Running head: AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 1

An Integrative Review: Chlorhexidine Bathing

Valerie Wallace
Nursing 4122
Bon Secours Memorial College of Nursing

On my honor, I have neither given nor received aid on this assignment, and I pledge that I am in

compliance with the BSMCON Honor System. Valerie Wallace

Abstract
The purpose of this paper is to evaluate available literature concerning the effectiveness of daily

chlorhexidine bathing in reducing adult intensive care unit patients infection risk when

compared to the infection risk of adult intensive care unit patents bathed with non-antimicrobial

soap. Hospital-acquired infections tarnish patient outcomes by increasing healthcare costs and

mortality risks. Topical chlorhexidine application may reduce patient risk for contracting a

hospital-acquired infection, thereby improving patient outcomes. This research follows an

integrative review design. Literature was collected using the online database EBSCO Discovery

Service. Search results uncovered 556 research articles, 5 of which met inclusion criteria and

were incorporated into the study. Results from article findings and analysis were inconclusive.
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 2

Some studies demonstrate that chlorhexidine bathing can be useful in reducing rates of

methicillin-resistant Staphylococcus aureus infections, Vancomycin-resistant Enterococcus

infections, and central-line associated bloodstream infections. Other studies suggest that

chlorhexidine bathing was not beneficial in reducing hospital-acquired infection for adult

intensive care unit patients. Research limitations include the use of a small body of research

from the last 10 years and a lack of experience on the part of the researcher. Additional

limitations include the incorporation of articles with questionable validity and reliability, and the

inclusion of articles that may contain bias. Implications for practice cannot be determined by

this integrative review because there were discrepancies amongst research findings. There is an

indication for future research that would ensure proper chlorhexidine bathing protocol adherence,

active infection surveillance, and the inclusion of varying patient populations from various

localities.

An Integrative Review: Chlorhexidine Bathing

The purpose of this integrative review is to analyze existing research so as to determine if

daily chlorhexidine bathing can reduce the incidence of infections for patients in critical care

units. Hospitalizations can be complicated by hospital-acquired infections, which in turn can

lead to greater lengths of stay, increased health care costs, and increased mortality risks (Noto et

al., 2015). Since patient skin is a housing site for many of the bacteria responsible for hospital-

acquired infections, including multidrug-resistant bacteria, health care facilities across the United

States have implemented chlorhexidine (CHG) bathing protocols for their critically ill patients.

2% chlorhexidine is a safe, low toxic antiseptic agent that is effective against a broad-spectrum

of microorganisms (Popovich, Hota, Hayes, Weinstein, & Hayden, 2010). CHG can be applied

directly to the skin, where it then can cause bacteria cell death by disrupting bacterial cell walls
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 3

(Boonyasiri et al., 2016). Conversely, as chlorhexidine use becomes more prevalent, there is a

chance that bacteria will build up resistance to the molecule (Noto et al., 2015). Furthermore,

chlorhexidine is more expensive than traditional non-antimicrobial soap and water.

Chlorhexidine bathing has the potential to improve patient outcomes by minimizing infection

risk, yet routine CHG use could nullify its antimicrobial effects if microbes are gaining resistance

against the solution. So, in order to determine if daily CHG bathing is beneficial for patient

outcomes, its infection-fighting efficacy needs to be determined. The researchers interest in this

topic is motivated by an interest in preventing hospital-acquired infections. In order to find out

more about the effects of chlorhexidine, research was gathered to answer the researchers PICOT

question: are adult intensive care unit (ICU) patients that receive daily chlorhexidine baths at a

decreased risk for contracting an infection compared to adult ICU patients that bathe daily with

soap and water during their hospitalization?

Research Design, Search Methods, & Search Outcomes
The design for this research is an integrative review. To find relevant research on

chlorhexidine bathing, the online EBSCO Discovery Service database was utilized. Search terms

included CHG, ICU, and infection. Findings were limited to quantitative research studies

that were full-text, peer reviewed, written in English, and published in the last ten years.

