Chlorhexidine Patient Chlorhexidine Patient Bathing as a Means to Bathing as a Means to Prevent Healthcare Prevent Healthcare Associated InfectionsAssociated Infections

Mark E. Rupp, MDMark E. Rupp, MDProfessor & Chief, Infectious DiseasesProfessor & Chief, Infectious Diseases

Director, Infection Control & EpidemiologyDirector, Infection Control & EpidemiologyUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center

Hosted by Martin KiernanHosted by Martin Kiernanmartin@webbertraining.commartin@webbertraining.com

www.webbertraining.com April 17, 2014

Potential Conflicts of Potential Conflicts of InterestInterest

Dr Rupp reports the following Dr Rupp reports the following pertinent potential conflicts of pertinent potential conflicts of interest:interest: Prior research support in the form of Prior research support in the form of

contracts to UNMC from 3M & contracts to UNMC from 3M & MolnlyckeMolnlycke

Consultant or Advisory Board for 3M & Consultant or Advisory Board for 3M & Molnlycke Molnlycke

ObjectivesObjectives

At the conclusion of this program the At the conclusion of this program the participant should:participant should:Have a better understanding of the antiseptic Have a better understanding of the antiseptic activity of chlorhexidine gluconate (CHG)activity of chlorhexidine gluconate (CHG)Be able to introduce a program of CHG patient Be able to introduce a program of CHG patient bathing in a targeted or general mannerbathing in a targeted or general mannerUnderstand the pros and cons of CHG patient Understand the pros and cons of CHG patient bathing bathing

Horizontal vs Vertical Infection Horizontal vs Vertical Infection Prevention InterventionsPrevention Interventions

Intervention that affects Intervention that affects narrow group of patients narrow group of patients (eg. Active surveillance (eg. Active surveillance cultures for MRSA) vs cultures for MRSA) vs intervention that cuts intervention that cuts across lines and affects across lines and affects numerous patient numerous patient groups (eg. Hand groups (eg. Hand Hygiene) Hygiene)

Chlorhexidine Patient Chlorhexidine Patient BathingBathing

ChlorhexidineChlorhexidine

Cationic bisbiguanide first synthesized in England Cationic bisbiguanide first synthesized in England in 1950 during search for antimalarial drugsin 1950 during search for antimalarial drugs

Mechanism of Action: Mechanism of Action: Rapid attraction to negatively-charged bacterial cellRapid attraction to negatively-charged bacterial cell Adsorption to phosphate-containing constituents of the Adsorption to phosphate-containing constituents of the

bacterial surfacebacterial surface Attraction to cytoplasmic membranesAttraction to cytoplasmic membranes Leakage of low-MW cytoplasmic components (KLeakage of low-MW cytoplasmic components (K++, Ca, Ca++++)) Inhibition of membrane-bound enzymes (Adenosyl Inhibition of membrane-bound enzymes (Adenosyl

triphosphatase)triphosphatase) Precipitation of cytoplasmPrecipitation of cytoplasm

1,6-di(4-chlorophenyl-diguanido) hexane

ChlorhexidineChlorhexidine

Antimicrobial Spectrum:Antimicrobial Spectrum: CHG exhibits broad spectrum activity CHG exhibits broad spectrum activity

against wide variety of Gram-positive against wide variety of Gram-positive & Gram-negative bacteria, fungi, and & Gram-negative bacteria, fungi, and lipid-coated viruses (HSV, HIV, RSV, lipid-coated viruses (HSV, HIV, RSV, flu, adeno, etc)flu, adeno, etc)

Inactive against bacterial sporesInactive against bacterial spores Inhibitory against acid-fast bacilliInhibitory against acid-fast bacilli

Cidal Activity of Cidal Activity of ChlorhexidineChlorhexidine

Denton GW. In: Disinfection, Sterilization, and Preservation, 2001

Clinical Applications of Clinical Applications of ChlorhexidineChlorhexidine

Preoperative surgical Preoperative surgical site scrubsite scrub

Preoperative showerPreoperative shower Surgical hand scrubSurgical hand scrub Hand disinfectantHand disinfectant Bladder irrigantBladder irrigant OB/GYN perineal OB/GYN perineal

antisepticantiseptic Devices: CVCs, Devices: CVCs,

dressingsdressings

Wound irrigantWound irrigant Burn wound cleansingBurn wound cleansing Mouthwash Mouthwash Oral care for patients Oral care for patients

on mechanical on mechanical ventilationventilation

Body wash for Body wash for prevention of MDROsprevention of MDROs

Body wash to prevent Body wash to prevent CVC BSICVC BSI

Residual Residual Activity and Activity and Cumulative Cumulative Effect of Effect of ChlorhexidineChlorhexidine

Paulson, DS. Amer J Infect Paulson, DS. Amer J Infect Control, 1993Control, 1993

4% CHG shower in 5 4% CHG shower in 5 volunteers for 5 days. volunteers for 5 days.

