Use of Chlorhexidine Baths to Reduce Central-Line Associated Bloodline Infections
Central lines are catheters which are placed in large veins of patients. Some of the large veins where the central line is placed include those in the groin, arm and neck. Central lines are used in drawing blood, administration of medications and fluids to critically ill patients. In certain situations, germs and bacteria can infiltrate the central line thus entering the bloodstream of the patient.
are infections of the bloodstream that are confirmed by the laboratory in a patient having a central line when the symptoms begin or within forty-eight hours before the symptoms begin. Rupp et al. (2012) report that CLABSIs have no relationship to an infection occurring at another site. The most common cause of CLABSI is the gram-positive organisms which include coagulase negative staphylococci and Staphylococcus aureus (Denny, 2016). Other causes are linked to the healthcare providers. Healthcare providers can cause CLABSI if they: do not perform hand hygiene, do not apply the correct antiseptic on the skin, and insert the prep agent when wet before insert in the central line. CLABSIs can also develop if healthcare provider fail to take the barrier precautions of ensuring maximum sterility such as masks, cap, gloves that are sterile and large drapes that are sterile.
Failure to follow the maintenance practices that are recommended after insertion of the central line by the healthcare provider can also lead to CLABSI. Insertion of the central line, by a healthcare provider, in a vein where the risk of infection is high can lead infection. Sometimes clinicians fail to wash their hands with a hand rub or soap and water before they touch the central line hence exposing patients to the risk of CLABSI. Kim et al. (2014) report that a delay in the removal of the central line when it is not needed increase the chances of infections. Failure of the healthcare professionals to wear gloves or clean their hand before changing the dressing that covers the region where the catheter enters the skin.
Shah et al. (2016) suggest that the use of targeted interventions especially in ICUs can have significant reduction in the risk of Hospital-Acquired Bloodstream Infections (HABIs) such as CLABIs. The use of antiseptics, especially chlorhexidine gluconate, is also highly recommended as an essential intervention for managing CLABSIs. Chlorehexidine gluconate (CHG) is an antiseptic which has a broad spectrum of activity against especially on gram positive microorganisms such as Staphylococcus aureas as well as gram negative microorganisms such as enterococcus species. Unlike other commonly used antiseptics such as normal soap and water, chlorhexidine possesses residual anti-bacterial activity, and therefore, can reduce the microbial burden on the skin of patients and prevents secondary contamination from the environment.
PICOT Question
This research is aimed at studying the impact of the daily use of Chlorhexidine bath on the outcomes of adult patients in the ICU with central-line associated bloodstream infection. This study is guided by the PICOT question: In adult patients in Intensive care units (P), does daily use of chlorhexidine bath (I) compared to the use of ordinary soap and water (C), decrease the central-line associated bloodline infections (O), in a period of five months (T)? The comprehension of the impact that chlorhexidine bath can hold on improving the outcome of the patients has a significant effect on nursing care. This information can provide evidence to the practices of nurses. When poor nursing practices are applied, they may lead poor patient outcomes, other complications and risk factors and in the long run an extended stay at the hospital. Therefore, by carrying out a study on CLABSI and ways to reduce it, will result in better patient care hence better patient outcome.
Prevalence
In the United States, about 250,000 infections of the bloodstream occur yearly, and most of these infections are related to intravascular devices such as central lines. In the US ICUs, the rate of CLABSI is approximated to be 0.8 per 1000 central line days (Shah et al. 2016). Research shows that most of the central lines are not found within the ICU. A study also showed that 24% of patients not in ICU and 55% of patients in ICU had central lines. However, the research showed that 70% of the hospitalised patients who had central venous catheters were not in the ICU.
