chlorhexidine gluconate bathing to reduce … gluconate bathing to reduce methicillin-resistant...

Chlorhexidine GluconateBathing to Reduce Methicillin-ResistantStaphylococcus aureusAcquisitionANN PETLIN, RN, MSN, CCRN-CSC, CCNS, PCCN, ACNS-BCMARILYN SCHALLOM, RN, PhD, CCRN, CCNSDONNA PRENTICE, RN, MSN(R), CCRN, ACNS-BCCARRIE SONA, RN, MSN, CCRN, CCNS, ACNS-BCPAULA MANTIA, RN, MSN, ANP-BCKATHLEEN McMULLEN, MPH, CICCASSANDRA LANDHOLT, BS

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,which tests your knowledge of the following objectives:

1. Discuss current research on chlorhexidine gluconate (CHG) bathing 2. Compare use of CHG-impregnated washcloths with CHG solution dissolved in bath water3. Describe the effects of CHG bathing on methicillin-resistant Staphylococcus aureus

©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014943

CNE Continuing Nursing Education

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BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism causing substantialmorbidity and mortality in intensive care units. Chlorhexidine gluconate, a topical antiseptic solution, iseffective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA.OBJECTIVES To examine the impact of a bathing protocol using chlorhexidine gluconate and bath basinmanagement on MRSA acquisition in 5 adult intensive care units and to examine the cost differencesbetween chlorhexidine bathing by using the bath-basin method versus using prepackaged chlorhexidine-impregnated washcloths. METHODS The protocol used a 4-oz bottle of 4% chlorhexidine gluconate soap in a bath basin of warmwater. Patients in 3 intensive care units underwent active surveillance for MRSA acquisition; patients in 2other units were monitored for a new positive culture for MRSA at any site 48 hours after admission. RESULTS Before the protocol, 132 patients acquired MRSA in 34333 patient days (rate ratio, 3.84). After-wards, 109 patients acquired MRSA in 41376 patient days (rate ratio, 2.63). The rate ratio difference is1.46 (95% CI, 1.12-1.90; P = .003). The chlorhexidine soap and bath basin method cost $3.18 as comparedwith $5.52 for chlorhexidine-impregnated wipes (74% higher).CONCLUSIONS The chlorhexidine bathing protocol is easy to implement, cost-effective, and led to decreasedunit-acquired MRSA rates in a variety of adult intensive care units. (Critical Care Nurse. 2014;34[5]:17-26)

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Methicillin-resistant Staphylococcusaureus (MRSA) is a virulent organ-ism that causes substantial mor-bidity and mortality in intensivecare units (ICUs). The Centers for

Disease Control and Prevention estimated that morethan 80000 cases of invasive MRSA infections occurredin the United States in 2011, with more than 11000deaths.1 Colonization with S aureusmay precede infec-tion. Culture swabs of the anterior nares can identifypatients who are colonized with MRSA even thoughthey may show no signs or symptoms of infection.2

MRSA and other microbes have been cultured frombath basins in ICUs,3 which may contribute to colo-nization of the patient’s skin and lead to secondarycontamination at other sites.4

Reduction and elimination of hospital-acquired infec-tions requires a multipronged approach. Hand hygieneis the primary strategy to reduce hospital-acquiredinfections and prevent transmission of resistant microbesbetween patients.5 Rapid reporting of culture results allowsthe health care team to initiate timely contact isolationprecautions that help reduce the spread of infection oncea resistant organism is identified. A multidisciplinarycritical care team partnership with infection preventionspecialists can facilitate these evidence-based preven-tion strategies. The increase in MRSA prevalence in thecommunity and the high level of mortality associatedwith MRSA (3.62 deaths per 100000 population in theUnited States)1 require clinicians to continuouslyexplore measures to prevent MRSA acquisition in criti-cally ill patients. MRSA colonization can be a source offear, anxiety, and uncertainty for patients.6-8 Therefore,

prevention of hospital-acquired MRSA is an importantnursing intervention.Chlorhexidine gluconate (CHG), a topical antiseptic

