Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus

aureus Acquisition
Ann Petlin, Marilyn Schallom, Donna Prentice, Carrie Sona, Paula Mantia, Kathleen McMullen and
Cassandra Landholt

Crit Care Nurse 2014, 34:17-24. doi: 10.4037/ccn2014943

2014 American Association of Critical-Care Nurses
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 Cover

Chlorhexidine Gluconate
Bathing to Reduce
Methicillin-Resistant
Staphylococcus aureus
Acquisition
ANN PETLIN, RN, MSN, CCRN-CSC, CCNS, PCCN, ACNS-BC
MARILYN SCHALLOM, RN, PhD, CCRN, CCNS
DONNA PRENTICE, RN, MSN(R), CCRN, ACNS-BC
CARRIE SONA, RN, MSN, CCRN, CCNS, ACNS-BC
PAULA MANTIA, RN, MSN, ANP-BC
KATHLEEN McMULLEN, MPH, CIC
CASSANDRA LANDHOLT, BS

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism causing substantial

morbidity and mortality in intensive care units. Chlorhexidine gluconate, a topical antiseptic solution, is
effective against a wide spectrum of gram-positive and gram-negative bacteria, including MRSA.
OBJECTIVES To examine the impact of a bathing protocol using chlorhexidine gluconate and bath basin
management on MRSA acquisition in 5 adult intensive care units and to examine the cost differences
between chlorhexidine bathing by using the bath-basin method versus using prepackaged chlorhexidine-
impregnated washcloths.
METHODS The protocol used a 4-oz bottle of 4% chlorhexidine gluconate soap in a bath basin of warm
water. Patients in 3 intensive care units underwent active surveillance for MRSA acquisition; patients in 2
other units were monitored for a new positive culture for MRSA at any site 48 hours after admission.
RESULTS Before the protocol, 132 patients acquired MRSA in 34 333 patient days (rate ratio, 3.84). After-
wards, 109 patients acquired MRSA in 41 376 patient days (rate ratio, 2.63). The rate ratio difference is
1.46 (95% CI, 1.12-1.90; P = .003). The chlorhexidine soap and bath basin method cost $3.18 as compared
with $5.52 for chlorhexidine-impregnated wipes (74% higher).
CONCLUSIONS The chlorhexidine bathing protocol is easy to implement, cost-effective, and led to decreased
unit-acquired MRSA rates in a variety of adult intensive care units. (Critical Care Nurse. 2014;34[5]:17-26)

CNE Continuing Nursing Education

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:

1. Discuss current research on chlorhexidine gluconate (CHG) bathing

2. Compare use of CHG-impregnated washcloths with CHG solution dissolved in bath water
3. Describe the effects of CHG bathing on methicillin-resistant Staphylococcus aureus

