Standardizing Direct Observation for Assessing Compliance to a Daily Chlorhexidine Bathing Protocol Among Hospitalized Patients.
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ABSTRACT:
SUBMITTER: Musuuza JS
PROVIDER: S-EPMC7371340 | biostudies-literature | 2016 Dec
REPOSITORIES: biostudies-literature
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Standardizing Direct Observation for Assessing Compliance to a Daily Chlorhexidine Bathing Protocol Among Hospitalized Patients.
Musuuza Jackson S JS Hundt Ann Schoofs AS Zimbric Michele M Carayon Pascale P Safdar Nasia N
Infection control and hospital epidemiology 20160928 12
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Project description:Results of previous single-center, observational studies suggest that daily bathing of patients with chlorhexidine may prevent hospital-acquired bloodstream infections and the acquisition of multidrug-resistant organisms (MDROs).We conducted a multicenter, cluster-randomized, nonblinded crossover trial to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of MDROs and the incidence of hospital-acquired bloodstream infections. Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine-impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. The incidence rates of acquisition of MDROs and the rates of hospital-acquired bloodstream infections were compared between the two periods by means of Poisson regression analysis.A total of 7727 patients were enrolled during the study. The overall rate of MDRO acquisition was 5.10 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.007), a 28% lower rate with chlorhexidine-impregnated washcloths. No serious skin reactions were noted during either study period.Daily bathing with chlorhexidine-impregnated washcloths significantly reduced the risks of acquisition of MDROs and development of hospital-acquired bloodstream infections. (Funded by the Centers for Disease Control and Prevention and Sage Products; ClinicalTrials.gov number, NCT00502476.).
| S-EPMC5703051 | biostudies-literature
Project description:ImportanceThe ABATE Infection trial investigated the effects of universal bacterial decolonization with chlorhexidine for patients in non-intensive care unit settings to reduce hospital-onset bacteremia and fungemia (HOB) events. Among patients with medical devices (central venous catheters, midline catheters, and lumbar drains), universal decolonization (UD) resulted in a significant and meaningful reduction in bacteremia compared with the standard of care (SOC), but cost-effectiveness is unclear.ObjectiveTo examine the cost-effectiveness of universal and targeted bathing strategies compared with SOC in general medical and surgical units.Design, setting, and participantsA decision analytic model was constructed from June 1, 2021, to May 31, 2024, to simulate the frequency of HOB and costs under 3 strategies: SOC, UD, and targeted decolonization (TD). The model included a simulated cohort representative of the cluster-randomized ABATE Infection trial, which involved more than 500 000 participants across the US.Main outcomes and measuresIn TD, decolonization was administered for patients with medical devices only. Upstream costs of bathing and downstream costs of HOB, under payer and hospital perspectives were included. Parameters were informed by the ABATE Infection Trial and additional literature. Willingness-to-pay per HOB prevented was adopted as $25 000 for payers and $10 000 for hospitals. Sensitivity analyses were tailored to populations with different characteristics.ResultsThe simulated cohort, based on the population from the ABATE trial, included 529 000 adult admissions with a mean (SD) age of 63 (18) years, 54% female, and 13% with a central venous catheter, midline catheter, or lumbar drain. In the base case, the SOC was least effective and most costly. Targeted decolonization was least costly and UD resulted in the fewest HOB events. Targeted decolonization was the cost-effective strategy from payer and hospital perspectives. Compared with TD, UD had an incremental cost-effectiveness ratio of $119 700 per HOB averted from the payer perspective, and $126 600 per HOB averted from the hospital perspective. Depending on willingness-to-pay, UD may be preferred in scenarios with a higher proportion of patients with medical devices, greater reductions in HOB from decolonizing in those with devices, and lower adherence under TD.Conclusions and relevanceIn this decision analytic model studying universal and targeted bathing, TD was cost-effective under a broad range of scenarios for both hospital system and payer decision-makers. Universal decolonization was cost-effective in some scenarios, such as in specific units where many patients have medical devices or if it were difficult to implement a targeted approach.
