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Cover

Chlorhexidine Gluconate
Bathing to Reduce
Methicillin-Resistant
Staphylococcus aureus
Acquisition
ANN PETLIN, RN, MSN, CCRN-CSC, CCNS, PCCN, ACNS-BC
MARILYN SCHALLOM, RN, PhD, CCRN, CCNS
DONNA PRENTICE, RN, MSN(R), CCRN, ACNS-BC
CARRIE SONA, RN, MSN, CCRN, CCNS, ACNS-BC
PAULA MANTIA, RN, MSN, ANP-BC
KATHLEEN McMULLEN, MPH, CIC
CASSANDRA LANDHOLT, BS

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism causing substantial


morbidity and mortality in intensive care units. Chlorhexidine gluconate, a topical antiseptic solution, is
effective 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 basin
management on MRSA acquisition in 5 adult intensive care units and to examine the cost differences
between 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 warm
water. Patients in 3 intensive care units underwent active surveillance for MRSA acquisition; patients in 2
other 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 34 333 patient days (rate ratio, 3.84). After-
wards, 109 patients acquired MRSA in 41 376 patient days (rate ratio, 2.63). The rate ratio difference is
1.46 (95% CI, 1.12-1.90; P = .003). The chlorhexidine soap and bath basin method cost $3.18 as compared
with $5.52 for chlorhexidine-impregnated wipes (74% higher).
CONCLUSIONS The chlorhexidine bathing protocol is easy to implement, cost-effective, and led to decreased
unit-acquired MRSA rates in a variety of adult intensive care units. (Critical Care Nurse. 2014;34[5]:17-26)

CNE Continuing Nursing Education


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 water
3. 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

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M
ethicillin-resistant Staphylococcus prevention of hospital-acquired MRSA is an important
aureus (MRSA) is a virulent organ- nursing intervention.
ism that causes substantial mor- Chlorhexidine gluconate (CHG), a topical antiseptic
bidity and mortality in intensive solution, is effective against a wide spectrum of gram-
care units (ICUs). The Centers for positive and gram-negative bacteria, including MRSA.3
Disease Control and Prevention estimated that more Low concentrations of CHG, such as when it is diluted in
than 80000 cases of invasive MRSA infections occurred bath-basin water or as supplied in bathing wipes, alter
in the United States in 2011, with more than 11000 the integrity of bacterial cell walls.9 Additionally, CHG
deaths.1 Colonization with S aureus may precede infec- has residual activity on the skin that helps to reduce skin
tion. Culture swabs of the anterior nares can identify microbes and prolongs skin antisepsis.10 A review of the
patients who are colonized with MRSA even though literature provides evidence that CHG bathing has sev-
they may show no signs or symptoms of infection.2 eral benefits.4,10-28 CHG bathing reduces the acquisition
MRSA and other microbes have been cultured from of vancomycin-resistant Enterococcus by hospitalized ICU
bath basins in ICUs,3 which may contribute to colo- patients,4,10-14 Clostridium difficile,15 and hospital-acquired
nization of the patients skin and lead to secondary MRSA.4,11-13,16,17 Bathing with CHG also reduces MRSA
contamination at other sites.4 skin colonization in known MRSA carrier patients during
Reduction and elimination of hospital-acquired infec- their treatment.18-21 Several studies showed that bathing
tions requires a multipronged approach. Hand hygiene with CHG and nasal administration of mupirocin reduce
is the primary strategy to reduce hospital-acquired the risk of infections,2,22 and CHG bathing alone specifi-
infections and prevent transmission of resistant microbes cally reduces the risk of central catheterassociated blood-
between patients.5 Rapid reporting of culture results allows stream infections in ICU patients4,23-26 and long-term acute
the health care team to initiate timely contact isolation care patients.27 Two studies24,28 demonstrated that CHG
precautions that help reduce the spread of infection once bathing reduced the rate of blood culture contamination.
a resistant organism is identified. A multidisciplinary Two of the ICUs at Barnes-Jewish Hospital, a Mid-
critical care team partnership with infection prevention western university teaching hospital were among the units
specialists can facilitate these evidence-based preven- involved in a multi-institutional quasi-experimental study
tion strategies. The increase in MRSA prevalence in the by Climo et al11 on the effect of CHG bathing and MRSA
community and the high level of mortality associated acquisition. Climos study demonstrated a 32% reduction
with MRSA (3.62 deaths per 100000 population in the in MRSA acquisition. Those 2 ICUs resumed typical
United States)1 require clinicians to continuously soap-and-water bathing of their patients when the CHG
explore measures to prevent MRSA acquisition in criti- bathing intervention ended at the completion of the study.
cally ill patients. MRSA colonization can be a source of Infection surveillance data showed a return to higher
fear, anxiety, and uncertainty for patients.6-8 Therefore, MRSA acquisition rates with the soap-and-water baths