solution, is effective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA.3

Low concentrations of CHG, such as when it is diluted inbath-basin water or as supplied in bathing wipes, alterthe integrity of bacterial cell walls.9 Additionally, CHGhas residual activity on the skin that helps to reduce skinmicrobes and prolongs skin antisepsis.10 A review of theliterature provides evidence that CHG bathing has sev-eral benefits.4,10-28 CHG bathing reduces the acquisitionof vancomycin-resistant Enterococcus by hospitalized ICUpatients,4,10-14 Clostridium difficile,15 and hospital-acquiredMRSA.4,11-13,16,17 Bathing with CHG also reduces MRSAskin colonization in known MRSA carrier patients duringtheir treatment.18-21 Several studies showed that bathingwith CHG and nasal administration of mupirocin reducethe risk of infections,2,22 and CHG bathing alone specifi-cally reduces the risk of central catheter–associated blood-stream infections in ICU patients4,23-26 and long-term acutecare patients.27 Two studies24,28 demonstrated that CHGbathing reduced the rate of blood culture contamination.

Two of the ICUs at Barnes-Jewish Hospital, a Mid-western university teaching hospital were among the unitsinvolved in a multi-institutional quasi-experimental studyby Climo et al11 on the effect of CHG bathing and MRSAacquisition. Climo’s study demonstrated a 32% reductionin MRSA acquisition. Those 2 ICUs resumed typicalsoap-and-water bathing of their patients when the CHGbathing intervention ended at the completion of the study.Infection surveillance data showed a return to higherMRSA acquisition rates with the soap-and-water baths

Ann Petlin is a clinical nurse specialist in the cardiothoracic intensive care unit at Barnes-Jewish Hospital, St Louis, Missouri.

Marilyn (Lynn) Schallom is a clinical nurse specialist and research scientist in the Department of Research for Patient Care Services atBarnes-Jewish Hospital.

Donna Prentice is a clinical nurse specialist in a medical intensive care unit at Barnes-Jewish Hospital.

Carrie Sona is a clinical nurse specialist in the surgery/burns/trauma intensive care unit at Barnes-Jewish Hospital.

Paula Mantia is the advanced practice nurse in a medical intensive care unit at Barnes-Jewish Hospital.

Kathleen McMullen is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at Barnes-JewishHospital.

Cassandra (Casey) Landholt is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention atBarnes-Jewish Hospital.Corresponding author: Ann Petlin, RN, MSN, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Mail stop 90-00-056, St Louis, MO 63110 (e-mail: [email protected]).

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

Authors

18 CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 www.ccnonline.org


in both ICUs. Decolonization with nasal mupirocin wasnot included during the study period. The purpose ofthis study was to expand the intervention of the bathingprotocol to 5 ICUs at our hospital by using CHG bathingand a bath-basin protocol and to examine its impact onthe acquisition of MRSA in our patients. Our goals were(1) to determine if there was a difference in MRSA acqui-sition between soap-and-water baths and CHG bathing,and (2) to examine the cost differences between CHGbathing using the bath-basin method versus usingprepackaged CHG-impregnated washcloths.

Theoretical FrameworkThe Synergy Model from the American Association

of Critical-Care Nurses provided a theoretical frame-work for the clinical nurse specialists’ (CNSs’) interest inand design of this study.29 This model encourages aholistic view of patients, each with varying capacitiesfor health and vulnerability to illness. The model alsoidentifies nursing’s unique contribution to patient careand outcomes. The patient characteristics of the Syn-ergy Model that apply particularly well in our study arethe complexity and vulnerability of ICU patients aswell as their limited available resources to preventhospital-acquired infections. The ICU itself is a complexenvironment that can place patients at risk of havinghospital-acquired complications. The CNSs bring thenursing competencies of clinical inquiry, collaboration,and facilitation of learning to the clinical research proj-ect. If the intervention reduced MRSA acquisition, ourstudy worked toward patient outcomes goals of absenceof complications, decreased infection acquisition, andeffective cost-resource utilization.