Additionally, all research included had to compare the infection rates of adult intensive care unit

patients bathed daily with chlorhexidine gluconate to adult ICU patients bathed daily with non-

antimicrobial soap. As a result of this search, 556 articles were located. Articles were screened

using the above-mentioned screening criteria; articles that did not meet the criteria were

excluded from this integrative review. Articles were also excluded if they were meta-analyses.

Five quantitative articles met the criteria and were included.

Findings/Results
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 4

Results from the reviewed articles suggest that the effectiveness of CHG in reducing

infection transmissions in still inconclusive (Boonyasiri et al., 2016; Dicks et al., 2016; Noto et

al., 2015; Popovich, et al., 2010; Viray et al., 2014). Article summaries can be seen in Table 1.

The following themes were extracted from the research in order to categorize findings:

inconsistent benefits of chlorhexidine, dependent variables studied, and implementation of the

intervention.
Inconsistent Benefits of Chlorhexidine
All five of the research articles included in this integrative review were found to have

varying results with chlorhexidine bathing (Boonyasiri et al., 2016; Dicks et al., 2016; Noto et

al., 2015; Popovich, et al., 2010; Viray et al., 2014). In the quantitative experimental,

randomized, open-lab trial study, Boonyasiri et al (2016) sought to test the hypothesis that daily

chlorhexidine bathing for adult ICU patients would lead to an increase in favorable events

(defined in Table 1), a decrease in the time of multidrug-resistant (MDR) bacterial colonization,

and a decrease in the incidence of hospital-acquired infections including ventilator-associated

pneumonia (VAP), central-line associated bloodstream infection (CLABSI), and catheter-

associated urinary tract infection (CAUTI). Convenience sampling was used to recruit 481

patients for this study. Intervention groups were bathed daily with CHG-impregnated

washcloths, while the control groups were bathed twice daily with non-antimicrobial soap.

Swabs were collected from the nares, axilla, antecubital, groin, and perianal areas on ICU days 3,

5, 7, and 14, or on the day of ICU discharge; swabs were then analyzed by infectious disease

personnel. Data was analyzed using PASW statistical software, version 18.0. Data was

processed further using the 2 test or Fisher exact test, the unpaired t test or Mann-Whitney test,

and survival analysis. No significant differences were found between the intervention and
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 5

control groups rates of favorable events, MDR bacteria colonization-free time, hospital-acquired

infections, or lengths of ICU stay.

Dicks et al. (2016) conducted an interrupted time series analysis within their quantitative,

experimental study. In this study, the researchers sought to find evidence supporting the notion

that daily chlorhexidine bathing can lead to a reduction in the occurrence of hospital-acquired

infections including methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant

Enterococci (VRE), and other non-species specific infections. ICU patients from 33 different

hospitals in the Duke Infection Control Outreach Network (DICON) from January 2008 through

December 2013 were included using convenience sampling. Some of those ICUs instituted daily

CHG bathing protocols, so those ICUs populated the intervention group; the remaining hospitals

continued to bathe their patients daily with non-antimicrobial soap. Data collection required

nurses to collecting blood, urine, or swab samples from patients; those swabs were then analyzed

for microorganism growth. Data analysis was completed using a multivariate piecewise Poisson

mixed-effects model, Akaike Information Criterion, nonlinear modeling, and a change-in-

estimate approach. The results of this study found that there was a significant decrease in

CLABSIs, bloodstream infections (BSI), and VRE infections in patients that were bathed with

CHG. There was not a significant difference in the rate of CAUTIs caused by VRE or MRSA

infections though in those bathed daily with CHG.

Noto et al. (2015) designed a pragmatic cluster randomized, crossover, controlled,

quantitative experimental study to identify the effect of daily bathing with CHG-impregnated

cloths on the contraction of the following hospital-acquired infections: CLABSI, CAUTI, VAP,

or Clostridium difficile. 9,340 participants were recruited from five adult ICUs at a tertiary care

facility for this study using convenience sampling. Patients enlisted in the intervention group

received daily CHG baths, whereas patients in the control group received daily non-antimicrobial
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 6

soap baths. Data collection methods were not described. Researchers analyzed their findings

using Mann-Whitney U tests, the Poisson model, a logistic regression model, and a sensitivity

analysis. The findings from this study suggest that there was no significant difference in the

contraction rates of hospital-acquired infections between patients bathed with CHG and patients

bathed with non-antimicrobial soap.