CHG impregnated CHG impregnated sponges used for 60 sponges used for 60 seconds, rinse, and seconds, rinse, and repeat.repeat.

Cup-scrub culture Cup-scrub culture method method

CVC-BSI Prevention with CHG CVC-BSI Prevention with CHG Skin DisinfectionSkin Disinfection

Maki DR, et al. Maki DR, et al. Lancet, 1991Lancet, 1991.. Prospective, Prospective,

randomized randomized clinical trial clinical trial involving 668 involving 668 CVCs in SICUCVCs in SICU

10% povidone 10% povidone iodineiodine

70% alcohol70% alcohol 2% CHG 2% CHG

P=0.02

P=0.04

CVC-BSI Prevention with CHG CVC-BSI Prevention with CHG Skin DisinfectionSkin Disinfection

Chaiyakunapruk N, Chaiyakunapruk N, et al. Ann Intern et al. Ann Intern Med, 2002Med, 2002

Meta-analysis of Meta-analysis of RCTs comparing RCTs comparing CHG vs PI for CVC CHG vs PI for CVC insertion and careinsertion and care

8 studies, 4143 8 studies, 4143 CathetersCatheters CVCs: RR 0.51 (95% CI 0.27-0.97)

CHG CVC DRESSINGSCHG CVC DRESSINGS

Timsit, et al. JAMA, 301:1231-41, 2009Timsit, et al. JAMA, 301:1231-41, 2009 Timsit, et al. Am J Respir Crit Care Med. Timsit, et al. Am J Respir Crit Care Med.

186:1272-78 186:1272-78

Chlorhexidine Patient Chlorhexidine Patient BathingBathing

Arch Intern Med 2007 ICHE 2007

ICHE 2007

Quasi-experimental, Prospective, Staggered-Quasi-experimental, Prospective, Staggered-Initiation, Dose-escalation StudyInitiation, Dose-escalation Study

3 Cohorts; 6 months M/W/F followed by 3 Cohorts; 6 months M/W/F followed by every day CHG bathing every day CHG bathing

19 month intervention, 4 month washout 19 month intervention, 4 month washout periodperiod

188,859 patient days, 68,302 CHG baths188,859 patient days, 68,302 CHG baths HAIs monitored (CLA-BSI, CA-UTI, VAP, VRE, HAIs monitored (CLA-BSI, CA-UTI, VAP, VRE,

MRSA, CDI)MRSA, CDI)

(Infect Control Hosp Epidemiol. Nov 2012)

Time Table for Introduction of CHG Bathing to Inpatient Units

Grp 1 (ICUs)

Grp 2 (Univ Tower)

Grp 3 (Clarkson Tower)

MWF CHG Phase

Daily CHG Phase

Washout Phase

Month

Information and Teaching Information and Teaching SheetsSheets

Available at Infection Control Intranet site or call 9-5276

CHG Bathing CHG Bathing ComplianceCompliance

Rupp et al. ICHE 2012

CHG vs CHG vs C. difficileC. difficile

Rupp et al. ICHE 2012

Chlorhexidine Patient Chlorhexidine Patient BathingBathing

VREVRE

Rupp et al. ICHE 2012

DiscussionDiscussion

Effect on Effect on C difficile C difficile was unexpected:was unexpected: Bactericidal vs vegetative cellsBactericidal vs vegetative cells Inhibits spore germinationInhibits spore germination Bed bath and physical removal of Bed bath and physical removal of

spores (was effect of study simply to spores (was effect of study simply to improve bathing?); Decreased improve bathing?); Decreased environmental contamination and environmental contamination and spread?spread?

Surfactant may aid removal of sporesSurfactant may aid removal of spores

DiscussionDiscussion Confounding?Confounding?

Laboratory diagnostic changesLaboratory diagnostic changes CDI control measuresCDI control measures

Isolation, hand hygiene, glove use, bleach cleaningIsolation, hand hygiene, glove use, bleach cleaning Antibiotic useAntibiotic use Seasonality (increases in winter) Seasonality (increases in winter)

Changes in Changes in C difficile C difficile strain typestrain type Study should be “hypothesis generating” Study should be “hypothesis generating”

and result in efforts to replicate our and result in efforts to replicate our experienceexperience

Future DirectionsFuture Directions

Does use of CHG result in selection Does use of CHG result in selection of qac(+) staphylococci and CHG of qac(+) staphylococci and CHG resistance?resistance?