2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014943

www.ccnonline.org CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 17

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M
ethicillin-resistant Staphylococcus
aureus (MRSA) is a virulent organ-
ism that causes substantial mor-
bidity and mortality in intensive
care units (ICUs). The Centers for
Disease Control and Prevention estimated that more
than 80000 cases of invasive MRSA infections occurred
in the United States in 2011, with more than 11000
deaths.1 Colonization with S aureus may precede infec-
tion. Culture swabs of the anterior nares can identify
patients who are colonized with MRSA even though
they may show no signs or symptoms of infection.2
MRSA and other microbes have been cultured from
bath basins in ICUs,3 which may contribute to colo-
nization of the patients skin and lead to secondary
contamination at other sites.4
Reduction and elimination of hospital-acquired infec-
tions requires a multipronged approach. Hand hygiene
is the primary strategy to reduce hospital-acquired
infections and prevent transmission of resistant microbes
between patients.5 Rapid reporting of culture results allows
the health care team to initiate timely contact isolation
precautions that help reduce the spread of infection once
a resistant organism is identified. A multidisciplinary
critical care team partnership with infection prevention
specialists can facilitate these evidence-based preven-
tion strategies. The increase in MRSA prevalence in the
community and the high level of mortality associated
with MRSA (3.62 deaths per 100000 population in the
United States)1 require clinicians to continuously
explore measures to prevent MRSA acquisition in criti-
cally ill patients. MRSA colonization can be a source of
fear, anxiety, and uncertainty for patients.6-8 Therefore,
prevention of hospital-acquired MRSA is an important
nursing intervention.
Chlorhexidine gluconate (CHG), a topical antiseptic
solution, is effective against a wide spectrum of gram-
positive and gram-negative bacteria, including MRSA.3
Low concentrations of CHG, such as when it is diluted in
bath-basin water or as supplied in bathing wipes, alter
the integrity of bacterial cell walls.9 Additionally, CHG
has residual activity on the skin that helps to reduce skin
microbes and prolongs skin antisepsis.10 A review of the
literature provides evidence that CHG bathing has sev-
eral benefits.4,10-28 CHG bathing reduces the acquisition
of vancomycin-resistant Enterococcus by hospitalized ICU
patients,4,10-14 Clostridium difficile,15 and hospital-acquired
MRSA.4,11-13,16,17 Bathing with CHG also reduces MRSA
skin colonization in known MRSA carrier patients during
their treatment.18-21 Several studies showed that bathing
with CHG and nasal administration of mupirocin reduce
the risk of infections,2,22 and CHG bathing alone specifi-
cally reduces the risk of central catheterassociated blood-
stream infections in ICU patients4,23-26 and long-term acute
care patients.27 Two studies24,28 demonstrated that CHG
bathing reduced the rate of blood culture contamination.
Two of the ICUs at Barnes-Jewish Hospital, a Mid-
western university teaching hospital were among the units
involved in a multi-institutional quasi-experimental study
by Climo et al11 on the effect of CHG bathing and MRSA
acquisition. Climos study demonstrated a 32% reduction
in MRSA acquisition. Those 2 ICUs resumed typical
soap-and-water bathing of their patients when the CHG
bathing intervention ended at the completion of the study.
Infection surveillance data showed a return to higher
MRSA acquisition rates with the soap-and-water baths

Authors
Ann Petlin is a clinical nurse specialist in the cardiothoracic intensive care unit at Barnes-Jewish Hospital, St Louis, Missouri.
Marilyn (Lynn) Schallom is a clinical nurse specialist and research scientist in the Department of Research for Patient Care Services at
Barnes-Jewish Hospital.
Donna Prentice is a clinical nurse specialist in a medical intensive care unit at Barnes-Jewish Hospital.
Carrie Sona is a clinical nurse specialist in the surgery/burns/trauma intensive care unit at Barnes-Jewish Hospital.
Paula Mantia is the advanced practice nurse in a medical intensive care unit at Barnes-Jewish Hospital.
Kathleen McMullen is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at Barnes-Jewish
Hospital.
Cassandra (Casey) Landholt is an infection prevention specialist for the Department Hospital Epidemiology and Infection Prevention at
Barnes-Jewish Hospital.
Corresponding author: Ann Petlin, RN, MSN, Barnes-Jewish Hospital, One Barnes-Jewish Hospital Plaza, Mail stop 90-00-056, St Louis, MO 63110 (e-mail: amp2645@bjc.org).
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

