Running head: CHLORHEXIDINE VERSUS SOAP/WATER BATH IN HAI REDUCTION

Chlorhexidine Bath Versus Soap and Water Bath In Reduction of HAIs

Samuel Turner
University of South Florida

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

Abstract
Clinical Problem: There is a need to reduce the number of hospital acquired infections (HAIs).
The effects of HAIs include increased length of hospital stay, use of nursing staff man hours,
use of hospital supplies, increased stress for patient, and poor outcomes. Effective bathing can
reduce the number of HAIs, but what is the most effective bathing practice: chlorhexidine bath
or soap and water bath?
Objective: To determine if bathing daily with chlorhexidine is more effective at lowering the
incidence of HAIs than soap and water (nonantimicrobial) bathing in a hospital setting.
National Guideline Clearinghouse, CINAHL, and OVID were utilized to retrieve clinical trials
and the guidelines about chlorhexidine baths reducing HAIs. The search terms used to obtain
the clinical trial information were chlorhexidine, baths, bathing, infection, and HAIs.
Results: Currently, the CDC, suggests bathing with soap and water or an antiseptic; it does not
give preference to one or the other (CDC, 2012). All three clinical trials showed a significant
decrease in HAIs when comparing chlorhexidine baths to soap and water baths.
Conclusion: Patients who bath with chlorhexidine have a reduced rate of HAI incidence than
those who bath with soap and water. A reduced rate of HAIs can correlate to decreased costs
and a reduction in the use of hospital resources.

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

Chlorhexidine Versus Soap and Water Bath in Reduction of HAIs

According to the Centers for Disease Control and Preventions (CDCs) healthcareassociated infection (HAI) prevalence survey (which gives a national estimate of HAIs in US
hospitals), one in twenty-five patients will have at least one HAI and approximately 75,000
hospital patients with a HAI died during their hospital stay (CDC, 2015). Cassir et al. (2015)
say hospital acquired infections (HAIs) are associated with increased morbidity, mortality, and
costs. Hospitals have made it a goal to reduce the incidence of HAIs. The hospitals goals were
motivated by improved patient outcomes, lowered costs, lowered use of hospital resources, and
to increase insurance reimbursements from private insurance companies as well as Centers for
Medicaid and Medicare Services. Currently, the CDC suggests bathing with soap and water or
an antiseptic; it does not give preference to one or the other (CDC, 2012). The CDC only
mentions chlorhexidine bathing in their prevention guidelines as an also consider instead of
suggesting it to be used every time (CDC, 2012). A review of evidence about this topic was
guided by the following PICOT question: In patients within a hospital setting, how does a
chlorhexidine bath compare to a soap and water bath and influence the incidence of hospital
acquired infections?
Literature Search
National Guideline Clearinghouse, CINAHL, and OVID were utilized to retrieve clinical
trials and the guidelines about chlorhexidine baths reducing HAIs (see Table 1). The search
terms used to obtain the clinical trial information were chlorhexidine, baths, bathing, infection,
and HAIs.
Literature Review

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

One guideline and three randomized controlled trials (RCTs) were used to determine the
effectiveness of bathing with chlorhexidine over soap and water (nonantimicrobial). Using a
randomized retrospective analysis of prospectively collected data, Cassir et al. (2015)
investigated to determine if daily bathing with chlorhexidine gluconate is better than soap and
water baths (the control) for the prevention of hospital acquired infections (HAIs) in an ICU
setting. The trial included 325 hospital patients during two 6 month periods. Each group
underwent the baths daily for a period of 1000 patient days. The rates of HAIs were compared
between the two groups. The data from both groups showed that use of chlorhexidine
impregnated washcloths (p=0.01) significantly decreased the incidence of gram negative HAIs
when compared to the use of soap and water baths (p=0.017). The study states that all
participants were selected due to having at least one episode of suspected sepsis. Some of the
limitations are a small population size from a single intensive care unit (ICU), they did not us a
nonantimicrobial washcloth group, and did not screen the isolates for chlorhexidine resistance.
The major weakness of this study was that both the researchers and participants knew what
group they belonged to (intervention or control). Another weakness is the small sample size.
The strengths of the study was randomization of the participants, the use of a crossover design
utilizing two six month timeframes in which all patients in the ICU were participants, and they
allowed for a two month timeframe for floor personnel to get used to using the chlorhexidine
wipes instead of the soap and water baths. The treatment is easily implemented into any clinical
setting. A recommendation grade A has been assigned to this study due to the design and
significance level of the statistical analysis.
Climo et al. (2013) used a cluster-randomized trial to find out if chlorhexidineimpregnated wash cloths are better than nonantimicrobial washcloths for the prevention of