In the quantitative, quasi-experimental study, Popovich et al. (2010) used a pre-post study

design to evaluate the effect of daily CHG bathing of ICU patients on the transmission rate of

CLABSIs, C. difficile infections, BSIs, VAP, UTIs; additionally, this study monitored patients for

MDR bacterial growth, and they monitored blood cultures for contamination. A total of 3,695

patient days in the ICU were examined as the researchers tracked patients at the Rush University

Medical Center ICU from September 2004 through October 2006. Convenience sampling was

used to collect the studys participants. Patients that were admitted to the ICU from September

2004 to October 2005 served as the control group for this study; these patients were bathed daily

with a non-antimicrobial Dial brand bar soap. Patients admitted to the ICU from November

2005 to October 2006 served as the intervention group, as they were bathed daily with CHG-

impregnated cloths. Patient culture data was collected from patient, administration, infection

control practitioner, and microbiology databases. The data gathered was then analyzed using the

Poisson regression model, proc genmod distribution, t tests, and the SAS 9.1. The results of this

study suggest that there was a significant decrease in blood culture contamination after the

implementation of daily CHG bathing, but there was no significant difference in the contraction

of UTIs, BSIs, VAP, C. difficile infections, and CLABSIs, and there was no evidence to suggest

that MDR bacterial colonization rates were diminished.

Viray et al. (2014) organized a quantitative experimental study using a prospective pre-

post-intervention design in order to find a trend between the use of CHG bathing and the
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 7

contraction of Staphylococcus aureus infections, particularly MRSA infections. Convenience

sampling was used to enlist medical and surgical ICU patients admitted to the Barnes-Jewish

hospital in St. Louis, Missouri from 2002 to 2007; a total of 53,526 patient days in the ICU were

studied. Patients that were admitted to the ICU before the implementation of a daily CHG

bathing protocol were used as the control group; these patients were bathed daily with a non-

antimicrobial soap, Aloe Vesta 2-n-1 Body Wash and Shampoo. Patients admitted after the daily

CHG bathing protocol was put in place were used as the intervention group. Nurses participated

in data collection as they swabbed patient nares on the day of ICU admission, 48 hours after

admission, weekly during the ICU stay, and at the time of ICU discharge. Those swabs were

then cultured to test for S. aureus growth. The data collection from cultured swabs was analyzed

with EViews 6 (HIS Global) system, using the ordinary least squares regression tool, Durbin

Watson statistic test, Box-Ljung Q(k) test, autoregression moving average model, Andrews-

Ploberger test, and Wilcoxon rank-sum test. The researchers found that there was a significant

decrease in MRSA and non-Methicillin resistant S. aureus infections when patients were bathed

daily with CHG.

Dependent Variables Studied
As each of the studies included in this integrative review examine varying infections, it is

hard to determine the true impact of CHG bathing on reducing infections. The findings from the

Viray et al. (2014) study suggest that CHG bathing is effective in reducing MRSA infections, but

that study did not evaluate the effect of CHG against any other type of infection. Dicks et al.

(2016) also studied the effects of CHG on MRSA, but VRE, CLABSI, VAP, CAUTI, and BSIs

were also examined; findings suggest that CHG was only beneficial in reducing CLABSI and

VRE infections. Popovich et al. (2010) examined the effects of CHG bathing against CLABSI,

UTI, VAP, BSI, and C. difficile infections, in addition to MDR bacterial colonization; findings
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 8

suggest that CHG was not effective against any of those infections. Boonyasiri et al. (2016) and

Noto et al. (2015) also examined the effects of CHG on reducing CLABSI, CAUTI, and VAP

rates, but Boonyasiri et al. (2016) also examined MDR colonization in contrast to Noto et al.

