Various infection control strategies are used to decrease the incidence of healthcare-associated infections (HAIs). For example, chlorhexidine gluconate (CHG), an antiseptic with a wide range of antimicrobial activity, has been proven through numerous studies to act as an infection prevention tool in intensive care units (Milstone et al, 2008; Septimus et al, 2104; Pallotto et al, 2019). CHG is a broad-spectrum cationic biguanide antiseptic which is effective against Gram-positive bacteria, Gram-negative bacteria, enveloped viruses (in vitro) and some fungi (McDonnell and Russell, 1999). CHG solutions are approved as antiseptic skin cleansers to reduce micro-organisms on the skin that may cause disease. They are not intended to treat or prevent any specific disease or infection as a standalone therapy, but may serve as part of a comprehensive infection prevention bundle. CHG reduces the density of micro-organisms on the skin by binding to the negatively charged bacterial cell walls, causing bacterial cell death (Donskey and Deshpande, 2016). Daily bathing with CHG, as part of a comprehensive infection prevention bundle, is a highly effective intervention for HAI prevention (Hopkins et al, 2006; Donskey and Deshpande, 2016; Huang et al, 2019). It is used throughout a patient's stay in a hospital, where a nurse or support worker will help clean an individual using a CHG skin cleanser and water, in the place of a soap bath. CHG bathing, implemented universally across the hospital offers a key tool to reduce the incidence of HAIs.
There are examples of successful interventions by hospitals that demonstrate the benefit that CHG bathing has in preventing the spread of HAIs, reducing long-term costs, and promoting greater patient satisfaction (Edmiston et al, 2007; Wyncoll et al, 2015; Knobloch et al, 2021). Treatments that use 2% or 4% CHG have been found to kill pathogens on contact and patients who have benefited from daily CHG bathing have reported fewer complications, greater ease of use than soap and water bathing and are less likely to be re-admitted to hospital (Musuuza et al, 2019).
A randomised controlled, single-blinded study of two intensive care units comparing the incidence rate of HAI in Italy demonstrated the benefit of bathing with 4% CHG liquid (Pallotto et al, 2019). In the study, 449 patients were randomised to either a control arm of daily bathing with soap or a treatment arm using daily bathing with 4% CHG liquid. Of 226 patients in the treatment arm, 15% reported an HAI compared to 25.6% in the control group (P=0.008), or 23.2 infections per 1000 patient days compared to 40.9 infections per 1000 patient days, respectively (P=0.037). Incidence of all blood stream infections was significantly reduced in the treatment group using CHG compared to soap and water (9.2 versus 22.6/1000 patient days; P=0.027).
Overcoming risk stratification challenges: horizontal approaches to CHG bathing in the hospital
The benefits of CHG bathing as part of a broader, horizontal approach have been demonstrated by the reduction of HAIs across acute care facilities and subsequent financial savings that the protocol can help provide in the longer term (Reagan et al, 2019). In a systematic review of 5259 hospital-acquired bloodstream infections (HABI) over 861 546 patient days, there was a statistically significant difference in HABI rates for patients using CHG bathing in a variety of forms (2% wipes, 4% liquid, diluted 4% solutions) compared to non-CHG bathing: 4.4 (95% confidence interval [CI]: 4.2–4.6) in the CHG group and 7.5 (95% CI: 7.3–7.8) in the non-CHG group (Musuuza et al, 2019). In this level-one study, the impact of CHG bathing was consistent across the sub-group analyses. In both randomised and non-randomised studies, facilities using bundled and non-bundled CHG approaches demonstrated a consistent effect regardless of their choice of CHG wipes vs CHG liquid solutions. These findings were similar in the intensive care unit (ICU) (0.58, 95% CI: 0.49–0.68) vs non-ICU settings (0.56, 95% CI: 0.38–0.83) supporting the benefit of a hospital-wide approach.
The reduction in downstream costs, such as readmittance to hospitals and reduced hospital stay provides a case for using this intervention (Sikora and Zahra, 2022). An example of cost reduction using daily CHG bathing comes from an unexpected opportunity: the ability of CHG bathing to potentially reduce the need for contact precautions and the associated cost of isolation materials for healthcare workers.
