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September 21, 2017

EJRC ARTICLE REVIEW

EJRC ARTICLE REVIEW

Background

The risk of ICU population to develop healthcare acquired infections (HCAIs) is high due to the invasive nature of many treatments such as central venous access, urinary catheterisation, and mechanical ventilation. Skin decontamination with chlorhexidine (CHG) has been supported to reduce bacterial burden, and subsequently HCAIs rates as skin of critical care patients is a rich source of pathogens. Although previous research has reported that daily bathing with CHG has an effect on reduction of HCAIs rates, effectiveness of CHG is still uncertain due to studies variability research design.

Frost and colleagues have performed a systematic review and meta-analysis of 17 studies to summarise the effectiveness of daily CHG to reduce risk of infections amongst critical care patients [1]. Infections included were: bloodstream Infections; central line associated blood stream infections-(CLABSI); catheter associated urinary tract infections, ventilator associated pneumonia, methicillin-resistant staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus; and clostridium difficile. Authors have included in the analysis both randomised controlled (n=7) and before-after studies (n=10), while Bayesian models were applied to interpret the results. The meta-analysis found that CHG bathing was most effective in preventing CLABSIs by reducing its risk by 56%. MRSA colonisation and MRSA bacteraemia risk was also reduced by approximately 41% and 36%, respectively. Although results have shown that CHG bathing was effective, the magnitude of the benefit was depended on the underlying risk of the infection rates for a given ICU population. Three hundred sixty patients will need to be bathed with CHG to prevent a single CLABSI, when the baseline rate was 5 CLABSI per 1000 catheter days. If the underlying risk of CLABSI was 1 per 1000 catheter days, then NNT was increased to 1780. In case of MRSA colonisation and MRSA bacteraemia risk, NNT was 600 and 2800, respectively.

The findings from the present meta-analysis support the results from previous studies which they have also suggested that daily bathing is a relatively straight forward preventive strategy to reduce the risk of CLABSI [2] and MRSA [2,3] in ICU patients. Nevertheless, universal decolonisation strategies such as daily bathing with CHG are not without risk. Other approaches such as improved adherence with hand hygiene should be considered, since it is less likely affect the ecology of bacterial resistance in ICU setting [4].

Article review was prepared and submitted by EJRC Member Katerina Iliopoulou, King’s College, London, UK on behalf of the N&AHP Committee.


References

1. Frost SA , Alogso M-C, Metcalfe L,. Lynch JM et al.  Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis. Critical Care (2016); 20: 379.

2. Kim HY, Lee WK,  Sungwon Na S, Roh YH,  Shin CS, Kim J. The effects of chlorhexidine gluconate bathing on health care–associated infection in intensive care units: A meta-analysis. Journal of Critical Care (2016); 32: 126–137.

3. Climo MW, Yokoe DS, Warren DK, Perl TM et al. Effect of Daily Chlorhedine Bathing on Hospital-Acquired Infection. N.Engl J Med (2013); 368:533-42.

4. Pittet D, Angus DC. Daily Chlorhexidine Bathing for Critically Ill Patients. A Note of Caution. JAMA (2015); 313(4) :365-366.

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