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INTEGRATIVE REVIEW OF LITERATURE

Integrative Review of Literature

Makenzie Ludwig

Karen Mellott, PhD, RN

NUR 4322: Nursing Research

Bon Secours Memorial College of Nursing

April 12, 2020

I pledge.
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Abstract

Purpose: The purpose of this integrative review is to identify if there is a correlation between

daily bathing with chlorhexidine gluconate and hospital acquired infection rate.

Background: Hospital acquired infections (HAIs) are becoming more prevalent as certain

diseases increase their resistance to medication and techniques. Although Chlorhexidine has been

in existence for 50 years, it has recently been introduced to bedside nursing to combat HAIs.

PICOT Question: In Intensive care unit (ICU) patients (P) how does bathing with CHG (I)

compared with soap and water (C) influence the rate of hospital acquired infections (O) during a

hospital stay (T).

Method: Research was collected with the use of online databases. Each database was vigorously

dissected to locate five separate articles. Three qualitative based articles and two statistical

analyses. This would help to determine if a correlation existed between CHG and HAI’s.

Limitations: The researcher’s lack of experience in performing an integrative review is biggest

limitation noted. However, many other limitations occurred ultimately causing the researcher to

have limited access to discovering quality evidenced based research.

Results and Findings: The evidence that is brought to attention to the researcher indicates that

daily use of CHG can decrease the incidence of HAI’s in the ICU setting.

Implications and Recommendations: It is understood that daily use of CHG should be

implemented in critical care areas of the hospital. To increase staff compliance and patient

outcomes, it is recommended that staff education is conducted before research begins.

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Integrative Review of Literature

The purpose of this integrative review is to compare chlorhexidine gluconate (CHG)

usage to the combination of soap and water to reduce the rate of hospital acquired infections

(HAIs). HAIs are infections that take place 48 hours after admission to a hospital, infections that

otherwise would not have occurred. One notable topic: the average human epidermis contains

microbial flora that is an important pathogenic reservoir for different pathogens that commonly

cause HAI’s (Pallotto et al., 2019). HAI’s are currently among the top leading causes of death in

the United States (“Health Care-Associated Infections”, 2020). These deaths can be prevented

with the proper precautions and understanding the use of the different antiseptic agents.

Common HAI’s are central line associated bloodstream infections (CLABSI), surgical

site infections (SSI), bloodstream infections (BSI), hospital acquired pneumonia (HAP),

ventilator associated pneumonia (VAP), and catheter associated urinary tract infections

(CAUTI). The agents that are involved in most HAI’s include (but not limited to): Clostridium

Difficile, Methicillin Resistant Staph Aureus (MRSA), Vancomycin-resistant enterococci, and

coagulase negative staphylococci. Chlorhexidine gluconate is shown to be a broad-spectrum

bactericidal antiseptic agent (Cassir et al., 2015). These HAIs are causing hospitals to experience

increased morbidity (the development of disease) and mortality (the number of deaths), but are

also increasing hospital debt thus causing costs of healthcare to rise.

What has become standardized, is the use of a CHG (0.2% to 4% concentration) wash

before/after surgical procedures, CHG impregnated discs used with central lines, and CHG

impregnated wipes to bathe with. The aim of this study is to research, analyze and discuss

published articles related to the researcher’s patient/population, intervention, comparison,

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outcome and time (PICOT) question: In Intensive Care Unit (ICU) patients how does bathing

with CHG compared to soap and water influence the rate of HAI’s during a hospital stay?

Design and Methods

This design of this study is an integrative literature review. The researcher utilized

computer-based search engines, such as PubMed, Google Scholar, Science Direct, Elsevier, the

Nursing Reference Center and Ovid. Search words included the word “Chlorhexidine” combined

with “bathing”, “infection”, “ICU”, “hospital acquired infections”, “intensive care”, “healthcare

associated infections”, and “soap/water”. This resulted in over 500 different articles with varying

publication dates and topics. Certain websites included filters to add to each search. These filters

included: within 10 years of publication (2010 – 2020), language (English), clinical trial,

evidenced based, peer reviewed, and qualitative/quantitative based. Having the article available

in a free-full text format eliminated half of the options.