Authors
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 at
Barnes-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-Jewish
Hospital.
Cassandra (Casey) Landholt is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at
Barnes-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: amp2645@bjc.org).
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, reprints@aacn.org.

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in both ICUs. Decolonization with nasal mupirocin was and in newsletters about the protocol and monitored for
not included during the study period. The purpose of implementation progress and supply needs. Before this
this study was to expand the intervention of the bathing study, we did not have a standard bathing protocol aside
protocol to 5 ICUs at our hospital by using CHG bathing from the traditional use of a bath basin with soap and
and a bath-basin protocol and to examine its impact on water. The hospitals institutional review board approved
the acquisition of MRSA in our patients. Our goals were this study as exempt from human subjects committee
(1) to determine if there was a difference in MRSA acqui- review because it was minimal risk, the CHG bathing
sition between soap-and-water baths and CHG bathing, intervention applied to all patients in the study units,
and (2) to examine the cost differences between CHG and only unit-level data would be collected.
bathing using the bath-basin method versus using
prepackaged CHG-impregnated washcloths. Bathing Protocol
The CHG bathing protocol directed the nurse to mix
Theoretical Framework the contents of a 4-ounce bottle of 4% CHG with warm
The Synergy Model from the American Association water in a 6-quart basin in the same fashion as per-
of Critical-Care Nurses provided a theoretical frame- formed in the study by Climo et al.11 Typical linens used
work for the clinical nurse specialists (CNSs) interest in for a bath included 6 washcloths and 4 bath towels,
and design of this study.29 This model encourages a although these numbers were not specified in the proto-
holistic view of patients, each with varying capacities col. Washcloths were used for 1 body area only and were
for health and vulnerability to illness. The model also not reinserted into the CHG water after use. Staff bathed
identifies nursings unique contribution to patient care patients from the neck down, avoiding contact with the
and outcomes. The patient characteristics of the Syn- face, all mucous membranes, and wounds, as recom-
ergy Model that apply particularly well in our study are mended by the manufacturer. Bath basins were marked
the complexity and vulnerability of ICU patients as as dedicated
well as their limited available resources to prevent for bathing Implementation of the chlorhexidine gluconate
hospital-acquired infections. The ICU itself is a complex only. Staff (CHG) bathing protocol was led by clinical
environment that can place patients at risk of having rinsed the nurse specialists.
hospital-acquired complications. The CNSs bring the basin after
nursing competencies of clinical inquiry, collaboration, use and towel-dried it before storing it. If skin and
and facilitation of learning to the clinical research proj- wound care items needed storage, the staff used a sepa-
ect. If the intervention reduced MRSA acquisition, our rate basin or other container. Nurses had been educated
study worked toward patient outcomes goals of absence about the bathing protocol and bath basin maintenance
of complications, decreased infection acquisition, and steps by the end of 2009. Education strategies included
effective cost-resource utilization. the services of the unit champions, use of posters and
newsletters, and inclusion of the CHG bathing protocol in
Methods unit orientations. Implementation of the protocol began
Overview of Study Design in January 2010.
This study used a pre/post-intervention design. The
hospital leadership model includes a unit-based critical Procedure
care CNS in each ICU. The CNSs individually worked The hospital performed active surveillance for MRSA,
with their unit-based physician leadership and infection which included nasal swabs for MRSA upon ICU admis-
prevention staff. Additionally, a CNS in the hospitals sion, weekly, and upon discharge in the cardiothoracic,
research department collaborated with each CNS to medical, and surgical/burn/trauma ICUs for several years
implement the protocol. A champion(s) was also identi- before this project. This surveillance continued through-
fied for each unit. Champions were typically staff nurses out this study. We defined MRSA acquisition in these 3
and/or chairs of the units practice committees with the units as a nasal swab or clinical culture that was positive
support of the clinical nurse managers. The CNSs and for MRSA 48 hours after admission in any patient who
champions provided an educational overview both orally had a negative result or no nasal swab at admission.