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

acquiring multidrug-resistant organisms (MDROs) and hospital acquired bloodstream

infections. The trial included 7727 hospital patients who were randomized into two groups.
Each group underwent the baths daily for a period of 6 months then switched for another 6
months. The incidence of both the MDROs and the bloodstream infections (hospital acquired)
were examined between the two 6 month periods utilizing a Poisson regression analysis. The
data from both periods showed that use of chlorhexidine impregnated washcloths significantly
decreased the incidence of both MDROs (p = 0.03) bloodstream infections that were hospital
aquired (p = 0.007) when compared to the use of nonantimicrobial washcloths. There were no
indications of serious skin reactions with either method. A major weakness of the study was that
both the participants and the researchers were not blind to which group they were assigned to.
Another weakness was an interruption in the middle of the intervention group study due to the
product used (Sage Products chlorhexidine washcloths) was recalled due to a Burkholderia
cepacia contamination. The study, being partially funded by a grant from Sage products (the
manufacturer of the chlorhexidine washcloths), could be a potential conflict of interest and could
be called on some as a source for potential bias. Some strengths of the study are there were a
large number of participants, randomization of the participants, and the use of a crossover design
utilizing two six month timeframes. A recommendation grade A has been assigned to this study
due to the design and significance level of the statistical analysis.
Swan et al. (2014) conducted this randomized control trial to determine if 2%
chlorhexidine gluconate washcloths are better than soap and water bathing for the prevention of
HAIs. The trial included 350 hospital patients in the surgical intensive care unit (SICU) who
were randomized into two groups. Each group underwent the baths every 48 hours for a period
of up to 28 days. The patients and clinicians knew which of treatment groups the patients

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

belonged to; however the investigators who either determined what the outcome was or who
enrolled the patients were blind to which treatment group the patients belonged to. The data
from both groups showed that use of 2% chlorhexidine gluconate washcloths significantly
decreased the incidence of HAIs when compared to soap and water baths. The data sets show
the information to be valid (p=0.049). A major weakness was that the patients and clinicians
knew their group assignment. Another weakness was the baths were only every 48 hours
whereas all the other trials have been every 24 hours. Some strengths of this trial are the
investigators were blind and the group assignments were randomized. A recommendation grade
A has been assigned to this study due to the design and significance level of the statistical
analysis.
The HAI prevention guidelines from the CDC currently suggests bathing with soap and
water or an antiseptic; it does not give preference to one or the other (CDC, 2012). The CDC
only mentions chlorhexidine bathing in their prevention guidelines as an also consider instead
of suggesting it to be used every time (CDC, 2012). This CDC recommendation is a category II
strength grade, which shows that it is evidence based on epidemiologic or observational research.
Synthesis
Cassir et al. (2015) showed that use of chlorhexidine impregnated washcloths (p=0.01)
significantly decreased the incidence of gram negative HAIs when analyzed against the use of
soap and water baths (p=0.017). Additionally, Climo et al. (2013) found that use of
chlorhexidine impregnated wash cloths significantly decreased the incidence of both MDROs
(p=0.03) and bloodstream infections acquired in the hospital (p=0.007) when compared to the
use of nonantimicrobial washcloths. Swan et al. (2014) reported that use of 2% chlorhexidine
gluconate washcloths significantly decreased the incidence of HAIs (p=0.049) when compared

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

to soap and water baths. Finally, the HAI prevention guidelines from the CDC currently
suggests bathing with soap and water or an antiseptic; it does not give preference to one or the
other (CDC, 2012).
The research shows that by bathing patients with chlorhexidine, the incidence of HAIs
can be lowered. With the decrease in HAIs, the effects of HAIs (increased length of hospital
stay, use of nursing staff man hours, use of hospital supplies, increased stress for patient, and
poor outcomes) should inherently decrease as well. Additional research is needed in acute care
(as most of the research has been in an ICU setting) to see if these results will translate to the
overall hospital environment. We can make the general assumption that the results will correlate
to the acute care setting as the chlorhexidine baths simply reduce the overall bodily infestations
of flora which, in general, the lower number of flora (good or bad) translates to lower likely
hood of an infection. The CDCs guidelines may need to be updated as well. The last update was
in 2012 and most of the research used in this study has been in the last few years. The evidence
has been given a grade of A according to the USPSTF scale. An A grade has been assigned
due to the high certainty that the net benefit is substantial.
Clinical Recommendations
The research demonstrates that patients in a hospital setting (mostly ICU settings) should
be bathed daily with chlorhexidine to reduce HAIs. Chlorhexidine baths should be used with
other HAI prevention techniques such as hand hygiene, contact precautions, follow aseptic
techniques, administer antimicrobial prophylaxis (when needed), and other evidence based
interventions. Additional research needs to be completed to evaluate the effectiveness of
chlorhexidine baths in preventing HAIs in acute care settings.

