Running head: HOSPTIAL-ACQUIRED MRSA PREVENTION 1

Hospital-Acquired Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention

Kristina Nealy

University of South Florida

HOSPTIAL-ACQUIRED MRSA PREVENTION 2

Abstract
Clinical problem: Patients among the hospitalized population are at risk for developing hospital

acquired infections such as methicillin-resistant staphylococcus aureus (MRSA) which is

potentially fatal bacteria that causes increased mortality rates as well as unnecessary medical

expenses if the transmission could have been prevented. Objective: To determine if the practice

of daily chlorhexidine bathing in hospitalized patients will lower the rate of hospital acquired

MRSA. PubMed, the Centers for Disease Control and Prevention (CDC), and the National

Guideline Clearinghouse were the databases used to access randomized controlled trials and

guidelines related to MRSA prevention. Key words used in the search include MRSA,

chlorhexidine bathing, prevention, and hospitalized patients.

Results: Research supports that routine daily chlorhexidine bathing decreases the risk of hospital-

acquired MRSA. Armellino et al. (2014) had a 95% confidence interval: 0.14-0.058 (P < .001)

after a randomized controlled trial. In a study conducted by Climo et al. (2013) there was a p

interval of p=0.03 in favor of CHG bathing, and Kassakian, Mermel , Jefferson, Parenteau, &

Machan (2011) performed a study with a p interval of p=0.01. Also, the Centers for Disease

Control and Prevention (CDC) recommends bathing patients daily with 2% chlorhexidine

gluconate as a supplemental measure to decrease the rate of MRSA acquisition while in the

hospital.
Conclusion: The practice of daily chlorhexidine bathing reduces the rate of hospital-acquired

MRSA in patients in an intensive care unit (ICU) or on a general medical floor, decreases

mortality rates and reduces hospital expenses for patients.

Hospital-Acquired Methicillin-Resistant Staphylococcus Aureus (MRSA) Prevention

HOSPTIAL-ACQUIRED MRSA PREVENTION 3

The opportunity for clinical improvement is the foundation of evidenced based practice.

The most important reasons for consistently implementing EBP are that it leads to the highest

quality of care and the best patient outcomes (Melnyk & Fineout-Overholt, 2015, p. 6). It

allows for improved outcomes in the clinical setting in the aspect of patient care, safety,

necessary interventions, and lowered healthcare costs for patients as health care providers are

able to strategically promote the most appropriate care specific to each and every patient based

off of evidence provided. According to the Centers of Disease Control and Prevention (CDC),

methicillin-resistant staphylococcus aureus (MRSA) is the second most common cause of

hospital associated infections (HAIs) reported but there was a 54% decline in transmission from

2005 to 2011. The most recent protocol that the CDC reports for the prevention of MRSA is

bathing with basin soap and water for the general hospital population and use of 2%

chlorhexidine gluconate in patients who at high risk for infection.

This paper evaluates an intervention to prevent MRSA that is acquired during hospital

stay; the patient outcome varies greatly as the patient does not end up with a life threatening

bacteria, contact precautions, and expenses that could have been prevented. In patients in the

intensive care unit (ICU) and general medical floors how does the use of chlorhexidine body-

washing compared with use of soap and water or non-antimicrobial washcloths affect the rate of

MRSA transmission over the period hospitalization?

Literature Search
PubMed, the Centers for Disease Control and Prevention (CDC), and the National

Guideline Clearinghouse were the databases used to access randomized controlled trials and

guidelines relative to MRSA prevention. Key words used in the search include MRSA,

chlorhexidine bathing, infection prevention, hospital, and hospitalized patients.