Impact
CLABSI increase the cost of healthcare. In the United States, an estimated 2 million cases of healthcare associated infections (HAIs) are reported per year. This leads to the demise of about ninety thousand people. Bloodstream infections due to central lines have also been led to increase in the hospital stay of patients (CDC, 2011). These infections often lead to further complications since the patient might acquire other nosocomial infections from the healthcare centre or persons. This will necessitate the patient to stay in the hospital for an extended period to receive treatment. CLABSI often leads to complications that are either immediate or delayed, and this varies depending on the vein that is assessed. High morbidity and mortality often result from these complications. These complications, in the long run, lead to an increase in the burden of treatment, long hospital stay and low quality of life of the patients
ANALYSIS
In recent times, CLABIs have been a major concern in most health care settings. This has prompted various researchers to dig deep and come up with an intervention of controlling this menace. It has been projected that the use of chlorhexidine could be having better patient outcomes compared to the use of normal soap and water in managing CLABSIs. Various scholars have conducted studies to try and determine the effectiveness of chlorhexidine in reducing CLABIs. For instance, Karki & Cheng (2012) carried out a systematic review using 16 published studies and 4 conference abstracts. The review aimed at examining the impact of skin cleansing or body bath using chlohexidine gluconate (CHG) in controlling hospital acquired infections as well as colonization. The studies used were consisted of cross-over trials, randomized controlled trials, cohort studies as well as before-and-after studies. Karki & Cheng (2012) compared the effect of 2% chlohexidine non-rinse washcloths with the effect of normal soap and water and cleansed using non-medicated washcloths. The study concluded that the use of 2% CGH non-rinse washcloths in skin cleansing aids in reducing the risk of CLABSI, colonization with methicillin resistant Staphylococcus aureas, surgical site infections, and vancomycin-resistant enterococci (VRE).
As similar study was done by Kim et al. (2016) whose primary objective was to examine the effect of chlorhexidine gluconate bathing on hospital-acquired infections in patients who are critically ill. The researchers, used eighteen studies where six of the studies used randomized control designs while 12 used the quasi-experimental design. The meta-analysis study found out that daily usage of chlorhexidine gluconate bathing reduced the infection of MRSA, CLABSI as well as VRE in patients who are admitted in ICU settings.
Climo et al. (2013) also carried out a study whose hypothesis was daily bathing of patients using chlorhexidine gluconate aids in preventing CLABSI and colonization with multidrug-resistant microorganisms (MDRMs). In the study, chlorhexidine impregnated in washcloths was used. Nine ICU centers and bone marrow transplantation settings in 6 hospitals were chosen randomly to bathe patients using 2% chlorhexidine gluconate (Climo et al. 2013). Some patients who served as a control group were washed using non-antimicrobial washcloths. The study was carried out for a period of six months after which the rate of infection with CLABSI and acquisition of MDRMs were compared between the two groups. Data was analyzed using a Poisson regression analysis. A total of 7727 patients were enrolled in the study. The findings indicated that the overall rate of central line acquired bloodstream infections was 4.78 for patients bathing with chlorhexidine and 6.6 for patients bathing with non-antimicrobial washcloths. In addition. The acquisition rate of MDRMs was 5.10 for patients using chlorhexidine and 6.6 for those using non-antimicrobial washcloths. During both studies, no serious dermatological infections were noted. The researchers concluded that bathing patients using chlorhexidine that is impregnated in washcloths significantly reduces patients’ risk of acquiring MDRMs and infection from hospital acquired bloodstream infections.
Before their study, Seyman et al. (2014) acknowledged that the use of chlorhexidine had been used as a measure for reducing hospital acquired infections. However, the frequency of chlorhexidine application was not clear since some health centers apply it daily while others weekly. As a result, they conducted a study with the aim of finding out the effectiveness of conducting weekly whole-body douche with chlorhexidine gluconate in the control of hospital acquired bloodstream infections. For the study, three centers, that is surgical, medical as well as anesthesiology ICUs were used from June 2011 to Nov 2012. This period was divided into distinct periods whereby patients were subject on daily bathing using normal water and soap in the first period. In the second period, patients were subjected to weekly douche using normal soap and water while in the third period weekly douche of chlorhexidine gluconate was used. The results for hospital acquired blood stream infections for each period were determined and a comparison done. After the study, the researchers noted that the rates of infection were 7.1 for the first period, 4 for the second period, and 1.7 for the third period. They concluded that weekly douching with chlorhexidine gluconate is superior in reducing bloodstream infections compared to weekly douching with normal soap and water.
According to Rupp et al. (2014), chlorhexidine gluconate has for some time been used in bathing patients in critical care centers to prevent CLABSI as well as acquisition of multidrug resistant infections. Rupp et al. (2014) conducted their own research to find out the impact of bathing patients using CHG with regard to hospital acquired bloodstream infections. The study was done using three cohorts. An academic medical center was used an all patients in critical centers were included in the study except neonates and infants. A total of 68, 302 chlorhexidine baths were administered. Admnistration was done thrice weekly or daily and compliance monitored. The findings indicated that there was a significant decrease in the number of patients infected with Clostridium difficile. However, the rate of infection among the three cohorts increased during the washout period. Based on their study, the scholars concluded that bathing with CHG was properly tolerated and had a considerable decrease in the rate of Closridium difficile infections among patients who were hospitalized in critical settings.
