Infection Control & Hospital Epidemiology (2019), 40,392–399 doi:10.1017/ice.2019.20
Original Article
Effectiveness of daily chlorhexidine bathing for reducing gram-negative infections: A meta-analysis
Aditi Patel MD1,a, Parth Parikh MD1,a, Aaron N. Dunn BA2,a, Jonathan A. Otter PhD3, Priyaleela Thota MD4, Thomas G. Fraser MD5, Curtis J. Donskey MD6 and Abhishek Deshpande MD PhD1,5
1Medicine Institute Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, 2Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, 3National Institute for Healthcare Research Health Protection Research Unit (NIHR HPRU) in HCAI and AMR, Imperial College London & Public Health England, Hammersmith Hospital, London, 4Hemex Health Incorporation, Portland, Oregon, 5Department of Infectious Diseases, Medicine Institute, Cleveland Clinic, Ohio and 6Geriatric Research, Education, and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
Abstract
Objective: Multiple studies have demonstrated that daily chlorhexidine gluconate (CHG) bathing is associated with a significant reduction in infections caused by gram-positive pathogens. However, there are limited data on the effectiveness of daily CHG bathing on gram-negative infections. The aim of this study was to determine whether daily CHG bathing is effective in reducing the rate of gram-negative infections in adult intensive care unit (ICU) patients.
Design:Wesearched MEDLINE and 3 other databases for original studies comparing daily bathing with and without CHG. Two investigators extracted data independently on baseline characteristics, study design, form and concentration of CHG, incidence, and outcomes related to gram-negative infections. Data were combined using a random-effects model and pooled relative risk ratios (RRs), and 95% confidence intervals (CIs) were derived.
Results: In total, 15 studies (n = 34,895 patients) met inclusion criteria. DailyCHGbathing was not significantly associated with a lower risk of gram-negative infections compared with controls (RR, 0.89; 95% CI, 0.73–1.08; P = .24). Subgroup analysis demonstrated that daily CHG bathing was not effective for reducing the risk of gram-negative infections caused by Acinetobacter, Escherichia coli, Klebsiella, Enterobacter,or Pseudomonas spp.
Conclusions: The use of daily CHG bathing was not associated with a lower risk of gram-negative infections. Further, better designed trials with adequate power and with gram-negative infections as the primary end point are needed.
(Received 18 September 2018; accepted 18 January 2019)
Chlorhexidine (CHG) is a topical antiseptic agent with broad- spectrum antimicrobial activity.1 Multiple studies have found that daily bathing with CHG decreases the incidence of healthcare associated infections (HAIs) due to gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).2–4 However, the effect of daily CHG bathing on preventing and controlling infec- tions caused by gram-negative organisms is unclear.5–9 Previous meta-analyses reporting on the positive impact of
CHG bathing on reducing HAIs in intensive care unit (ICU) settings have focused largely on the intervention’s effects on central-line–associated bloodstream infections (CLABSIs) or ventilator-associated pneumonia (VAPs), but they did not group the pathogens based on their gram stain status.10–12 A systematic review evaluating the evidence on the effectiveness ofCHGbathing on colonization and infection concluded that there was a paucity of
Author for correspondence: Abhishek Deshpande, Email:
abhishekdp@gmail.com aAuthors of equal contribution.
Cite this article: Patel A, et al. (2019). Effectiveness of daily chlorhexidine bathing for
reducing gram-negative infections: A meta-analysis. Infection Control & Hospital Epidemiology, 40: 392–399,
https://doi.org/10.1017/ice.2019.20
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
data on gram-negative infections among the 7 included studies.9 A more recent meta-analysis of randomized crossover trials evalu- ating the impact ofCHGbathing on hospital acquired bloodstream infections grouped the data into gram-positive and gram-negative microorganisms as part of a subgroup analysis. Although they found a reduction in gram-positive HAIs with CHG bathing, the study did not find a significant reduction in gram-negative HAIs among the 4 included studies.13 However, the studies on the topic were limited by the study design and a smaller number of studies was included. We conducted a systematic review and meta-analysis of all published observational and randomized trials with the primary objective of better understanding the effect of dailyCHGbathing in the ICU setting on the rate of infections with gram-negative bacteria.
Methods
All study procedures adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement guide- lines.14 We prospectively developed a study protocol that clearly identified our study objective, search strategy, inclusion/exclusion criteria, plan for data extraction, and statistical analyses.
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