| S-EPMC11894500 | biostudies-literature
Project description:Contact precautions are a traditional strategy to prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA). Chlorhexidine bathing is increasingly used to decrease MRSA burden and transmission in intensive care units (ICUs). We sought to evaluate a hospital policy change from routine contact precautions for MRSA compared with universal chlorhexidine bathing, without contact precautions. We measured new MRSA acquisition in ICU patients and surveyed for MRSA environmental contamination in common areas and non-MRSA patient rooms before and after the policy change. During the baseline and chlorhexidine bathing periods, the number of patients (453 vs. 417), ICU days (1999 vs. 1703) and MRSA days/1000 ICU days (109 vs. 102) were similar. MRSA acquisition (2/453 vs. 2/457, P = 0·93) and environmental MRSA contamination (9/474 vs. 7/500, P = 0·53) were not significantly different between time periods. There were 58% fewer contact precaution days in the ICU during the chlorhexidine period (241/1993 vs. 102/1730, P < 0·01). We found no evidence that discontinuation of contact precautions for patients with MRSA in conjunction with adoption of daily chlorhexidine bathing in ICUs is associated with increased MRSA acquisition among ICU patients or increased MRSA contamination of ICU fomites. Although underpowered, our findings suggest this strategy, which has the potential to reduce costs and improve patient safety, should be assessed in similar but larger studies.
| S-EPMC5943043 | biostudies-literature
Project description:BackgroundBacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children.MethodsIn an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393).Findings1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02).InterpretationCritically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated.FundingSage Products, US National Institutes of Health.
| S-EPMC4128170 | biostudies-literature
Project description:BackgroundBathing intensive care unit (ICU) patients with chlorhexidine gluconate (CHG) decreases healthcare-associated infections (HAIs). The optimal method of CHG bathing remains undefined.MethodsProspective crossover study comparing CHG daily bathing with 2% CHG-impregnated cloths versus 4% CHG solution. In phase 1, from January 2020 through March 2020, 1 ICU utilized 2% cloths, while the other ICU utilized 4% solution. After an interruption caused by the coronavirus disease 2019 pandemic, in phase 2, from July 2020 through September 2020, the unit CHG bathing assignments were reversed. Swabs were performed 3 times weekly from patients' arms and legs to measure skin microbial colonization and CHG concentration. Other outcomes included HAIs, adverse reactions, and skin tolerability.Results411 assessments occurred after baths with 2% cloth, and 425 assessments occurred after baths with 4% solution. Average microbial colonization was 691 (interquartile range 0, 30) colony-forming units per square centimeter (CFU/cm2) for patients bathed with 2% cloths, 1,627 (0, 265) CFUs/cm2 for 4% solution, and 8,519 (10, 1130) CFUs/cm2 for patients who did not have a CHG bath (P < .001). Average CHG skin concentration (parts per million) was 1300.4 (100, 2000) for 2% cloths, 307.2 (30, 200) for 4% solution, and 32.8 (0, 20) for patients without a recorded CHG bath. Both CHG bathing methods were well tolerated. Although underpowered, no difference in HAI was noted between groups.ConclusionsEither CHG bathing method resulted in a significant decrease in microbial skin colonization with a greater CHG concentration and fewer organisms associated with 2% CHG cloths.
| S-EPMC11883645 | biostudies-literature
Project description:ImportanceDaily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections.ObjectiveTo determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections.Design, setting, and participantsA pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013.InterventionsUnits performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study.Main outcomes and measuresThe primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU.ResultsDuring the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit.Conclusion and relevanceIn this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine.Trial registrationclinicaltrials.gov Identifier: NCT02033187.
| S-EPMC4383133 | biostudies-literature
Project description:BackgroundChlorhexidine gluconate (CHG) body washes and emollient application may modulate bacterial pathogen colonization and prevent neonatal hospital-acquired infections.MethodsThis pilot, non-randomized, open-label trial, enrolled preterm neonates (1000-1500g; day 1-3 of life) at a tertiary hospital in Cape Town, South Africa. Participants were sequentially allocated to 4 trial arms (n=20 each): 1% aqueous CHG (CHG), 1% CHG plus emollient (CHG+EM), emollient only (EM) and standard of care (SOC: no antiseptic/emollient). Trial treatment/s were applied daily for 10 days (d) post-enrolment, documenting neonatal skin condition score. Anterior nose, neck, umbilical and perianal swabs for bacterial culture were collected at d1, d3, d10 and d16 post-enrolment, (±1 day), reporting pathogen acquisition rates and semi-quantitative bacterial colony counts. (ClinicalTrials.gov identifier: NCT03896893; trial status: closed).FindingsEighty preterm neonates (mean gestational age 30 weeks [SD 2]) were enrolled between 4 March and 26 August 2019. The bacterial pathogen acquisition rate (comparing d1 and d16 swabs) varied from 33·9% [95%CI 22·9-47·0] at the umbilicus, 39·3% [95%CI 27·6-52·4] at the neck, to 71·4% [95%CI 58·5-81·7] at both the nose and perianal region. At d10, CHG babies had reduced bacterial density detected from neck, umbilicus, and perianal swabs compared to other groups (see Table 3). Following intervention cessation, colonization density was similar across all trial arms, but S. aureus colonization was more prevalent among EM and CHG+EM babies. Neonatal skin condition score improved in babies receiving emollient application (EM: -0·87 [95%CI 0·69-1·06] and CHG+EM: -0·73 [0·45-0·99]), compared to the SOC and CHG arms (Table 2); no CHG-related skin reactions occurred.InterpretationBacterial colonization density was significantly reduced in babies receiving 1% CHG washes but colonization levels rebounded rapidly post-intervention. Emollient application improved skin condition but was associated with higher rates of S. aureus colonization.FundingSouth African Medical Research Council; National Institutes of Health (TW010682).
