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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
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
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.
daily chlorhexidine bathing can reduce the incidence of infections for patients in critical care
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 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
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
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.
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:
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,
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
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
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
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
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
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
post-intervention design in order to find a trend between the use of CHG bathing and the
AN INTEGRATIVE REVIEW: CHLORHEXIDINE BATHING 7
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
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
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
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
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,
which were published in the last ten years; so, this integrative review is not an exhaustive
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
References
Boonyasiri, A., Thaisiam, P., Permpikul, C., Judaeng, T., Suiwongsa, B., Apiradeewajeset, N., . . .
care unit patients: A randomized trial in Thailand. Infection Control & Hospital
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).
bathing in community hospital intensive care units. Infection Control & Hospital
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.
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
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
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