Chlorhexidine-based Body Washing for Colonization and Infection of Methicillin-Resistant Staphylococcus Aureus and Vancomycin-resistant Enterococcus: An Updated Meta-analysis

Figures & data

Figure 1 Flow diagram of articles selected for inclusion in the meta-analysis.

Table 1 Characteristics of the included studies

Study	Year	Study design	Patient selection	Study setting	Major intervention	Control intervention	Outcome measures
Lowe et al^Citation18	2017	Prospective crossover study	Patients from four inpatient medical units (25 beds each) from May 1, 2014 to August 10, 2015	Four medical inpatient units in an urban, academic Canadian hospital	Daily CHW over a 7-month period, including a 1 -month wash-in phase	Daily bathing with nonmedicated soap and water	Rates of hospital- associated MRSA and VRE colonization or infection
Amirov et al^Citation19	2017	C1 uster-random ized, open-label, controlled trial	Chronic care patients	Three hospital units	Daily CHW	Daily nonantiseptic bathing	MRSA incidence
Kim et al^Citation20	2016	Interrupted time series study	Patients admitted to the ICU for >48 hours	A 829-bed tertiary care hospital in Hallym University Sacred Heart Hospital	16-month CHW between August 2013 and November 2014	14-month without bathing with chlorhexidine between June 2012 and July 2013	Rates for MRSA acquisition
Millar et al^Citation21	2015	Three-group, field-based, cl uster-random ized trial	US Army soldiers 17 to 42 years of age, ethnically diverse, and in generally good physical condition	A US army soldier hospital	CHW with a wash cloth after using their personal soap during an additional once-weekly shower	Standard, enhanced standard body wash without using chlorhexidine	MRSA skin and soft-tissue infections’ colonization prevalence
Colling et al^Citation22	2015	Multicenter,retrospective, controlled study	Patients undergoing hip and knee arthroplasties at two affiliated hospitals in the Fairview Hospital System between January 2010 and June 2012	An 874-bed hospital and a community hospital	Having preoperative CHG shower or bath policy in place	Having no antiseptic shower or bath	Rate of S. aureus and MRSA surgical site infections
Climo et al^Citation5	2013	A multicenter, cluster- randomized, nonblinded crossover trial	Patients in nine 1C Us and bone marrow transplantation units in six hospitals	Nine ICUs and bone marrow transplantation units in six hospitals in USA	C H W-i mpregnated washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months	Bathing with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months	The incidence rates of acquisition of hospital- acquired BSIs and acquisition of multidrug- resistant organisms
Huang et al^Citation23	2013	Three-group, cluster- randomized trial	Patients in adult ICUs in Hospital Corporation of America hospitals	45 hospitals in 16 states with a total of 74 adult ICUs	Bathing with 2% CHG washcloths	Bathing without 2% CHG washcloths	MRSA BSI
Bass et al^Citation11	2013	Before-and-after study	Hematology/oncology patients at the Alfred Hospital	A 34-bed major tertiary teaching hospital in Melbourne, Australia	Bathing with 2% CHG- impregnated washcloths	Bathing with routine soap and water	Incidence rate of VRE colonization
Montecalvo	2012	Prospective, three-	Patients from a tertiary care	A medical ICU and the	Intervention phase: patients	Preintervention phase:	Hospital-acquired CVC-
et al^Citation24		phase, multi ple-hospital, non-randomized trial	hospital and four community hospitals in Westchester County, New York	respiratory care unit of a tertiary care hospital and the medical-surgical ICUs of 4 community hospitals	were bathed with 2% CHG cloths, with the number of baths administered and skin tolerability assessed Postintervention phase: CHG bathing was continued but without oversight by research personnel	patients were bathed with soap and water or nonmedicated bathing cloths	associated BSI rates
Kassakian et al^Citation9	201 1	Quasi-experi mental study	Patients at four general medicine units, with a total of 94 beds, at a 719-bed academic tertiary care facility	Four general medicine units at a 719-bed academic tertiary care facility in Providence, Rl	Daily bathing withchlorhexidine-impregnatedcloths	Daily bathing with soap and water	Incidence of MRSA and VRE HAIs
Evans et al^Citation26	2010	Retrospective before- and-after study design	Severely injured patients in a 41 3-bed level 1 trauma center that serves patients from four states	A 12-bed ICU in a level 1 trauma center	Daily chlorhexidine bathing during the 6-month intervention	Bathed without chlorhexidine prior to the intervention	HAIs and the rate of isolation of multi drug- resistant organisms
Fraser et al^Citation25	2010	Retrospective quasi- experimental study	Patients in the medical ICU	An 18-bed medical ICU at a tertiary care center in Cleveland, Ohio	Daily CHG baths	Daily body wash without CHG	The incidence of hospital- acquired BSI, the incidence of ventilator-associated pneumonia
Popovich et al^Citation10	2010	Quasi-experimental, pre-post study	Patients in the 30-bed surgical ICU at Rush University Medical Center, a 720-bed tertiary care teaching hospital in Chicago	A medical ICU at Rush University Medical Center and a tertiary care teaching hospital in Chicago	Substituted skin cleansing with no rinse, 2% CHG- impregnated cloths	Soap and water bathing	ICU-acquired CLABSI; blood culture contamination and other ICU-acquired nosocomial infection
Climo et al^Citation28	2009	Multicenter, before- after interventional study	Patients from six IC Us at four academic centers	Six ICUs at four major tertiary care referral hospitals in USA	Daily bathing with achlorhexidine-containingsolution	Soap and water bathing	Incidence of MRSA and VRE colonization and BSI
Popovich et al^Citation27	2009	Quasi-experimental, pre-post study	Patients in the 21-bed medical ICU at Rush University Medical Center, a 720-bed tertiary care teaching hospital in Chicago	A medical ICU at Rush University Medical Center and a tertiary care teaching hospital in Chicago	Substituted skin cleansing with no rinse, 2% CHG- impregnated cloths	Skin cleansing with soap and water	Medical ICU-acquired CVC-associated BSI, blood culture contamination, and other medical ICU- acquired nosocomial infection
Ridenour et al^Citation29	2007	Interrupted time series study	Patients in a 427-bed tertiary care Veterans Affairs hospital	A medical-coronary ICU	Chlorhexidine bathing	Bathing without chlorhexidine	The incidence of MRSA colonization and infection
Vernon et al^Citation30	2006	Prospective, sequential group, single-arm clinical trial	Patients in a 21-bed medical ICU at a 720-bed hospital in Chicago	A medical ICU at a 720- bed hospital in Chicago	Bath with 2% CHG washcloths	Soap and water bathing	Incidence of VRE acquisition