What drives compliance with pt What drives compliance with pt bathing? bathing?

Cost effectiveness?Cost effectiveness?

Prospective, cluster-randomized study in 9 Prospective, cluster-randomized study in 9 ICUs involving 7727 patients, 6 mo crossover ICUs involving 7727 patients, 6 mo crossover

23% decrease in acquisition of MDROs (p= 23% decrease in acquisition of MDROs (p= 0.03)0.03)

28% decrease in bloodstream infections (P = 28% decrease in bloodstream infections (P = 0.007)0.007)

Feb 7, 2013

Prospective, cluster-randomized study in ICUs in 43 Prospective, cluster-randomized study in ICUs in 43 hospitals. Grp 1 - MRSA screening and isolation; Grp 2 hospitals. Grp 1 - MRSA screening and isolation; Grp 2 - Targeted decolonization; Grp 3 – Universal - Targeted decolonization; Grp 3 – Universal decolonization (mupirocin & CHG baths)decolonization (mupirocin & CHG baths)

HR for MRSA (intervention vs baseline): 0.92 vs 0.75 vs HR for MRSA (intervention vs baseline): 0.92 vs 0.75 vs 0.63 (P= 0.01)0.63 (P= 0.01)

HR for BSI (intervention vs baseline): 0.99 vs 0.78 vs HR for BSI (intervention vs baseline): 0.99 vs 0.78 vs 0.56 (P = <0.001)0.56 (P = <0.001)

June 13, 2013

CHG ResistanceCHG Resistance Multi-drug efflux pumps (Multi-drug efflux pumps (qacqacA/B, A/B, smrsmr) decrease ) decrease

susceptibility to CHGsusceptibility to CHG Prevalence surveys indicate qacA/B to be present in Prevalence surveys indicate qacA/B to be present in

0.5% - 80% of MRSA isolates.0.5% - 80% of MRSA isolates. MIC CHG ~4-8 ug/mL increases to 16-32 ug/mLMIC CHG ~4-8 ug/mL increases to 16-32 ug/mL Clinical Significance?Clinical Significance?

Elevated MIC remains well below clinical concentrationElevated MIC remains well below clinical concentration qacA/B + mupirocin R = persistent colonization (Lee et al, qacA/B + mupirocin R = persistent colonization (Lee et al,

CID, 2011)CID, 2011) CHG use selected for qacA/B (+) strains in ICU (Batra et al, CHG use selected for qacA/B (+) strains in ICU (Batra et al,

CID 2010)CID 2010)

Bath Basin ContaminationBath Basin Contamination

Bacterial contamination Bacterial contamination of simulated CHG bed of simulated CHG bed bath solutionbath solution

101088 cfu of cfu of E coli, S epi, E E coli, S epi, E facaelisfacaelis

Immediate and Residual Immediate and Residual experimentsexperiments

Rupp et al, ICHE 2013

Immediate

3 Hr Residual

Effective Infection Prevention is Effective Infection Prevention is a Multi-Piece Puzzlea Multi-Piece Puzzle

Education and TrainingEducation and Training Surveillance and ReportingSurveillance and Reporting Isolation and Source ControlIsolation and Source Control Elimination of Fomites Elimination of Fomites Insertion and Care of DevicesInsertion and Care of Devices Vaccination and PresenteeismVaccination and Presenteeism Environmental CleaningEnvironmental Cleaning Hand HygieneHand Hygiene CHG BathingCHG Bathing

April 24 (Free Teleclass) ARE WE TOO CLEAN FOR OUR OWN GOOD? THE HYGIENE

HYPOTHESIS AND ITS IMPLICATIONS FOR HYGIENE, LIFESTYLE, AND PUBLIC HEALTH

Dr. Sally Bloomfield, London School of Hygiene and Tropical Medicine

May 5 (Free ... WHO Teleclass – Europe) SPECIAL LECTURE FOR 5 MAY, 2014Prof. Didier Pittet, World Health Organization

May 8 VENTILATOR-ASSOCIATED EVENTS: A PATIENT SAFETY OPPORTUNITY

Dr. Michael Klompas, Harvard Medical School

May 13 (British Teleclass)VENTILATION IN HEALTHCARE FACILITIESDr. Peter Hoffman, Health Protection Agency, UK

May 15 METHODS TO EVALUATE HAND HYGIENE PRODUCTS