January 29, 2015
Many intensive care units (ICUs) across the U.S. have instituted antiseptic bath protocols for prevention of healthcare associated infections. These protocols have included the use of various products, but traditionally 2% chlorhexidine and simple soap and water have been the products of first choice. A major study in JAMA of 9,340 patients in 5 adult ICUs over a 1-year period who received a once-daily bathing of 2% chlorhexidine vs. a non-antimicrobial cloth for a 10 week period concluded that 2% chlorhexidine did note reduce the incidence of central line-associated bloodstream infections, catheter associated urinary tract infections, ventilator associated pneumonia or Clostridium difficile infections (2.86 vs. 2.90 per 1000 patient days, p=0.95).1
Recently, a publication in the Society of Critical Medicine analyzed 325 patients expected to stay more than 48 hours in a single ICU (161 chlorhexidine vs. 164 soap and water) using either 2% chlorhexidine bath every 48 hours interspersed with soap and water baths cut the risk of healthcare-associated infections by 44% (18 vs. 35 infections, p=0.049) for a number needed to treat 11.2
Both studies have hypothesized whether chlorhexidine is better than soap and water. However, there were many limitations to both trials, including the fact that both were single-centered studies, the contact time of antiseptic was not determined, neither study could blind ICU to the intervention, and protocols were not descriptive enough regarding how chlorhexidine was used. Although the question of whether once-a-day chlorhexidine cleansing is better than every-other-day soap and water bathing is not clear, it is clear that patients do receive a daily bath. Until some of these limitations can be addressed in a larger multicenter, randomized trial, the superior strategy will be elusive.
I welcome comments on how clinicians are addressing this issue. Do you use chlorhexidine, soap and water or other products on a daily basis? Have you performed your own quality control assessment of these products within your own critical care units? Have you changed your protocols multiple times due to the mixed results in the literature?
Michael J. Cawley, PharmD, RRT, CPFT, FCCM, is a Professor of Clinical Pharmacy at the Philadelphia College of Pharmacy, University of the Sciences. He has greater than 25 years of experience practicing in the areas of medical, surgical, trauma, and burn intensive care as both a critical care clinical pharmacist and registered respiratory therapist.
1. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care associated infections: A randomized clinical trial. JAMA. 2015;313(4):369-378.
2. Swan JT, et al. RCT of chlorhexidine vs soap and water bathing for prevention of hospital acquired infections in SICU. SCCM. 2015; Abstract 4.