The study of Chlorhexidine gluconate use to prevent hospital acquired infections in that —CHG-BATH—is unique in many regards. It is one of the few randomized controlled trials performed to investigate the efficacy of CHG bathing. While it was not possible to carry out this trial in a double-blinded fashion, single blinded-ness was achieved as the investigators determining efficacy and safety outcomes were blinded. Further, the majority of previous trials were carried out in medical ICU patients, evaluating for CA-UTI, VAP and CLA-BSI. CHG-BATH was one of the few conducted in surgical ICU patients, and evaluating for SSI, in addition to other HAIs. This trial confirms that the previous evidence that CHG bathing prevents the most common infections acquired in the ICU.
Several issues of interest should be noted. Firstly, extant literature suggests CHG baths should be done daily, yet the CHG-BATH trial showed similar results with every other day CHG bathing. The rationale for this is CHG decolonizes the skin, with recolonization taking about 5 days. With this line of thinking, every other day bathing should be just as effective as daily bathing, potentially decreases adverse skin effects, and is less costly; this seemed to hold true.
Secondly, patients randomized to the control group received soap and water bath every other day, whereas those randomized to the experimental group received CHG every other day. However, the methods describe patients receiving “ad hoc baths” with soap and water on an as-needed basis. For example, if a patient needed to be cleansed of feces, urine or blood, a bath was performed with soap and water. How many of these ad hoc baths were performed in the soap and water vs. the CHG group was not documented. If may be the patients in the CHG group received many ad hoc baths, then the lowered infection rate in that group may not be attributable to the effect of CHG only. It is more likely that both groups received a comparable number of ad hoc baths, but one cannot be sure. It is surprising to us that the Critical Care Medicine editors/reviewers did not comment upon this potentially confounding factor.
Thirdly, the trial protocol calls for disposal of the washbasin after each use. However, compliance with this instruction was not observed. Thus, it is possible that washbasins were used for a second or third time after the initial bath. One could easily imagine that the soap and water-only basin might be more likely to be colonized with bacteria than the one in which CHG was used. Again, it is likely this non-compliance, if it occurred at all, occurred equally in both arms, but there is no way to know for certain.
The case against CHG baths largely rests in the argument that CHG may compromise the skin. This appears to be untrue. In Popp et al.’s study—a before and after design—of thermally injured patients, 0.9 percent CHG baths twice daily decreased the HAI rate to near-zero, and no integumentary difficulties or delayed wound healing were found. We would argue that in the context of risk-benefit, CHG is safe and effective.
The implications of the study under discussion are tremendous: every other day CHG baths should be performed in all ICU patients, perhaps in all hospital patients. The number needed to treat (NNT) is 11; that is, for every eleven patients we bathe with CHG, one HAI is prevented.
The cost of the bathing product is not an issue of consideration: CHG-BATH used CHG diluted in water in a washbasin instead of the relatively more expensive CHG impregnated cloths. The former manner of bathing entails a cost of $3.18 per bath; without any doubt, CHG solution baths are cost effective.
Quality is not a checklist, nor is it an antiseptic solution or a new device. The provision of high quality, patient, and family-centered care can only be achieved if we work in teams, pay careful attention to each aspect of the patient’s care, and utilize best practice and evidence-based medicine as much as possible. In this context, the recommendations of CHG-BATH are but one of several measures which, if implemented thoughtfully, should lead to better quality care, improved outcomes and decreased iatrogenic infectious complications. The benefit we obtain through all of these measures is due to attention to detail.
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