Literature Review
Three randomized controlled trials and one guideline were accessed to support the

intervention of daily 2% chlorhexidine gluconate bathing in preventing hospital-acquired

HOSPTIAL-ACQUIRED MRSA PREVENTION 4

infections (HAIs) and MRSA. Using a double-blind randomized placebo-controlled trial, Camus

et al. (2014) analyzed two different interventions to reduce the rate of hospital acquired MRSA;

one of them being bathing with chlorhexidine. This study is actually a post hoc analysis, the

original study was conducted from 1996 to 1999. Five hundred fifteen patients from three

medical ICUs located in different facilities in France were included in this study. For this specific

study, the patient had to be intubated or expected to be intubated and over 18 years old to meet

criteria to be analyzed. From April 1996 to June 1999 they used chlorhexidine 4% soap and

washed the patients bodies twice a day. The results were significant in reducing MRSA (p=0.04)

as it had many strengths. It was a double blind study, subjects were randomly and appropriately

assigned to the control and experimental groups, there were reasons given as to why a large

number of patients did not complete the study, and the instruments used to measure the outcome

were reliable and valid. This study is relevant to the proposed intervention in this paper as use of

chlorhexidine bathing reduced the rate of MRSA transmission significantly.

As the rate of hospital acquired infections is a prevalent issue, this controlled trial by

Climo et al. (2013) aimed to study effects of bathing patients daily with chlorhexidine gluconate

wipes (intervention) versus non-antimicrobial washcloths (control) in preventing the spread of

infection in ICUs or bone marrow transplantation units. Nine intensive care units and 7,727

patients participated in the study over the course of twelve months; six months with the control

and six months with the intervention. The patients were tested for MRSA via nares swab within

fourty-eight hours of admission, during hospitalization and before discharge. One hundred sixty-

five cases of MRSA were witnessed during the control period and one hundred and nineteen

were tested positive during the intervention period which is a 19% lower transmission rate

(p=0.03). The results of the trial suggest that use of chlorhexidine wipes reduces the transmission
HOSPTIAL-ACQUIRED MRSA PREVENTION 5

rate of MRSA and VRE specifically. This study had many strengths; patients were randomly

assigned to the control or intervention group. Follow-up assessments were conducted long

enough to fully study the effects of CHG bathing. The subjects were analyzed in the group to

which they were randomly assigned (soap & water or CHG baths). The control group was

appropriate. Methods used to measure outcomes were valid. Subjects in each group were similar.

The only limitations were the preintervention time period was shorter than intervention period

and nurses completing study observations were not blind to the study group. This study supports

that use of chlorhexidine bathing decreases MRSA transmission in the hospital.

Another randomized controlled trial analyzed by Kassakian, Mermel , Jefferson,

Parenteau, & Machan (2011) to study the effectiveness of chlorhexidine bathing procedures

versus soap and water to prevent the spread of MRSA and VRE in hospitalized patients was

successful in identifying a decrease in hospital acquired infections. Instead of conducting a study

on ICU patients only, this was based off of general medical patients in a small hospital facility.

There were 7,102 patients in the control group who were bathed with soap and water and 7,699

patients in the intervention group who were bathed with chlorhexidine from four general medical

units, the control group was analyzed from January 1 to December 31, 2008 and the intervention

group from February 1, 2009 through March 31, 2010. There were 20 cases of MRSA and VRE

detected during the control period and 10 detected during the intervention. The results (p=0.01)

from this study demonstrates that the use of chlorhexidine is effective in reducing the

transmission of MRSA acquired during hospital stay. Patients were randomly assigned to the

experimental and study control groups.

Follow-up assessments were conducted long enough to fully study the effects of CHG bathing,

the subjects were analyzed in the group to which they were randomly assigned (soap & water or
HOSPTIAL-ACQUIRED MRSA PREVENTION 6

CHG baths), the control group was appropriate and methods used to measure outcomes were

valid. Subjects in each group were also similar. The only weakness to this study is the nurses

completing study observations were not blind to the study group. The article is useful in the

research for my PICOT proposal in evidenced based practice.

The evidenced based practice national guideline retrieved from the National Guidelines

Clearinghouse from Liu et al. (2011) recommends that patients (adults and pediatrics) at high

risk for developing/have already developed MRSA infections should be bathed with

chlorhexidine daily to prevent transmission and reduce rates associated with hospital-acquired

MRSA.

Synthesis

Camus et al. (2014) suggested a decrease in the transmission of MRSA during a

randomized placebo controlled trial with the use of chlorhexidine bathing (p=0.04). Climo et al.