Abbreviations: BSI, bloodstream infections; CHG, chlorhexidine; CHW, chlorhexidine-based body washing; CLABSI, central line-associated bloodstream infections; CVC, central venous catheter; HAIs, health care-associated infections; ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus; S. aureus; Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus.

Figure 2 Forest plots comparing the effects of CHW on the risk of (A) MRSA colonization, (B) MRSA infection, (C) VRE colonization, and (D) VRE infection with those of the routine intervention.

Note: Weights are from random-effects analysis.
Abbreviations: CHW, chlorhexidine-based body washing; IRR, incidence rate ratio; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus.

Table 2 Results of meta-analysis for the effects of CHW on the risk of MRSA colonization or infection and VRE colonization or infection; analyses of the publication bias with different models

Variable	No of studies	IRR (95% CI)	P	I^2,Phet
CHw and MRSA colonization	9	0.61 (0.48-0.77)	<0.001	60.9, 0.009
CHw and MRSA infection	10	0.65 (0.52-0.81)	<0.001	0.0, 0.723
CHw and vRE colonization	8	0.58 (0.42-0.80)	0.001	53.8, 0.034
CHw and vRE infection	6	0.61 (0.30-1.25)	0.176	30.6, 0.206
Publication bias	Begg’s P-value	Egger’s P-value	T&F (Fill), IRR (95% CI)
CHW and MRSA colonization	0.917	0.817	0.61 (0.48-0.77)
CHW and MRSA infection	0.592	0.896	0.65 (0.52-0.81)
CHW and VRE colonization	1.000	0.617	0.58 (0.42-0.80)
CHW and VRE infection	0.707	0.983	0.61 (0.30-1.25)

Notes: Fill, number of studies added by trim-and-fill method; het, heterogeneity; T&F, result of trimmed and filled analysis, using assumption of random effects.