The study by Swanson et al. (2016) was a single bling, singe-center, randomized trial. The objective of this study was to do a comparison between daily bathing patients with 2% chlorhexidine with daily use of normal soap and water. A total of 161 participants were used in the study and 164 were control patients. Results indicated that there was an overall reduction in the rate of catheter associated urinary tract infections (CAUTI), surgical site infections (SSIs), ventilator associated pneumonia (VAP) as well as primary bloodstream infections. Based on the results, Swanson et al. (2016) made a conclusion that daily bathing of critically ill patients is effective in reducing the incidence of bacteremia.
Summarize the research and Validity of Methods
This study aims at reviewing literature which answers the following PICOT question: In adult patients in Intensive care units (P), does daily use of chlorhexidine bath (I) compared to the use of ordinary soap and water (C), decrease the central-line associated bloodline infections (O), in a period of five months (T)? The results obtained in this study are consistent with those of other studies in that the use of chlorhexidine in bathing critically ill patients in ICUs can help in decreasing the risk of Central Line Associated Bloodstream Infections (CLABSIs). Bathing with chlorhexidine gluconate reduces gram positive bacteremias which in turn reduces the overall reduction of the incidence of CLABSIs, VRE, MDRMs, and MRSA.
In clinical studies, the use of systematic reviews is preferred since they are not only thorough, but also an explicit and comprehensive way of analyzing medical literature (Polit & Beck, 2017). Conversely, meta-analysis is also an important research approach which entails combination of data obtained from systematic reviews. These methods are valid because they are based on previous studies which were are peer-reviewed and therefore can be relied upon as important sources of medical data. Randomized clinical studies are quasi-experimental in nature hence help in obtaining precise and reliable information on what the patients experience during daily delivery of care. They can also be relied upon because they help in highlighting the current situation on health centers. Unlike systematic studies that are based on previously done studies which by time could have different data based on the dynamic nature of health centers particularly the nature of microorganisms. For instance, microorganisms could have mutated and brought a different picture from what was being observed a while ago this cannot be noticed in systematic or meta-analysis studies. All these methods indicated that the use of 2% chlorhexidine gluconate can be effective in reducing the rates of CLABSIs in critically ill patients.
Consistencies and Contradictions
The results obtained in this study are consistent with previous research that chlorhexidine gluconate is a superior antiseptic compare to normal water and soap in the management of CLABSIs in ICUs. Some of the contradictions that were noted in this study is that it is the frequency for administering chlorhexidine is not clear since some studies recommend either daily administration or weekly administration. Also, the impact of using impregnated chlorhexidine (soaked chlorhexidine) or plain chlorhexidine is not clearly settled.
Conclusion/Recommendations
There is a high prevalence of CLABSIs among critically ill patients such as those in ICUs. CLABSIs can result to several complications which can cause mortality and morbidity among patients. This why several practices have been developed to aid in mitigating this CLABIS. The use of chlorhexidine has been fronted as an effective way of reducing the risk of CLABSIs. A number of studies were used all of which gave credible evidence that use of chlorhexidine has positive patient outcomes. Therefore, use of chlorhexidine can aid in reducing the morbidity and mortality related to CLABSIs.
Health centers with critically ill patients where CLABSIs are common should adopt the intervention of daily bathing of the patients using chlorhexidine gluconate. This is a straightforward measure which does not require significant change from patient-bathing practices. The strategy has also proven to be more effective compared to the use of normal soap and water which increases the risk of patients to CLABSIs. It is also important to note that bathing patients using CHG is a simple, safe, and cost-effective strategy that can easily be implemented in any clinical setting. From the studies, it was evident that most of the studies aimed at reducing CLABSI caused by bacterial infections. CLABSIs can also be caused by other microorganisms such as fungi, and therefore, further research is required to examine the effect of chlorhexidine gluconate on fungal infections.
References
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Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., & … Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. The New England Journal of Medicine, 368(6), 533-542. doi:10.1056/NEJMoa1113849
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