Articles were selected based off of the researcher’s PICOT question: In ICU patients how

does bathing with CHG compared to soap and water influence the rate of HAI’s during a hospital

stay? The articles were then further selected based on inclusion criteria such as: patient

population (an ICU in a Hospital), comparisons involving CHG, and CHG bathing. Due to a lack

of consistent data, step-down and medical-surgical units were omitted from the study. Articles

that did not include/meet these criteria were excluded from the review. Therefore, this integrative

review focuses on the composition of five specific evidenced based research studies. This

included three qualitative (Climo et al., 2013; Pallotto et al., 2019; Swan et al., 2016) and two

quantitative studies (Cassir et al., 2015; Dicks et al., 2016).

Findings
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The findings and results of the five reviewed studies concluded that there is a positive

correlation between bathing with CHG and reduced numbers of HAI’s (Cassir et al., 2015; Climo

et al., 2013; Dicks et al., 2016; Pallotto et al., 2019; Swan et al., 2016). A synopsis of each of the

studies is discussed in Table 1. The following paragraphs contain the findings from each of the

five individual studies and two common themes: staff education and positive patient outcomes.

A randomized controlled trial conducted by Pallotto et al. (2019) identified the difference

between the use of soap and water compared to the use of a 4% CHG solution on patient’s

acquiring HAI’s. The sample consisted of a total of 449 patients in the ICU and Post-operative

Cardiosurgical Intensive Care Unit (PC-ICU) in a hospital in Italy. The researchers used

inclusion/exclusion criteria to pick their appropriate patient population. Data was collected by

blood sampling, microbiological testing, case reporting and diagnoses were determined by an

infectious disease specialist. They also collected the data of HAI’s from a few months previous

to the trial in what they referred to as pre-trial incidence data.

Pallotto et al. (2019) then used the Kolmogorov-Smirnov test to determine their

distribution variables, which is appropriate in terms of better interpreting the data set. They also

used a two-tailed unpaired t-test to calculate variable distribution, which is appropriate for this

data set. They determined that the value of P less than 0.5 was statistically significant. Their

findings concluded that a 40.4% decrease in HAI’s was noted with use of the composition of 4%

CHG compared to the use of soap and water. They further determined that CHG significantly

reduced the number of gram negative bacterial associated HAI’s.

Another randomized control trial; specifically, a single centered, pragmatic, bath trial was

conducted by (Swan et al. (2016) and, focused on comparing soap and water daily bathing to

bathing every other day with 2% CHG will reduce the percentage of HAI’s. The researchers
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focused on four common HAI’s (CAUTI’s, VAP’s, SSI’s, and BSI’s). These researchers

determined the sample size based off of the Chi-square results compared to the Cox proportional

hazards regression. This sample included 350 patients that stayed in the 24-bed surgical ICU in a

Texas hospital. The participants were divided into a control group (daily soap and water bathing)

and a treatment group (CHG bathing every other day).

Swan et al. (2016) then collected data on each participant was recorded using Microsoft

software, then independently reviewed by two committee members to decipher the results. For

statistical analysis of the researcher’s data they used the chi-square tests to compare HAI’s, the

HR rate was calculated using survival models, and length of stay was identified with the t test.

These tests are appropriate for the study that was conducted. Their results showed that more

patients were infected with HAI’s who were in the control group compared to the treatment

group (CHG utilization) in a 35:18 ratio.

Dicks et al. (2016) performed an interrupted time series analysis involving 33 different

hospitals over a specific time frame (2008 – 2013). The researchers collected data based on total

ICU patient days. The hospitals that utilized daily CHG bathing outnumbered the non-CHG by

over 100,000 patient days. All of the hospitals that participated in the analysis had measures to

obtain the number of HAI’s present in their ICU’s. The researchers analyzed these results and

determined that with the implementation of CHG there was a significant downward trend in the

occurrence of HAI’s. However, this analysis determined that there was no significant

decrease/increase in MRSA infections.

Cassir et al. (2015) previously performed a retrospective analysis using collected data over

the course of one year. They further divided that year into two six-month portions, each portion

was focused on either daily bathing strictly with soap and water or bathing with CHG
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impregnated wipes (excluding the eyes and mouth). Their sample size consisted of 325 ICU

patients in a hospital in France: 175 bathed with soap and water and 150 bathed using the CHG

wipes. The data collected included: mortality, internal catheters used, participants

demographics/background, and hospital acquired infections. This analysis resulted in the soap

and water control group obtaining 56 total HAI’s, compared to the CHG group that obtained 29

HAI’s.

