Running head: EFFECTS OF CHLORHEXIDINE ON INCIDENCE OF HOSPITALACQUIRED INFECTIONS IN CRITICALLY ILL PATIENTS

Effects of Chlorhexidine on Incidence of Hospital-Acquired Infections in Critically Ill Patients

Ashley Raybold
University of South Florida

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Abstract

Clinical problem: Critically ill patients with intravenous access are at increased risk for catheterrelated infections (CRIs) and bloodstream infections (BSI), commonly referred to as sepsis.
Objective: To determine the effect of using chlorhexidine skin antiseptics and chlorhexidineimpregnated dressings on reducing the risk of hospital-acquired infections (HAIs), specifically
CRIs and BSIs, compared with standard skin antiseptics and transparent film dressings. PubMed,
Web of Science and Google Scholar were accessed to search for randomized control trials
(RCTs) with a focus on critically ill adults with intravenous access and prevention of HAIs.
Keywords that assisted in the search were RCT, critically ill adults, chlorhexidine, prevention
and HAIs.
Results: Four RCTs done within intensive care units (ICUs) assessed the effectiveness of
chlorhexidine, either as a skin antiseptic or a dressing, in reducing the incidence of CRIs and
BSIs. These RCTs found that chlorhexidine significantly reduces the incidence of CRIs when
compared to standard care and other treatment options.
Conclusion: Critically ill patients with intravenous access that receive treatment with a
chlorhexidine skin antiseptic or a chlorhexidine-impregnated dressing have a decreased risk of
CRIs and BSIs.

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Effects of Chlorhexidine on Incidence of Hospital-Acquired Infections in Critically Ill Patients

Reducing the incidence of HAIs is important to all hospitals. Hospital administration and
staff are continuously searching for new and more effective methods to reduce HAIs. A report
from Center for Disease Prevention and Control (CDC), states that thousands of patients are
affected by these HAIs each year within healthcare institutions in the United States (CDC, 2015).
Catheter-related infections (CRIs), and the resulting casually related bloodstream
infections (BSIs) are two of the numerous types of HAIs that plague the hospitals. BSIs are also
commonly referred to as sepsis. Currently, researchers are attempting to discover improved
methods to reduce the incidence of sepsis in critically ill patients, where intravenous access
creates a risk for infection to occur. One treatment being explored is the use of chlorhexidine.
Chlorhexidine can be used as a skin antiseptic or it can be impregnated into dressings, including
intravenous access dressings. Presently, in clinical practice at a local hospital, chlorhexidine skin
antiseptics are scarcely used and chlorhexidine-impregnated dressings are unavailable.
The lack of use of a bacteriostatic agent during patient care immediately raises certain
questions. What are the current rates of sepsis in critically ill patients with intravenous access
and what point in intravenous therapy are the bacteria being introduced? Would having
chlorhexidine skin antiseptics and dressings help to decrease the incidence of sepsis? In critically
ill patients with intravenous access, what is the effect of using chlorhexidine skin antiseptics and
chlorhexidine-impregnated dressings on reducing the risk of HAIs, specifically CRIs and BSIs
compared with standard skin antiseptics and transparent film dressings within three months or
quarterly?
By incorporating chlorhexidine in the care of critically ill patients it is expected that the
rate of CRIs and BSIs will decrease. By reducing the rates of these HAIs, we can expect a
decrease in antibiotic treatment, length of hospitalization, as well as potential mortality.
Literature search

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To search for new methods and evidence-based solutions for prevention of CRIs and
BSIs three search engines were utilized; PubMed, Web of Science and Google Scholar. These
search engines assisted in discovering four randomized control trials (RCTs) that studied the
effects of chlorhexidine. Key words that helped in the process of the literature search were
randomized control trial, critically ill adults, prevention, and chlorhexidine.
Literature review
Mimoz et al. (2015) conducted a RCT to compare the effectiveness of chlorhexidinealcohol to povidone iodine-alcohol as a skin antiseptic to prevent intravascular-CRI. There were
a total of 2,349 patients in eleven ICUs among six different hospitals. The patients were
randomly assigned to two main groups, using chlorhexidine-alcohol or povidone iodine-alcohol
as a skin antiseptic. These groups were further divided into using or not using a scrubbing
technique when applying the antiseptic. The outcome was chlorhexidine-alcohol was associated
with lower incidence of CRI (p = .0002). Additional, scrubbing showed no significant difference
in reducing catheter colonization (p = .3877). Limitations for this study include physicians and
nurses were not blinded and that formal audits were not performed to test adhesion to the study
protocol.
Timsit et al. (2012) conducted a study with the design of an assessor masked randomized
trial. The investigators and ICU staff were not blind in the study; however, other participants in
the study were blinded, including the microbiologists and judging committee. Tismit et al. (2012)
conducted this study to determine if chlorhexidine-impregnated and strongly adherent dressings
decrease catheter colonization and CRI. The study determined the effectiveness of chlorhexidine
by comparing three types of transparent dressings and their effects on CRIs and BSIs. The three
transparent dressings examined were a chlorhexidine dressing, a highly adhesive dressing, and a

