Source: APIC Guide to Preventing CAUTI, 2014. Used with permission, Linda Greene, RN, MPS, CIC,
Highland Hospital, Rochester, NY
Chlorohexidine Gluconate Bathing vs. Soap and
and Water for Perineum Care
Marguerite Gribogiannis, SM(ASCP),MPA, CIC
Department of Infection Prevention, Advocate Lutheran General Hospital
Abstract:
Methods:
Introduction: About 12% to 16% of patients may receive an indwelling urinary
catheter during their hospital stay. The daily risk of acquiring a urinary tract
infection varies from 3% to 6% when a urinary catheter is in place. Basic
interventions to reduce the risk of acquiring a CAUTI (catheter assocaited urinary
tract infection) include: (1) indications for use; (2) aseptic technique; (3) daily need
assessment; (4) maintenance of the catheter while it is in place (eg., securement,
collection bag below level of bladder, unobstructive urine flow, regular emptying
urinary bag, patient bathing). The Infection Prevention team at Advocate Lutheran
General Hospital and Corporate have conducted point prevalence surveys on
interventions to reduce the risk of CAUTI. Current practice is to use
chlorohexidine gluconate (CHG) wipes to bath patients with devices in place (e.g.,
central lines). To further reduce CAUTI, other interventions such as perineum
care were considered. It was decided to review perineum cleansing with CHG for
any potential adverse affects, compared to standard soap and water.
Method: The clinical question was posed based upon evidence based practice
PICO model: In Patients who receive CHG bathing, does CHG compared to
standard bathing adversely affect the perineum area? Literature review was
conducted using an evidence based (EBP) tool focused on study design, outcome
measures, setting, population, intervention and key findings.
Supports cleansing perineal area with CHG
 Evidence-based practice (EBP) problem-solving approach tools were used to
research the problem, determine the level of evidence, and appraise the
evidence with the use of a study evaluation table.3
Type of Evidence
Yes
Timeframe of
evidence reviewed
No
Timeframe of
evidence reviewed
 The clinical question was posed in PICO format: “In patients who receive
CHG bathing (P), does CHG bathing (I) compared to standard bathing (C )
adversely affect the perineum area (O)?” Basic concern was about potential
irritation of the urethral meatus area.
RCT
1
2010
2
 At the end of the database search, 13 studies found in PubMed, AHRQ
(Agency for Healthcare Research and Quality)), Medscape and AJIC
( American Journal of Infection Control) seemed to best answer the clinical
question.
2008
2010
Systematic review /metaanalysis
3
1980-2008
 The studies were appraised using the study evaluation table below.
 Summary review was classified by type of evidence, timeframe of the study
and conclusions .
 Random controlled trial , systematic review and cohort studies were
considered to be good evidence to support recommendation. Expert opinion
was considered to be a low quality evidence suggesting net clinical benefits
or harms or an accepted practice.
Result: The studies were evaluated as to the level of research, size and quality
of study (e.g., timeframe). Overall the literature search appears to support
cleansing the perineum with soap and water versus CHG.
Conclusion: More studies advocated using soap and water for perineum care
when bathing the patient. However, the timeframe of the studies ranged from
1980’s to 2010. Whereas, perineum care during CHG bathing was supported by
studies in 2010-2011. Currently, the Center of Disease Control and Prevention
recommends soap and water for perineum care, although their references are
based on studies from the past ten years and older. CHG should not be ruled out
as a viable alternative to soap and water for perineum care, but the transition
needs additional study and review.
Introduction:
CHG success story
Chlorohexide gluconate is an antiseptic widely used in heatlhcare facilities for
peri-operative bathing, skin preparation solutions , insertion site vascular access
dressings, oral hygiene care , and hand hygiene. The success of CHG can be
attributed to its unique properties which enables it to bind to the proteins present
in human tissues such as skin and mucous membranes with limited systemic or
bodily absorption. In fact, CHG’s antimicrobial activity has been documented to
last at least 48 hours on the skin. 1
As a broad-spectrum antiseptic, it is effective against Gram-positive bacteria,
Gram-negative bacteria and fungi. Its use in bathing and other product s helps
to de-colonize the bacteria residing on the surface of human skin. For example,
daily bathing with chlorhexidine gluconate impregnated washcloths has shown to
significantly reduce the risks of acquiring healthcare infections such as multiple
drug resistant organisms (MDROs) and central line associated bloodstream
infections (CLABSIs). 2
Patients at Advocate receive CHG (2%) bathing when a central vascular access
device is in place. One of the preventive measures for CAUTI includes perineum
care. This led to consideration of potentially using one product for both bathing
and perineum care. As Figure 1, shows , current regulatory guidelines promote
use of non –antiseptic products for perineum care.
