Centre conducting review
Singapore National University Hospital Centre for Evidence Based Nursing:
Joanna Briggs Collaborating Centre for Evidence Review
Name: Tan Lai Poh
Singapore National University Hospital Centre for Evidence Based
Nursing: Joanna Briggs Collaborating Centre for Evidence Review
Mobile: (65) 96833635
Telephone: (65) 6772 5440
Facsimile: (65) 6772 2944
Name: Soh Poh Choo @ Mona
Singapore National University Hospital Centre for Evidence Based
Nursing: Joanna Briggs Collaborating Centre for Evidence Review
Mobile: (65) 9146 5989
Telephone: (65) 6772 5134
Facsimile: (65) 6772 4032
Name: Goh Mien Li
Singapore National University Hospital Centre for Evidence Based
Nursing:Joanna Briggs Collaborating Centre for Evidence Review
Telephone: 65 67724665
Facsimile: 65 67724032
1) To evaluate the effectiveness of chlorhexidine bath in eradicating MRSA carriage.
2) To evaluate the efficacy of chlorhexidine bath on MRSA incidence rate in the adult inpatient wards.
3) To evaluate the effectiveness of chlorhexidine bathing with or without topical decolonization therapy in reducing risk of MRSA infection among MRSA colonized inpatients.
1) To evaluate the development of MRSA infection and tolerance to chlorhexidine bath with or without topical decolonization therapy.
2) To assess the effectiveness of chlorhexidine bath on the rates of Blood Stream Infections (BSI).
1) Can chlorhexidine bath reduce the acquisition rate of MRSA during their hospitalisation?
2) Is the use of chlorhexidine more effective in preventing incidence of MRSA than soap and water?
3) Is the combination of chlorhexidine bath and decolonization therapy more effective in the eradicating MRSA than chlorhexidine bath alone?
4) Can Chlorhexidine bath alone decrease blood stream infection?
Methicillin Resistant Staphylococcus Aureus (MRSA) was first described as a nosocomial pathogen in Europe in 1961. Nosocomial pathogen is defined as an agent of disease acquired in the hospital.12 By 1980, MRSA was reported by numerous hospitals for its outbreaks in all geographical regions of United States of America (USA) and was recognised as an endemic nosocomial pathogen. Over the past 2 decades, the burden of disease caused by MRSA has continued to increase.1 In fact, many studies have shown that MRSA blood stream infection and surgical site infections had led to unnecessary increased health care cost, increased hospital length of stay as well as increased hospital mortality. 1, 2 Nosocomial MRSA is a major health problem in most developed countries. It is estimated by US Centre of Disease Control that more than 125 000 patients are hospitalised with infection due to MRSA.3 Locally in Singapore Hospitals, 35% of isolates of S. Aureus are Methicillin Resistant. MRSA is the dominant hospital-acquired pathogen accounting for 0.31 bacteraemia/1000 inpatient days. It is equivalent to Singapore's largest hospitals; each identifying on average of 2 to 3 MRSA bacteraemia per week.13 Nosocomial infection is defined as infections identified in patients after 48 - 72 hours of hospitalisation or 48 - 72 hours after discharge from hospital in the absence of evidence of active or incubating infection on admission. 15 It is often termed as “hospital onset” and is defined using only information related to the timing of specimen collection in relation to hospital admissions. Specifically, it is recommended that hospital onset MRSA infection be considered if the organism is isolated after the 3rd calendar day of hospitalisation, with day 1 being the day of admission (the admission day is the date of inpatient overnight stay not outpatient or/and emergency visits).15 The prevalence rate of MRSA infection or colonisation is defined as the total number of patients with MRSA infection or colonisation in a specific population at a specific point of time MRSA (includes all old and new cases at point of per admission) whereas, an incidence rate of MRSA infection or colonisation is the total number of patients with newly acquired MRSA infection or colonisation in a specific population during a specific period.15 Thus, it is important to know which patients have a history of colonisation or infection in order to identify a prevalence or incidence rate. The number of admissions to hospital is used as the denominator for both prevalence and incidence rate. It is recommended to use a simple prevalence or incidence per 100 patients admitted to the hospital as it is easily understood. The number of patient days which is the population density (1000) is used as the denominator for calculation of prevalence density and incidence density; a better account for length of patient stay.15 MRSA poses a major threat especially to the critically ill patients.4 For the past 2-3 decades, the control of MRSA in hospitals in USA had been based on prompt identification of patients colonised with MRSA through active surveillance cultures (ASC) and reinforcement of contact precautions such as hand hygiene, as well as barrier precautions to decrease horizontal transmission between patients.1-5 Unrecognised MRSA carriers, who are not placed under isolation precautions on