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

References
Cassir, N., Thomas, G., Hraiech, S., Brunet, J., Fournier, P., LaScola, B., & Papazian, L.
(2015). Chlorhexidine daily bathing: Impact on health care associated infections
caused by gram negative bacteria. American Journal of Infection Control, 43, 640643.
Centers for Disease Control and Prevention (2012). Top CDC recommendations to prevent
healthcare-associated infections. Retrieved from
http://www.cdc.gov/HAI/prevent/top-cdc-recs-prevent-hai.html
Centers for Disease Control and Prevention (2015). Data and statistics. Retrieved from
http://www.cdc.gov/HAI/surveillance/index.html
Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . .
Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired
infection. New England Journal of Medicine, 368, 533-542.
Swan, J., Bui, L., Pham,V., Shirkey, B., Graviss, E., Hai, S., . . . Wray, N. (2014). RCT of
chlorhexidine vs. soap & water bathing for prevention of hospital-aquired infections
in SICU. Critical Care Medicine, 42(12), A1369-A1370.

CHLORHEXIDINE VERSUS SOAP AND WATER BATH IN REDUCTION OF HAIS

Table 1
Literature Review
Reference
Cassir, N., Thomas,
G., Hraiech, S.,
Brunet, J., Fournier,
P., LaScola, B., &
Papazian, L. (2015).
Chlorhexidine daily
bathing: Impact on
Health care associated infections
caused by gram negative bacteria.
American Journal
of Infection Control,
43, 640-643.
Climo, M. W.,
Yokoe, D. S.,
Warren, D. K., Perl,
T. M., Bolon M.,
Herwaldt, L. A,.
Wong, E. S. (2013).
Effect of daily
chlorhexidine
bathing on hospitalacquired infection.
The New England
Journal of
Medicine, 386(6),
533-542.

Aims

Design and
Measures
To determine if
RCT using a
daily bathing with Retrospective
chlorhexidine
analyisis of prospecgluconate is better tively collected data
than soap and
from March 2012 water baths (the
March 2013. Included
control) for the
all ICU patients for
prevention of
Two 6 month periods
HAIs in an ICU One for control (soap
setting.
and water) and one
for the intervention
group(chlorhexidine).

Sample

To examine if daily
bathing with
chlorhexidineimpregnated
washcloths are
better than
nonantimicrobial
washcloths for the
prevention of
acquiring
multidrug-resistant
organisms
(MDROs) and
HAIs (specifically
bloodstream
infections).

N=7727 patients
randomized, 8
patients were
excluded;
n=3970
chlorhexidine
group, n=3757
nonantimicrobial
washcloth group

Cluster-randomized,
Crossover trial
between August 2007
February 2009 from
patients in 9 ICUs and
1 bone marrow
transplant unit in 6
hospitals. Two 6
month periods. One
for intervention
(chlorhexidine) and
one for control
(nonantimicrobial).

N=325 patients
randomized, 0
patients were
excluded;
n=150
chlorhexidine
group, n=175
soap and water
group

Outcomes /
statistics
Patients bathed
daily with
chlorhexidine
had a significant
decrease in the
incidence rate
of HAIs
(p=0.01) than
patients bathed
with soap and
water (p=0.017)

Patients who had

daily baths with
chlorhexidine
had a significant
decrease in the
incidence rate
of MDRO
(p=0.03) and a
rate decrease
of central
catheter
associated
bloodstream
infections
(p=0.004) when
compared to
patients who
were bathed
with
antimicrobial
cloths.

Swan, J., Bui, L.,

Pham,V., Shirkey, B.,
Graviss, E., Hai, S.,
Ashton, C., Wray, N.
(2014). RCT of
chlorhexidine vs.
soap & water bathing
for prevention of
hospital-aquired
infections in SICU.
Critical Care
Medicine, 42(12),
A1369-A1370.

To determine if
2% chlorhexidine
gluconate
washcloths are
better than soap
and water bathing
for the prevention
of HAIs.

The trial included 350

hospital patients in
the surgical intensive
care unit (SICU) who
were randomized into
two groups. Each
group underwent the
baths every 48 hours
for a period of up to
28 days. The patients
and clinicians knew
of treatment group
assignment; however
the investigators who
enrolled patients or
determined outcomes
were blind to which
treatment group the
patients were
assigned to.

N=349 patients
randomized, 24
patients were
excluded;
n=161
chlorhexidine
group, n=164
soap and water
group.

The data from

both groups
showed that use
of 2%
chlorhexidine
gluconate
washcloths
significantly
decreased the
incidence of
HAIs when
compared to
soap and water
baths. The data
sets show the
information to
be valid
(p=0.049).