(2015), who studied C. difficile rates in addition to those previously stated. As for both

Boonyasiri et al. (2016) and Noto et al. (2015), findings suggest that CHG is not effective in

reducing infection or colonization rates.

Implementation of Intervention
While all of the studies identified daily chlorhexidine bathing as their intervention, the

researchers implemented the baths in different ways. Noto et al. (2015) and Popovich et al.

(2010) both detailed their bathing process as one using Sage Products no-rinse 2% chlorhexidine

gluconate cloths; the bathing procedure in both studies was explained as one that followed the

manufacturers instructions, although those instructions were not included in the study.

Boonyasiri et al. (2016) described their chlorhexidine bathing process as one that was issued by

nurses using six sequential washcloths from neck to toe; washcloths were impregnated with a 2%

CHG solution that was created in the hospitals lab. Instead of using CHG-impregnated cloths,

Viray et al. (2014) implemented a CHG bathing policy that required hospital staff to wash

patients from neck to toe using cotton washcloths dipped in a 0.175% CHG solution from a bath

basin; the CHG solution was not applied to the perineum, open wounds, or areas above the neck.

The bathing process used by Dicks et al. (2016) cannot be determined, as it was not described in

the study. Because all of these studies applied the intervention differently, clear comparisons in

the findings cannot be drawn.

Discussion/Implications
Findings collected in this integrative review examine the effects of daily CHG baths in

reducing infection transmission rates in adult ICU patients; therefore, all of the articles included
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 9

directly relate to the researchers PICOT question which asks if daily CHG bathing reduces

infection rates in adult ICU patients during their hospitalization compared to daily non-

antimicrobial soap bathing. Findings from Viray et al. (2014) suggest that CHG bathing is useful

in reducing MRSA and S. aureus infections, and findings from Dicks et al. (2016) suggest that

CHG bathing may reduce the transmission of CLABSIs and VRE infections. Results from

Popovich et al. (2010), Boonyasiri et al. (2016), and Noto et al. (2015) contend with the other

studies in that their findings suggest that chlorhexidine is not effective in reducing the

transmission of various hospital-acquired infections. Implications for practice are difficult to

determine due to the discrepancies in study findings. In order to disseminate the true efficacy of

CHG, further research is indicated. Follow up research would be most beneficial if diverse

patient populations from varying states were included. Furthermore, future research could hold

more validity if researchers clearly outlined CHG bathing protocols, and if proper CHG bathing

administration was ensured. Data from future research could also support the findings more

thoroughly if active infection surveillance, such as regular nasal swab or blood culture collection,

was ongoing and clearly detailed.

Limitations
Several factors limit this research. Only five articles were included in this study, all of

which were published in the last ten years; so, this integrative review is not an exhaustive

examination. Furthermore, an undergraduate student with very little research experience

completed this integrative review as a class assignment, so the quality of the findings may be

lacking.
Articles included in this study also have limitations that threaten the validity of the

findings. Some of the articles in this study do not clearly describe CHG bathing procedures, so

findings from those studies have limited validity and reliability (Coughlan, Cronin, & Ryan,

2007). The validity and reliability of research is questionable when data collection methods are
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 10

poorly described, as was the case in the Dicks et al. (2016), Noto et al. (2015), and Popovich

(2010) studies (Coughlan et al., 2007). All of the studies included are prone to bias since all of

them utilized a convenience sampling method (Boonyasiri et al., 2016; Dicks et al., 2016; Noto

et al., 2015; Popovich, et al., 2010; Viray et al., 2014; Coughlan et al., 2007). Findings from

Popovich et al. (2010) are weaker because this study was a quasi-experimental study (Coughlan

et al., 2007). Findings are limited further because none of the articles clearly operationalize their

variables, and none of them discuss the validity of instruments used (Boonyasiri et al., 2016;

Dicks et al., 2016; Noto et al., 2015; Popovich, et al., 2010; Viray et al., 2014; Coughlan et al.,

2007).
Conclusions
Findings from this integrative review are contended. One study indicates that daily CHG

bathing may be useful in reducing MRSA infection transmission (Viray et al., 2014). Another

study suggests that CHG is not useful in reducing MRSA transmission but is effective in

reducing CLABSI and VRE infections (Dicks et al., 2016). Then there are several studies

indicating that CHG is not effective in reducing CLABSIs or other hospital-acquired infections

(Boonyasiri et al., 2016; Noto et al., 2015; Popovich et al., 2010). Overall, it cannot be

determined if daily chlorhexidine bathing is useful for reducing infection risks in adult ICU

patients when compared to daily non-antimicrobial soap bathing.