admission is another contributing factor to the poor efficacy of infection control practices.1,3 Meanwhile, hand hygiene has been considered by many experts as the primary action to decrease healthcare associated infection and cross transmission of anti-microbial-resistant pathogens.4 However, compliance to this simple, fast and effective procedure among health care workers remains low.4 Therefore, additional strategies such as improving the stewardship of antibiotics, cohorting patients in dedicated unit, leadership support in training as well as designated staff to care only for MRSA patients are several other methods adopted to manage the rising hospital acquired MRSA.4 There are more than 40 clinical trials examining the outcomes and or efficacy of chlorhexidine for a variety of conditions including Surgical Site Infections (SSIs), MRSA, Vancomycin Resistant Enterococci (VRE) colonisation and nosocomial bacteremia.6 Chlorhexidine is described as cationic bisbigunide that reverses the surface charge of bacterial cell, resulting in leakage of cytoplasmic contents and cell death.2,6 It reduces skin organism and inhibits their rebound growth and has been demonstrated to be more effective in decreasing catheter-associated Blood Stream Infection (BSIs) when compared to other skin disinfectant products like povidone and iodine. 3 Chlorhexidine based products are also said to decrease the density of skin colonisation with pathogens like MRSA and VRE, therefore, lowering the risk for horizontal transmission between patients and healthcare workers.3 Chlorhexidine gluconate (CHG), meanwhile, in the form of 2% 5 or 4% solution, 2,5,7 as well as wipes or 2% CHG-impregnated clothes 8-9, had been shown to reduce BSI because of it's broad spectrum anti-microbial activity, durability and low toxicity. 2, 8-11The CHG impregnated cloth or wipes is simple to use and also an effective alternative for patients who have difficulty bathing post-operatively or who are critically ill. 6 Although many studies have stated that Chlorhexidine has been widely used to control cross infections and was one of the measures taken to control MRSA outbreak 1, 3, 7 and health care-associated BSI,3, 8 there are still widespread debates regarding the emergence of chlorhexidine resistance when chlorhexidine is used routinely and frequently. 1 One quasi-experimental study examined the association between daily chlorhexidine bathing and the incidence of colonisation, and blood stream infection related to blood stream infections due to MRSA among the Intensive Care Unit (ICU) patients. They found that the use of daily chlorhexidine bathing compared to non-medicated soap and water showed a significant reduction in the MRSA acquisition (32%) and colonisation was significantly lower. 3 Likewise, controlled studies in Medical Intensive Care Unit (MICU) had demonstrated CHGs efficacy in decreasing the rates of colonisation and decreasing the rates of Central Venous Catheter (CVC) associated BSI. 8, 9-10, 12 Thus, the use of chlorhexidine bathing is simple and inexpensive to implement. It may also be an important adjuvant intervention to minimise the risk of MRSA infection and subsequent development of healthcare-associated BSIs. 3 The main reservoir for spread of MRSA in hospital were infected and colonised patients.1 Patients are classified as MRSA infected if MRSA is isolated from any body site and there is clinical evidence of an active infection warranting specific therapy determined by the medical professional or Infectious Disease Consultant. Patients are classified as MRSA colonised if they have either 1) a surveillance culture positive for MRSA or 2) a clinical culture positive for MRSA without any clinical evidence of active infection due to MRSA.1 Some infection control programmes had recommended the use of topical decolonisation therapy to decolonise MRSA carriers whereas others do not.5 Decolonisation therapy refers to the use of topical agents (intranasal mupirocin, antiseptic body wash and shampoo) to reduce nasal and skin carriage of MRSA. A Cochrane systematic review of trials assessing topical decolonisation therapy of MRSA concluded there was insufficient evidence to support the wide spread of this intervention.7 Hospitals in Scandinavian countries who have maintained low MRSA prevalence reported that all patients identified as MRSA positive will be eradicated for MRSA colonisation as part of a routine isolation procedure. 1 There were 2 other studies done in a French and Brazilian Intensive Care Units (ICUs) using nasal mupirocin and daily chlorhexidine bath. The results of both studies showed a positive reduction of MRSA infection where nasal mupirocin and daily chlorhexidine bath were used. 1 Another randomized clinical trial was conducted using oral chlorhexidine rinse and nasal mupirocin rinse, was compared with another group using the same treatment but included a Chlorhexidine body wash. The latter treatment showed a reduction of skin colonisation.7 Despite these facts, the development of mupirocin resistance is still a major concern. Contamination with MRSA remains an ever increasing problem for the hospital.
