Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Marschall, Jonas; Mermel, Leonard A.; Fakih, Mohamad G.; Hadaway, Lynn; Kallen, Alexander J.; O’Grady, Naomi P.; Pettis, Ann Marie; Rupp, Mark E.; Sandora, Thomas J.; Maragakis, Lisa L.; Yokoe, Deborah S.

doi:10.1086/676533

Cited by 423 publications

(218 citation statements)

References 230 publications

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“…CHG bathing to prevent CLABSIs is recommended for all ICU patients, 26 but it is unclear whether hospitals with low baseline infection rates gain additional benefit from CHG bathing. In our study, hospitals that chose not to implement CHG bathing had significantly lower incidence rates of CAUTIs, CLABSIs, primary BSIs, all combined MRSA infections, and all combined VRE infections than did hospitals that implemented CHG bathing.…”

Section: Discussionmentioning

confidence: 99%

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

Dicks

Lofgren

Lewis

et al. 2016

Infect. Control Hosp. Epidemiol.

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Objective To determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Design Interrupted time series analysis. Setting The study included 33 community hospitals participating in the Duke Infection Control Outreach Network from January 2008 through December 2013. Participants All ICU patients at study hospitals during the study period. Methods Of the 33 hospitals, 17 hospitals implemented CHG bathing during the study period, and 16 hospitals that did not perform CHG bathing served as controls. Primary pre-specified outcomes included ICU central-line–associated bloodstream infections (CLABSIs), primary bloodstream infections (BSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs). MRSA and VRE HAIs were also evaluated. Results Chlorhexidine gluconate (CHG) bathing was associated with a significant downward trend in incidence rates of ICU CLABSI (incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.93–0.99), ICU primary BSI (IRR, 0.96; 95% CI, 0.94–0.99), VRE CLABSIs (IRR, 0.97; 95% CI, 0.97–0.98), and all combined VRE infections (IRR, 0.96; 95% CI, 0.93–1.00). No significant trend in MRSA infection incidence rates was identified prior to or following the implementation of CHG bathing. Conclusions In this multicenter, real-world analysis of the impact of CHG bathing, hospitals that implemented CHG bathing attained a decrease in ICU CLABSIs, ICU primary BSIs, and VRE CLABSIs. CHG bathing did not affect rates of specific or overall infections due to MRSA. Our findings support daily CHG bathing of ICU patients.

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Section: Discussionmentioning

confidence: 99%

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

Dicks

Lofgren

Lewis

et al. 2016

Infect. Control Hosp. Epidemiol.

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“…Chlorhexidine is a bisbiguanide antiseptic (10) that is incorporated into a number of infection control products, including chlorhexidine-and silverimpregnated central venous catheters (11,12). The practice of chlorhexidine bathing is recommended for all acute-care hospitals to reduce CLABSI occurrence (13). For chlorhexidine bathing, patients are bathed daily with a no-rinse chlorhexidine preparation or chlorhexidine-impregnated washcloths (14).…”

mentioning

confidence: 99%

Chlorhexidine Induces VanA-Type Vancomycin Resistance Genes in Enterococci

Bhardwaj

Ziegler

Palmer

2016

Antimicrob Agents Chemother

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Chlorhexidine is a bisbiguanide antiseptic used for infection control. Vancomycin-resistant E. faecium (VREfm) is among the leading causes of hospital-acquired infections. VREfm may be exposed to chlorhexidine at supra-and subinhibitory concentrations as a result of chlorhexidine bathing and chlorhexidine-impregnated central venous catheter use. We used RNA sequencing to investigate how VREfm responds to chlorhexidine gluconate exposure. Among the 35 genes upregulated >10-fold after 15 min of exposure to the MIC of chlorhexidine gluconate were those encoding VanA-type vancomycin resistance (vanHAX) and those associated with reduced daptomycin susceptibility (liaXYZ). We confirmed that vanA upregulation was not strain or species specific by querying other VanA-type VRE. VanB-type genes were not induced. The vanH promoter was found to be responsive to subinhibitory chlorhexidine gluconate in VREfm, as was production of the VanX protein. Using vanH reporter experiments with Bacillus subtilis and deletion analysis in VREfm, we found that this phenomenon is VanR dependent. Deletion of vanR did not result in increased chlorhexidine susceptibility, demonstrating that vanHAX induction is not protective against chlorhexidine. As expected, VanA-type VRE is more susceptible to ceftriaxone in the presence of sub-MIC chlorhexidine. Unexpectedly, VREfm is also more susceptible to vancomycin in the presence of subinhibitory chlorhexidine, suggesting that chlorhexidine-induced gene expression changes lead to additional alterations in cell wall synthesis. We conclude that chlorhexidine induces expression of VanA-type vancomycin resistance genes and genes associated with daptomycin nonsusceptibility. Overall, our results indicate that the impacts of subinhibitory chlorhexidine exposure on hospital-associated pathogens should be further investigated in laboratory studies.

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“…Our study shows almost universal adoption by US hospitals of maximum sterile barrier precautions and chlorhexidine as a site antiseptic during insertion of central lines, which likely contributes to this substantial reduction in CLABSI rates. Both of these practices are considered ‘basic practices that should be adopted by all acute care hospitals’ in recent guidelines, with a grade of 1 (high quality evidence) for chlorhexidine disinfectant and a grade of 2 (moderate quality evidence) for maximum sterile barrier precautions 25. Moreover, these practices were a standard part of the technical component (or CLABSI prevention bundle) that was used as part of the highly successful Veterans Affairs initiative45 and the Keystone ICU collaborative 46 47.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, these practices were a standard part of the technical component (or CLABSI prevention bundle) that was used as part of the highly successful Veterans Affairs initiative45 and the Keystone ICU collaborative 46 47. Antimicrobial catheters, which according to current guidelines are classified under ‘special approaches for preventing CLABSI’ for use in locations or populations with unacceptably high CLABSI rates,25 remain consistently used by about a third of hospitals. In contrast, use of an antimicrobial dressing, also considered a special approach, has continued to increase with nearly 80% of hospitals reporting use of this practice in 2013.…”

Section: Discussionmentioning

confidence: 99%

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013

et al. 2015

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Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Cited by 423 publications

References 230 publications

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units

Chlorhexidine Induces VanA-Type Vancomycin Resistance Genes in Enterococci

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013

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