Lastly, a multicenter, cluster randomized crossover study conducted by Climo et al. (2013)

was set to determine daily bathing with CHG’s efficacy against HAI specific organisms on

patients in an ICU setting. They conducted this trial over the course of two years, with an

unknown total sample size. However, the researchers compared results over the course of 1000

patient days. They split their sample participants into two different categories: control group

(non-antimicrobial cloths used for bathing) and an interventions group (CHG cloths used for

bathing). Those categories, over the course of 12 months, documented monthly VRE, healthcare

associated bloodstream infections (HABSI) and MRSA occurrences. There were nine total ICU-

type units that participated, and each would send these results to the researchers.

The Climo et al. (2013) study assessed these monthly occurrences using the Poisson

regression model. They also utilized the cox-proportional hazards regression model to account

for the time from admission to onset of disease state in each participant. A few findings that

resulted from this study was a lower prevalence of MRSA and VRE with the use of CHG wipes

for daily baths compared to the non-antimicrobial wipes. A statistically significant finding would

be the fact that, with the daily intervention of CHG, VRE was reduced by nearly 30% compared

to the MRSA which only was reduced by nearly 20%.

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The researcher identified common themes found in each article staff education and

positive patient outcomes. These themes helped to match each article with the original PICOT

question as well as form a basis for this literature review. The next few paragraphs will discuss

how each reviewed article aligns with the set of themes that the researcher seemed fit.

Staff Education

Education is essential for a hospital to fulfill its roles, safety qualification, and quality

improvement. It was only noted in the Swan et al. (2016) study that they specifically educated

and reviewed the use of chlorhexidine with the staff prior to the start of the study. This helped to

create an even more cohesive environment for the study to be conducted in. If the staff did not

understand key aspects of how to use chlorhexidine during the other studies, it is unknown to the

reader. This could have created an anomaly for each study by skewing the results and possibly

increasing the infection rate. It is recommended for future research that the implementation of

proper education regarding chlorhexidine be part of the protocol. This can be implemented on

the nursing leaders as they can then ensure the education of the nursing staff.

Positive Patient Outcome

The whole purpose of the review is to understand if daily use of chlorhexidine can

decrease infection rate, which leads to an increase in positive patient outcomes. In each of the

five studies there was a noticeable decrease in at least one of each of the major hospital acquired

infections that is commonly found in the Intensive care environment (Cassir et al., 2015; Climo

et al., 2013; Dicks et al., 2016; Pallotto et al., 2019; Swan et al., 2016). As a result, more positive

patient outcomes were created. Most hospitals have designated patient advocates and most

healthcare professionals are trained to be advocates for patients and their outcomes. When a new

product, like Chlorhexidine, is created for patient use, staff are normally interested or unaware as
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to what it does. Therefore, when they fully understand the use (of CHG), they can begin properly

begin to implement it on their units thus leading to a decrease in negative patient outcomes.

These studies, supported by evidenced based practice, have created a basis for chlorhexidine use

which have proven to lead to an increase in positive patient outcomes.

Discussion/Implications

Each article was formulated to align with the researchers original PICOT question.

Among those qualifications the research discovered two reoccurring themes: patient outcomes

and staff education. The importance of educating staff on the use of new materials can help to

strengthen the implementation of new changes in the hospital therefore correlating with a

decrease in negative patient outcomes. A recommendation for future research would be

conducting each study in the most steadily controlled environment, the ICU, can help to create

more consistent data. According to the American Nurses Association a nurse in the ICU cannot

receive more than two patients. Which typically makes an Intensive Care Unit not exceed 25

beds. Therefore, researchers can ensure that in a 24-hour period their patients will receive their

desired treatment plan (CHG bathing).

Properly educating staff on correct utilization of each type of chlorhexidine being studied

can help eliminate potential anomalies in the experiment. Each study was focused on the

infection rate involving each patient, ideally wanting each patient to leave the hospital without

acquiring a HAI. By focusing on patient outcomes, the researchers were focused on infection

rates, thus circling back to the use of chlorhexidine in combating those. A recommended for a

new standard of care would be the increased utilization of chlorhexidine for daily bathing in ICU

settings. This is shown to decrease hospital costs, mortality and morbidity as noted by (Cassir et

al., 2015; Climo et al., 2013; Dicks et al., 2016; Pallotto et al., 2019; Swan et al., 2016).
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Therefore, increasing the wellbeing of each patient and protect them from unnecessary harm,

while staying in a place that is intended to do no harm.