MethodsOverview of Study DesignThis study used a pre/post-intervention design. The

hospital leadership model includes a unit-based criticalcare CNS in each ICU. The CNSs individually workedwith their unit-based physician leadership and infectionprevention staff. Additionally, a CNS in the hospital’sresearch department collaborated with each CNS toimplement the protocol. A champion(s) was also identi-fied for each unit. Champions were typically staff nursesand/or chairs of the units’ practice committees with thesupport of the clinical nurse managers. The CNSs andchampions provided an educational overview both orally

and in newsletters about the protocol and monitored forimplementation progress and supply needs. Before thisstudy, we did not have a standard bathing protocol asidefrom the traditional use of a bath basin with soap andwater. The hospital’s institutional review board approvedthis study as exempt from human subjects committeereview because it was minimal risk, the CHG bathingintervention applied to all patients in the study units,and only unit-level data would be collected.

Bathing ProtocolThe CHG bathing protocol directed the nurse to mix

the contents of a 4-ounce bottle of 4% CHG with warmwater in a 6-quart basin in the same fashion as per-formed in the study by Climo et al.11 Typical linens usedfor a bath included 6 washcloths and 4 bath towels,although these numbers were not specified in the proto-col. Washcloths were used for 1 body area only and werenot reinserted into the CHG water after use. Staff bathedpatients from the neck down, avoiding contact with theface, all mucous membranes, and wounds, as recom-mended by the manufacturer. Bath basins were markedas dedicatedfor bathingonly. Staffrinsed thebasin afteruse and towel-dried it before storing it. If skin andwound care items needed storage, the staff used a sepa-rate basin or other container. Nurses had been educatedabout the bathing protocol and bath basin maintenancesteps by the end of 2009. Education strategies includedthe services of the unit champions, use of posters andnewsletters, and inclusion of the CHG bathing protocol inunit orientations. Implementation of the protocol beganin January 2010.

ProcedureThe hospital performed active surveillance for MRSA,

which included nasal swabs for MRSA upon ICU admis-sion, weekly, and upon discharge in the cardiothoracic,medical, and surgical/burn/trauma ICUs for several yearsbefore this project. This surveillance continued through-out this study. We defined MRSA acquisition in these 3units as a nasal swab or clinical culture that was positivefor MRSA 48 hours after admission in any patient whohad a negative result or no nasal swab at admission.

Implementation of the chlorhexidine gluconate(CHG) bathing protocol was led by clinicalnurse specialists.



The 2 other ICUs in our study, the coronary care unitand a second medical ICU, did not have protocols foractive surveillance. They used incident surveillanceinstead. We defined MRSA acquisition in these 2 unitsas any patient with a new culture positive for MRSA atany site 48 hours after admission.The ICU physicians in all the study units were informed

of swabs and cultures that were positive for MRSA by atelephone call from the microbiology laboratory. Patientswent on contact isolation precautions immediately uponthe report of a culture positive for MRSA. Infection pre-

vention staffmonitored theMRSA acqui-sition ratesand compli-

ance with admission, weekly, and discharge surveillanceswabs, and they reported the data monthly to the 3 ICUsin the study that were performing active surveillance.They also observed hand hygiene compliance monthlyin all ICUs by using “secret shoppers” as data collectorsduring both study periods.

Data Analysis We used OpenEpi30 software to calculate MRSA

acquisition rate ratios in the preintervention and postin-tervention periods. We defined the MRSA acquisitionrate as the number of patients with nasal swabs negativefor MRSA upon admission, or no nasal swab performedon admission, in whom MRSA from any source developedmore than 48 hours after their ICU admission, dividedby the number of patient days per month times 1000.Patients who were known to be positive for MRSA onICU admission were excluded from the calculations. Wedefined MRSA nasal swab compliance as the percentageof admission, weekly, and discharge nasal swabs obtained.

We did not collect a final nasal swab on patients whodied or were already found to be MRSA positive via theactive surveillance. We defined hand hygiene compli-ance as the percentage of staff members who wereobserved performing hand hygiene upon entering orexiting a patient’s room.