Figure 2. EVP table
Meatal
cleaning
CDC
HICPAC
Y- Routine
without
antiseptics
IDSA
Y- Routine without
antiseptics
SHEA
Compendium
Y- Routine
without
antiseptics
SHEA/APIC
Prevention
of Infections
in Long
Term Care
N
2010
2011
1
2010
Expert Opinion
2
2010
2011
2
1980-2009
1990-2004
Comments:
Supports cleansing of perineal
area with CHG
Source
Design Type*
Study Design & Study Outcome Measure(s) Study Setting & Study Population
Study Intervention
Key Findings
International Conference on HAI, March 18-22, 2010.
Janis Ober,BSN
Interrupted time series
Segmented regression modeling. Evaluate
Three adult ICUs (medical ,surgical and neurosurgical)
impact of 3 interventions to reduce CAUTI
accounting for 42 beds in an 820-bed urban, academic medical
including daily bathing with CHG; cath removal center in Richmond Virginia, 2008.
and use of CHG for daily perineal care.
Use of CHG for daily perineal care.
No (RCT)
Use of CHG wipes for perineal care did not
significantly reduce CAUTI, although may be
due to inadequate data points as analysis was
based on quarterly rates and not monthly.
CHG in Healthcare: Your Questions Answered, Aug 4,
2010. Laura Stokowski RN, MS
Medscape Nursing
Expert Opinion
Can CHG be used on perineum?
Advised if bathing patient with CHG, you can
clean the foley (gently) and the perineum with
CHG, but only the external genital region
should be cleaned with CHG.
Mary Beth Flynn Makic, RN, PhD.
EBP Habits: Putting More Sacred Cows Out to
Pasture.Critical Care Nurse vol 31, no.2, April 2011,
p38-60.
Evidence based practice
recommendations from AACC 2009
and 2010 National Teaching
Institute
Review of presentations on EVP from AACN
National Teaching Institute.
Review of related beliefs, current evidence and
Perform routine meatal care with
Use of antiseptic cleansers is not better
recommendations for practice related to nursing interventions to soap and water during daily bathing. than perineal care with soap and water.
reduce CAUTI.
Antiseptic agents may irritate the urethral
meatus.
No (expert opinion)
Yale New Haven Hospital
Nursingynhh.org
Procedure,2011
CHG Bath Technique
Oncology patients
Hibiclens wet cloth for genitalia and
perineum.
Yes (expert opinion)
Margaret Wilson, RN, et al.
Systematic article review search of
Nursing Interventions to Reduce Risk of CAUTI,Staff
electronic databases
Education,Monitoring and Care Techniques. Journal of
Wound Ostomy and Continence Nursing; Mar/Apr 2009,
vol.36, no. 2, p137-154.
Systematic article review search of electronic
databases for studies published between
1980-2008.
All studies reviewed by at least 2 of the authors to determine
eligibility for inclusion.
Meatal care
Briggs Best Practice Document recommends
“good personal hygiene” around urethral
meatus, but routine use of antiseptic
products was not recommended.
No (Systematic review)
Amy Kirby, RN
CAUTI Team 2010
www.qsource.org
Study to test hypothesis use of 2%
CHG bath wipes would reduce
CAUTI.
Trial using 2%CHG bath wipes.
Baptist Memorial Hospital , Tenn.
ICU patients
64% decrease in CAUTI rate in ICU. Daily external perineal cleansing with 2%
Process spread to other patient
CHG bath wipes.
units.
Barbara Roman.
Nationwide Children’s Hospital.
2011
www.nationalwidechildrens.org
CAUTI Reduction Committee. Single Single cohort study Included PICU, ED and
cohort study
OR.
Nationwide Children’s Hospital, Columbus Ohio. 451 beds.
Various interventions including
“foley Fridays” and Catheter Care
Card in each patient room.
Jeong Sil Choi. Effects of Perineal Care in Preventing
CAUTI in ICUs. Journal Korean Academy Fundamental
Nursing, vol. 19, no.2, 223-232, May 2012.
RCT
RCT of ICU patients with foley catheters.
Compare effects of preventing CAUTIs through
practice of using 0.05% CHG vesus normal
saline for perineal care.
National Health Insurance Medical Center, Il-San Hospital. 79
CHG versus normal saline for
ICU patients who received perineal care with 0.05 % CHG
perineal care.
compared to 81 ICU patients who had perineal care with normal
saline.
No significant difference in CAUTI reduction
between two interventions.
No (RCT)
Mikel Gray PhD, PNP. Reducing CAUTI in the Critical
Care Unit. AACN July/Sept 2010, vol.21, issue 3, p 247257
Review of EVP prevention studies
Review of studies
Department of Urology and School of Nursing, University of
Virginia
Cites studies from 1990s and 2004.
Found none of protocols that used
antiseptic solutions proved more
effective for CAUTI prevention than
routine urethral meatus cleansing
with soap and water.
Routine meatal care using soap and water or
water alone to remove visible soiling.
No (expert opinion)
AHRQ, September 2013.
