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Purpose of the review
Daily bathing with 2% chlorhexidine gluconate (CHG) cloths is common in intensive care units (ICUs) because CHG lowers the number of bacteria on the skin, and skin flora can travel along catheters into the blood. This review asks whether the evidence supports CHG bathing for all ICU patients, using three large randomized trials found in CINAHL and PubMed.
The studies
| Study | Design and setting | Main finding |
|---|---|---|
| Climo et al. (2013) | Cluster-randomized crossover trial; 9 ICUs and bone marrow transplant units in 6 hospitals; 7,727 patients | Hospital-acquired bloodstream infections were 28% lower with CHG bathing (4.78 vs. 6.60 per 1,000 patient-days), and acquisition of multidrug-resistant organisms was 23% lower |
| Huang et al. (2013) | Cluster-randomized trial; 43 hospitals, 74 ICUs, 74,256 patients | Universal decolonization (CHG bathing plus nasal mupirocin for every patient) reduced bloodstream infections from any pathogen more than screening and isolation or targeted decolonization; 1 bloodstream infection was prevented for every 54 patients decolonized |
| Noto et al. (2015) | Pragmatic cluster-randomized crossover trial; 5 ICUs in one medical center; 9,340 patients | No difference in a composite of central line infections, catheter-associated urinary tract infections, ventilator-associated pneumonia and C. difficile (2.86 vs. 2.90 per 1,000 patient-days) |
Synthesis
Two of the three trials found fewer bloodstream infections with CHG, and the largest one did so across 43 community and teaching hospitals. The negative trial measured a different outcome: a composite that included urinary infections, pneumonia and C. difficile, which skin antisepsis would not be expected to prevent as directly as bloodstream infections. Its baseline infection rate was also low, which makes a difference harder to detect. Read together, the trials suggest CHG bathing is most likely to help where bloodstream infections are the target and baseline rates are higher.
Limitations of the evidence
None of the trials could blind staff to the type of cloth, and two used crossover designs, so practice changes over time could affect results. Huang et al. (2013) combined CHG with mupirocin, so its effect can't be credited to bathing alone. Adverse skin reactions were rare in all three studies.
Implications for nursing practice
The evidence supports CHG bathing in ICUs as part of a bloodstream infection prevention bundle, done correctly: no-rinse cloths, avoiding the face and mucous membranes, and not mixing CHG with incompatible soaps or lotions. Units should track their own bloodstream infection rates before and after a change, because the benefit depends on the starting rate.
References
Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., Weinstein, R. A., Sepkowitz, K. A., Jernigan, J. A., Sanogo, K., & Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368(6), 533–542. https://doi.org/10.1056/NEJMoa1113849
Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T. R., Lankiewicz, J., Gombosev, A., Terpstra, L., Hartford, F., Hayden, M. K., Jernigan, J. A., Weinstein, R. A., Fraser, V. J., Haffenreffer, K., Cui, E., Kaganov, R. E., Lolans, K., Perlin, J. B., & Platt, R. (2013). Targeted versus universal decolonization to prevent ICU infection. New England Journal of Medicine, 368(24), 2255–2265. https://doi.org/10.1056/NEJMoa1207290
Noto, M. J., Domenico, H. J., Byrne, D. W., Talbot, T., Rice, T. W., Bernard, G. R., & Wheeler, A. P. (2015). Chlorhexidine bathing and health care–associated infections: A randomized clinical trial. JAMA, 313(4), 369–378. https://doi.org/10.1001/jama.2014.18400