The review question thus sets out to answer the following:
1) Can Chlorhexidine bath reduce the MRSA acquisition rate during the patient's hospitalization?
2) Should normal soap and water, or should Chlorhexidine be used for bathing to reduce the incidence of MRSA?
3) Is the combination of Chlorhexidine bath and decolonisation therapy more effective in eradicating MRSA than Chlorhexidine bath alone?
4) Can Chlorhexidine bath alone minimise blood stream infection? In conducting this systematic review, the authors hope that it will contribute beneficial effects to the inpatient adult patients in terms of reduction in the incidence of MRSA infection and colonisation.
Before developing the protocol, the Cochrane Library, Joanna Briggs Institute Library of Systematic Review, MEDLINE and Database of Abstracts and Review were searched and found one systematic review from Cochrane library on “Preoperative bathing or showering with skin antiseptics to prevent surgical site infection.” Webster, Joan. Osborne, Sonya. Cochrane Wounds Group Cochrane Database of Systematic Reviews. 4, 2009. This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.
However, as the review focus was on “surgical site infection” and was of different interest from our review, decision was made to continue present project.
Types of participants
- Adults over age of 18
- Both Female and Male
- Admitted to inpatient adult wards
- Admitted with MRSA surveillance screening swab cultures performed on the following screening sites: nasal nares, axilla and groin on admission prior to treatment. (Patient who have MRSA surveillance cultures done on admission and results shows to be infected or colonised)
Types of intervention(s)/phenomena of interest
The use of chlorhexidine shower/bath/wipes/wash with or without combination of other pharmacological therapies such as antibiotics, topical decolonisation therapy for MRSA. The various administration methods, duration and frequency will be included in the review.
Types of Comparator
The comparator group includes no chlorhexidine shower (usual care with soap and water), with or without antibiotics or topical decolonisation therapy.
Types of outcomes
The outcomes of interest include:
1) Development of MRSA infection: Objective or subjective indicators of MRSA infection: Culture results or clinical evidence of infections
2) Eradication of MRSA carriage using chlorhexidine shower/bath/wipes/wash
1) The duration and the frequency of the use of daily chlorhexidine shower to eradicate skin and nasal carriage of MRSA & preventing colonisation.
2) Comparative Benefits of combination therapy with chlorhexidine shower with decolonisation therapy vs. chlorhexidine shower only.
3) Tolerance to chlorhexidine shower with or without decolonisation therapy.
4) Blood stream infection (with or without MRSA)
Types of studies
All Randomised Control Trails (RCTs) and all quasi -experimental studies examining the effectiveness of chlorhexidine shower in the treatment of MRSA with or without other combination therapy will be considered.