18 CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 www.ccnonline.org

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in both ICUs. Decolonization with nasal mupirocin was
not included during the study period. The purpose of
this study was to expand the intervention of the bathing
protocol to 5 ICUs at our hospital by using CHG bathing
and a bath-basin protocol and to examine its impact on
the acquisition of MRSA in our patients. Our goals were
(1) to determine if there was a difference in MRSA acqui-
sition between soap-and-water baths and CHG bathing,
and (2) to examine the cost differences between CHG
bathing using the bath-basin method versus using
prepackaged CHG-impregnated washcloths.
Theoretical Framework
The Synergy Model from the American Association
of Critical-Care Nurses provided a theoretical frame-
work for the clinical nurse specialists (CNSs) interest in
and design of this study.29 This model encourages a
holistic view of patients, each with varying capacities
for health and vulnerability to illness. The model also
identifies nursings unique contribution to patient care
and outcomes. The patient characteristics of the Syn-
ergy Model that apply particularly well in our study are
the complexity and vulnerability of ICU patients as
well as their limited available resources to prevent
hospital-acquired infections. The ICU itself is a complex
environment that can place patients at risk of having
hospital-acquired complications. The CNSs bring the
nursing competencies of clinical inquiry, collaboration,
and facilitation of learning to the clinical research proj-
ect. If the intervention reduced MRSA acquisition, our
study worked toward patient outcomes goals of absence
of complications, decreased infection acquisition, and
effective cost-resource utilization.
Methods
Overview of Study Design
This study used a pre/post-intervention design. The
hospital leadership model includes a unit-based critical
care CNS in each ICU. The CNSs individually worked
with their unit-based physician leadership and infection
prevention staff. Additionally, a CNS in the hospitals
research department collaborated with each CNS to
implement the protocol. A champion(s) was also identi-
fied for each unit. Champions were typically staff nurses
and/or chairs of the units practice committees with the
support of the clinical nurse managers. The CNSs and
champions provided an educational overview both orally
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and in newsletters about the protocol and monitored for
implementation progress and supply needs. Before this
study, we did not have a standard bathing protocol aside
from the traditional use of a bath basin with soap and
water. The hospitals institutional review board approved
this study as exempt from human subjects committee
review because it was minimal risk, the CHG bathing
intervention applied to all patients in the study units,
and only unit-level data would be collected.
Bathing Protocol
The CHG bathing protocol directed the nurse to mix
the contents of a 4-ounce bottle of 4% CHG with warm
water in a 6-quart basin in the same fashion as per-
formed in the study by Climo et al.11 Typical linens used
for a bath included 6 washcloths and 4 bath towels,
although these numbers were not specified in the proto-
col. Washcloths were used for 1 body area only and were
not reinserted into the CHG water after use. Staff bathed
patients from the neck down, avoiding contact with the
face, all mucous membranes, and wounds, as recom-
mended by the manufacturer. Bath basins were marked
as dedicated
for bathing Implementation of the chlorhexidine gluconate
only. Staff (CHG) bathing protocol was led by clinical
rinsed the nurse specialists.
basin after
use and towel-dried it before storing it. If skin and
wound care items needed storage, the staff used a sepa-
rate basin or other container. Nurses had been educated
about the bathing protocol and bath basin maintenance
steps by the end of 2009. Education strategies included
the services of the unit champions, use of posters and
newsletters, and inclusion of the CHG bathing protocol in
unit orientations. Implementation of the protocol began
in January 2010.
Procedure
The hospital performed active surveillance for MRSA,
which included nasal swabs for MRSA upon ICU admis-
sion, weekly, and upon discharge in the cardiothoracic,
medical, and surgical/burn/trauma ICUs for several years
before this project. This surveillance continued through-
out this study. We defined MRSA acquisition in these 3
units as a nasal swab or clinical culture that was positive
for MRSA 48 hours after admission in any patient who
had a negative result or no nasal swab at admission.
CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 19
 Table Acquisition rates for methicillin-resistant Staphylococcus aureus (MRSA) in the units with active
surveillance for MRSA acquisition and in all 5 units

Three units with active All 5 units (with and without

Period MRSA surveillance
Preintervention (July 2008-December 2009) 111 MRSA acquisitions in
22 292 patient days
MRSA acquisition rate = 4.98
Postintervention (January 2010-April 2011) 91 MRSA acquisitions in
31 233 patient days
MRSA acquisition rate = 2.91
active surveillance)
132 MRSA acquisitions in
34 333 patient days
MRSA acquisition rate = 3.84
109 MRSA acquisitions in
41 376 patient days
MRSA acquisition rate = 2.63

