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Antimicrobial Trumps Soap and Water in the ICU

 |  By cclark@healthleadersmedia.com  
   February 07, 2013

Hospital infection preventionists need wait no longer. The debate is over.

A study in the New England Journal of Medicine helps settle the question once and for all: which solution is more effective for cleaning patients in the ICU: chlorhexidine or soap and water?

The answer: Cleaning patients with wash cloths impregnated with 2% chlorhexidine solution every dayfights hospital-acquired infections in the ICU better than wash cloths wettened with simple soap and water.   

Researchers recorded (clean) hands down win for chlorhexidine, especially as an agent effective against multiple drug-resistant organisms.

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Researchers from the Centers for Disease Control and Prevention, Johns Hopkins University, Virginia Commonwealth University Medical Center, Brigham & Women's Hospital/Harvard Medical School, Northwestern University, Cook County Health and Hospitals System, and the Veterans Affairs Medical Center all signed their names to it.

Multiple centers from Iowa City to Boston suggest the results can be extrapolated to apply to various regions of the country, both urban and rural.

"This has not been standard of care, and the controversy has been, is the daily chlorhexidine wash evidence-based enough to make it standard of care," says study author Edward S. Wong, MD, chief of infectious diseases at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, VA.

"And then, if it should be standard of care, should it be in the intensive care unit only, with high risk patients, or should it be generalized to the whole acute care population?  I know in our region, most hospitals don't use it at all."

The multi-center, cluster-randomized trial certainly had enough power—7,727 patients—and tested incidence of infections in hospital settings where they are most likely to thrive: nine medical/surgical intensive care units and bone marrow transplant units, including coronary care and surgery. 

Researchers were so judicious that three other centers were kicked out for not following the protocol closely enough.

And the trial was a crossover, which means hospital units whose patients were assigned to be cleaned with chlorhexidine wash cloths were reassigned six months later to be cleaned with the non-antimicrobial wash cloths, and vice versa, to eliminate any factors in a particular setting being blamed for biasing the result.

The verdict: Patients cleaned with chlorhexidine bathing were 23% less likely to get an infection with a multi-drug resistant organism than those cleaned without the antimicrobial.

"During the control period, when nonantimicrobial cloths were used, 165 new cases of MRSA (methicillin-resistant staphlococcus aureus or vancomycin-resistant enterococcus (VCE) acquisition were detected, as compared with 127 during the periods of bathing with chlorhexidine," the study said.

"The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1,000 patient-days with chlorhexidine bathing versus 6.60 cases per 1,000 patient-days with non-antimicrobial wash cloths."

Bloodstream infections also were reduced in the treated group, with 165 during the control period and 119 in the chlorhexidine period.

"The rate of hospital acquired bloodstream infections was 28% lower during the intervention period than during the control period."

The same was true for central catheter-associated bloodstream infections, which were 53% lower during the intervention period than during the control period. Catheter-associated fungal bloodstream infections also dropped.

"If our results are confirmed, topical use of chlorhexidine could be added to strategies to prevent fungal infections," the authors  wrote.

And the longer patients were hospitalized in each unit, the more the chlorhexidine wash worked better than the non-antimicrobacterial wash.

And despite concerns, there were no serious skin reactions, and no skin reactions at all were attributed to the chemical wash.

The authors launched the study because "the use of antiseptic agents for patient bathing is currently considered controversial."  Previous studies were ambivalent, or if they showed a benefit for chlorhexidine, were criticized for being small, limited, or single-center studies.

And some studies have been negative, especially as a prevention against surgical site infections, when the patient is washed or is asked to wash with chlorhexidine in the hours or day before surgery. 

For example, a meta-analysis of clinical trials published in the American Journal of Infection Control this month by researchers in Singapore, said there is "no appreciable benefit of preoperative whole-body chlorhexidine bathing for prevention of surgical site infections. However, most studies omitted details of chlorhexidine application."

Wong says that work is ongoing with other studies of preoperative showering with chlorhexidine.

There is concern about the expense of chlorhexidine products.

"Some hospitals don't use it because it's more expensive than soap and water," says Michael Edmond, MD, chair of the division of infectious diseases and hospital epidemiologist for Virginia Commonwealth University Medical Center. He says the NEJM report "adds further evidence as to (chlorhexidine's) effectiveness."

However, he adds, "We have bathed patients daily with it in our ICUs for several years, and more recently outside of ICUs. Soon all patients in our hospital will be bathed daily with it. In my opinion, chlorhexidine has been instrumental in the significant reductions in infections that we have observed."

In their paper, Wong and co-authors noted that "concern regarding increased resistance of nosocomial bacteria to biocides and disinfectants such as  chlorhexidine has tempered enthusiasm for wider adoption of their use in hospitals for skin antisepsis."  That potential, for "emergence of resistance to chlorhexidine remains a substantial concern and should be monitored over time."

But the bottom line, which is what everyone cares about now, is that adding the use of an antimicrobial impregnated wash cloth, instead of one with just soap and water, to the routine daily bathing of patients in the ICU and some other high risk units such as those performing bone marrow transplants, can reduce infections that can cost hospitals millions.

The study was funded by the CDC and Sage Products, which makes both chlorhexidine and non-chlorhexidine wash cloths for hospitalized patient use.

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