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Chlorhexidine wipes don’t prevent ICU infections

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Wash your hands instead

The current study suggests that widespread adoption of daily chlorhexidine bathing is not indicated at this time. Rather, institutions with infection rates similar to those reported should adopt a simpler, less expensive approach that focuses on basic hygiene practices, according to Dr. Didier Pittet and Dr. Derek Angus.

Although chlorhexidine bathing was found previously to reduce health care–acquired infection, the largest benefit appears to be in settings with a high baseline prevalence of multidrug-resistant organisms. In these settings, the same potential benefits could be gained through other approaches, such as improved hand hygiene, which may be safer and less likely to affect the ecology of bacterial resistance in the ICU.

Widespread treatment of patients with antimicrobials – whether antibiotics, antivirals, antifungals, or biocides – has never been a good idea. Issues around chlorhexidine use include allergy, costs, resistance, and even safety. Widespread use of biocidal antiseptics might constitute a biologic hazard via increased selective pressure on microbial populations, potentially allowing more pathogenic organisms to flourish or facilitating resistance gene transfer.

These remarks were excerpted from an accompanying editorial (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18482]).

Dr. Pittet is director of the infection control program at the University of Geneva Hospitals in Switzerland. Dr. Angus is chair of the department of critical care medicine at the University of Pittsburgh Medical Center. They reported having no financial disclosures.


 

AT THE CRITICAL CARE CONGRESS

References

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

An illustration of the ultrastructural morphology exhibited by a single Gram-positive Clostridium difficile bacillus. CDC / Jennifer Hulsey

An illustration of the ultrastructural morphology exhibited by a single Gram-positive Clostridium difficile bacillus.

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

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