Universal ICU Decolonization: An Enhanced Protocol
RCT studies
REDUCE MRSA Trial. Large-scale IC trial to
Three-way cluster-randomized trial of 43 hospitals (74 ICUs) in
establish whether targeted decolonization of
Hospital Corporation of America Health System in 2010.
MRSA carriers versus universal decolonization
of all ICU patients was most effective
intervention.
Use of daily 2% CHG cloths for
bathing.
Yes (RCT)
CHG is safe to use on perineum and
external mucosa. For foley catheters, clean up
to 6 in. of tubing including point of connection.
Targeted systematic review of best available
evidence using GRADE system for evaluating
quality of evidence and strength of
recommendations
Do not clean periurethral area with
antiseptics to prevent CAUTI.
Routine hygiene (e.g. cleansing of
meatal surface during daily bathing
or showering) is appropriate.
Daily cleansing with soap and water . No
recommendation for antiseptics.
No (systematic review)
Use prepackaged bath cloth for daily perineal
care (non-CHG).
Yes (expert opinion)
No for pediatrics
(cohort study)
Eight studies did not support perineum cleaning with CHG. Five studies did
support perineum cleaning with CHG. Evidence type included: four expert opinion
studies, three cohort studies, three systematic review and threee randomized
controlled trials.
Although the preponderance of evidence supports cleaning perineum with soap
and water, the timeframe of this evidence was based on older research studies
ranging from 1980-2010.
Evidence supporting CHG cleansing of the perineum was supported by more
recent research from 2010-2011. In particular in 2010, a RCT to Reduce MRSA
involved 43 hospitals and 74 ICUs recommended CHG as safe to use on
perineum and external mucosa. Also recommended was the use of CHG to
clean up to 6 inches of the foley catheter tubing including point of connection.
Conclusions:
1. Most of the studies advocated using soap and water for peineum care when
bathing the patient.
2. However the timeframe of the studies advocating soap and water were dated
ranging form 1980’s to 2010.
3. Studies supporting CHG cleaning of the perineum were based on recent
research ranging from 2010-2011. No integunentary or skin irritations
complications were reported.
Systematic article review search of
electronic databases.
SHEA/IDSA Practice Recommendation. Strategies to
Prevent CAUTI in Acute Care Hospitals, 2008
Highlight practical recommendations Cochrane reviews with meta-analysis
in concise format.
evaluating interventions to prevent CAUTI.
Management of indwelling
catheters.
Cleaning meatal area with antiseptic solutions
unnecessary, routine hygiene is appropriate.
No (meta-analysis)
Janet A. Popp, MSN,RN, et all. Hospital-Acquired
Infections and Thermally Injured Patients: CHG baths
work. AJIC, February 2014, vol 42, p 129-32.
Cohort study
CAUTI rate decreased to only 1
case.
Use of twice-daily 0.9% CHG baths
comparable to commercially available CHG
wipes. Used on entire body except the face.
No integumentary complications.
Yes (cohort study)
Not expected to present a skin hazard under
anticipated conditions of normal use. Product
does not absorb well through skin.
NA
Cohort study . Baseline HA! rates collected for Shands Hospital Burn Center, Gainesville Florida.8 bed
12 months prior to interventions (2010).
Intensive care burn unit. 203 patients pre and 277 patients post
Bathing intervention began in 2011.
intervention of twice daily bathing with 0.9 % CHG solution in
sterile water including perineal area.
Results:
Yes (cohort study)
HICPAC Guideline for Prevention of CAUTI, 2009
Sage CHG 2% MSDS sheet
Figure 1. Summary of regulatory guidelines for perineum cleaning to prevent CAUTI.
Source: APIC Guide to Preventing CAUTI, 2014. Used with permission, Linda Greene,Highland
Hospital, Rochester, NY
2
Figure 4. Evaluation Table Summary of Studies Reviewed
EPIC 2 2007
Y- Routine
without
antiseptics
Cohort study
Figure 3. AHRQ Universal Reduce MRSA --ICU Decolonization: Enhanced Protocol.
Summary Prevention Practice Issues Addressed in Guidelines
Intervention
Does not support cleansing perineal area with CHG
4. Current guidelines referring to soap and water cleansing are based on studies
over ten years past and older.
5. Regulatory guidelines should be updated to reflect more current evidence
supporing the use of CHG cleansing of the perineum as an appropriate
alternative to soap and water, especially with its efficacy to reduce microbial
burden on skin and mucous membranes and healthcare associated infections.
References:
1. ;www.chlorhexidinefacts.com/mechanism-of-action.html
2. Effect fo Daily Chlorhexidine Bathing on Hospital-Acquired Infectio. Climo, Michael W. et al. Nengl J Med 2013;
368: 533-542..
3. Evidence-Based Practice Step by Step: Critical Appraisal of the Evidence. Fineout-Overholt, Ellen , et. AJHN, July
201;, Vol. 110, Issue 7: 47-52.
4. APIC Update on Guidelines to the Elimination of Catheter Associated Urinary Tract Infections, 2014