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

Three units with active All 5 units (with and without


Period MRSA surveillance active surveillance)
Preintervention (July 2008-December 2009) 111 MRSA acquisitions in 132 MRSA acquisitions in
22 292 patient days 34 333 patient days
MRSA acquisition rate = 4.98 MRSA acquisition rate = 3.84
Postintervention (January 2010-April 2011) 91 MRSA acquisitions in 109 MRSA acquisitions in
31 233 patient days 41 376 patient days
MRSA acquisition rate = 2.91 MRSA acquisition rate = 2.63

The 2 other ICUs in our study, the coronary care unit We did not collect a final nasal swab on patients who
and a second medical ICU, did not have protocols for died or were already found to be MRSA positive via the
active surveillance. They used incident surveillance active surveillance. We defined hand hygiene compli-
instead. We defined MRSA acquisition in these 2 units ance as the percentage of staff members who were
as any patient with a new culture positive for MRSA at observed performing hand hygiene upon entering or
any site 48 hours after admission. exiting a patients room.
The ICU physicians in all the study units were informed
of swabs and cultures that were positive for MRSA by a Results
telephone call from the microbiology laboratory. Patients In the preintervention period (July 2008-December
went on contact isolation precautions immediately upon 2009) when soap-and-water bathing was the routine,
the report of a culture positive for MRSA. Infection pre- there were 132 MRSA acquisitions in 34333 patient days
vention staff (see Table). This equaled a MRSA acquisition rate of
Patients bathed with soap and water monitored the 3.84 per 1000 patient days. In the postintervention period,
were 1.5 times more likely than patients MRSA acqui- (January 2010-April 2011) with the CHG bathing proto-
bathed with CHG to acquire MRSA. sition rates col, there were 109 MRSA acquisitions in 41376 patient
and compli- days. This equaled a MRSA acquisition rate of 2.63 per
ance with admission, weekly, and discharge surveillance 1000 patient days. The MRSA rate ratio difference is
swabs, and they reported the data monthly to the 3 ICUs 1.46 (95% CI=1.12-1.90, P=.003; Figure 1). Patients in
in the study that were performing active surveillance. the preintervention period were almost 1.5 times more
They also observed hand hygiene compliance monthly likely to acquire MRSA than patients who received the
in all ICUs by using secret shoppers as data collectors CHG bathing protocol.
during both study periods. No significant differences in compliance were found
with nasal swabbing or with hand hygiene between
Data Analysis the study periods. Compliance rates with nasal swab-
We used OpenEpi30 software to calculate MRSA bing for MRSA were 87% to 90% in the preinterven-
acquisition rate ratios in the preintervention and postin- tion period and 86% to 92% after the intervention.
tervention periods. We defined the MRSA acquisition The patients in the medical ICU showed the greatest
rate as the number of patients with nasal swabs negative decline in MRSA acquisition rates from 6.8 per 1000
for MRSA upon admission, or no nasal swab performed patient days before the intervention to 3.8 per 1000
on admission, in whom MRSA from any source developed patient days after the intervention. They also had the
more than 48 hours after their ICU admission, divided highest compliance (92%) with nasal swabbing. The
by the number of patient days per month times 1000. surgical/burn/trauma ICU had been one of the units
Patients who were known to be positive for MRSA on in the multi-institutional study by Climo et al.11 Their
ICU admission were excluded from the calculations. We MRSA acquisition rate returned to the multisite study
defined MRSA nasal swab compliance as the percentage level when the CHG bathing protocol resumed with
of admission, weekly, and discharge nasal swabs obtained. our study.