The 2 other ICUs in our study, the coronary care unit
and a second medical ICU, did not have protocols for
active surveillance. They used incident surveillance
instead. We defined MRSA acquisition in these 2 units
as any patient with a new culture positive for MRSA at
any site 48 hours after admission.
The ICU physicians in all the study units were informed
of swabs and cultures that were positive for MRSA by a
telephone call from the microbiology laboratory. Patients
went on contact isolation precautions immediately upon
the report of a culture positive for MRSA. Infection pre-
vention staff
Patients bathed with soap and water monitored the
were 1.5 times more likely than patients MRSA acqui-
bathed with CHG to acquire MRSA. sition rates
and compli-
ance with admission, weekly, and discharge surveillance
swabs, and they reported the data monthly to the 3 ICUs
in the study that were performing active surveillance.
They also observed hand hygiene compliance monthly
in all ICUs by using secret shoppers as data collectors
during both study periods.
Data Analysis
We used OpenEpi30 software to calculate MRSA
acquisition rate ratios in the preintervention and postin-
tervention periods. We defined the MRSA acquisition
rate as the number of patients with nasal swabs negative
for MRSA upon admission, or no nasal swab performed
on admission, in whom MRSA from any source developed
more than 48 hours after their ICU admission, divided
by the number of patient days per month times 1000.
Patients who were known to be positive for MRSA on
ICU admission were excluded from the calculations. We
defined MRSA nasal swab compliance as the percentage
of admission, weekly, and discharge nasal swabs obtained.
We did not collect a final nasal swab on patients who
died or were already found to be MRSA positive via the
active surveillance. We defined hand hygiene compli-
ance as the percentage of staff members who were
observed performing hand hygiene upon entering or
exiting a patients room.
Results
In the preintervention period (July 2008-December
2009) when soap-and-water bathing was the routine,
there were 132 MRSA acquisitions in 34333 patient days
(see Table). This equaled a MRSA acquisition rate of
3.84 per 1000 patient days. In the postintervention period,
(January 2010-April 2011) with the CHG bathing proto-
col, there were 109 MRSA acquisitions in 41376 patient
days. This equaled a MRSA acquisition rate of 2.63 per
1000 patient days. The MRSA rate ratio difference is
1.46 (95% CI=1.12-1.90, P=.003; Figure 1). Patients in
the preintervention period were almost 1.5 times more
likely to acquire MRSA than patients who received the
CHG bathing protocol.
No significant differences in compliance were found
with nasal swabbing or with hand hygiene between
the study periods. Compliance rates with nasal swab-
bing for MRSA were 87% to 90% in the preinterven-
tion period and 86% to 92% after the intervention.
The patients in the medical ICU showed the greatest
decline in MRSA acquisition rates from 6.8 per 1000
patient days before the intervention to 3.8 per 1000
patient days after the intervention. They also had the
highest compliance (92%) with nasal swabbing. The
surgical/burn/trauma ICU had been one of the units
in the multi-institutional study by Climo et al.11 Their
MRSA acquisition rate returned to the multisite study
level when the CHG bathing protocol resumed with
our study.

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MRSA acquisition rate per 1000 patient days 4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Soap and water
Figure 1 The acquisition rate of methicillin-resistant
Staphylococcus aureus (MRSA) was 3.84 per 1000 patient
days before the chlorhexidine gluconate bathing routine was
implemented and 2.63 per 1000 patient days after the
implementation of chlorhexidine bathing. The difference in
MRSA rates is 1.46 (95% CI, 1.12-1.90; P = .003).
As part of this study, we collaborated with our hos-
pitals Patient Care Products Committee to analyze the
cost of bathing with the CHG soap and bath basin
method and compare that with the cost of bathing with
CHG-impregnated wipes. Our institution pays $1.75 for
each 4-ounce bottle of 4% CHG. The reusable bath basin
costs $0.35. The cost of the bath linens includes purchase
and reprocessing. Cotton washcloths are $0.04 each (6 per
bath=$0.24) and bath towels are $0.21 each (4 per bath
=$0.84). These individual items total $3.18 for 1 bed bath.
Reusing the bath basin reduces the cost of subsequent
baths. One vendor (D. Short, Cardinal Health, Dublin,
Ohio, e-mail communication, November 5, 2012) said
that 6 of the washcloths impregnated with 2% CHG,
enough for 1 bath, would cost $5.52.
Discussion
The adverse effects of bathing with CHG are related
to contact dermatitis or skin irritation that subsides
after stopping the use of CHG in the bath water. Many
studies report no skin reaction or do not report on this
outcome. In a study27 of long-term patients in an acute
care hospital, 1% of patients had dryness of skin develop
with a 4% CHG bath basin method. In another study,4
researchers reported skin reactions in 2% of patients
with use of 2% CHGimpregnated cloths; however, 3.4%
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of patients in the same study had a skin reaction to
cloths that were not impregnated with antimicrobial
soap. There were no reports of skin irritation during the
study in our hospital.
Johnson and colleagues3 demonstrated patients bath
basins as potential sources of infections, with 98% of
basins growing potentially pathogenic microbes. Soon
after that study, many hospitals decided to abandon
bath basins for ICU bathing in favor of using washcloths
impregnated with 2% CHG. Historically, several stud-
ies11,15-18,20-22,27 of the effects of CHG bathing used 4% CHG
in bath basins or showering; other studies4,10,12-14,23-26,28
used cloths impregnated with 2% CHG. Our surgical/
Chlorhexidine
burn/trauma ICU staff nurses willingly tried the CHG-
gluconate impregnated cloths before this study but were not satis-
fied with their performance and preferred the bath-basin
method for patient bathing. Since the report of bath basin
contamination by Johnson et al,3 Powers and colleagues31
studied the presence of bacterial contaminants in wash
basins when CHG solution was used in place of standard
soap and water to wash patients. They reported that bac-
terial growth in patients bath basins decreased by 95.5%
with the use of CHG in the bath water. Similar results
were found in a comparison bench study32 of 2 different
brands of 4% CHG and 1 brand of liquid soap. Soap and
CHG were equally effective at preventing initial contami-
nation compared with tap water. However, both brands
of CHG had
significant Using prepackaged CHG wipes ($5.52 per
marked bath) was 74% more expensive than using the
residual CHG soap and bath method ($3.18 per bath).
effect on
bacterial contamination compared with soap and water
or tap water only.32 These 2 studies31,32 demonstrated that
bathing with CHG using a bath basin and tap water does
not increase the risk of exposing patients to bacterial
contaminants from the basin and tap water. Addition-
ally, in a bench study of MRSA isolated over 4 years in a
setting that used 4% CHG bathing, researchers found no
detectable loss of antibiotic effectiveness or increase in
MRSA resistance or infection with other organisms.33
Using washcloths impregnated with 2% CHG ($5.52 per
bath) would be 74% more expensive than our CHG soap
and bath basin method ($3.18 per bath; Figure 2). Ritz
et al13 reported that a bath basin protocol was $2.50 less
than cloths impregnated with 2% CHG. To translate the
magnitude of this cost difference, the 41376 CHG-in-water
CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 21
 Compliance with nasal swab screening and hand
6.00
hygiene are essential measures to analyze the impact of
5.00
CHG bathing. Otherwise, many nasal swabs may be
missed or too few CHG baths may be given to show the
4.00 effects of the intervention. High nasal swab compliance
rates played an important role in ensuring that the
Cost, $