A 333-bed regional medical centre evaluated the impact of a hospital policy change from requiring routine contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) compared to universal daily CHG bathing without contact precautions (McKinnell et al, 2017). In the pre-intervention period, patients received daily bathing with soap and water and continued standard contact precautions as per hospital policy. During the intervention period, 4% CHG universal bathing was implemented from the neck down, in addition to a modification of hospital policy to no longer require contact isolation for patients with MRSA colonisation or infection. During the pre-intervention period, 453 patients were admitted to the ICU and spent 1993 patient days in ICU. In the post-intervention period 417 patients were admitted to ICU with only 1730 patient days in ICU. MRSA present on admission was similar between the patients in the two periods (6.3% and 6.0% admission screen, P=0.86; 1.8% vs 1.7% clinical culture, P=0.92). Additionally, there were no differences in admission MRSA patient days/100 ICU patient days between the groups (109 vs 102, P=0.57). Results indicated that there was a 58% reduction in contact precaution days during the CHG period compared to isolation period (102/1730 vs 241/1993, P=0.01) and a statistically significant reduction in MRSA contact precaution days favouring the CHG period (0/1730 vs 218/1993, P=0.01). There were no significant differences in MRSA acquisition events in the two periods (P=0.93), nor in positive environmental cultures (P=0.53).
The authors concluded that there was no evidence that discontinuing contact precautions following the introduction of CHG bathing was associated with any increased MRSA acquisition or MRSA contamination of ICU fomites, leading to the potential of reduced costs for the hospital. Moreover, hospitals that recognised the benefits of horizontal approaches have seen increases in the quality of services provided by healthcare teams. For example, to reduce joint infections, a 2020 study using a hospital-wide approach using nasal decolonisation and CHG bathing resulted in a decrease in HAI, morbidity, and costs for the hospital (Franklin, 2020).
In a performance improvement project addressing similar policies in Maine General Medical Center, a horizontal approach requiring all inpatients to bathe daily with CHG led to considerable cost savings and staff efficiency when contact precautions and MRSA/vancomycin-resistant Enterococcus (VRE) surveillance swabs were discontinued (Cutler, 2020). Although underpowered, the project reported a 49.9% decrease in gown spend, a saving of US$113 282 per year. When including costs for use of 4% CHG products, the hospital reported a net cost decrease of this project to be 34.4% or US$80 000 annually. The author reported no transmission increase in MRSA or VRE, while achieving a 50% decrease in central line-associated bloodstream infection (CLABSI) during the improvement project time period. Based on the various studies presented, horizontal bathing with CHG may have many positive advantages for hospitals from an infection prevention and cost savings perspective.
Maximising CHG benefit: improving compliance with hospital-wide bathing
The COVID-19 pandemic had a considerable impact on HAI rates and adherence to hospital infection prevention protocols compared to the pre-pandemic period. In a study analysing 2021 data from the National Hospital Safety Network (NHSN), infection ratios were reported to be significantly higher with the incidence of HAI elevating during the pandemic (Lastinger et al, 2022). Specifically, a study compared the results from the same quarters in 2019 with the 2021 data and compared standardised infection ratios (SIRs) and standardised utilisation ratios (SURs) (Lastinger et al, 2022). For example, the first quarter 2021 CLABSI SIRs were reported as 0.998 compared to 0.687 in 2019, a percentage change of 45.3%. MRSA bacteraemia and ventilator-associated events demonstrated 51% and 39% increases, respectively.
During this time period, an unprecedented relief package was ordered by the Centers for Medicare and Medicaid Services (CMS) for facilities participating in quality reporting programmes. During the height of the pandemic and continuing into the subsequent year, CMS announced exceptions and exemptions from quality reporting requirements to the NHSN. The decision was critical to allow clinicians and hospitals weary from an exhaustive response to COVID to divert resources for reporting requirements to more critical efforts (CMS, 2022). However, a potential side effect of this decision may come at the cost of adherence to infection prevention protocols, compliance with preventive interventions and a loss of knowledgeable staff due to high clinician turnover. Multiple organisations have stepped forward to respond to the need to ‘get back to basics,’ highlighting the importance of measures such as CHG bathing, in order to reset pre-pandemic practice. A recent CHG toolkit, designed to raise awareness, provide education on appropriate frequency and technique, provide customisable tools, and thereby improve implementing these protocols has been published (Musuuza et al, 2020).
While the use of CHG bathing is well-established as an efficacious and effective method for the prevention of HAIs, its true impact over time is determined by consistent delivery of care. Compliance to an infection prevention protocol, which includes CHG bathing as well as consistent and effective delivery of the appropriate bathing technique, is critical for success. In the systematic review and meta-analysis by Musuuza et al (2019), only three studies were identified that discussed fidelity of the CHG intervention (Holder and Zellinger, 2009; Martínez-Reséndez et al, 2014; Huang et al, 2019). The authors similarly conclude that it is not sufficient to report compliance as documentation of a bath given, but instead using observation or other methods to verify full protocol and technique compliance.