A search strategy was developed to guide the systematic review. Mesh terms from Pubmed were used to determine the words used to search in MEDLINE and CINAHL. The first search from MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and the next term used to describe the articles. A second search using all identified keywords and the index terms will be utilised across all accessible and relevant data bases from year 1990 till October 2010 in English language only. Thirdly, the relevant lists of all identified articles will be searched for any additional studies. Data bases to search will include: 1) CINAHL 2) Embase 3) MEDLINE
(See Appendix I for details of the search strategy):
Standard Search Strategy Concept Key word(s) Entry Terms: 1Population Adult ·Adults 2Exposure Chlorhexidine Chlorhexidine bath* Chlorhexidine * Chlorhexidine wipe* Chlorhexidine wash* Chlorhexidine clean* Hibiscrub Chlorhexidine gluconate 3Outcome Methicillin Resistant Staphylococcus Aereus · Methicillin Resistant Staphylococcus Aereus MRSA · Concept 1Population AND Concept 2Exposure (Chlorhexidine bath*) OR (Chlorhexidine shower*) OR (Chlorhexidine wipe*OR (Chlorhexidine wash*) OR (Chlorhexidine clean*) OR (Hibiscrub) AND Concept 3Outcome (Methicillin Resistant Staphylococcus Aereus) OR (MRSA)
Assessment of methodological quality
Articles selected for retrieval will be appraised by 2 reviewers independently for methodology validity prior to inclusion in the review using the standardised appraising instruments from Joanna Briggs Institute Meta Analysis Statistics Assessment and Review instrument (JBI-MAStaRI) (Appendix II). Any disagreement arising between the 2 reviewers will be resolved through discussion with a third reviewer.
Data will be extracted from the articles included in the review using the standardised data extraction tool from JBI-MAStARi (Appendix III).
Quantitative data may be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subjected to double data entry. Odd ratios (for categoric data) and weighted mean difference (for continuous data) and their 95% confidence interval will be calculated for analysis. Heterogeneity will be assessed using the standard Chi Square. Where pooling of statistical data is not possible, the findings will be presented in the narrative form.
Conflicts of interest
The primary, secondary and associate reviewers have no conflict of interest.
We would like to thank Prof Paul Ananth Tambyah, Ms Siti Zubaidah Binte Mordiffi, Ms Tho Poh Chi, Ms Goh Mien Li, Ms Dora Lang Siew Ping and Ms Yip Wai Kin for their guidance in making this protocol possible to be written.
1) 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: 1155-1161.
2) Veiga DF, Damasceno CAV, Viega-Filho J, et al. Randomized control trial of the effectiveness of chlorhexidine showers before elective plastic surgical procedures. Infect Control Hosp Epidemiol 2009; 30(1): 78-79.
3) Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus areus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: Results of a quasi-experimental multicenter trial. Crit Care Med 2009; 37(6):1858-1865.
4) Parienti J-J. A paradigm shift to prevent nosocomial infection: “Take a bath before I touch you” Crit Care Med 2009; 37(6): 2097-2098.
5) Robicsek A, Beaumont JL, Thomson RB, Govindarajan G, Peterson LR. Topical therapy for methicillin-resistant Staphylococcus aureus colonization: Impact on infection risk. Infect Control Hosp Epidemiol 2009; 30(7):623-632.
6) O'Malley P. Chlorhexidine Wipes: The new weapon against surgical site infections? Clin Nurse Spec. 2008; 22(2):61-62.
7) Wendt C, Schinke S, Württemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: A randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol 2007; 28(9):1036-1043.
8) 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.
9) Bleasdale SC, Trick WE, Gonzalez, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167(19): 2073-2079.
10) Munoz-Price LS, Hota B, Stemer A, Weinstein RA. Prevention of blood stream infections by use of chlorhexidine baths for patients at a long-term acute hospital. Infect Control Hosp Epidemiol 2009; 30(11):1031-1035.
11) Peterson LR, Singh K. Universal Patient disinfection as a tool for infection control: Rub-A-Dub-Dub, No need for a tub. Arch Intern Med 2006; 166: 274-276.
12) Vernon MO, Hayden MK, Trick WE, Hayes RA, Blom DW, Weinstein RA. 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: 306-312.
15) Cohen AL, Calfee D, Fridkin SK, Huang SS, Jernigan JA and et al. Recommendations for Metrics for Multi-Resistant Organisms in Healthcare Settings: SHEA/HICPAC Position Paper. Infect Control Hosp Epidemiol 2008; 29(10): 901-913
Appendix I: Standard Search Strategy