References
Boonyasiri, A., Thaisiam, P., Permpikul, C., Judaeng, T., Suiwongsa, B., Apiradeewajeset, N., . . .

Thamlikitkul, V. (2016). Effectiveness of chlorhexidine wipes for the prevention of

AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 11

multidrug-resistant bacterial colonization and hospital-acquired infections in intensive

care unit patients: A randomized trial in Thailand. Infection Control & Hospital

Epidemiology, 37(3), 245-253. doi: 10.1017/ice.2015.285

Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1:

Quantitative research. British Journal of Nursing, 16(11), 658-663. doi:

10.12968/bjon.2007.16.11.23681
Dicks, K. V., Lofgren, E., Lewis, S. S., Moehring, R. W., Sexton, D. J., & Anderson, D. J. (2016).

A multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate

bathing in community hospital intensive care units. Infection Control & Hospital

Epidemiology, 37(7), 791-797. doi: 10.1017/ice.2016.23

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. Journal of the

American Medical Association, 313(4), 369-378. doi: 10.1001/jama.2014.18400

Popovich, K. J., Hota, B., Hayes, R., Weinstein, R. A., & Hayden, M. K. (2010). Daily skin

cleansing with chlorhexidine did not reduce the rate of central-line associated

bloodstream infection in a surgical intensive care unit. Intensive Care Med, 36, 854-858.

doi: 10.1007/s00134-010-1783-y
Viray, M. A., Morley, J. C., Coopersmith, C. M., Kollef, M. H., Fraser, V. J., & Warren, D. K.

(2014). Daily bathing with chlorhexidine-based soap and the prevention of

Staphylococcus aureus transmission and infection. Infection Control and Hospital

Epidemiology, 35(3), 243-250. doi: 10.1086/675292

 AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 12

First Author Noto (2015) M.D. PhD, pulmonary and critical care medicine,
(Year)/Qualifications Vanderbilt University Medical Center and the Department of
Medicine, Vanderbilt University, Nashville Tennessee
Background/Problem Hospital acquired infections decrease patient outcomes by
Statement increasing length of hospitalizations, increasing costs, and
increasing rates of death.
Chlorhexidine (CHG) may lower the incidence of hospital-
acquired infections
Conceptual/theoretica No theoretical framework was included in this study.
l Framework

Design/ Quantitative experimental

Method/Philosophical Pragmatic cluster randomized, crossover, controlled study
First Author
Underpinnings Experimental
Boonyasiri group:
(2016) patients
MD,bathed
facultydaily with CHGSiriraj
of medicine, cloths Hospital,