Using a systems engineering approach, a large academic university medical centre used direct observation and patient and provider surveys to determine compliance in four ICUs and 13 non-ICUs using a checklist (Caya et al, 2015). The 566 bed facility began using 4% foam CHG bathing for all in-patients 6 months prior to initiating the study. Compliance was determined on a 10-point scale based on appropriate supply gathering, hand hygiene, donning gloves, using 2-pumps of CHG foam on one cloth applicator per body part, rinsing the area, and applying a CHG-compatible lotion. Compliance rates demonstrated 57% full compliance, 36% partial compliance, and 7% non-compliance with this checklist. Appropriate CHG amount and use of clean washcloths for each body part on washing and rinsing were reported as 93%, 71%, and 68%, respectively. There were no statistically significant differences in compliance between ICU and non-ICU units.
In an 800-bed academic university medical centre, a 32% reduction in HAIs following the implementation of hospital-wide bathing was demonstrated using a Markov model; however, this reduction was dependent on increasing CHG bathing compliance from 60% to 90% (Reagan et al, 2019). Moreover, daily CHG bathing has been reported as feasible and safe in a variety of patient populations, such as following remission or post-stem cell transplantation without skin toxicity (Deeren et al, 2016).
This raises the need for resource allocation to accomplish compliance audits, which may not be feasible for many facilities still facing staffing shortages.
Patient-related compliance associated with refusal of CHG bathing has been investigated at a level one trauma centre with 505 beds (Caya et al, 2019). In this retrospective and prospective study, compliance rate (documented baths compared to patient days) and refusal rate (documented refusals in the electronic health record) were assessed using medical records. Prospectively, patients were interviewed using the health belief model as the theoretical framework, with constructs including perceived susceptibility/seriousness, perceived severity/threat, perceived benefits, barriers, cues to action, and self-efficacy. During the 2-year study period compliance with CHG bathing across all units was 78% with ranges per unit between 57% and 91%. The refusal rate was 16% on average across all units with a per ward range of 3%-29%. In the patient interviews, thematic review revealed that most patients:
- Perceived they had a low risk of acquiring a HAI in the hospital
- Had a high trust in medical professionals and were likely to do what was recommended by them during their stay
- Had low health literacy in regard to what CHG was, the potential benefits to bathing and these were a barrier to patient use
- Did not believe they had a role in HAI prevention.
In this study, 35% of all participants indicated that they were not educated on what CHG was, why it was different from regular soap, what the benefits were, or how to use it. Personal preference for their own bathing products were cited; however, respondents indicated that had they known the benefits they would have been more likely to use the product. Often, CHG bathing is connected with bed-bath patients only, however, 42% of patients in this study were self-bathers, which highlights the need to ensure not only the importance of CHG use, but the appropriate showering technique for application is explained. In other studies involving 2% CHG wipes, refusal has been reported to be secondary to patients experiencing: ‘stickiness’, ‘feeling unclean after use’, ‘stinging or burning after use’ due to secondary ingredients, or ‘general desire to have a true bath’ (Musuuza et al, 2017; Knobloch et al, 2021; Prudowsky et al, 2023).
Continuum of infection prevention after discharge: reducing readmissions and infection through decolonisation in long-term care and at home
While CHG bathing is primarily discussed in the context of acute-care patients, evidence for the benefit of CHG bathing exists across the continuum of care. Outside of the acute care setting, a patient-centred approach is vital to ensure that recommendations for decolonisation will be followed by appropriate patients. For example, in a cross-sectional survey of 255 nursing home residents and 528 aged care residents receiving home and community-based services, the decision on when to bathe was reported as an important preference for a majority of residents in each segment of care (77%-93%) (Abbott et al, 2018). Therefore, the need to bear in mind differences in acute care bathing frequency versus other settings should be considered.
Long-term acute care
In long-term acute care (LTAC) facilities, the prevalence of multidrug-resistant organisms (MDROs) has been reported to be as high as 80% (McKinnel et al, 2019). CHG bathing protocols in these facilities tend to mirror acute care hospital recommendations. For example, a robust quality improvement project investigated the prevention of colonisation and infection by Klebsiella pneumoniae carbapenemase (KPC) producing Enterobacteriaceae at four LTACs, using a step-wedge design (Hayden et al, 2015). The study evaluated the impact of isolation of KPC-positive patients, bathing all patients daily with CHG and healthcare worker compliance on the primary outcome of KPC rectal colonisation. The researchers indicated that adherence to all intervention bundle components was high (70.8%-95.4%), with the only exception being healthcare worker hand hygiene adherence at room entrance (24.4%). The prevalence of colonisation was consistent in the pre-intervention point prevalence (45.8%, 95% CI (0.421, 0.054), P=0.47 linear change). The slope of the pre-intervention point prevalence declined immediately during the intervention period and then reached a stable state in regard to potential exponential decline (34.3%, 95% CI (0.0324, 0.362), P<0.001). In terms of KPC acquisition only, colonisation fell from 4 to 2 KPC per 100 patient-weeks (P=0.004), representing a 32% reduction in the rate of clinical culture, 53% reduction in blood culture, and 56% reduction in KPC bacteraemia. Additionally, HABI related to any pathogen was decreased by 32% (Hayden et al, 2015).