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of patients in the same study had a skin reaction to
MRSA acquisition rate per 1000 patient days 4.5
cloths that were not impregnated with antimicrobial
4.0 soap. There were no reports of skin irritation during the
3.5 study in our hospital.
Johnson and colleagues3 demonstrated patients bath
3.0
basins as potential sources of infections, with 98% of
2.5 basins growing potentially pathogenic microbes. Soon
2.0
after that study, many hospitals decided to abandon
bath basins for ICU bathing in favor of using washcloths
1.5
impregnated with 2% CHG. Historically, several stud-
1.0 ies11,15-18,20-22,27 of the effects of CHG bathing used 4% CHG
0.5
in bath basins or showering; other studies4,10,12-14,23-26,28
used cloths impregnated with 2% CHG. Our surgical/
0.0
Soap and water Chlorhexidine
burn/trauma ICU staff nurses willingly tried the CHG-
gluconate impregnated cloths before this study but were not satis-
Figure 1 The acquisition rate of methicillin-resistant fied with their performance and preferred the bath-basin
Staphylococcus aureus (MRSA) was 3.84 per 1000 patient method for patient bathing. Since the report of bath basin
days before the chlorhexidine gluconate bathing routine was
implemented and 2.63 per 1000 patient days after the contamination by Johnson et al,3 Powers and colleagues31
implementation of chlorhexidine bathing. The difference in studied the presence of bacterial contaminants in wash
MRSA rates is 1.46 (95% CI, 1.12-1.90; P = .003).
basins when CHG solution was used in place of standard
soap and water to wash patients. They reported that bac-
As part of this study, we collaborated with our hos- terial growth in patients bath basins decreased by 95.5%
pitals Patient Care Products Committee to analyze the with the use of CHG in the bath water. Similar results
cost of bathing with the CHG soap and bath basin were found in a comparison bench study32 of 2 different
method and compare that with the cost of bathing with brands of 4% CHG and 1 brand of liquid soap. Soap and
CHG-impregnated wipes. Our institution pays $1.75 for CHG were equally effective at preventing initial contami-
each 4-ounce bottle of 4% CHG. The reusable bath basin nation compared with tap water. However, both brands
costs $0.35. The cost of the bath linens includes purchase of CHG had
and reprocessing. Cotton washcloths are $0.04 each (6 per significant Using prepackaged CHG wipes ($5.52 per
bath=$0.24) and bath towels are $0.21 each (4 per bath marked bath) was 74% more expensive than using the
=$0.84). These individual items total $3.18 for 1 bed bath. residual CHG soap and bath method ($3.18 per bath).
Reusing the bath basin reduces the cost of subsequent effect on
baths. One vendor (D. Short, Cardinal Health, Dublin, bacterial contamination compared with soap and water
Ohio, e-mail communication, November 5, 2012) said or tap water only.32 These 2 studies31,32 demonstrated that
that 6 of the washcloths impregnated with 2% CHG, bathing with CHG using a bath basin and tap water does
enough for 1 bath, would cost $5.52. not increase the risk of exposing patients to bacterial
contaminants from the basin and tap water. Addition-
Discussion ally, in a bench study of MRSA isolated over 4 years in a
The adverse effects of bathing with CHG are related setting that used 4% CHG bathing, researchers found no
to contact dermatitis or skin irritation that subsides detectable loss of antibiotic effectiveness or increase in
after stopping the use of CHG in the bath water. Many MRSA resistance or infection with other organisms.33
studies report no skin reaction or do not report on this Using washcloths impregnated with 2% CHG ($5.52 per
outcome. In a study27 of long-term patients in an acute bath) would be 74% more expensive than our CHG soap
care hospital, 1% of patients had dryness of skin develop and bath basin method ($3.18 per bath; Figure 2). Ritz
with a 4% CHG bath basin method. In another study,4 et al13 reported that a bath basin protocol was $2.50 less
researchers reported skin reactions in 2% of patients than cloths impregnated with 2% CHG. To translate the
with use of 2% CHGimpregnated cloths; however, 3.4% magnitude of this cost difference, the 41376 CHG-in-water

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Compliance with nasal swab screening and hand
6.00
hygiene are essential measures to analyze the impact of
5.00
CHG bathing. Otherwise, many nasal swabs may be
missed or too few CHG baths may be given to show the
4.00 effects of the intervention. High nasal swab compliance
rates played an important role in ensuring that the
Cost, $