Limitations

While creating this integrative review of literature, the researcher was faced with many

different limitations. First, the review of five studies provides a very narrow insight into

answering the original PICOT question. This is the first integrative literature review for the

researcher, which can include an incredible lack of knowledge regarding the structure of the

review. The researcher does not have any qualifications, therefore may not be able to conduct

informational/educational discussions on the studies reviewed. This review also had a narrow

time frame only including articles from the past 10 years, which can eliminate quality research.

The researcher became involved in this study as a class assignment, thus automatically limiting

the time frame for this to be conducted in. Lastly, finding articles that fit the proper qualifications

(PICOT) that were available in full text limited many options.

Certain articles included slight variables that did not strictly align to the Researcher’s

guidelines. Pallotto et al. (2019) studied a specific percentage of chlorhexidine (4%) compared to

soap and water, when other studies did not specify. Another study, Cassir et al. (2015) strictly

focused on gram-negative bacteria in their results, which does not encompass all HAI’s. There

were a few qualitative studies which could be determined overall a small study compared to

quantitative studies. Finally, all studies that were reviewed were not identical, in fact they all had

small differences (sample size, type of chlorhexidine, type of bathing, type of intensive care

unit), but managed to all arrive at the same conclusion.

Conclusions
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Throughout this integrative review of literature each of studies by: Cassir et al., 2015,

Climo et al., 2013, Dicks et al., 2016, Pallotto et al., 2019 and Swan et al., 2016 provided an

answer to the original PICOT question; that daily bathing with chlorhexidine corresponds with a

decrease in infection rate in ICU patients. This integrated review of literature also identified two

emerging themes in the articles reviewed: positive patient outcomes and staff education. When

implementing the use of chlorhexidine gluconate on a unit for the first time it is important to

provide quality education to staff about the product. This will increase the proper usage and

implementation of that product (CHG). Since there was a decrease in overall infection rate

shown by each article there was an increase in positive patient outcome. It is important to

acknowledge these findings as they can help to decrease the incidence in harmful HAI’s leading

to shorter stays, decreased hospital debts, and more positive outcomes. Thus, fostering the idea

that hospitals are a place that strictly heal their patients.

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References

Cassir, N., Thomas, G., Hraiech, S., Brunet, J., Fournier, P., La Scola, B., & Papazian, L. (2015).

Chlorhexidine daily bathing: Impact on health care–associated infections caused by

gram-negative bacteria. American Journal of Infection Control, 43(6), 640-643. doi:

10.1016/j.ajic.2015.02.010

Climo, M., Yokoe, D., Warren, D., Perl, T., Bolon, M., Herwaldt, L., Weinstein, R., Sepkowitz,

K., et al. (2013). Effect of daily chlorhexidine bathing on hospital-acquired

infection. New England Journal of Medicine, 368(6), 533-542. doi:

10.1056/nejmoa1113849

Dicks, K., Lofgren, E., Lewis, S., Moehring, R., Sexton, D., & Anderson, D. (2016). A

multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate

bathing in community hospital intensive care units. Infection Control & Hospital

Epidemiology, 37(7), 791-797. doi: 10.1017/ice.2016.23

Health Care-Associated Infections. (2020). Retrieved 7 April 2020, from

https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety

resources/resources/hais/index.html

Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam Girolamo, L.,

Volpi, F., Iorio, p., et al. (2019). Daily bathing with 4% chlorhexidine gluconate in

intensive care settings: Arandomized controlled trial. Clinical Microbiology and

Infection, 25(6), 705-710. doi:10.1016/j.cmi.2018.09.012

Swan, J., Ashton, C., Bui, L., Pham, V., Shirkey, B., Blackshear, J., Bersamin, J., May, R., et al.
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(2016). Effect of chlorhexidine bathing every other day on prevention of hospital-

acquired infections in the surgical ICU. Critical Care Medicine, 44(10), 1822-1832.

doi:10.1097/ccm.000000000000182
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ARTICLE EVALUATION