3.00 MRSA acquisition rate data were accurate in the ICUs

2.00
1.00
0.00
CHG and Prepackaged
bath basin CHG wipes
Figure 2 The chlorhexidine gluconate (CHG) soap and bath
basin method cost $3.18 as compared with $5.52 for the
wipes impregnated with CHG. The prepackaged CHG wipes
are 74% higher in cost than the CHG soap and bath basin
method.
baths given during our study cost our hospital about
$131000 whereas bathing with washcloths impregnated
with 2% CHG would have cost about $228000. The cost
of providing any
Hand hygiene compliance monitoring
intervention mer-
helped to ensure that staff members
its consideration
adhered to other accepted measures
in a climate of cost
that reduce cross-contamination of
containment. Each
patients.
institution negoti-
ates prices with their vendors, so costs of the 2 methods
may vary.
We examined only the impact of CHG bathing on
MRSA and not on hospital-acquired infections from
vancomycin-resistant Enterococcus, C difficile, central
catheterassociated bloodstream infections, or surgical
site infections. All units had low rates of central catheter
associated bloodstream infections and surgical units had
low rates of surgical site infections in the preintervention
period. Those low infection rates would have required a
very large number of patients from several years to
demonstrate a significant difference with CHG bathing.
We were not tracking catheter-associated urinary tract
infection rates in the preintervention period. However,
for units with high rates of any of these infections, CHG
bathing provides a reasonable intervention to reduce
such infections,4,22-27 although not all studies showed
reductions in infection rates.28
that performed active surveillance. Compliance with
nasal swabbing helped to ensure that MRSA infections
were not overlooked by decreased testing. Use of the
CHG soap by each ICU is monitored by the rate of
restocking that item in each units supply area. Hand
hygiene compliance monitoring helped to ensure that
staff members adhered to other accepted measures that
reduce cross-contamination of patients.
AACNs evidence-based leveling system identifies a
rating of class B evidence for interventions developed
from well-designed controlled studies, both random-
ized and nonrandomized, with results that consistently
support a specific action, intervention, or treatment.34
Publications on the reduction of acquisition or decolo-
nization of multidrug-resistant organisms provide class
B evidence for CHG bathing.
Research studies in the past several years, including
our results, have demonstrated the benefits of CHG
bathing in ICU patients. Our results also demonstrated
the role of the unit-based CNS in conducting research
and implementing best practices. Each unit-based CNS
partnered with his or her bedside nursing colleagues,
physicians, infection prevention staff, and hospital-wide
departments and provided a structure for implement-
ing the protocol in multiple units simultaneously. By
implementing the protocol in multiple units, the results
and impact could be examined both at the unit level
and more widely. Unit-based results provided informa-
tion to the bedside clinicians that was a direct result of
their practice. Combining the data from multiple ICUs
strengthened the findings for statistical analysis.
Limitations
Our study examined only 1 bathing protocol, the
same one as described by Climo et al11 in 2009. We used
this protocol because 2 of our ICUs had been involved in
that study. Other products and protocols have been
described since then.13-15 Another limitation of our study
was the differences in surveillance protocols for MRSA.
We had active surveillance in the cardiothoracic, medical,

