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Chlorhexidine Bathing and Health Care-Associated Infections Among Adult Intensive Care Patients: a Systematic Review and Meta-Analysis
Frost SA, Alogso M, Metcalfe L, et al. Critical Care. 2016;20:379.
Study Question: How effective is daily chlorhexidine (CHG) bathing in preventing health care-associated infections (HAI) among adult intensive care patients?
Study Description: A systematic literature search was conducted via keywords utilizing MEDLINE, EMBASE and Cochrane Library databases up to March 2016. Trials reporting the effectiveness of CHG in infection reduction among adult intensive care unit (ICU) patients were included. Review papers were excluded, as were trials of non-ICU and non-adult populations. Data extracted from each trial included study design, site, type of ICU setting, infection of interest and number of events per ICU days-at-risk. Specific infections studied were bloodstream infections (BSI), central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and Clostridium difficile (C diff). A Bayesian approach to statistical analysis was utilized to account for the variation between study designs. As a result, statistical significance was reported with the use of credible intervals (CrI) rather than confidence intervals. The CrI interpretation is the same as a confidence interval (i.e. not including 1.0 is considered statistically significant).
Results: A total of 114 trials were identified, and after content review, 17 were included in this review. A total of 7 trials utilized a cluster-randomized, crossover design and the remainder utilized a before-and-after design. Daily CHG bathing was estimated to reduce BSI by 21% (95% CrI 0.60-1.03), CLABSI by 56% (95% CrI 0.26-0.75), CAUTI by 7% (95% CrI 0.45-1.66), VAP by 18% (95% CrI 0.57-1.25), MRSA colonization and bacteremia by 41% and 36% respectively (95% CrI 0.36-0.94 and 0.43-0.91, respectively), both VRE colonization and bacteremia by 37% (95% CrI 0.20-1.55 and 0.15-2.26, respectively), and C diff by 7% (95% CrI 0.48-1.80). Numbers needed to treat (NNT) were reported; the lowest NNTs were demonstrated for the prevention of CLABSI (NNT = 360) and VRE colonization (NNT = 425). The largest NNTs were demonstrated for the prevention of MRSA bacteremia (NNT = 2,780) and C diff (NNT = 14,290).
Conclusion(s): Daily CHG bathing was found to reduce CLABSI and MRSA infections in adult intensive care patients.
Perspective: While this study reports statistically significant reductions in CLABSI and MRSA infection rates in adult intensive care patients who receive daily CHG bathing, significant NNTs were also demonstrated. These NNTs were estimated using a median baseline risk of the specific HAI per 1000 days. Therefore, the results are highly dependent upon the underlying risk of the HAI in a specific ICU. In an ICU with CLABSI rates lower than the median for example, the NNT would significantly increase. This may be more prevalent in ICUs with bundles and procedures already in place to prevent HAIs. If the findings of this study are to be incorporated into an organization’s infection control plan, they must be interpreted through the lens of that specific organization’s infectious milieu.