(Year)/QualificationsControl group: Mahidol
patients bathed daily with
University, non-antimicrobial
Bangkok, Thailand
Background/Problem cloths
Multidrug-resistant (MDR) bacteria, which may reside on
Sample/
Statement Sample: 9,340 skin,
patients adult cause
ICU patients
infections which increase healthcare costs,
Setting/Ethical Sample size required for power analysis of 90% was not acquired
prolong hospitalizations, increase morbidity, and increase
Considerations Setting: 5 adult intensive care units (ICUs) at a tertiary care
mortality for patients.
medical center
Daily bathing with CHG-impregnated washcloths may prevent
Ethical considerations: Informed consent was waived, IRB
MDR bacteria colonization and hospital-acquired infections
approval was acquired
Conceptual/theoretica A conceptual framework was not discussed in this study
Major Variables Independent variable: daily bathing with Sage Products no-rinse
l Framework
Studied (and their 2% CHG cloths
definition), if o Defined as a bath that follows the manufacturers
Design/ Quantitative experimental
appropriate instructions
Method/Philosophical Randomized,
Dependent variable:open-label
contractiontrial
of central-line associated
Underpinnings Experimental group: patients bathed daily with CHG-
bloodstream infections (CLABSI), catheter-associated urinary
impregnated washcloths
tract infections (CAUTI), possible or probable ventilator-
Control group: patients bathed twice daily with non-
associated pneumonia (VAP), and C difficile infections
o antimicrobial cleansers by infection control personnel
Infections determined
Sample/
Measurement collection
Data Sample: 481 critically
methods wereillnot
adult patientsin this study
presented
Setting/Ethical
Tool/Data Collection Power analysis of 80% was acquired
MethodConsiderations Setting: 4 medical intensive care units (ICUs) in Thailand
Ethical considerations: All patients, or their legal representatives,
were provided informed consent. IRB approval was acquired.
Major
Data Analysis Variables Independent
Statistical analysis:variable: daily bathing
Mann-Whitney with
U tests, 2% CHG-impregnated
Poisson model,
Studied (and their washcloths
logistic regression model, significance, sensitivity analysis
definition), if
Findings/Discussion o Defined
No significant as baths
difference given between
was found in the morning by nurses
daily CHG using 6
bathing
appropriate cloths in infection
and hospital-acquired sequentialrates
order from neck to toe. Washcloths
were impregnated with a CHG solution made in the
Appraisal/Worth to CHG bathinghospitals
may be a lab.
costly and risky practice that does not
practice seem to have an affect on lowering the rates of hospital-acquired
infections in critically ill patients.
CHG is an unnecessary, expensive alternate to non-antimicrobial
bathing that may cause more harm than good, as daily use could
lead to bacterial resistance.
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 13

Dependent variables: favorable events (all samples negative

throughout ICU admission, or initially positive samples with
subsequent negative samples); (2) MDR bacteria colonization-
free time (the time for which a favorable event was maintained);
(3) hospital-acquired Infection (ventilator-associated pneumonia
(VAP), central-line associated bloodstream infection (CLABSI),
and catheter-associated urinary tract infection (CAUTI) which
was determined by trained infection control personnel using
criteria defined by the Centers for Disease Control) ; (4) length
of ICU and hospital stay; (5) adverse skin reactions (graded by
the ward nurses as (1) faint erythematous macule or dry skin, (2)
erythematous papule, (3) skin blisters, or (4) skin ulceration)
Measurement Swabs were collected from the nares, axilla, antecubital, groin,
Tool/Data Collection and perianal areas from each enrolled patient within 48 hours of
Method admission to the ICU and on days 3, 5, 7, and 14, or until the
patient left the ICU. The swabs were then sent to the infectious
disease laboratory for analysis
Data Analysis PASW statistical software, version 18.0 (IBM), was used for data
analyses.
2 test or Fisher exact test was used to compare the proportions
of categorical variables between the groups.
The unpaired t test or Mann-Whitney test, as appropriate, was
used to compare continuous variables.
Survival analysis was used to compare favorable events between
the 2 groups.
P<.05 was considered significant.
Findings/Discussion There was no significant difference in the occurrence of
favorable outcomes between the control and test groups
There was no significant difference in the MDR bacteria
colonization free-time between the control and test groups
There was no significant difference in the rate of hospital-
acquired infections between the control and test groups
There was no significant difference in the length of ICU stays
between the control and test groups
2.5% of patients in the test group developed mild skin reactions;
these patients were then washed exclusively with non-
antimicrobial cloths
Appraisal/Worth to Once-daily bathing with 2% CHG impregnated washcloths
practice did not prevent or delay gram-negative bacteria colonization
compared with routine twice-daily cleansing with non-
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 14

antimicrobial soap

First Author Viray (2014) MD, affiliated with the Washington University
(Year)/Qualifications School of Medicine, St. Louis, Missouri
Background/Problem Staphylococcus aureus infections, especially those that are
Statement resistant to methicillin (MRSA) are responsible for many
hospital-acquired infections in critically ill patients
Chlorhexidine has been shown to reduce drug-resistant
bacteria transmission