3.00 MRSA acquisition rate data were accurate in the ICUs


that performed active surveillance. Compliance with
2.00 nasal swabbing helped to ensure that MRSA infections
were not overlooked by decreased testing. Use of the
1.00
CHG soap by each ICU is monitored by the rate of
0.00 restocking that item in each units supply area. Hand
CHG and Prepackaged hygiene compliance monitoring helped to ensure that
bath basin CHG wipes
staff members adhered to other accepted measures that
reduce cross-contamination of patients.
Figure 2 The chlorhexidine gluconate (CHG) soap and bath AACNs evidence-based leveling system identifies a
basin method cost $3.18 as compared with $5.52 for the
wipes impregnated with CHG. The prepackaged CHG wipes rating of class B evidence for interventions developed
are 74% higher in cost than the CHG soap and bath basin from well-designed controlled studies, both random-
method.
ized and nonrandomized, with results that consistently
support a specific action, intervention, or treatment.34
baths given during our study cost our hospital about Publications on the reduction of acquisition or decolo-
$131000 whereas bathing with washcloths impregnated nization of multidrug-resistant organisms provide class
with 2% CHG would have cost about $228000. The cost B evidence for CHG bathing.
of providing any Research studies in the past several years, including
Hand hygiene compliance monitoring our results, have demonstrated the benefits of CHG
intervention mer-
helped to ensure that staff members bathing in ICU patients. Our results also demonstrated
its consideration
adhered to other accepted measures the role of the unit-based CNS in conducting research
in a climate of cost
that reduce cross-contamination of and implementing best practices. Each unit-based CNS
containment. Each
patients. partnered with his or her bedside nursing colleagues,
institution negoti-
ates prices with their vendors, so costs of the 2 methods physicians, infection prevention staff, and hospital-wide
may vary. departments and provided a structure for implement-
We examined only the impact of CHG bathing on ing the protocol in multiple units simultaneously. By
MRSA and not on hospital-acquired infections from implementing the protocol in multiple units, the results
vancomycin-resistant Enterococcus, C difficile, central and impact could be examined both at the unit level
catheterassociated bloodstream infections, or surgical and more widely. Unit-based results provided informa-
site infections. All units had low rates of central catheter tion to the bedside clinicians that was a direct result of
associated bloodstream infections and surgical units had their practice. Combining the data from multiple ICUs
low rates of surgical site infections in the preintervention strengthened the findings for statistical analysis.
period. Those low infection rates would have required a
very large number of patients from several years to Limitations
demonstrate a significant difference with CHG bathing. Our study examined only 1 bathing protocol, the
We were not tracking catheter-associated urinary tract same one as described by Climo et al11 in 2009. We used
infection rates in the preintervention period. However, this protocol because 2 of our ICUs had been involved in
for units with high rates of any of these infections, CHG that study. Other products and protocols have been
bathing provides a reasonable intervention to reduce described since then.13-15 Another limitation of our study
such infections,4,22-27 although not all studies showed was the differences in surveillance protocols for MRSA.
reductions in infection rates.28 We had active surveillance in the cardiothoracic, medical,

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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 did To learn more about chlorhexidine bathing, read Chlorhexidine
Bathing and Microbial Contamination in Patients Bath Basins
not occur. We based compliance with the protocol on the by Powers et al in the American Journal of Critical Care, September
inventory of the 4-oz (120-mL) bottles of 4% CHG as 2012;21:338-342. Available at www.ajcconline.org.
compared with the unit census. One bottle of 4% CHG
was considered to indicate 1 patient bath. References
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you want to comment on. In the full-text or PDF view of the article, click Staphylococcus aureus: a randomized, placebo-controlled, double-blind
Responses in the middle column and then Submit a response. clinical trial. Infect Control Hosp Epidemiol. 2007;28(9):1036-1043.

