers (including doctors, nurses and healthcare assistants) had their mobile phones sampled for microbiology before and after work shifts. Samples were taken with a swab in a standardised modality.
Results:  Fifty healthcare workers participated in the study (91% of the department staff). One hundred swabs were taken from 50 mobile phones. Forty-three healthcare workers (86%) reported a habitual use of their phones during the work shift. All phones (100%) were positive for bacteria. The most frequently isolated bacteria were Coagulase Negative Staphylococci, Bacillus sp. and Methicillin-resistant Staphylococcus aureus (97%, 56%, 17%, respectively). No patient admitted to the intensive care unit during the study period was positive for bacteria found on healthcare workers’ mobile phones. No difference in bacteria types and burden was found between the beginning and the end of work shifts.
Conclusion:  Healthcare workers’ mobile phones are colonized even before the work shift and irrespective of the patients’ microbiological flora.
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Video didactic at the point of care impacts hand hygiene compliance in the neonatal intensive care unit (NICU)

This paper was published in Journal of Healthcare Risk Management February 2018 by Hoang et al.
Objective:  To increase the hand-washing (HW) duration of staff and visitors in the NICU to a minimum of 20 seconds as recommended by the CDC.
Methods:  Intervention included video didactic triggered by motion sensor to play above wash basin. Video enacted Centers for Disease Control and Prevention (CDC) HW technique in real time and displayed timer of 20 seconds. HW was reviewed from surveillance video. Swabs of hands plated and observed for qualitative growth (QG) of bacterial colonies.
Results:  In visitors, the mean HW duration at baseline was 16.3 seconds and increased to 23.4 seconds at the 2-week interval (p = .003) and 22.9 seconds at the 9-month interval (p < .0005). In staff, the mean HW duration at baseline was 18.4 seconds and increased to 29.0 seconds at 2-week interval (p = .001) and 25.7 seconds at the 9-month interval (p < .0005). In visitors, HW compliance at baseline was 33% and increased to 52% at the 2-week interval (p = .076) and 69% at the 9-month interval (p = .001). In staff, HW compliance at baseline was 42% and increased to 64% at the 2-week interval (p = .025) and 72% at the 9-month interval (p = .001). Increasing HW was significantly associated with linear decrease in bacterial QG.
Conclusions:  The intervention significantly increased mean HW time, compliance with a 20-econd wash time and decreased bacterial QG of hands and these results were sustained over a 9-month period.
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Comparative Antimicrobial Efficacy of Two Hand Sanitizers in Intensive Care Units Common Areas: A Randomized, Controlled Trial

The paper written by Deshpande et al was published in “Infection control and hospital epidemiology” January 2018.
Objective:  Contaminated hands of healthcare workers (HCWs) are an important source of transmission of healthcare-associated infections. Alcohol-based hand sanitizers, while effective, do not provide sustained antimicrobial activity. The objective of this study was to compare the immediate and persistent activity of 2 hand hygiene products (ethanol [61% w/v] plus chlorhexidine gluconate [CHG; 1.0% solution] and ethanol only [70% v/v]) when used in an intensive care unit (ICU).
Design:  Prospective, randomized, double-blinded, crossover study
Setting: Three ICUs at a large teaching hospital
Participants: In total, 51 HCWs involved in direct patient care were enrolled in and completed the study.
Methods:   All HCWs were randomized 1:1 to either product. Hand prints were obtained immediately after the product was applied and again after spending 4-7 minutes in the ICU common areas prior to entering a patient room or leaving the area. The numbers of aerobic colony-forming units (CFU) were compared for the 2 groups after log transformation. Each participant tested the alternative product after a 3-day washout period.
Results:  On bare hands, use of ethanol plus CHG was associated with significantly lower recovery of aerobic CFU, both immediately after use (0.27 ± 0.05 and 0.88 ± 0.08 log10 CFU; P = .035) and after spending time in ICU common areas (1.81 ± 0.07 and 2.17 ± 0.05 log10 CFU; P<.0001). Both the antiseptics were well tolerated by HCWs.
Conclusions:  In comparison to the ethanol-only product, the ethanol plus CHG sanitizer was associated with significantly lower aerobic bacterial counts on hands of HCWs, both immediately after use and after spending time in ICU common areas.
Library members can order the full text of individual articles such as this one via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Reducing catheter-associated urinary tract infections in the ICU