Conceptual/theoretica No theoretical framework was mentioned in this study

l Framework

Design/ Quantitative experimental

Method/Philosophical
Underpinnings
Sample/
Setting/Ethical
Considerations
Major Variables
Studied (and their
definition), if
appropriate
Prospective pre-post-intervention study
Test group: patients in the surgical ICU that would receive
daily CHG bathing
Control group: patients in the medical ICU that would
receive daily bathing with non-antimicrobial soap (Aloe
Vesta 2-n-1 body wash & shampoo)
Sample: Medical and surgical ICU patients admitted between
2002 2007, accounting for 53,526 patient days
Setting: Surgical and Medical ICUs in Barnes-Jewish
hospital, St. Louis, Missouri
Ethical considerations: This study was approved by the
Washington University Human Research Protection Office
Independent variable: implementation of daily-bathing with
chlorhexidine policy
o CHG baths defined as those using 4% CHG soap
diluted in 4L of water to produce a solution of
0.125% CHG. The CHG solution was not applied
above the neck, to the perineum, or to open wounds
Dependent variables: (1) MRSA transmission among ICU
patients; (2) overall S. aureus transmission among ICU
patients and ICU-acquired infections resulting from S.
aureus infections
o S. aureus transmissions were operationally defined as
cultures that grew from nasal swabs collected more
than 48 hours after an ICU admission
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 15

Measurement Patients were tested using a nasal swab for S. aureus

Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
infections on the day of ICU admission, 48 hours after ICU
admission, weekly in the ICU, and at ICU discharge.
Nasal swabs were then cultured and tested for S. aureus
growth using standard protocol
Ordinary least squares regression tool was used to perform a
time-series between the two different ICUs
Durbin Watson statistic and Box-Ljung Q(k) tests were used
to assess autocorrelations for first-order and second-order
serial models
An autoregressive moving average model was used for the
first outcome
The Andrews-Ploberger test for a break in mean was
performed to determine the month with the maximal change
in mean MRSA transmission rate in both units.
All analysis was conducted in EViews 6 (IHS Global).
The Wilcoxon rank-sum test was used to examine differences
between medians
MRSA transmission dropped significantly in the surgical
ICU when the chlorhexidine bathing protocol was
implemented. There was no significant difference in MRSA
transmission rates in the control group
Chlorhexidine can be used routinely in ICUs to lower the
MRSA transmission rate

First Author Dicks (2016) MD, MPH, affiliated with the department of
(Year)/Qualifications medicine, division of infectious diseases, Duke University
Medical Center, Durham, North Carolina
Background/Problem Hospital-acquired infections (HAIs) increase patient
Statement mortality and healthcare costs.
Chlorhexidine (CHG) bathing may reduce microorganism
colonization on patient skin, thus reducing the incidence of
infection
Conceptual/theoretica No theoretical framework was mentioned in this study
l Framework

Design/ Quantitative experimental

Method/Philosophical Interrupted time series analysis
Underpinnings Intervention group: bathed daily with CHG-impregnated
cloths
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 16