Home health
The home setting has been investigated for ongoing decolonisation with CHG especially in postoperative patients at risk of surgical site infections, patients who are carriers of MDROs and who are at risk of transitioning from colonisation to infection and pre-operative patients who use CHG showering as a method of risk reduction before elective surgery.
The impact of decolonisation interventions in the home was investigated in a multicentre, randomised controlled trial comparing post-discharge hygiene education vs education plus CHG showering, CHG mouthwash and nasal mupirocin 5 days a week, twice monthly, in MRSA carriers for a period of 1 year after discharge (Huang et al, 2019). In a per-protocol analysis, the rate of MRSA infection was significantly less in the group decolonised with CHG (6.3%) compared to the educational group alone (9.5%). The number needed to treat to prevent any infection was 26 (95% CI 13-212), to prevent an associated hospitalisation was 27 (95% CI 20-46) and to prevent a MRSA infection was 30 (95% CI, 20-336). The decolonisation group had a lower risk of hospitalisation and for those who fully adhered to the protocol, there was a 44% decreased risk of MRSA infection and a 40% decrease of infection of any cause.
For the presurgical patient, showering with CHG prior to the day of surgery is recommended for the reduction of surgical site infection risk (Wang et al, 2017). However, there are varied results from various frequencies suggested for the number of days before surgery. In general, consistent daily application of 4% CHG liquid is necessary to develop appropriate skin concentration levels. Levels of CHG concentration rates have been reported to require ≥18.75μg/mL for Gram-positive microbial density reduction, while MDROs often require a greater resting concentration (Popovich et al, 2012). A randomised prospective cohort study of patients undergoing orthopaedic surgeries at four hospitals compared three separate pre-operative techniques including 2-day, 3-day and 6-day treatment periods, which included a bath immediately before surgery (Warren et al, 2021). All three techniques achieved CHG concentrations above the recommended threshold; however, there was a statistically significant difference in the skin concentration of 6-day bathers and those only having two or three preoperative baths.
The nurses' role from a home health perspective is to provide sufficient education, awareness and support for the patient providing CHG bathing at home, including the schedule and protocol for successful bathing. For example, to ensure successful decolonisation before surgery, patients require education including educational videos or demonstrations to optimise the effectiveness of the shower for risk reduction. Additionally, nurses may need to assess patients for their functional capacity to perform self care and devices such as long-handled brushes or loofahs may be needed to ensure access to hard-to-reach locations. Lastly, in those patients with severe physical limitations or morbid obesity, the nurse may need to teach a caregiver or provide the patient with assistance in appropriate product application. In addition, the nurses' role to promote safety, such as avoiding contact of CHG products with the eyes is imperative in their interventions within the community.
Conclusion
CHG bathing is an efficient and effective method for skin decolonisation and reducing the risk of HAI and surgical site infections across the continuum of care. From the initial use of CHG in the intensive care setting, the practice has expanded to targeted bathing of non-ICU device patients to recent trends demonstrating the success of a horizontal bathing approach, ‘hospital-wide’. Regardless of setting, staff and patient compliance with the use of CHG, appropriate technique, frequency of bathing, and protocol adherence are critical for reducing and sustaining reductions in HAIs.
KEY POINTS
- Chlorhexidine gluconate (CHG) bathing, as part of a comprehensive infection control strategy, has been demonstrated to reduce the risk of healthcare-associated infections (HAIs) in intensive care unit patients and patients with central lines compared to soap and water bathing
- Consistent delivery of daily patient bathing with CHG, using an appropriate technique by nursing staff, determines the effectiveness of this treatment intervention for patient decolonisation
- Patient education to ensure understanding of HAI risk while in hospital is a key step to improve CHG bathing compliance
- Nurses should assess the potential benefits of CHG bathing across the continuum of care, such as in residential facilities and in the community
- Routine data surveillance of HAIs is imperative to demonstrate the cost-effectiveness and return on investment of CHG before and after implementation
CPD reflective questions
- How do you provide surveillance for hospital-acquired infections in your healthcare facility?
- What level of importance does your practice put on patient hygiene and appropriate decolonisation to ensure positive patient outcomes?
- Do you currently advocate for chlorhexidine gluconate (CHG) bathing in your practice setting? Why or why not?