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and surgical/burn/trauma ICUs. We had incident sur-
veillance in the coronary care unit and the second med-
ical ICU. Finally, actual observation of CHG bathing did
not occur. We based compliance with the protocol on the
inventory of the 4-oz (120-mL) bottles of 4% CHG as
compared with the unit census. One bottle of 4% CHG
was considered to indicate 1 patient bath.
Nursing Implications
Daily CHG bathing in the ICU is a simple and effec-
tive means of decreasing MRSA acquisition. Although
reactions are infrequently reported, nurses should moni-
tor each patients skin for any reaction. CHG bathing
has not been shown to increase antibiotic resistance. Both
a bath basin bathing protocol that uses 4% CHG and a
bathing protocol that uses prepackaged 2% CHG cloths
demonstrated reductions in hospital-acquired infections.
The costs of prepackaged cloths are higher, although
individual unit preferences and time requirements also
should be considered.13 CNSs and unit champions can
provide the evidence and assist with implementation
and monitoring for success. AACNs Synergy Model is a
useful framework for clinical inquiry that helps to opti-
mize outcomes for patients and their families, nurses,
and the system.
Conclusions
The CHG bathing protocol was easy to implement,
was cost-effective, and led to decreased unit-acquired
MRSA rates in a variety of adult ICUs at a Midwestern
university teaching hospital. Prevention of MRSA acqui-
sition in ICU patients is important to reduce infection
and prevent anxiety and suffering for patients. Daily
bathing with CHG in the bath basin with tap water is
both effective and cost-efficient. CCN
Acknowledgments
The authors gratefully acknowledge the hundreds of intensive care unit
nurses who gave thousands of baths and obtained numerous nasal swabs
during the study.
Financial Disclosures
None reported.
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To learn more about chlorhexidine bathing, read Chlorhexidine
Bathing and Microbial Contamination in Patients Bath Basins
by Powers et al in the American Journal of Critical Care, September
2012;21:338-342. Available at www.ajcconline.org.
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bathing on hospital-acquired infections among general medical patients.
Infect Control Hosp Epidemiol. 2011;32:238-243.
13. Ritz J, Pashnik B, Padula C, et al. Effectiveness of 2 methods of CHG
bathing. J Nurs Care Qual. 2012:27(2):171-175.
14. Bass P, Karki S, Rhodes D, et al. Impact of chlorhexidine-impregnated
washcloths on reducing incidence of vancomycin-resistant enterococci
colonization in hematology-oncology patients. Am J Infect Control. 2013;
41:345-348.
15. Rupp ME, Cavalieri J, Lyden E, et al. Effect of hospital-wide chlorhexidine
patient bathing on healthcare-associated infections. Infect Control Hosp
Epidemiol. 2012;33:1094-1100.
16. Ridenour G, Lampen R, Federspiel J, et al. Selective use of intranasal
mupirocin and chlorhexidine bathing and the incidence of methicillin-
resistant Staphylococcus aureus colonization and infection among inten-
sive care unit patients. Infect Control Hosp Epidemiol. 2007;28:1155-1161.
17. Gould IM, MacKenzie FM, MacLennan G, et al. Topical antimicrobials
in combination with admission screening and barrier precautions to
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sive care unit. Int J Antimicrobial Agents. 2007;29:536-543.
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287-292.
19. Sandri AM, Dalarosa MG, de Alcantara LR, et al. Reduction in incidence
of nosocomial MRSA infection in an ICU: mupirocin and CHG baths for
nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27(2):185-187.
20. Wendt C, Schinke S, Wrttemberger M, et al. Value of whole-body
washing with chlorhexidine for the eradication of methicillin-resistant
Staphylococcus aureus: a randomized, placebo-controlled, double-blind
clinical trial. Infect Control Hosp Epidemiol. 2007;28(9):1036-1043.
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 21. Fritz SA, Camins BC, Eisenstein KA, et al. Effectiveness of measures to
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22. Camus C, Bellissant E, Sebille V, et al. Prevention of acquired infections
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23. Bleasdale SC, Trick WE, Gonzalez IM, et al. Effectiveness of chlorhexi-
dine bathing to reduce catheter-associated bloodstream infections in
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2079.
24. Popovich KJ, Hota B, Haynes R, et al. Effectiveness of routine patient