ResultsIn the preintervention period (July 2008-December

2009) when soap-and-water bathing was the routine,there were 132 MRSA acquisitions in 34333 patient days(see Table). This equaled a MRSA acquisition rate of3.84 per 1000 patient days. In the postintervention period,(January 2010-April 2011) with the CHG bathing proto-col, there were 109 MRSA acquisitions in 41376 patientdays. This equaled a MRSA acquisition rate of 2.63 per1000 patient days. The MRSA rate ratio difference is1.46 (95% CI=1.12-1.90, P=.003; Figure 1). Patients inthe preintervention period were almost 1.5 times morelikely to acquire MRSA than patients who received theCHG bathing protocol.No significant differences in compliance were found

with nasal swabbing or with hand hygiene betweenthe study periods. Compliance rates with nasal swab-bing for MRSA were 87% to 90% in the preinterven-tion period and 86% to 92% after the intervention.The patients in the medical ICU showed the greatestdecline in MRSA acquisition rates from 6.8 per 1000patient days before the intervention to 3.8 per 1000patient days after the intervention. They also had thehighest compliance (92%) with nasal swabbing. Thesurgical/burn/trauma ICU had been one of the unitsin the multi-institutional study by Climo et al.11 TheirMRSA acquisition rate returned to the multisite studylevel when the CHG bathing protocol resumed withour study.


Patients bathed with soap and waterwere 1.5 times more likely than patientsbathed with CHG to acquire MRSA.

Period

Preintervention (July 2008-December 2009)

Postintervention (January 2010-April 2011)

All 5 units (with and without active surveillance)

132 MRSA acquisitions in 34 333 patient days

MRSA acquisition rate = 3.84

109 MRSA acquisitions in 41 376 patient days


Three units with active MRSA surveillance

111 MRSA acquisitions in22 292 patient days


91 MRSA acquisitions in31 233 patient days


Table Acquisition rates for methicillin-resistant Staphylococcus aureus (MRSA) in the units with active surveillance for MRSA acquisition and in all 5 units


As part of this study, we collaborated with our hos-pital’s Patient Care Products Committee to analyze thecost of bathing with the CHG soap and bath basinmethod and compare that with the cost of bathing withCHG-impregnated wipes. Our institution pays $1.75 foreach 4-ounce bottle of 4% CHG. The reusable bath basincosts $0.35. The cost of the bath linens includes purchaseand reprocessing. Cotton washcloths are $0.04 each (6 perbath=$0.24) and bath towels are $0.21 each (4 per bath=$0.84). These individual items total $3.18 for 1 bed bath.Reusing the bath basin reduces the cost of subsequentbaths. One vendor (D. Short, Cardinal Health, Dublin,Ohio, e-mail communication, November 5, 2012) saidthat 6 of the washcloths impregnated with 2% CHG,enough for 1 bath, would cost $5.52.

DiscussionThe adverse effects of bathing with CHG are related

to contact dermatitis or skin irritation that subsidesafter stopping the use of CHG in the bath water. Manystudies report no skin reaction or do not report on thisoutcome. In a study27 of long-term patients in an acutecare hospital, 1% of patients had dryness of skin developwith a 4% CHG bath basin method. In another study,4

researchers reported skin reactions in 2% of patientswith use of 2% CHG–impregnated cloths; however, 3.4%

of patients in the same study had a skin reaction tocloths that were not impregnated with antimicrobialsoap. There were no reports of skin irritation during thestudy in our hospital. Johnson and colleagues3 demonstrated patients’ bath

basins as potential sources of infections, with 98% ofbasins growing potentially pathogenic microbes. Soonafter that study, many hospitals decided to abandonbath basins for ICU bathing in favor of using washclothsimpregnated with 2% CHG. Historically, several stud-ies11,15-18,20-22,27 of the effects of CHG bathing used 4% CHGin bath basins or showering; other studies4,10,12-14,23-26,28

used cloths impregnated with 2% CHG. Our surgical/burn/trauma ICU staff nurses willingly tried the CHG-impregnated cloths before this study but were not satis-fied with their performance and preferred the bath-basinmethod for patient bathing. Since the report of bath basincontamination by Johnson et al,3 Powers and colleagues31

