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HLORHEXIDINE
C N E 1.0 Hour
Notice to CNE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Compare the rate of bacterial contamination
on bath basins using soap to those basins
where a standardized chlorhexidine solution is
used for bathing.
2. List 3 common organisms found in patients
bath basins.
3. Describe how basin, device, infection control,
and isolation variables affect culture results
when using chlorhexidine for patient baths.
To read this article and take the CNE test online,
visit www.ajcconline.org and click CNE Articles
in This Issue. No test fee for AACN members.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012242
338
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5
www.ajcconline.org
atients bath basins in hospitals are a known source of microbial contamination.1,2 In a previous study,1 bath basins from which samples were cultured in 3
acute care hospitals were found to be reservoirs for bacteria and potentially associated with the development of hospital-acquired infections. Bacteria grew in 98%
of the basin samples, with the most prominent being enterococci (54%) and
gram-negative organisms (32%).1 More alarming in this study was the association between
microbes found in the bath basins and infection of patients.
Methods
Bathing Procedure
Before the start of the study, standardized procedures for patient hygiene and storage of wash basins
were in place. ICU nurses bathe patients with 2 fl
oz (60 mL) CHG to 3 qt (2.85 L) water in bath
About the Authors
Jan Powers is director of clinical nurse specialists and a
clinical nurse specialist in the trauma intensive care unit
at St Vincent Hospital in Indianapolis, Indiana. Jennifer
Peed and Lindsey Burns are staff nurses in the medical
intensive care unit at St Vincent Hospital. Mary ZiembaDavis is a research scientist on the clinical nurse specialist
team at St Vincent Hospital.
Corresponding author: Jan Powers, RN, PhD, Director of
Clinical Nurse Specialists and Nursing Research, Trauma
Intensive Care Unit Clinical Nurse Specialist, St Vincent
Hospital, 2001 West 86th Street, Indianapolis, Indiana
46260 (e-mail: jmpowers@stvincent.org).
www.ajcconline.org
Patients hospital
bath basins are
a known source
of microbial
contamination.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5
339
Table 1
Bath basin study comparisonsa
No. (%) of patients
Cleaning agent used
Chlorhexidine (current study)
Soap and water (Johnson et al., 2009)1
a
Bacterial
growth
No bacterial
growth
4 (4.4)
86 (95.6)
90 (97.8)
2 (2.2)
Results
Ninety bath basins from ICU patients were
examined, 42 from female (46.7%) and 48 (53.3%)
from male patients. Patients were from 24 to 88 years
340
Discussion
In dramatic contrast to an existing study1 that
showed 97.8% bacterial growth in 92 bath basins
when soap and water was used to bathe patients,
we observed 4.4% bacterial growth in 90 basins
when CHG solution was used for patients baths.
Our finding reflects a 95.5% reduction in cultures
of bath basins positive for bacteria, indicating that
patient bath basins may not be inevitable sources
of bacterial growth when CHG is used. The
patients sex was the only factor that was associated with positive cultures; other patients characteristics, length of basin use, the presence of
indwelling devices, identified infections, antibiotic
use, and isolation status were not related to positive culture results.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5
www.ajcconline.org
Table 2
Bacterial growth in bath basins by patient,
device, and infection/isolation characteristics
No. (%) of patientsa
Characteristic
Bacterial growth
No bacterial growth
Sex
Female
Male
4 (100.0)
0 (0.0)
38 (44.2)
48 (55.8)
Diagnosis
Medical
Surgical
3 (75.0)
1 (25.0)
71 (82.6)
15 (17.4)
Pb
.04
.55
Age, median, y
Length of stay, median, d
In hospital
In intensive care unit
68.0
60.5
.64c
7.5
7.5
9.0
7.5
.36d
.87e
Central catheter
Yes
No
3 (75.0)
1 (25.0)
43 (50)
43 (50)
.62
Arterial catheter
Yes
No
1 (25.0)
3 (75.0)
12 (14.0)
74 (86.0)
2 (50.0)
2 (50.0)
47 (54.7)
39 (45.3)
Endotracheal tube
Yes
No
3 (75.0)
1 (25.0)
45 (52.3)
41 (47.7)
Tracheostomy tube
Yes
No
0 (0.0)
4 (100.0)
20 (22.2)
70 (77.8)
Ventilator
Yes
No
2 (50)
2 (50)
52 (60.5)
34 (39.5)
Foley catheter
Yes
No
4 (100.0)
0 (0.0)
76 (88.4)
10 (11.6)
1 (25.0)
3 (75.0)
16 (18.6)
70 (81.4)
2 (50.0)
2 (50.0)
52 (60.5)
34 (39.5)
Antibiotics
Yes
No
2 (50.0)
2 (50.0)
65 (75.6)
21 (24.4)
Isolation
Yes
No
0 (0.0)
4 (100.0)
20 (23.3)
66 (76.7)
.47
>.99
.62
.57
>.99
>.99
.57
>.99
.27
.57
aUnits
for age and length of stay are as specified in first column; all other values are No. (%) of patients.
P values based on Fisher exact test, unless W value indicated in footnote.
cWilcoxon rank sum test, W = 3888.5.
dWilcoxon rank sum test, W = 3960.5.
eWilcoxon rank sum test, W = 3922.0.
bMost
www.ajcconline.org
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5
341
Patients bath
basins may not
be inevitable
sources of bacterial growth
when chlorhexidine is used.
342
REFERENCES
1. Johnson D, Lineweaver L, Maze L. Patients bath basins as
potential sources of infection: a multicenter sampling study.
Am J Crit Care. 2009;18:31-40.
