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Running head: PREVENTING METHICILLIN-RESISTANT STAPHYLOCCUS AUREUS Preventing Methicillin-resistant Staphylococcus aureus Using Bathing Techniques Krista Caprio University of South Florida 1 PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 2 Abstract Clinical problem: Methicillin-resistant Staphylococcus aureus (MRSA) is one of many hospital acquired infections that pose a threat to all hospitalized patients. Acquiring MRSA in a healthcare setting can lead to additional problems such as bloodstream infections, pneumonia, and surgical site infections; these unexpected complications will prolong a patient’s stay in the hospital and increase the risk of mortality (Center for Disease Control and Prevention, 2014). Objective: To determine if the use of chlorhexidine gluconate for daily bathing will decrease the incidence of MRSA in critical care patients. CINAHL and the National Guideline Clearinghouse were the search engines used to find clinical trials and guidelines to support the objective. The key search terms used were MRSA and bathing, chlorhexidine bathing, and MRSA prevention. Results: Climo et al. (2013) reported that patients receiving daily chlorhexidine baths had a 23% lower incidence of MRSA (P= 0.03) than patients bathed with non-antimicrobial soap. Ferrara, Courson, & Paulson (2011) reported that a smaller amount of MRSA colonized in areas treated with chlorhexidine (mean=1.67 log10, P< 0.0001) than areas treated with non-medicated soap (mean=3.23 [log.sub.10)]. Septimus et al. (2014) reported that daily chlorhexidine bathing had the lowest rate of blood culture contamination (95% confidence interval, 0.43-0.71). Cincinnati Children's Hospital Medical Center (2013) recommends using 2% chlorhexidine gluconate for daily baths in critical care settings to decrease the risk of blood stream infections. Conclusion: Critical care patients that receive daily chlorhexidine baths will have a decreased incidence of MRSA. This will prevent complications that increase the risk of morbidity and mortality. Additionally, healthcare costs should decrease because of the lessened length of hospitalization. PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 3 Preventing Methicillin-resistant Staphylococcus aureus Using Bathing Techniques Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to methicillin or other commonly used antibiotics such as Penicillin (Lopez et al., 2015). It is recognized as one of the most common antibiotic resistant pathogens in a hospital setting. MRSA colonizes on the skin. For this reason, contaminated hands, clothes, or equipment can easily transfer it from one patient to another. Upon admission to an intensive care unit (ICU), patient incidence of MRSA rises from 1.5% to 5.8% - 8.3% (Lopez et al., 2015). Eighteen to thirty-three percent of adult patients with colonized MRSA will develop a MRSA infection such as pneumonia or blood stream infection (Lopez et al., 2015). These complications will increase morbidity, mortality, and medical costs significantly (Center for Disease Control and Prevention, 2014). In critical care patients, how does using chlorhexidine (CHG) cloths and water for daily bathing compared with non-antimicrobial soap and water prevent the incidence of MRSA in the course of three months? Literature Search CINAHL and National Guideline Clearinghouse were used to obtain clinical trials and guidelines about preventing the incidence of MRSA in critical care patients by using CHG for daily bathing. The key search terms used were MRSA and bathing, chlorhexidine bathing, and MRSA prevention. Literature Review Cincinnati Children's Hospital Medical Center (2013) strongly recommends that in order to reduce blood stream infections patients in critical care settings should receive daily baths with 2% CHG. Climo et al. (2013) assessed the use of CHG washcloths and non-medicated soap on the incidence of MRSA. Patients were screened for MRSA up to 48 hours after admission and upon discharge from the hospital. Overall, there was a 23% lower incidence of MRSA when PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 4 using chlorhexidine cloths (5.10 vs. 6.60 cases per 1,000 patient days, P=0.03). The strengths of this study were that the nine ICUs were randomly assigned to use either the intervention or the control product. Reasons why patients/hospitals did not complete the study were given. Followup assessments were conducted long enough to fully study the effects of the intervention. The subjects were analyzed in the groups to which they were assigned. The control group was appropriate. Instruments used to measure the occurrence of MRSA and VRE in ICU patients were valid. Patients in both groups were similar in regards to baseline variables. The weaknesses of this study were that the random assignment was not concealed from the individuals who were first enrolling subjects into the study. In addition, the clinical staff was aware of the use of the control or intervention product. Ferrara, Courson, & Paulson (2011) examined the preventative effects of CHG against MRSA using twenty volunteers. One of the participant’s forearms was washed for two minutes with the control product and the other with the test product. Three test sites were designated to each arm. One site was exposed to MRSA for 1 hour, another for 2 hours, and the last site was exposed to MRSA for 4 hours. The number of bacteria after exposure to forearms treated with chlorhexidine (mean= 1.67 log10) were fewer (P< 0.0001) than the control product (mean= 3.23 [log.sub.10]). The number of bacteria recovered from forearms treated with chlorhexidine did not differ when cultured at 1-4hrs (P=0.236). Strengths of this study were that the test and control product were randomly assigned to the subjects. Reasons why volunteers did not complete the study were given. Volunteers in this study were similar in regards to baseline variables. The control group was appropriate. The instruments used to measure the colonization of MRSA were valid. The