studied the presence of bacterial contaminants in washbasins when CHG solution was used in place of standardsoap and water to wash patients. They reported that bac-terial growth in patients’ bath basins decreased by 95.5%with the use of CHG in the bath water. Similar resultswere found in a comparison bench study32 of 2 differentbrands of 4% CHG and 1 brand of liquid soap. Soap andCHG were equally effective at preventing initial contami-nation compared with tap water. However, both brandsof CHG hadsignificantmarkedresidualeffect onbacterial contamination compared with soap and wateror tap water only.32 These 2 studies31,32 demonstrated thatbathing with CHG using a bath basin and tap water doesnot increase the risk of exposing patients to bacterialcontaminants from the basin and tap water. Addition-ally, in a bench study of MRSA isolated over 4 years in asetting that used 4% CHG bathing, researchers found nodetectable loss of antibiotic effectiveness or increase inMRSA resistance or infection with other organisms.33

Using washcloths impregnated with 2% CHG ($5.52 perbath) would be 74% more expensive than our CHG soapand bath basin method ($3.18 per bath; Figure 2). Ritzet al13 reported that a bath basin protocol was $2.50 lessthan cloths impregnated with 2% CHG. To translate themagnitude of this cost difference, the 41376 CHG-in-water

Using prepackaged CHG wipes ($5.52 perbath) was 74% more expensive than using theCHG soap and bath method ($3.18 per bath).


Figure 1 The acquisition rate of methicillin-resistantStaphylococcus aureus (MRSA) was 3.84 per 1000 patientdays before the chlorhexidine gluconate bathing routine wasimplemented and 2.63 per 1000 patient days after theimplementation of chlorhexidine bathing. The difference inMRSA rates is 1.46 (95% CI, 1.12-1.90; P = .003).

MRS

A acquisition ra

te per 1000 patie

nt days

Soap and water Chlorhexidinegluconate

4.5

4.0

2.0

1.5

1.0

0.5

0.0

2.5

3.0

3.5


baths given during our study cost our hospital about$131000 whereas bathing with washcloths impregnatedwith 2% CHG would have cost about $228000. The cost

of providing anyintervention mer-its considerationin a climate of costcontainment. Eachinstitution negoti-

ates prices with their vendors, so costs of the 2 methodsmay vary.We examined only the impact of CHG bathing on

MRSA and not on hospital-acquired infections fromvancomycin-resistant Enterococcus, C difficile, centralcatheter–associated bloodstream infections, or surgicalsite infections. All units had low rates of central catheter–associated bloodstream infections and surgical units hadlow rates of surgical site infections in the preinterventionperiod. Those low infection rates would have required avery large number of patients from several years todemonstrate a significant difference with CHG bathing.We were not tracking catheter-associated urinary tractinfection rates in the preintervention period. However,for units with high rates of any of these infections, CHGbathing provides a reasonable intervention to reducesuch infections,4,22-27 although not all studies showedreductions in infection rates.28

Compliance with nasal swab screening and handhygiene are essential measures to analyze the impact ofCHG bathing. Otherwise, many nasal swabs may bemissed or too few CHG baths may be given to show theeffects of the intervention. High nasal swab compliancerates played an important role in ensuring that theMRSA acquisition rate data were accurate in the ICUsthat performed active surveillance. Compliance withnasal swabbing helped to ensure that MRSA infectionswere not overlooked by decreased testing. Use of theCHG soap by each ICU is monitored by the rate ofrestocking that item in each unit’s supply area. Handhygiene compliance monitoring helped to ensure thatstaff members adhered to other accepted measures thatreduce cross-contamination of patients. AACN’s evidence-based leveling system identifies a

rating of class B evidence for interventions developedfrom “well-designed controlled studies, both random-ized and nonrandomized, with results that consistentlysupport a specific action, intervention, or treatment.”34

Publications on the reduction of acquisition or decolo-nization of multidrug-resistant organisms provide classB evidence for CHG bathing.Research studies in the past several years, including

our results, have demonstrated the benefits of CHGbathing in ICU patients. Our results also demonstratedthe role of the unit-based CNS in conducting researchand implementing best practices. Each unit-based CNSpartnered with his or her bedside nursing colleagues,physicians, infection prevention staff, and hospital-widedepartments and provided a structure for implement-ing the protocol in multiple units simultaneously. Byimplementing the protocol in multiple units, the resultsand impact could be examined both at the unit leveland more widely. Unit-based results provided informa-tion to the bedside clinicians that was a direct result oftheir practice. Combining the data from multiple ICUsstrengthened the findings for statistical analysis.