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medical intensive care unit. Infect Control Hosp Epidemiol. 2009;30(10):
959-963.
25. Dixon JM, Carver RL. Daily chlorhexidine gluconate bathing with
impregnated cloths results in statistically significant reduction in cen-
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 CCN Fast Facts
Chlorhexidine Gluconate Bathing to Reduce
Methicillin-Resistant Staphylococcus aureus
Acquisition
Facts
Methicillin-resistant Staphylococcus aureus (MRSA) is
a virulent organism causing substantial morbidity and
mortality in intensive care units. Because of the increase
in MRSA prevalence in the community and the high level
of mortality associated with MRSA, prevention of hospital-
acquired MRSA is an important nursing intervention.
Chlorhexidine gluconate (CHG), a topical antiseptic
solution, is effective against a wide spectrum of gram-
positive and gram-negative bacteria, including MRSA.
Low concentrations of CHG, such as when it is diluted
in bath-basin water or as supplied in bathing wipes,
alter the integrity of bacterial cell walls. Additionally,
CHG has residual activity on the skin that helps to
reduce skin microbes and prolongs skin antisepsis.
CHG bathing has several benefits. CHG bathing
reduces the acquisition of vancomycin-resistant
Enterococcus, Clostridium difficile, and hospital-
acquired MRSA. Bathing with CHG also reduces
MRSA skin colonization in known MRSA carrier
patients during their treatment. Bathing with CHG
and nasal administration of mupirocin reduce the
risk of infections, and CHG bathing alone specifically
reduces the risk of central catheterassociated blood-
stream infections. CHG bathing has also been shown
to reduce the rate of blood culture contamination.
The adverse effects of bathing with CHG are related
to contact dermatitis or skin irritation that subsides
after stopping the use of CHG in the bath water.
Many studies report no skin reaction or do not report
on this outcome.
Compliance with nasal swab screening and hand
hygiene are essential measures to analyze the impact
of CHG bathing. Otherwise, many nasal swabs may
be missed or too few CHG baths may be given to
Petlin A, Schallom M, Prentice D, Sona C, Mantia P, McMullen K, Landholt C. Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus aureus
Acquisition. Critical Care Nurse. 2014;34(5):17-26.
www.ccnonline.org
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CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing
show the effects of the intervention. High nasal swab
compliance rates played an important role in ensuring
that the MRSA acquisition rate data were accurate in
the intensive care units (ICUs) that performed active
surveillance.
Research studies, including our results, have demonstrated
the benefits of CHG bathing in ICU patients. Our results
also demonstrated the role of the unit-based clinical nurse
specialist (CNS) in conducting research and implement-
ing best practices. Each unit-based CNS partnered with
his or her bedside nursing colleagues, physicians, infection
prevention staff, and hospital-wide departments.
By implementing the protocol in multiple units, the results
and impact could be examined both at the unit level and
more widely. Unit-based results provided information to the
bedside clinicians that was a direct result of their practice.
Nursing Implications
Daily CHG bathing in the ICU is a simple and effective
means of decreasing MRSA acquisition.
Although reactions are infrequently reported, nurses
should monitor each patients skin for any reaction.
CHG bathing has not been shown to increase antibiotic
resistance.
Both a bath basin bathing protocol that uses 4% CHG
and a bathing protocol that uses prepackaged 2% CHG
cloths demonstrated reductions in hospital-acquired
infections. The costs of prepackaged cloths are higher,
although individual unit preferences and time require-
ments also should be considered.
CNSs and unit champions can provide the evidence and
assist with implementation and monitoring for success.
AACNs Synergy Model is a useful framework for clinical
inquiry that helps to optimize outcomes for patients and
their families, nurses, and the system. CCN
CriticalCareNurse Vol 34, No. 5, OCTOBER 2014 25
CNE Test Test ID C1453: Chlorhexidine Gluconate Bathing to Reduce Methicillin-Resistant Staphylococcus Aureus Acquisition
Learning objectives: 1. Discuss current research on chlorhexidine gluconate (CHG) bathing 2. Compare use of CHG-impregnated washcloths with CHG
solution dissolved in bath water 3. Describe the effects of CHG bathing on methicillin-resistant Staphylococcus aureus

