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Does Chlorhexidine Bathing in Adult Intensive Care Units Reduce Blood Culture Contamination? A Pragmatic Cluster-Randomized Trial

Published online by Cambridge University Press:  10 May 2016

Edward J. Septimus ,
Mary K. Hayden ,
Ken Kleinman ,
Taliser R. Avery ,
Julia Moody ,
Robert A. Weinstein ,
Jason Hickok ,
Julie Lankiewicz ,
Adrijana Gombosev  and
Katherine Haffenreffer
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Edward J. Septimus
Affiliation:
Hospital Corporation of America, Nashville, Tennessee Texas A&M Health Science Center, College of Medicine, Texas A&M University, Houston, Texas
Mary K. Hayden
Affiliation:
Rush University Medical Center, Chicago, Illinois
Ken Kleinman
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
Taliser R. Avery
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
Julia Moody
Affiliation:
Hospital Corporation of America, Nashville, Tennessee
Robert A. Weinstein
Affiliation:
Cook County Health and Hospitals System, Chicago, Illinois
Jason Hickok
Affiliation:
Hospital Corporation of America, Nashville, Tennessee
Julie Lankiewicz
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
Adrijana Gombosev
Affiliation:
University of California Irvine School of Medicine, Orange, California
Katherine Haffenreffer
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
Rebecca E. Kaganov
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
John A. Jernigan
Affiliation:
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and for the Agency for Healthcare Research and Quality Developing Evidence to Inform Decisions about Effectiveness Network and Healthcare-Associated Infections Program and the CDC Prevention Epicenters Program
Jonathan B. Perlin
Affiliation:
Hospital Corporation of America, Nashville, Tennessee
Richard Piatt
Affiliation:
Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
Susan S. Huang
Affiliation:
University of California Irvine School of Medicine, Orange, California
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Objective.

To determine rates of blood culture contamination comparing 3 strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization.

Design.

Pragmatic cluster-randomized trial.

Setting.

Forty-three hospitals with 74 ICUs; 42 of 43 were community hospitals.

Patients.

Patients admitted to adult ICUs from July 1, 2009, to September 30, 2011.

Methods.

After a 6-month baseline period, hospitals were randomly assigned to 1 of 3 strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all 3 arms.

Results.

During the 6-month baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. Among all individual draws, for arms 1,2, and 3, the contamination rates were 4.1%, 3.9%, and 3.8% for the baseline period and 3.3%, 3.2%, and 2.4% for the intervention period, respectively. When we evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8% (N = 108 sets) in the baseline period and 7.5% (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4% (N = 78) compared to 7.5% (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7% (N = 119) contaminated blood cultures during the baseline period to 5.1% (N = 184) during the intervention period. Logistic regression models demonstrated a significant difference across the arms when comparing the reduction in contamination between baseline and intervention periods in both unadjusted (P = .02) and adjusted (P = .02) analyses. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 (95% confidence interval [CI], 0.044-0.71) and an adjusted OR of 0.55 (95% CI, 0.43-0.71).

Conclusion.

In this large cluster-randomized trial, we demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 35 , Issue S3: Preventing Healthcare–Associated Infections: Results and Lessons Learned from AHRQ's HAI Program , October 2014 , pp. S17 - S22
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2014

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