Control group: bathed daily with non-antimicrobial soap

Sample/ Sample: All ICU patients within the setting from January
Setting/Ethical 2008 through December 2013.
Considerations Setting: 33 community hospitals participating in the Duke
Infection Control Outreach Network (DICON) from January
2008 through December 2013
Ethical considerations: this study received Duke University
IRB approval.
Major Variables Independent variable: daily bathing using 2% CHG-
Studied (and their impregnated cloths
definition), if o Bathing procedure was not defined
appropriate Dependent variable: incidence of hospital-acquired
infections, namely methicillin-resistant Staphylococcus
aureus (MRSA) and Vancomycin-resistant Enterococci
(VRE), and non-species-specific infections
Measurement All cases of central-line associated bloodstream infection
Tool/Data Collection (CLABSI), ventilator-associated pneumonia (VAP), catheter-
Method associated urinary tract infection (CAUTI), and bloodstream
infection (BSI) were examined for causative microorganism
by infection preventionists. Liaison infection preventionists
then validated these findings.
Data Analysis Multivariate piecewise Poisson mixed-effects model
(interrupted time series model)
Incidence rate ratio calculated with a 95% confidence
interval
Nonlinear modeling used
Akaike Information Criterion used to determine trend shapes
Change-in-estimate approach used to account for
confounding variables
Findings/Discussion CHG bathing led to a significant decrease in ICU CLABSIs
and BSIs
Overall, CHG bathing led to a significant decrease in VRE
infections in ICUs, including VRE CLABSIs; CHG bathing
did not have a significant impact on the rate of VRE CAUTIs
though.
CHG bathing did not have a significant effect on the rate of
MRSA infections
Appraisal/Worth to CHG bathing has been shown to reduce ICU CLABSI and
practice bloodstream infections.
CHG bathing has not been shown to have an impact on
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 17

CAUTIs or MRSA infections

First Author Popovich (2010) Stroger Hospital of Cook County, Chicago, IL

(Year)/Qualifications and Rush Medical college, Rush University Medical Center,
Chicago, IL
Background/Problem Studies using daily chlorhexidine (CHG) bathing in medical
Statement ICUs have demonstrated that CHG is effective in reducing
the incidence of vancomycin-resistant enterococci (VRE)
infections, methicillin resistant Staphylococcus aureus
(MRSA) infections, multidrug-resistant Acinetobacter
baumannii colonization, and central-line associated
bloodstream infections (CLABSI)
While the effects of CHG bathing in medical ICUs has been
studied, CHG bathing practices have not been analyzed in
surgical ICUs
Conceptual/theoretica No conceptual framework was mentioned in this article
l Framework

Design/ Quantitative quasi-experimental

Method/Philosophical pre-post study design
Underpinnings Intervention group: daily bathing using Sage products 2%
CHG cloths
Control group: daily bathing with non-antimicrobial soap,
Dial bar soap, and water
Sample/ Sample: Patient admitted to the setting from September, 2004
Setting/Ethical October, 2006, allowing 3,695 central line days to be
Considerations studied
o Power analysis of 75% was satisfied
Setting: 30-bed SICU at Rush University Medical Center, a
tertiary care teaching hospital in Chicago, IL
Ethical Considerations: RUMC Institutional Review Board
approval acquired. Informed consent was waived
Major Variables Independent variable: daily bathing with Sage Products no-
Studied (and their rinse 2% CHG cloths
definition), if o Nurses and patient care technicians were instructed
appropriate on how to administer CHG baths using
manufacturers bathing instructions
Dependent variables: Incidence of CLABSI, blood culture
contamination, Clostridium difficile associated diarrhea
(CDAD), secondary bloodstream infection (BSI), ventilator-
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 18

associated pneumonia (VAP), urinary tract infection (UTI),

and cultures that grew multidrug-resistant bacteria
o Infections were defined using recommendations
established by the Centers for Disease Control (CDC)
Measurement Data was collected from patient, infection control
Tool/Data Collection practitioner, administrative, and microbiology databases
Method

Data Analysis Poisson regression model used to compare infection rates

Segmented regression was used using proc genmod and the
Poisson distribution
Continuous variables were evaluated using the t test
All statistical analyses were done using SAS 9.1
Findings/Discussion CDAD, secondary BSI, VAP, and UTI rates were not affected
by CHG bathing
Multidrug-resistant bacteria colonization rates were not
affected by CHG bathing
There was no significant difference in the rates of CLABSI
between the two different trial periods, but the causative
agents were different organisms
o Staphylococci and Enterococci were responsible for
most of the CLABSIs during the soap and water
period, whereas yeast and gram-negative bacilli
caused most of the CLABSIs during the CHG bathing
period
There was a significant decrease in the rate of blood culture
contamination during the CHG bathing period
Appraisal/Worth to CHG bathing in the SICU did not prove beneficial in
practice reducing CLABSI and other infection rates
CHG bathing is not recommended for use in surgical ICUs