1. Which of the following statements is true regarding colonization with 7. Essential measures to analyze the impact of CHG bathing include which
Staphylococcus aureus? of the following?
a. The Centers for Disease Control and Prevention estimates that more than a. Staff satisfaction with the protocol
11 000 deaths occurred due to colonization with methicillin-resistant b. Survey of patient comfort
S aureus (MRSA) in 2011. c. Compliance with nasal swab screening
b. Patients may be colonized with S aureus without signs of infection. d. Utilization rate of the CHG soap
c. Culture swabs of the nares are the only reliable method to diagnose MRSA.
d. Microbes in bath basins may lead to contamination of the lungs. 8. According to the AACN evidence-based leveling system, publications on
multidrug-resistant organisms provide what level of evidence for CHG
2. Which of the following describes CHGs mechanism of action? bathing?
a. Washing microbes off the skin a. Class IA
b. Killing all gram-negative bacteria b. Class 2
c. Altering integrity of bacterial cell walls c. Class A
d. Interacting with mupirocin d. Class B

3. Patient characteristics of the AACNs Synergy Model applicable to this 9. The decision to use prepackaged clothes versus bath basin bathing
study are which of the following? should include consideration of which of the following?
a. Available resources and costs a. The method that provides best reduction in MRSA
b. Complexity and collaboration b. Time requirements
c. Resiliency and predictability c. Increase of bacterial resistance
d. Complexity and vulnerability d. Availability of a clinical nurse specialist to support compliance

4. The bathing protocol used in this study included which of the following? 10. Limitations of this study include which of the following?
a. Use of a new dedicated wash basin daily a. Small sample size
b. Complete bathing from the neck down b. The study used a different bathing protocol than the study on which it was
c. 4-ounce bottle of 2% CHG with warm water in a 4-quart basin based on.
d. Use of 1 washcloth per body area c. Active surveillance only took place in the coronary care unit.
d. It relied on the nurses report that the bath was provided per the protocol.
5. Which of the following are adverse effects of CHG bathing?
a. Serious rashes 11. Which of the following describes the design of this study?
b. Contact dermatitis a. Retrospective design
c. Allergic reactions b. Randomized control group design
d. Should not be a cause for concern c. Pre/post-intervention design
d. Experimental crossover design
6. In this study, which of the following is true regarding using washcloths
impregnated with 2% CHG? 12. Results of previous studies on bath basins include which of the following?
a. Provided benefits that justify the cost a. Soap and tap water and CHG techniques both had residual effects on bacterial
b. Cost the hospital approximately $131000 contamination.
c. Is more expensive than the CHG soap and basin method b. Ninety-eight percent of basins grow potentially pathogenic microbes.
d. Cost $5.52 more than the bath-basin method c. Over time CHG use may result in loss of antibiotic effectiveness.
d. Bacterial growth in bath basins is eliminated when bathing with CHG soap
in the bath water.

Test answers: Mark only one box for your answer to each question. You may photocopy this form.

1.  a 2.  a 3.  a 4.  a 5.  a 6.  a 7.  a 8.  a 9.  a 10.  a 11.  a 12.  a

b b b b b b b b b b b b
c c c c c c c c c c c c
d d d d d d d d d d d d
Test ID: C1453 Form expires: October 1, 2017 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%)
Synergy CERP Category A Test writer: Patricia Kelly Rosier, MS, RN, ACNS-BC

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