This review provides a summary of CAUTI reduction strategies that are specific to the intensive care setting | Current Opinion in Critical Care

Patients in the ICU are at higher risk for catheter-associated urinary tract infection (CAUTI) due to more frequent use of catheters and lower threshold for obtaining urine cultures.

The surveillance definition for CAUTI is imprecise and measures catheter-associated bacteriuria rather than true infection. Alternatives have been proposed, but CAUTI rates measured by this definition are currently required to be reported to the Centers for Medicare and Medicaid Services and high CAUTI rates can result in financial penalties. Although CAUTI may not directly result in significant patient harm, it has several indirect patient safety implications and CAUTI reduction has several benefits. Various bundles have been successful at reducing CAUTI both in individual institutions and on larger scales such as healthcare networks and entire states.

Full reference: Sampathkumar, P. (2017) Reducing catheter-associated urinary tract infections in the ICU. Current Opinion in Critical Care. Vol. 23 (Issue 5) pp. 372–377

 

Incidence, prevalence, and management of MRSA bacteremia across patient populations

A review of recent developments in MRSA management and treatment | Critical Care

B0006889 MRSA
Image source: Annie Cavanagh – Wellcome Images // CC BY-NC 4.0

Image shows clusters of methicillin-resistant Staphylococcus aureus bacteria.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is still a major global healthcare problem. Of concern is S. aureus bacteremia, which exhibits high rates of morbidity and mortality and can cause metastatic or complicated infections such as infective endocarditis or sepsis. MRSA is responsible for most global S. aureus bacteremia cases, and compared with methicillin-sensitive S. aureus, MRSA infection is associated with poorer clinical outcomes. S. aureus virulence is affected by the unique combination of toxin and immune-modulatory gene products, which may differ by geographic location and healthcare- or community-associated acquisition.

Management of S. aureus bacteremia involves timely identification of the infecting strain and source of infection, proper choice of antibiotic treatment, and robust prevention strategies. Resistance and nonsusceptibility to first-line antimicrobials combined with a lack of equally effective alternatives complicates MRSA bacteremia treatment.

This review describes trends in epidemiology and factors that influence the incidence of MRSA bacteremia. Current and developing diagnostic tools, treatments, and prevention strategies are also discussed.

Full reference: Hassoun, A. et al. (2017) Incidence, prevalence, and management of MRSA bacteremia across patient populations—a review of recent developments in MRSA management and treatment. Critical Care. 21:211

Reducing catheter-associated urinary tract infections in the ICU

This review provides a summary of CAUTI reduction strategies that are specific to the intensive care setting | Current Opinion in Critical Care

Purpose of review: Patients in the ICU are at higher risk for catheter-associated urinary tract infection (CAUTI) due to more frequent use of catheters and lower threshold for obtaining urine cultures.

Recent findings: The surveillance definition for CAUTI is imprecise and measures catheter-associated bacteriuria rather than true infection. Alternatives have been proposed, but CAUTI rates measured by this definition are currently required to be reported to the Centers for Medicare and Medicaid Services and high CAUTI rates can result in financial penalties. Although CAUTI may not directly result in significant patient harm, it has several indirect patient safety implications and CAUTI reduction has several benefits. Various bundles have been successful at reducing CAUTI both in individual institutions and on larger scales such as healthcare networks and entire states.

Summary: CAUTI reduction is possible in the ICU through a combination of reduced catheter usage, improved catheter care and stewardship of urine cultures.

Full reference: Sampathkumar, P. (2017) Reducing catheter-associated urinary tract infections in the ICU. Current Opinion in Critical Care: Published online: 28 July 2017