ArticlesDaily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial
Introduction
Bloodstream infections are associated with substantial morbidity, mortality, and health-care costs in adults.1 Children admitted to hospital usually have higher rates of bloodstream infections than do adults.2 In critically ill children, primary infections have an estimated attributable cost of US$39 000 per episode3 and associated mortality of 11–18%.4, 5 Furthermore, all positive blood cultures—including those due to commensal skin organisms such as coagulase-negative staphylococci—entail increased use of antibiotics, augmented laboratory charges, and longer hospital stays.6, 7, 8, 9, 10 Although national collaborations work to reduce general bloodstream infections and those associated with the central line (CLABSI),11, 12, 13 data are needed to address the efficacy and tolerability of novel prevention strategies in children.
Chlorhexidine gluconate (CHG) is a topical antiseptic that inhibits organism growth and reduces skin colonisation. It is used to prevent infection in many hospital settings.14 Because bloodstream infections are sometimes caused by a patient's bacterial flora, reduction of bacteria on the skin could lessen the risk of contamination at a catheter insertion site, catheter hub, or site of peripheral blood culture. At the time this study was designed in 2006–07, findings of two studies in adults admitted to hospital suggested that daily CHG baths could decrease bloodstream infections: one was a single-centre randomised study and the other was a multicentre before-and-after intervention study.15, 16 No data were available for whether daily CHG bathing was tolerated and effective in children admitted to hospital. We assembled a collaborative of children's hospitals with large paediatric intensive-care units (ICUs) to assess whether daily CHG bathing compared with standard bathing practices would reduce bacteraemia in critically ill children. Since CHG bathing might change the local ecological environment, we designed a cluster-randomised trial, with the ICU as the unit of randomisation, to prevent contamination between treated and untreated patients.
Section snippets
Study design
The Pediatric Scrubbing with Chlorhexidine Reduces Unwanted Bacteria (SCRUB) trial was an investigator-initiated, unmasked, cluster-randomised, two period, crossover trial in ten ICUs at five hospitals in the USA (Johns Hopkins Hospital, Children's Hospital of Philadelphia, St Louis Children's Hospital, Seattle Children's Hospital, and Children's National Medical Center). The trial was started in February, 2008, and ended in September, 2010 (appendix p 1). Two 6-month study periods were
Results
Of 6482 admissions to ICU units who were screened for study eligibility, 4947 (76%) were enrolled and had outcome data collected, 2525 in control and 2422 in treatment units (figure 1). These patient admissions formed the ITT population. Of 2422 admissions to treatment units, 354 guardians refused consent to receive the treatment and 521 were not available to provide consent; moreover, 32 admitted children did not receive treatment. Therefore, 4072 patient admissions formed the PP population.
Discussion
Findings of our study, in more than 4900 admissions to ICU, show a 36% reduction in the incidence of bacteraemia in patients receiving daily CHG bathing. Furthermore, daily CHG bathing was well tolerated in this population and could be quickly and widely implemented to prevent bacteraemia.
Large-scale interventions to decrease health care-associated infections have not generally included children (panel). During planning for this trial, early studies in adult ICU patients suggested that CHG
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2022, American Journal of Infection ControlCitation Excerpt :One cluster-crossover study reported that daily 2% CHG cloth bathing in the ICU resulted in a 23% reduction of vancomycin-resistant Enterococcus (VRE) and methicillin-resistant S. aureus (MRSA) acquisition and a 28% reduction in bloodstream infections (BSIs).70 In another study of pediatric ICU patients, Milstone et al found a significant association between 2% CHG cloth bathing and a decline in BSIs compared with standard bathing.71 Another trial, called the REDUCE MRSA study, used a cluster-randomly selected methodology in 43 hospitals (including 74 adult ICUs) to evaluate 3 MRSA prevention interventions: the first cluster implemented MRSA screening and isolation, the second cluster included screening, isolation, and decolonization of MRSA carriers with CHG bathing and nasal mupirocin (ie, targeted decolonization), and the ICUs in the third cluster did not screen any patients but instead, all patients were decolonized with CHG cloth bathing and nasal mupirocin (ie, universal decolonization).
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