Table 1.1

APA Citation Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam Girolamo, L.,Volpi, F.,
Iorio, p., et al. (2019). Daily bathing with 4% chlorhexidine gluconate in intensive care settings: A
randomized controlled trial. Clinical Microbiology and Infection, 25(6), 705-710.
doi:10.1016/j.cmi.2018.09.012
Author Qualifications 2 Doctors of Medicine (MD), 1 Doctor of Philosophy (PhD)
Background/problem There is a correlation between HAIs, Bloodstream infections (BSI) and central-line associated BSI’s and a
statement rise in hospital deaths and costs.
Conceptual/Theoretical Focus on studying the difference between daily soap and water bathing and 4% CHG bathing on HAIs in
Framework an ICU setting.
Design/Method/Philosophica Qualitative Study – Randomized Clinical Trial
l Underpinnings
Sample/Setting/Ethical  Setting: Post-Operative Cardiosurgical Intensive Care unit and Intensive Care Unit
Considerations  Sample Size: 449 total; Patients admitted to either unit from 8/10/15 – 1/27/16.
 Ethics: Written consent on admission, approval by the hospital ethics committee (CEAS Umbria),
Unconscious admitted patients were given a randomized consent by a Physician until they awoke
in which they would be allowed to Opt-Out.
Major Variables Studied  Age/Gender
(and definition), if  Co-morbidities: Diabetes/ immunosuppression
appropriate  If they had surgery, had been intubated, or catheterized
 Length of Stay
 Total Infections: each specifically identified – ventilator acquired pneumonia, bloodstream
infections, central line associated BSI, catheter associated UTI,
 Mortality rate
Measurement tool/ Data  The sample size was randomly divided in half: ½ was daily bathed with soap and water and ½ was
collection method daily bathed with 4% CHG.
 Infectious disease specialists collected date on patient background, health history, reason for
admission as well as diagnosing each patient with their specific HAI.
 Charlson Co-morbidity index collected the patient’s co-morbidities; if any.
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Data analysis  Comparisons between the control group and treatment group were conducted with a t-test .
 They utilized R statistical software to perform all analyses.
 They further divided the data into a table with baseline demographic data and clinical
characteristics.
 Another table showed the rate of infection over 1000 patient days.
Findings/Discussion They concluded that daily bathing with a solution of 4% CHG significantly reduced HAI incidence in
ICU settings.

Table 1.2

APA Citation Swan, J., Ashton, C., Bui, L., Pham, V., Shirkey, B., Blackshear, J. Bersamin, J., May, R., et al., (2016).
Effect of chlorhexidine bathing every other day on prevention of hospital-acquired infections in the
surgical ICU. Critical Care Medicine, 44(10), 1822-1832. doi:10.1097/ccm.0000000000001820
Author Qualifications 5 Doctors of Pharmacy (PharmD), 5 Masters of Public Health (MPH), 2 Board certified Pharmacotherapy
specialists (BCPS), 4 Doctors of Medicine (MD), 3 Doctors of Philosophy (PhD), 7 Registered Nurses
(RN), 4 Critical Care certified RNs, & 4 Bachelor of Science in Nursing (BSN).
Background/problem It is proven that over 1 million cases of HAIs are reported each year, with health care costs rising to nearly
statement 200 billion dollars. There are studies that show that Chlorhexidine usage decreases that number of HAIs.
The question being tested is its effects on each type of HAI.
Conceptual/Theoretical Test the effects of daily soap and water bathing compared to every other day bathing with 2% CHG on
Framework incidences of hospital acquired infections such as: catheter associated UTIs, ventilator associated
pneumonia, incisional surgical site infections, primary blood stream infections in ICU patients.
Design/Method/Philosophica Qualitative Study – Randomized Clinical Trial
l Underpinnings
Sample/Setting/Ethical  Sample: 350 patients over the admission period of July of 2012 to May of 2013
Considerations  Setting: 24 bed Surgical ICU (SICU) in Houston Methodist Hospital
 Ethics: Houston Methodist Hospital institutional review board approved the study. They required a
consent waiver to be signed by each patient before they were allowed to begin the study.
Major Variables Studied  Age/Gender/Weight/Race
(and definition), if  Reason for admission to SICU
appropriate  Type/number of Infection contracted
 If catheters, airways, or other forms of invasive access was involved
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Measurement tool/ Date The sample size was randomly divided in half: ½ receiving daily soap and water and ½ receiving CHG
collection method baths every 48 hours for their full length of stay (up to 28 days).
 They utilized the: 2008 Centers for Disease Control and Prevention (CDC) surveillance definitions
for diagnosing abnormal temperatures, 2013 CDC requirements for symptoms of disease
progression to diagnose each infection.
 Pneumonias that developed after 48 hours of admission with mechanical ventilation were collected
as ventilator acquired pneumonia.
Data analysis  Cox regression analysis: Multiple outcomes failure model
 Stata version 4 was used to correlate all analyses
 They created a Figure table to show how the simple was split and the results of each split.
 A table showed the patient demographics and baseline variables that were studied throughout
Findings/Discussion  This study showed that bathing with CHG every other day reduced the risks of acquiring four
primary HAIs: CAUTI, VAP, SSIs, and BSIs.
 That every 48-hour CHG bathing also did not increase the risk of developing allergic/adverse skin
reactions.