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24. Popovich KJ, Hota B, Haynes R, et al. Effectiveness of routine patient
cleansing with chlorhexidine gluconate for infection prevention in the
medical intensive care unit. Infect Control Hosp Epidemiol. 2009;30(10):
959-963.
25. Dixon JM, Carver RL. Daily chlorhexidine gluconate bathing with
impregnated cloths results in statistically significant reduction in cen-
tral line associated bloodstream infections. Am J Infect Control. 2010;30:
817-821.
26. Lopez AC. A quality improvement program combining maximal barrier
precaution compliance monitoring and daily CHG baths resulting in
decreased central line bloodstream infections. Dimens Crit Care Nurse.
2011;30(5):293-298.
27. Munoz-Price LS, Hota B, Stremer A, et al. Prevention of bloodstream
infections by use of daily chlorhexidine baths for patients at a long-term
acute care hospital. Infect Control Hosp Epidemiol. 2009;30(11):1031-1035.
28. Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Daily skin
cleansing with chlorhexidine did not reduce the rate of central-line
associated 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 of
the clinical nurse specialist. Crit Care Nurse. 1999;19(2):101-104.
30. Dean AG, Sullivan KM, Soe MM. OpenEpi: open source epidemiologic
statistics for public health, Version 3.01. Updated April 6, 2013.
www.OpenEpi.com. Accessed July 7, 2014.
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 administer
CHG baths. Infect Control Hospital Epidemiol. 2013;34(6):643-645.
33. Sangal V, Girvan EK, Jadhav S, et al. Impacts of a long-term programme
of 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:
whats new? Crit Care Nurse. 2009;29(4):70-73.

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

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CCN Fast Facts CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing

Chlorhexidine Gluconate Bathing to Reduce


Methicillin-Resistant Staphylococcus aureus
Acquisition

Facts show the effects of the intervention. High nasal swab


Methicillin-resistant Staphylococcus aureus (MRSA) is compliance rates played an important role in ensuring
a virulent organism causing substantial morbidity and that the MRSA acquisition rate data were accurate in
mortality in intensive care units. Because of the increase the intensive care units (ICUs) that performed active
in MRSA prevalence in the community and the high level surveillance.
of mortality associated with MRSA, prevention of hospital- Research studies, including our results, have demonstrated
acquired MRSA is an important nursing intervention. the benefits of CHG bathing in ICU patients. Our results
Chlorhexidine gluconate (CHG), a topical antiseptic also demonstrated the role of the unit-based clinical nurse
solution, is effective against a wide spectrum of gram- specialist (CNS) in conducting research and implement-
positive and gram-negative bacteria, including MRSA. ing best practices. Each unit-based CNS partnered with
Low concentrations of CHG, such as when it is diluted his or her bedside nursing colleagues, physicians, infection
in bath-basin water or as supplied in bathing wipes, prevention staff, and hospital-wide departments.
alter the integrity of bacterial cell walls. Additionally, By implementing the protocol in multiple units, the results
CHG has residual activity on the skin that helps to and impact could be examined both at the unit level and
reduce skin microbes and prolongs skin antisepsis. more widely. Unit-based results provided information to the
CHG bathing has several benefits. CHG bathing bedside clinicians that was a direct result of their practice.
reduces the acquisition of vancomycin-resistant
Enterococcus, Clostridium difficile, and hospital- Nursing Implications
acquired MRSA. Bathing with CHG also reduces Daily CHG bathing in the ICU is a simple and effective
MRSA skin colonization in known MRSA carrier means of decreasing MRSA acquisition.
patients during their treatment. Bathing with CHG Although reactions are infrequently reported, nurses
and nasal administration of mupirocin reduce the should monitor each patients skin for any reaction.
risk of infections, and CHG bathing alone specifically CHG bathing has not been shown to increase antibiotic
reduces the risk of central catheterassociated blood- resistance.
stream infections. CHG bathing has also been shown Both a bath basin bathing protocol that uses 4% CHG
to reduce the rate of blood culture contamination. and a bathing protocol that uses prepackaged 2% CHG
The adverse effects of bathing with CHG are related cloths demonstrated reductions in hospital-acquired
to contact dermatitis or skin irritation that subsides infections. The costs of prepackaged cloths are higher,
after stopping the use of CHG in the bath water. although individual unit preferences and time require-
Many studies report no skin reaction or do not report ments also should be considered.
on this outcome. CNSs and unit champions can provide the evidence and
Compliance with nasal swab screening and hand assist with implementation and monitoring for success.
hygiene are essential measures to analyze the impact AACNs Synergy Model is a useful framework for clinical
of CHG bathing. Otherwise, many nasal swabs may inquiry that helps to optimize outcomes for patients and
be missed or too few CHG baths may be given to their families, nurses, and the system. CCN

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

www.ccnonline.org CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 25


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CNE Test Test ID C1453: Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus Aureus Acquisition
Learning objectives: 1. Discuss current research on chlorhexidine gluconate (CHG) bathing 2. Compare use of CHG-impregnated washcloths with CHG
solution dissolved in bath water 3. Describe the effects of CHG bathing on methicillin-resistant Staphylococcus aureus

