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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.
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.
Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.
A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).
“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.
Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.
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.
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.
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.
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.
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.
Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.
A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).
“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.
Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.
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.
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.
Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.
A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).
“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.
Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.
AT THE CRITICAL CARE CONGRESS
Key clinical point: Save your money: Chlorhexidine wipes don’t cut infection rates in the ICU.
Major finding: The composite rate of ICU infections was 2.86/1,000 patient-days with chlorhexidine wipes, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95).
Data source: Randomized, crossover study of 9,340 patients at five adult ICUs
Disclosures: The work was funded by the National Institutes of Health and Vanderbilt University. The lead author has no disclosures. A coauthor reported that his spouse receives research funding from SanofiPasteur, Gilead, and MedImmune, and is an advisor for Teva.