LimitationsOur study examined only 1 bathing protocol, the

same one as described by Climo et al11 in 2009. We usedthis protocol because 2 of our ICUs had been involved inthat study. Other products and protocols have beendescribed since then.13-15 Another limitation of our studywas the differences in surveillance protocols for MRSA.We had active surveillance in the cardiothoracic, medical,


Hand hygiene compliance monitoringhelped to ensure that staff membersadhered to other accepted measuresthat reduce cross-contamination ofpatients.

Figure 2 The chlorhexidine gluconate (CHG) soap and bathbasin method cost $3.18 as compared with $5.52 for thewipes impregnated with CHG. The prepackaged CHG wipesare 74% higher in cost than the CHG soap and bath basinmethod.

Cost, $

CHG and bath basin

Prepackaged CHG wipes

6.00

3.00

2.00

1.00

0.00

4.00

5.00


and surgical/burn/trauma ICUs. We had incident sur-veillance in the coronary care unit and the second med-ical ICU. Finally, actual observation of CHG bathing didnot occur. We based compliance with the protocol on theinventory of the 4-oz (120-mL) bottles of 4% CHG ascompared with the unit census. One bottle of 4% CHGwas considered to indicate 1 patient bath.

Nursing ImplicationsDaily CHG bathing in the ICU is a simple and effec-

tive means of decreasing MRSA acquisition. Althoughreactions are infrequently reported, nurses should moni-tor each patient’s skin for any reaction. CHG bathinghas not been shown to increase antibiotic resistance. Botha bath basin bathing protocol that uses 4% CHG and abathing protocol that uses prepackaged 2% CHG clothsdemonstrated reductions in hospital-acquired infections.The costs of prepackaged cloths are higher, althoughindividual unit preferences and time requirements alsoshould be considered.13 CNSs and unit champions canprovide the evidence and assist with implementationand monitoring for success. AACN’s Synergy Model is auseful framework for clinical inquiry that helps to opti-mize outcomes for patients and their families, nurses,and the system.

ConclusionsThe CHG bathing protocol was easy to implement,

was cost-effective, and led to decreased unit-acquiredMRSA rates in a variety of adult ICUs at a Midwesternuniversity teaching hospital. Prevention of MRSA acqui-sition in ICU patients is important to reduce infectionand prevent anxiety and suffering for patients. Dailybathing with CHG in the bath basin with tap water isboth effective and cost-efficient. CCN

AcknowledgmentsThe authors gratefully acknowledge the hundreds of intensive care unitnurses who gave thousands of baths and obtained numerous nasal swabsduring the study.

Financial DisclosuresNone reported.

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Now that you’ve read the article, create or contribute to an online discussionabout this topic using eLetters. Just visit www.ccnonline.org and select the articleyou want to comment on. In the full-text or PDF view of the article, click“Responses” in the middle column and then “Submit a response.”

To learn more about chlorhexidine bathing, read “ChlorhexidineBathing and Microbial Contamination in Patients’ Bath Basins”by Powers et al in the American Journal of Critical Care, September2012;21:338-342. Available at www.ajcconline.org.


21. Fritz SA, Camins BC, Eisenstein KA, et al. Effectiveness of measures toeradicate Staphylococcus aureus carriage in patients with community-associated skin and soft-tissue infections: a randomized trial. Infect Con-trol Hosp Epidemiol. 2011;32(9):872-880.

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26. Lopez AC. A quality improvement program combining maximal barrierprecaution compliance monitoring and daily CHG baths resulting indecreased central line bloodstream infections. Dimens Crit Care Nurse.2011;30(5):293-298.

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28. Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Daily skincleansing with chlorhexidine did not reduce the rate of central-lineassociated blood stream infection in a surgical intensive care unit.Intensive Care Med. 2010;36:854-858.

29. Moloney-Harmon PA. The Synergy Model: contemporary practice ofthe clinical nurse specialist. Crit Care Nurse. 1999;19(2):101-104.