subjects were analyzed in the group to which they were assigned. Weaknesses of this study were that the random assignment was not concealed from the PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 5 individuals who were first enrolling subjects. The subjects were not blind to the study. Lastly, follow-up assessments were not conducted long enough to fully study the effects of the intervention. Septimus et al. (2014) compared three strategies to determine which produced the lowest blood culture contamination rate. Forty-three hospitals were involved in this study. In strategy one, all ICU patients received a MRSA nares screening. In strategy two, all patients were screened and a positive diagnosis resulted in twice-daily intranasal mupirocin and chlorhexidine baths for five days. In strategy three, patients were not screened for MRSA; however, contact precautions were enabled for patients with a history. Additionally, all ICU patients received intranasal ointment for 5 days and daily chlorhexidine baths. Strategy three showed the greatest reduction in blood culture contamination (95% confidence interval, 0.43-0.71). It avoided an additional 26.8 contaminations per 1,000 admissions compared to strategy two and 12.2 compared to strategy one. Strengths of this study were that the hospitals were randomly assigned one of three strategies. Participants in this study were similar in regards to baseline clinical variables. Subjects were analyzed in the groups to which they were randomly assigned. The control group was appropriate. The instruments used to measure the rate of blood culture contamination were valid. Follow-up assessments were conducted long enough to fully study the effects of the intervention. Weaknesses of this study were that it is unknown if the random assignment was concealed from the individuals who were first enrolling subjects into the study. In addition, reasons why patients did not complete the study were not given, and it is unknown whether the providers and subjects were blind to the study group. PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 6 Synthesis Climo et al. (2013) demonstrated that bathing patients with CHG produced a 23% lower incidence of MRSA (P= 0.03). Ferrara, Courson, & Paulson (2011) demonstrated that areas treated with chlorhexidine had a smaller colonization of MRSA (P< 0.0001). Septimus et al. (2014) demonstrated that daily chlorhexidine bathing produced the lowest rate of blood culture contamination (95% confidence interval, 0.43-0.71). The Cincinnati Children’s Hospital Medical Center (2013) guideline recommends the use of 2% chlorhexidine gluconate for daily baths in critical care settings to decrease the risk of blood stream infections. A strong similarity between all studies shows the significance of decreasing skin bacterial load with CHG to decrease the incidence of MRSA. Climo et al. (2013) and Ferrara, Courson, & Paulson (2011) focused specifically on comparing the use of non-medicated soap to CHG and their effects on MRSA. However, Ferrara, Courson, & Paulson (2011) also tested the bactericidal residual effect of chlorhexidine. Septimus et al. (2014) measured blood culture contamination rates rather than skin bacterial load of MRSA. However, decreasing skin bacterial load is how blood culture contamination can be prevented. Research has shown that using CHG for daily bathing can reduce the incidence of MRSA. This will prevent complications (blood stream infections) that increase the risk for morbidity and mortality. Due to the reduction in MRSA, healthcare costs should decrease because of the lessened length of hospitalization. Since only two non-antimicrobial soaps were tested, additional research is needed to determine if other non-medicated soaps would produce the same results. Further studies needs to be implemented to determine the length of time chlorhexidine can prevent the colonization of MRSA on the skin. PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 7 Clinical Recommendation Cincinnati Children's Hospital Medical Center’s (2013) guideline recommends the use of 2% CHG for daily bathing to reduce the rate of bloodstream infections in an inpatient critical care setting. Research confirms that the use of CHG for daily bathing reduced the incidence of MRSA. Based on these findings, daily CHG baths can be used in combination with screening, contact precautions, and hand hygiene in order to reduce the spread of MRSA in critical care settings. Taking precautions to prevent the spread of MRSA is crucial in order to keep patients healthy and improve client outcomes. PREVENTING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS 8 References Center for Disease Control and Prevention (2014). Methicillin-resistant staphylococcus aureus infections. Retrieved from http://www.cdc.gov/mrsa/healthcare/#q1 Cincinnati Children’s Hospital Medical Center. (2013). Daily bathing of children in critical care settings with chlorhexidine gluconate. Retrieved from http://www.guideline.gov/content.aspx?id=47066&search=chlorhexidine+bathing Climo, M. W., Yokoe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., . . . Wong, E. S. (2013). Effects of daily chlorhexidine bathing on hospital-acquired infection. The New England Journal of Medicine, 368(6), 533-542. doi: 10.1056/NEJMoa1113849 Ferrara, M. S., Courson, R. W., & Paulson, D. S. (2011). Evaluation of persistent antimicrobial effects of an antimicrobial formulation. Journal of Athletic Training, 46(6), 629-633. doi: 10.4085/1062-6050-46.6.629 Lopez, A. J., Mateos, M. M., Guevara. M., Conterno, L., Sola, I., Cabir, N. S., Bonfill, C. X. (2015). Gloves, gowns and masks for reducing the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in the hospital setting. Cochrane Database of Systematic Reviews. 7, N.PAG. doi: 10.1002/14651858.CD007087.pub2 Septimus, E. J., Hayden, M. K., Kleinman, K., Avery, T. R., Moody, J,.Weinstein, R. A., . . . Huang, S. S. (2014). Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial. Infection Control & Hospital Epidemiology, 35, 17-22. doi: 10.1086/677822