1. Which of the following statements is true regarding colonization with 7. Essential measures to analyze the impact of CHG bathing include which
Staphylococcus aureus? of the following?
a. The Centers for Disease Control and Prevention estimates that more than a. Staff satisfaction with the protocol
11 000 deaths occurred due to colonization with methicillin-resistant b. Survey of patient comfort
S aureus (MRSA) in 2011. c. Compliance with nasal swab screening
b. Patients may be colonized with S aureus without signs of infection. d. Utilization rate of the CHG soap
c. Culture swabs of the nares are the only reliable method to diagnose MRSA.
d. Microbes in bath basins may lead to contamination of the lungs. 8. According to the AACN evidence-based leveling system, publications on
multidrug-resistant organisms provide what level of evidence for CHG
2. Which of the following describes CHGs mechanism of action? bathing?
a. Washing microbes off the skin a. Class IA
b. Killing all gram-negative bacteria b. Class 2
c. Altering integrity of bacterial cell walls c. Class A
d. Interacting with mupirocin d. Class B

3. Patient characteristics of the AACNs Synergy Model applicable to this 9. The decision to use prepackaged clothes versus bath basin bathing
study are which of the following? should include consideration of which of the following?
a. Available resources and costs a. The method that provides best reduction in MRSA
b. Complexity and collaboration b. Time requirements
c. Resiliency and predictability c. Increase of bacterial resistance
d. Complexity and vulnerability d. Availability of a clinical nurse specialist to support compliance

4. The bathing protocol used in this study included which of the following? 10. Limitations of this study include which of the following?
a. Use of a new dedicated wash basin daily a. Small sample size
b. Complete bathing from the neck down b. The study used a different bathing protocol than the study on which it was
c. 4-ounce bottle of 2% CHG with warm water in a 4-quart basin based on.
d. Use of 1 washcloth per body area c. Active surveillance only took place in the coronary care unit.
d. It relied on the nurses report that the bath was provided per the protocol.
5. Which of the following are adverse effects of CHG bathing?
a. Serious rashes 11. Which of the following describes the design of this study?
b. Contact dermatitis a. Retrospective design
c. Allergic reactions b. Randomized control group design
d. Should not be a cause for concern c. Pre/post-intervention design
d. Experimental crossover design
6. In this study, which of the following is true regarding using washcloths
impregnated with 2% CHG? 12. Results of previous studies on bath basins include which of the following?
a. Provided benefits that justify the cost a. Soap and tap water and CHG techniques both had residual effects on bacterial
b. Cost the hospital approximately $131000 contamination.
c. Is more expensive than the CHG soap and basin method b. Ninety-eight percent of basins grow potentially pathogenic microbes.
d. Cost $5.52 more than the bath-basin method c. Over time CHG use may result in loss of antibiotic effectiveness.
d. Bacterial growth in bath basins is eliminated when bathing with CHG soap
in the bath water.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

1.  a 2.  a 3.  a 4.  a 5.  a 6.  a 7.  a 8.  a 9.  a 10.  a 11.  a 12.  a


b b b b b b b b b b b b
c c c c c c c c c c c c
d d d d d d d d d d d d
Test ID: C1453 Form expires: October 1, 2017 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%)
Synergy CERP Category A Test writer: Patricia Kelly Rosier, MS, RN, ACNS-BC

Program evaluation Name Member #


Yes No
Address
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Content was relevant to my Country Phone
For faster processing, take nursing practice  
E-mail
this CNE test online at My expectations were met  
This method of CNE is effective RN Lic. 1/St RN Lic. 2/St
www.ccnonline.org for this content  
or mail this entire page to: The level of difficulty of this test was: Payment by:  Visa  M/C  AMEX  Discover  Check
AACN, 101 Columbia  easy  medium  difficult
To complete this program, Card # Expiration Date
Aliso Viejo, CA 92656.
it took me hours/minutes. Signature
The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

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Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureus
Acquisition
Ann Petlin, Marilyn Schallom, Donna Prentice, Carrie Sona, Paula Mantia, Kathleen McMullen and
Cassandra Landholt
Crit Care Nurse 2014;34 17-24 10.4037/ccn2014943
2014 American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
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