2. Marchaim D, Abreu-Lanfranco O, Taylor AR, et al. Hospital
bath basins are frequently contaminated with multi-drug
resistant human pathogens. Poster presented as part of the
40th Annual Critical Care Congress of the Society of Critical
Care Medicine, January 15-19, 2011, San Diego, California.
http://www.sageproducts.com/documents/pdf/education
/symposia/skin/21529_Marchaim_SHEA_poster.pdf.
Accessed June 8, 2012.
3. Batra R, Cooper B, Whiteley C, et al. Efficacy and limitation of
a chlorhexidine-based decolonization strategy in preventing
transmission of methicillin-resistant Staphylococcus aureus
in an intensive care unit. Clin Infect Dis. 2010;50:210-217.
4. Ridenour G, Lampen R, Pederspiel J, et al. Selective use of
intranasal mupirocin and chlorhexidine bathing and the
incidence of methicillin-resistant Staphylococcus aureus
colonization and infection among intensive care unit
patients. Infect Control Hosp Epidemiol. 2007;28:1155-1161.
5. Sandri A, Dalarosa M, Ruschel de Alcantara L, et al. Reduction in incidence of nosocomial methicillin-resistant
Staphylococcus aureus (MRSA) infection in an intensive
care unit: role of treatment with mupirocin ointment and
chlorhexidine baths for nasal carriers of MRSA. Infection
Control Hosp Epidemiol. 2006;27:185-187.
6. Vernon M, Kayden M, Trick W, et al. Chlorhexidine gluconate
to cleanse patients in a medical intensive care unit: the
effectiveness of source control to reduce the bioburden of
vancomycin-resistant enterococci. Arch Intern Med. 2006;
166:306-312.
7. Kassakian SZ, Mermel LA, Jefferson JA, Parenteau SL,
Machan JT. Impact of chlorhexidine bathing on hospitalacquired infections among general medical patients. Infect
Control Hosp Epidemiol. 2011;32:238-243.
8. Climo M, Sepkowitz K, Zuccotti G, et al. The effect of daily
bathing with chlorhexidine on the acquisition of methicillinresistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and healthcare-associated bloodstream
infection: results of a quasi-experimental multicenter trial.
Crit Care Med. 2009;37:1858-1865.
9. Bleasdale S, Trick W, Gonzalez I, et al. Effectiveness of
chlorhexidine bathing to reduce catheterassociated bloodstream infections in medical intensive care unit patients.
Arch Intern Med. 2007;167(19):2073-2079.
10. Munoz-Price L, Hota B, Stemer A, et al. Prevention of bloodstream infections by use of daily chlorhexidine baths for
patients at a long-term acute care hospital. Infect Control
Hosp Epidemiol. 2009;30(11):1031-1035.
11. Popovich K, Hota B, Hayes R, et al. Effectiveness of routine
patient cleansing with chlorhexidine gluconate for infection
prevention in the medical intensive care unit. Infect Control
Hosp Epidemiol. 2009;30(10):959-963.
12. Clark AP, John LD. Nosocomial infections and bath water:
any cause for concern? Clin Nurse Spec. 2006;20:119-123.
13. Sievert D, Armola R, Halm MA. Chlorhexidine gluconate
bathing: does it decrease hospital-acquired infections? Am
J Crit Care. 2011;20:166-170.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5
www.ajcconline.org
CNE Test Test ID A1221052: Chlorhexidine Bathing and Microbial Contamination in Patients Bath Basins.
Learning objectives: 1. Compare the rate of bacterial contamination on bath basins using soap to those basins where a standardized chlorhexidine solution is used
for bathing. 2. List 3 common organisms found in patients bath basins. 3. Describe how basin, device, infection control, and isolation variables affect culture
results when using chlorhexidine for patient baths.
1. What was the purpose of the study described in this article?
a. To assess bath basins for bacterial contamination when chlorhexidine was
used in place of soap
b. To assess bath basins for bacterial contamination when soap was used in
place of chlorhexidine
c. To assess bath basins for bacterial contamination based on patient length
of stay
d. To assess bath basins for bacterial contamination in all ICU patients
2. Which of the following methods was used to determine study
eligibility?
a. Patients had to be admitted to the unit following a surgical procedure.
b. Patients had to use bath basins for at least 5 days.
c. Patients had to be bathed within 6 hours of admission.
d. Patients had to have bath basins changed out every 5 days during admission.
3. Which of the following was considered part of the standardized
bathing practice in the study hospital?
a. Using the bath basin for storing patient supplies
b. Using the bath basin as an emesis basin as needed
c. Using a paper towel to dry the basin following the bath
d. Using a new bath basin for each bath
4. Which of the following was considered a device variable in the study?
a. Time the culture was obtained in relation to time since last bath
b. Isolation status at the time the culture was obtained
c. Presence of a central venous catheter when the culture was obtained
d. Length of stay at the time the culture was obtained
5. How were cultures obtained from the basins in this study?
a. Culture swabs were rolled around the corners and bottom of the basin
when it was dry.
b. Culture swabs were rolled around the corners of the basin after wetting it
with tap water.
c. Culture swabs were rolled around the corners and bottom of the basin
prior to drying it following the bath.
d. Culture swabs were wetted with sterile saline and rolled around the corners
and bottom of the basin.
Test ID: A1221052 Contact hours: 1.0 Form expires: September 1, 2014. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
8. a
b
c
d
7. a
b
c
d
10. a
b
c
d
9. a
b
c
d
11. a
b
c
d
Fee: AACN members, $0; nonmembers, $10 Passing score: 8 correct (73%) Category: A Test writer: Marylee Bressie, RN, MSN, CCRN, CCNS, CEN.
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