Antisepsis in the ICU – Chlorhexadine and Patient Bathing

Published - Written by Sushrut Jangi

When I was an intern in the ICU, there were only a few minutes in the early mornings to examine patients before the attending arrived to hear our presentations.  During those frantic moments, I frequently walked into a patient’s room to find the nurses bathing the patients with a wash-cloth.  “Come back in a bit,” they’d say while I grumbled under my breath.

Nursing care is obviously critical in the ICU.   However, many of their responsibilities – including patient bathing – was in their domain and outside of mine.  Consequently, I regarded these activities as superfluous, especially when these patients were already sick enough to be intubated, ventilated, and on several powerful medications.  Bathing, in particular, seemed part of routine hygiene mostly for the comfort of the patient and family.  The details of why and how that patient was bathed was unknown to me.   Was this just my own ignorance?  When querying fellow physicians and residents whether they knew which soap was used to bathe critically ill patients – and why such baths were important – most had no clue.

Antisepsis is a much written about subject that is introduced to us during residency.  Our chiefs track how frequently we wash our hands; the insertion of lines and needles is accompanied by particular dedication to sterility.  Those who study antisepsis have long wondered whether systematic bathing of patients who are critically ill with antiseptic agents could have any effect on patient outcomes.   Prior, single-center studies have suggested such daily bathing practices may show promise, but no definitive trial had been conducted.

This week’s Journal reports on the results of a large, multi-center randomized control trial that evaluates the efficacy of antiseptic agents for patient bathing in the ICU and other high-acuity settings.  The article shows that the antiseptic agent chlorhexadine significantly reduces the risk of acquisition of multi-drug resistant organisms and helps prevent hospital-acquired bacteremia.   Impressively, the use of chlorhexadine-impregnated washcloths reduced hospital-acquired blood stream infections by a rate of nearly 30%.

Clearly – I had ignored an activity in the ICU that showed more promise in reducing the chances of bacteremia than many of the drugs we had in our pharmacopeia.  I returned to the ICU from my residency to see what I’d missed.   Around lunchtime, a group of nurses who were on a short break sat down with me.  “We bathe every patient each night with chlorhexadine,” one nurse volunteered.  “We apply it everywhere except in the face or other sensitive areas.”  Then, the nurses described, we let the soap sit on them for about two minutes.  “The patients get really cold during that part,” another nurse said.  “Sometimes we warm up the chlorhexadine or put on a bath-blanket.”   A third nurse detailed that she changed the wash-cloth for each body part – one cloth for the arm, another for the leg. “We’ve been doing this for more than a year.”  Another nurse asked:  “Are you here to tell us this doesn’t work?”

The opposite, I said.

Recently, a theme has emerged in multiple arenas that simple, cost-effective interventions – hand hygiene, isolation practices, and now – patient bathing – can be implemented into straightforward and practical protocols to reduce the acquisition of hospital acquired infections.  Many of these practices are already routine; making them part of protocol is not a difficult transition.

The nurses were pleased with my interest in this topic, and they were happy to hear that their efforts were paying off.   But – asked one nurse –  why does it take so long for you doctors to get interested in what we’ve been doing for awhile? She raised her eyebrow.

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