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31. Powers J, Peed J, Burns L, et al. Chlorhexidine bathing and microbial con-tamination in patients’ bath basins. Am J Crit Care. 2012;21(5):338-343.

32. Rupp ME, Huerta T, Yu S, et al. Hospital basins used to administerCHG baths. Infect Control Hospital Epidemiol. 2013;34(6):643-645.

33. Sangal V, Girvan EK, Jadhav S, et al. Impacts of a long-term programmeof active surveillance and chlorhexidine baths on the clinical and molec-ular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA)in an intensive care unit in Scotland. Int J Antimicrob Agents. 2012:40;323-331.

34. Armola RR, Bourgault AM, Halm MA, et al. AACN levels of evidence:what’s new? Crit Care Nurse. 2009;29(4):70-73.



CCN Fast FactsChlorhexidine Gluconate Bathing to ReduceMethicillin-Resistant Staphylococcus aureusAcquisition

CriticalCareNurseThe journal for high acuity, progressive, and critical care nursing

show the effects of the intervention. High nasal swabcompliance rates played an important role in ensuringthat the MRSA acquisition rate data were accurate inthe intensive care units (ICUs) that performed activesurveillance. • Research studies, including our results, have demonstratedthe benefits of CHG bathing in ICU patients. Our resultsalso demonstrated the role of the unit-based clinical nursespecialist (CNS) in conducting research and implement-ing best practices. Each unit-based CNS partnered withhis or her bedside nursing colleagues, physicians, infectionprevention staff, and hospital-wide departments. • By implementing the protocol in multiple units, the resultsand impact could be examined both at the unit level andmore widely. Unit-based results provided information to thebedside clinicians that was a direct result of their practice.

Nursing Implications• Daily CHG bathing in the ICU is a simple and effectivemeans of decreasing MRSA acquisition. • Although reactions are infrequently reported, nursesshould monitor each patient’s skin for any reaction. • CHG bathing has not been shown to increase antibioticresistance. • Both a bath basin bathing protocol that uses 4% CHGand a bathing protocol that uses prepackaged 2% CHGcloths demonstrated reductions in hospital-acquiredinfections. The costs of prepackaged cloths are higher,although individual unit preferences and time require-ments also should be considered.• CNSs and unit champions can provide the evidence andassist with implementation and monitoring for success. • AACN’s Synergy Model is a useful framework for clinicalinquiry that helps to optimize outcomes for patients andtheir families, nurses, and the system. CCN

FactsMethicillin-resistant Staphylococcus aureus (MRSA) is

a virulent organism causing substantial morbidity andmortality in intensive care units. Because of the increasein MRSA prevalence in the community and the high levelof mortality associated with MRSA, prevention of hospital-acquired MRSA is an important nursing intervention.

• Chlorhexidine gluconate (CHG), a topical antisepticsolution, is effective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA.• Low concentrations of CHG, such as when it is dilutedin bath-basin water or as supplied in bathing wipes,alter the integrity of bacterial cell walls. Additionally,CHG has residual activity on the skin that helps toreduce skin microbes and prolongs skin antisepsis.• CHG bathing has several benefits. CHG bathingreduces the acquisition of vancomycin-resistantEnterococcus, Clostridium difficile, and hospital-acquired MRSA. Bathing with CHG also reducesMRSA skin colonization in known MRSA carrierpatients during their treatment. Bathing with CHGand nasal administration of mupirocin reduce therisk of infections, and CHG bathing alone specificallyreduces the risk of central catheter–associated blood-stream infections. CHG bathing has also been shownto reduce the rate of blood culture contamination.• The adverse effects of bathing with CHG are relatedto contact dermatitis or skin irritation that subsidesafter stopping the use of CHG in the bath water.Many studies report no skin reaction or do not reporton this outcome. • Compliance with nasal swab screening and handhygiene are essential measures to analyze the impactof CHG bathing. Otherwise, many nasal swabs maybe missed or too few CHG baths may be given to

Petlin A, Schallom M, Prentice D, Sona C, Mantia P, McMullen K, Landholt C. Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureusAcquisition. Critical Care Nurse. 2014;34(5):17-26.



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