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standard breathable, hypoallergenic dressing. The study was performed in twelve ICUs among
eleven different hospitals. There were a total of 1,879 participants, each participant randomly
assigned to one dressing. The outcome was that chlorhexidine dressings significantly reduced the
rate of CRIs (p = .0006) and CRBSIs (p = .02) when compared to the non-chlorhexidine
dressings. An additional outcome was that the highly adhesive dressing decreased detachment (p
< .0001), but increased catheter colonization (p = .0016). Limitations for this study include
unfeasible double masking and cultures were not obtained for 6.9% of the catheters.
Timsit et al. (2009) designed randomized control trial to determine if the use of
chlorhexidine gluconate-impregnated sponge (CHGIS) with intravascular catheter dressing
would be effective at reducing CRIs. There were a total of 1,636 patients in seven ICUs among
five different hospitals. The control group received a standard dressing, a semipermeable
transparent dressing; and the intervention group included received a CHGIS dressing. The
outcome was that using CHGIS dressings significantly decreased the rates of major CRIs (p = .
03) and CRBSIs. Limitations for this study include unfeasible double blinding and that cultures
were not obtained for 6.5% of the catheters.
Valles et al. (2008) designed a randomized control trial that compared three antiseptic
solutions and the effectiveness in preventing intravenous catheter colonization. Using a blinded
block randomization schedule a total of 631 catheters were assigned to one of three groups being
aqueous povidone iodine, chlorhexidine gluconate or alcoholic chlorhexidine gluconate. The
outcome was that alcoholic chlorhexidine gluconate group had significantly reduced the rates of
catheter colonization compared to the aqueous povidone iodine group (p < .01). Additionally the
aqueous chlorhexidine gluconate group had significantly lower rates of catheter colonization
compared to the aqueous povidone iodine group (p = .03). Comparing the outcomes of the

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aqueous chlorhexidine gluconate to the alcoholic chlorhexidine gluconate group resulted in no

significant difference. Limitations to this study were unequal distribution of patients, sample
size not large enough to prove CRBSIs and only one ICU was involved.
Synthesis
Research found that chlorhexidine significantly reduced the incidence of CRIs and BSIs
within ICUs. Chlorhexidine was successful as either a skin antiseptic or an intravenous site
dressing. After reviewing these RCTs it is evident that chlorhexidine needs to be incorporated
into standard nursing care of intravenous access. By incorporating chlorhexidine into standard
care it will lead to improved patient outcomes by reducing risk of sepsis and decreasing the need
for antibiotic treatment, as well as decreasing the length of hospitalization and potentially
decreasing mortality. However, there are some considerations that should be taken when
incorporating chlorhexidine into standard care of intravenous access sites. These considerations
include potential risk of creating chlorhexidine-resistance organisms, adverse skin reactions to
chlorhexidine and the increased cost of chlorhexidine skin antiseptics and chlorhexidineimpregnated dressings. Potential risk of creating chlorhexidine-resistance organisms was
discussed in two of the RCTs review and the conclusion was that additional studies should be
done to examine this potential risk. Three of the RCTs found that chlorhexidine was associated
with a higher incidence of skin reactions. This skin reaction was most commonly skin dermatitis
and was resolved when chlorhexidine treatment was discontinued; the highest statistic for this
reaction was that it occurred in three percent of patients assigned to the chlorhexidine treatment.
Increased cost of chlorhexidine skin antiseptics and chlorhexidine-impregnated dressings were
addressed into two the RCTs. Both of the studies stated that the increased cost associated with
the use of chlorhexidine was acceptable when comparing it to the cost of one major CRI

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incident. Additional studies should be performed to determine if these considerations are

weaknesses that could limit the use of chlorhexidine as standard treatment for intravenous
access.
Clinical recommendations
With the evidence from the studies discussed it is clear that chlorhexidine could play an
important role in reducing the risk of CRIs that lead to BSIs. The use of chlorhexidine should be
incorporated into standard care of intravenous access, and can be implemented with the use of
chlorhexidine skin antiseptic or a chlorhexidine-impregnated dressing. Chlorhexidine can be
incorporated into the care of intravenous access among all hospitalized patients. To implement
chlorhexidine use in local hospitals struggling with high incidence of hospital-acquired
infections, the statistics from these RCTs should be taken to hospital administration and staff to
show the effectiveness of reducing the incidence of CRIs and CRBSIs. By implementing
chlorhexidine use hospital-wide nursing practices would change to include this new evidencebased practice and nurses would be taking direct action in assisting to decrease the incidence of
hospital-acquired infections directly associated with intravenous access care. Overall, by
implementing the use of chlorhexidine in standard care of intravenous access the rates of sepsis
will significantly decrease, improving patient outcomes.

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References

Center for Disease Control and Prevention. (2015). Healthcare-associated infections. Retrieved
from https://www.cdc.gov/HAI/research/research.html
Mimoz, O., Lucet, J., Kerforne, T., Pascal, J., Souweine, B., Goudet, V., . . . Timsit, J. (2015).
Skin antisepsis with chlorhexidinealcohol versus povidone iodinealcohol, with and
without skin scrubbing, for prevention of intravascular-catheter-related infection
(CLEAN): An open-label, multicentre, randomised, controlled, two-by-two factorial trial.
The Lancet, 386(10008), 2069-2077. doi:10.1016/s0140-6736(15)00244-5
Timsit, J., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste-Orgeas, M., Alfandari, S., . . .
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Valls, J., Fernndez, I., Alcaraz, D., Chacn, E., Cazorla, A., Canals, M., . . . Morn, A. (2008).
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