(2013) also demonstrated the effectiveness of CHG in preventing MRSA during their trial (0.03).

Furthermore, the study conducted by Kassakian et al. (2011) supported use of CHG bathing

practices in reducing MRSA (p=0.01). An additional resource in the support of the intervention,

the national guideline promoted by Liu et al. (2011) recommends use of CHG in both adult and

pediatric populations to decrease the rate of MRSA in hospital settings. The articles and studies

used in this paper were all very similar as they were evaluating the effectiveness of chlorhexidine

bathing procedures in reducing MRSA. Camus et al. (2014) and Climo et al. (2013) analyzed

patients in the ICU while the trial performed by Kassakian et al. (2011) was evaluated on general

medical floors. Camus et al. (2014) narrowed their sample size down even further by merely

including intubated patients.

HOSPTIAL-ACQUIRED MRSA PREVENTION 7

Research shows that daily chlorhexidine bathing reduces the rate of MRSA in the

hospital, specifically in the ICU. Although one RCT that included patients on the general medical

units suggested significant results, most of the randomized controlled trials found that were

relevant to this proposal were based off of the intensive care unit population. Further research

will be required to determine the effectiveness of CHG bathing in patients of all populations.

Clinical Recommendations

Given the synthesis of the literature, chlorhexidine bathing is a safe, preventative practice

that will decrease the rate of MRSA, mortality, and the cost of healthcare for patients. The CHG

bathing intervention is a clinical guideline used as a supplemental precaution and it is already

implemented in some intensive care units across the nation. According to the CDC (2011) in

addition to CHG bathing, the protocol for preventing MRSA and other HAIs is hand hygiene,

isolation precautions, use of antibiotics, etc. Practice has already changed in regards to CHG use

in evidenced based practice as there are many studies out there that have been testing trials of

this intervention for many years.

References
Camus, C., Sebille, V., Legras, A., Garo, B., Renault, A., Le Corre, P., Bellissant, E. (2014).

Mupirocin/chlorhexidine to prevent methicillin-resistant Staphylococcus aureus

infections: Post hoc analysis of a placebo-controlled, randomized trial using

mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired

infections in intubated patients. Clinical and Epidemiological Study, 42(3), 493-502.

http://dx.doi.org/10.1007/s15010-013-0581-1
Centers for Disease Control and Prevention (2011). Methicillin-resistant staphylococcus aureus

(MRSA) infections. Retrieved from http://www.cdc.gov/mrsa/healthcare/index.html.

HOSPTIAL-ACQUIRED MRSA PREVENTION 8

Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Maureen, B., Loreen, H. A., ... Edward,

W. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. The

New England Journal of Medicine, 368(6), 533-542.

http://dx.doi.org/10.1056/NEJMoa1113849

Kassakian, S. Z., Mermel, L. A., Jefferson, J. A., Parenteau, S. L., & Machan, J. T. (2011).

Impact of chlorhexidine bathing on hospital-acquired infections among general medical

patients. Infection Control and Hospital Epidemiology, 32(3), 238-243. Retrieved from

http://ovidsp.tx.ovid.com.ezproxy.hsc.usf.edu/sp-3.18.0b/ovidweb.cgi?

T=JS&PAGE=fulltext&D=ovft&AN=00004848-201103000-

00006&NEWS=N&CSC=Y&CHANNEL=PubMed

Liu C., Bayer A., Cosgrove S., Daum S., Fridkin S., Gorwitz R., Chambers H. (2011) Clinical

practice guidelines by the infectious diseases society of america for the treatment of

methicillin-resistant staphylococcus aureus infections in adults and children. Clinical

Infectious Diseases, 52(1) 38. Retrieved from http://www.guideline.gov/content.aspx?

id=25412&search=mrsa

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidenced-based practice in nursing &

healthcare: A guide to best practice (3rd ed., pp. 6). Philadelphia, PA: Wolters .
HOSPTIAL-ACQUIRED MRSA PREVENTION 9