Trial of Staphylococcus aureus Capsular Polysaccahride (CPS ...

Chlorhexidine Patient Bathing as a Means to Prevent Healthcare Associated Infections Mark E. Rupp, MD Professor & Chief, Infectious Diseases Director, Infection Control & Epidemiology University of Nebraska Medical Center Hosted by Martin Kiernan [email protected] April 17, 2014 Potential Conflicts of

Interest Dr Rupp reports the following pertinent potential conflicts of interest: Prior research support in the form of contracts to UNMC from 3M & Molnlycke Consultant or Advisory Board for 3M & Molnlycke Objectives At the conclusion of this program the

participant should: Have a better understanding of the antiseptic activity of chlorhexidine gluconate (CHG) Be able to introduce a program of CHG patient bathing in a targeted or general manner Understand the pros and cons of CHG patient bathing Horizontal vs Vertical Infection Prevention Interventions Intervention that affects

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

1,6-di(4-chlorophenyldiguanido) hexane Cationic bisbiguanide first synthesized in England in 1950 during search for antimalarial drugs Mechanism of Action: Rapid attraction to negatively-charged bacterial cell

Adsorption to phosphate-containing constituents of the bacterial surface Attraction to cytoplasmic membranes Leakage of low-MW cytoplasmic components (K+, Ca++) Inhibition of membrane-bound enzymes (Adenosyl triphosphatase) Precipitation of cytoplasm Chlorhexidine Antimicrobial Spectrum: CHG exhibits broad spectrum activity against wide variety of Gram-positive

& Gram-negative bacteria, fungi, and lipid-coated viruses (HSV, HIV, RSV, flu, adeno, etc) Inactive against bacterial spores Inhibitory against acid-fast bacilli Cidal Activity of Chlorhexidine Denton GW. In: Disinfection, Sterilization, and Preservation, 2001 Clinical Applications of Chlorhexidine

Preoperative surgical site scrub Preoperative shower Surgical hand scrub Hand disinfectant Bladder irrigant OB/GYN perineal antiseptic

Devices: CVCs, dressings Wound irrigant Burn wound cleansing Mouthwash Oral care for patients

on mechanical ventilation Body wash for prevention of MDROs Body wash to prevent CVC BSI Residual Activity and Cumulative Effect of Chlorhexidine

Paulson, DS. Amer J Infect Control, 1993 4% CHG shower in 5 volunteers for 5 days. CHG impregnated sponges used for 60 seconds, rinse, and repeat. Cup-scrub culture method CVC-BSI Prevention with CHG Skin Disinfection

Maki DR, et al. Lancet, 1991. Prospective, randomized clinical trial involving 668 CVCs in SICU P=0.02 10% povidone

iodine 70% alcohol 2% CHG P=0.04 CVC-BSI Prevention with CHG Skin Disinfection

Chaiyakunapruk N, et al. Ann Intern Med, 2002 Meta-analysis of RCTs comparing CHG vs PI for CVC insertion and care 8 studies, 4143 Catheters CVCs: RR 0.51 (95% CI 0.27-0.97) CHG CVC DRESSINGS Timsit, et al. JAMA, 301:1231-41, 2009 Timsit, et al. Am J Respir Crit Care Med.

186:1272-78 Chlorhexidine Patient Bathing Arch Intern Med 2007 ICHE 2007 ICHE 2007 (Infect Control Hosp Epidemiol. Nov 2012)

Quasi-experimental, Prospective, StaggeredInitiation, Dose-escalation Study 3 Cohorts; 6 months M/W/F followed by every day CHG bathing 19 month intervention, 4 month washout period 188,859 patient days, 68,302 CHG baths HAIs monitored (CLA-BSI, CA-UTI, VAP, VRE, MRSA, CDI) Time Table for Introduction of CHG Bathing to Inpatient Units

MWF CHG Phase Daily CHG Phase Washout Phase Grp 3 (Clarkson Tower) Grp 2 (Univ Tower) Grp 1 (ICUs) Month Information and Teaching Sheets

Available at Infection Control Intranet site or call 9-5276 CHG Bathing Compliance Rupp et al. ICHE 2012 CHG vs C. difficile Rupp et al. ICHE 2012 Chlorhexidine Patient Bathing VRE

Rupp et al. ICHE 2012 Discussion Effect on C difficile was unexpected: Bactericidal vs vegetative cells Inhibits spore germination Bed bath and physical removal of spores (was effect of study simply to improve bathing?); Decreased environmental contamination and spread?

Surfactant may aid removal of spores Discussion Confounding? Laboratory diagnostic changes CDI control measures Isolation, hand hygiene, glove use, bleach cleaning Antibiotic use Seasonality (increases in winter)

Changes in C difficile strain type Study should be hypothesis generating and result in efforts to replicate our experience Future Directions Does use of CHG result in selection of qac(+) staphylococci and CHG

resistance? What drives compliance with pt bathing? Cost effectiveness? Feb 7, 2013 Prospective, cluster-randomized study in 9 ICUs involving 7727 patients, 6 mo crossover 23% decrease in acquisition of MDROs (p= 0.03)

28% decrease in bloodstream infections (P = 0.007) June 13, 2013 Prospective, cluster-randomized study in ICUs in 43 hospitals. Grp 1 - MRSA screening and isolation; Grp 2 Targeted decolonization; Grp 3 Universal decolonization (mupirocin & CHG baths) HR for MRSA (intervention vs baseline): 0.92 vs 0.75 vs 0.63 (P= 0.01)

HR for BSI (intervention vs baseline): 0.99 vs 0.78 vs 0.56 (P = <0.001) CHG Resistance Multi-drug efflux pumps (qacA/B, smr) decrease susceptibility to CHG Prevalence surveys indicate qacA/B to be present in 0.5% - 80% of MRSA isolates. MIC CHG ~4-8 ug/mL increases to 16-32 ug/mL Clinical Significance?

Elevated MIC remains well below clinical concentration qacA/B + mupirocin R = persistent colonization (Lee et al, CID, 2011) CHG use selected for qacA/B (+) strains in ICU (Batra et al, CID 2010) Bath Basin Contamination Rupp et al, ICHE 2013 Bacterial contamination of

simulated CHG bed bath solution 108 cfu of E coli, S epi, E facaelis Immediate and Residual experiments Immediate 3 Hr Residual Effective Infection Prevention is a Multi-Piece Puzzle

Education and Training Surveillance and Reporting Isolation and Source Control Elimination of Fomites Insertion and Care of Devices Vaccination and Presenteeism

Environmental Cleaning Hand Hygiene CHG 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, 2014 Prof. Didier Pittet, World Health Organization VENTILATOR-ASSOCIATED EVENTS: A PATIENT SAFETY OPPORTUNITY May 8 Dr. Michael Klompas, Harvard Medical School May 13 (British Teleclass) VENTILATION IN HEALTHCARE FACILITIES Dr. Peter Hoffman, Health Protection Agency, UK


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