Abbreviations: CHW, chlorhexidine-based body washing; het, heterogeneity; IRR, incidence rate ratio; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus.

Figure 3 Sensitivity analyses for the effects of CHW on the risk of (A) MRSA colonization, (B) MRSA infection, (C) VRE colonization, (D) VRE infection.

Abbreviations: CHW, chlorhexidine-based body washing; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus.

Lowe CF, Lloyd-Smith E, Sidhu B, et al. Reduction in hospital-associated methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus with daily chlorhexidine gluconate bathing for medical inpatients. Am J Infect Control. 2017;45(3):255–259.

 PubMed Web of Science ®Google Scholar

Amirov CM, Binns MA, Jacob LE, Candon HL. Impact of chlorhexidine bathing on methicillin-resistant Staphylococcus aureus incidence in an endemic chronic care setting: A randomized controlled trial. Am J Infect Control. 2017;45(3):298–300.

 PubMed Web of Science ®Google Scholar

Kim JS, Chung YK, Lee SS, et al. Effect of daily chlorhexidine bathing on the acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit with methicillin-resistant S aureus endemicity. Am J Infect Control. 2016;44(12):1520–1525.

 PubMed Web of Science ®Google Scholar

Millar EV, Chen WJ, Schlett CD, et al. Frequent use of chlorhexidine-based body wash associated with a reduction in methicillin-resistant Staphylococcus aureus nasal colonization among military trainees. Antimicrob Agents Chemother. 2015;59(2):943–949.

 PubMed Web of Science ®Google Scholar

Colling K, Statz C, Glover J, Banton K, Beilman G. Pre-operative antiseptic shower and bath policy decreases the rate of S. aureus and methicillin-resistant S. aureus surgical site infections in patients undergoing joint arthroplasty. Surg Infect. 2015;16(2):124–132.

 PubMed Web of Science ®Google Scholar

Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533–542.

 PubMed Web of Science ®Google Scholar

Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255–2265.

 PubMed Web of Science ®Google Scholar

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(4):345–348.

 PubMed Web of Science ®Google Scholar

Montecalvo MA, Mckenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Am J Med. 2012;125(5):505–511.

 PubMed Web of Science ®Google Scholar

Kassakian SZ, Mermel LA, Jefferson JA, Parenteau SL, Machan JT. Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Infect Control Hosp Epidemiol. 2011;32(3):238–243.

 PubMed Web of Science ®Google Scholar

Evans HL, Dellit TH, Chan J, Nathens AB, Maier RV, Cuschieri J. Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients. Arch Surg. 2010;145(3):240–246.

 PubMedGoogle Scholar

Fraser TG, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779–783.

 PubMed Web of Science ®Google Scholar

Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Daily skin cleansing with chlorhexidine did not reduce the rate of central-line associated bloodstream infection in a surgical intensive care unit. Intensive Care Med. 2010;36(5):854–858.

 PubMed Web of Science ®Google Scholar

Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009;37(6):1858–1865.

 PubMed Web of Science ®Google Scholar

Popovich KJ, Hota B, Hayes R, Weinstein RA, Hayden MK. Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit. Infect Control Hosp Epidemiol. 2009;30(10):959–963.

 PubMed Web of Science ®Google Scholar

Ridenour G, Lampen R, Federspiel J, Kritchevsky S, Wong E, Climo M. Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol. 2007;28(10):1155–1161.

 PubMed Web of Science ®Google Scholar

Vernon MO, Hayden MK, Trick WE, et al. Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med. 2006;166(3):306–312.

 PubMedGoogle Scholar