| S-EPMC8225683 | biostudies-literature
Project description:BackgroundConcerns regarding potential risk of dermal irritation have led to the exclusion of NICU patients from the recommendation regarding the use of 2% chlorhexidine gluconate (CHG) wash for daily skin cleansing to reduce bloodstream infections. Our aim was to assess the safety of 2% CHG bathing in NICU patients.MethodsThe regulator required a stepwise study enrollment to three successive groups: term infants, followed by near-term and pre-term infants. For comparison, we used a cohort of matched controls. A propensity score-adjusted regression model was used to compare the groups.InterventionInfants were bathed thrice-weekly with 2% CHG-impregnated washcloths. Participant's skin was examined daily.ResultsOver a total of 661 days of treatment: 384,129, and 148 days for the term, near-term and pre-term groups, respectively, no skin reactions were observed. The intervention group was generally sicker, however, bloodstream infections were similar between the groups.ConclusionFor infants >30 weeks and >3 days old, 2% CHG bathing was safe. Large multicenter studies are urgently needed to establish the effectiveness of this practice in the NICU.
| S-EPMC10035923 | biostudies-literature
Project description: Not available
| S-EPMC6718196 | biostudies-literature
Project description:BackgroundChlorhexidine gluconate (CHG) bathing of hospitalized patients may have benefit in reducing hospital-acquired bloodstream infections (HABSIs). However, the magnitude of effect, implementation fidelity, and patient-centered outcomes are unclear. In this meta-analysis, we examined the effect of CHG bathing on prevention of HABSIs and assessed fidelity to implementation of this behavioral intervention.MethodsWe undertook a meta-analysis by searching Medline, EMBASE, CINAHL, Scopus, and Cochrane's CENTRAL registry from database inception through January 4, 2019 without language restrictions. We included randomized controlled trials, cluster randomized trials and quasi-experimental studies that evaluated the effect of CHG bathing versus a non-CHG comparator for prevention of HABSIs in any adult healthcare setting. Studies of pediatric patients, of pre-surgical CHG use, or without a non-CHG comparison arm were excluded. Outcomes of this study were HABSIs, patient-centered outcomes, such as patient comfort during the bath, and implementation fidelity assessed through five elements: adherence, exposure or dose, quality of the delivery, participant responsiveness, and program differentiation. Three authors independently extracted data and assessed study quality; a random-effects model was used.ResultsWe included 26 studies with 861,546 patient-days and 5259 HABSIs. CHG bathing markedly reduced the risk of HABSIs (IRR = 0.59, 95% confidence interval [CI]: 0.52-0.68). The effect of CHG bathing was consistent within subgroups: randomized (0.67, 95% CI: 0.53-0.85) vs. non-randomized studies (0.54, 95% CI: 0.44-0.65), bundled (0.66, 95% CI: 0.62-0.70) vs. non-bundled interventions (0.51, 95% CI: 0.39-0.68), CHG impregnated wipes (0.63, 95% CI: 0.55-0.73) vs. CHG solution (0.41, 95% CI: 0.26-0.64), and intensive care unit (ICU) (0.58, 95% CI: 0.49-0.68) vs. non-ICU settings (0.56, 95% CI: 0.38-0.83). Only three studies reported all five measures of fidelity, and ten studies did not report any patient-centered outcomes.ConclusionsPatient bathing with CHG significantly reduced the incidence of HABSIs in both ICU and non-ICU settings. Many studies did not report fidelity to the intervention or patient-centered outcomes. For sustainability and replicability essential for effective implementation, fidelity assessment that goes beyond whether a patient received an intervention or not should be standard practice particularly for complex behavioral interventions such as CHG bathing.Trial registrationStudy registration with PROSPERO CRD42015032523 .
| S-EPMC6518712 | biostudies-literature