Table 1.3

APA Citation Dicks, K., Lofgren, E., Lewis, S., Moehring, R., Sexton, D., & Anderson, D. (2016). Amulticenter
pragmatic interrupted time series analysis of chlorhexidine gluconate bathing in community hospital
intensive care units. Infection Control & Hospital Epidemiology, 37(7), 791-797. doi: 10.1017/ice.2016.23
Author Qualifications 5 Doctors of Medicine (MD), 4 Masters of Public Health (MPH), 1 Doctor of Philosophy (PhD), & 1
Masters of Science in Public Health (MSPH).
Background/problem Hospital Acquired infections lead to increased hospital debt and negative patient outcomes.
statement
Conceptual/Theoretical To evaluate whether daily CHG bathing has an effect on Hospital acquired infections in an ICU setting.
Framework
Design/Method/Philosophica Quantitative Study – Statistical Review
l Underpinnings
Sample/Setting/Ethical  Sample: Utilization of hospitals included in the Duke infection control outreach network
Considerations (DICON). 33 hospitals were chosen over the course of January of 2008 through December of
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2013.
 Setting: DICON hospitals in the southeast United States.
 Ethics: Approval by the Duke university Institutional Review Board. There is no reference of
ethical consideration as an overview, because each hospital decided to either implement the usage
or to remain a control.
Major Variables Studied  Infections were divided into groups: Methicillin Resistant Staph Aureus (MRSA) infections,
(and definition), if Vancomycin resistant enterococcus Infections, and non-species-specific infections. Further
appropriate dividing the HAIs (UTIs, CLABSI, VAP) to their causative agents.
Measurement tool/ Data  The National Healthcare Safety Network had infection preventionists at each hospital collect and
collection method record infection data from each ICU and share this information through a standardized data base
on a monthly basis.
 Decisions to use CHG was decided independently among each hospital. 17 implemented the use of
daily CHG and 16 did not (Control group)
Data analysis Data was analyzed using statistical analysis of each hospital and their relation to the infection groups: as
noted above.
 Interrupted time series model helped to identify the effects of bathing with CHG.
Findings/Discussion They determined that the rate of several HAIs: BSIs and VRE declined after the implementation of CHG
bathing. However, they found that bathing with CHG did not significantly decrease MRSA -caused HAIs.

Table 1.4

APA Citation Cassir, N., Thomas, G., Hraiech, S., Brunet, J., Fournier, P., La Scola, B., & Papazian, L. (2015).
Chlorhexidine daily bathing: Impact on health care–associated infections caused by gram-negative
bacteria. American Journal of Infection Control, 43(6), 640-643. Doi:
10.1016/j.ajic.2015.02.010
Author Qualifications 6 Doctors of Medicine (MD) & 3 Doctors of Philosophy (PhD).
Background/problem Hospital Acquired Infections lead to an increase in cost, mortality and morbidity in hospitals, affecting
statement roughly 30% of ICU-specific patients.
Conceptual/Theoretical Assess the effects of daily bathing with chlorhexidine comparatively to the control group (soap and water)
Framework on HAI occurrence.
Design/Method/Philosophica Quantitative study – Statistical Analysis
l Underpinnings
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Sample/Setting/Ethical  Sample: 325 patients, divided into 2, 6-month periods over the course of May 2012 – May 2013.
Considerations  Setting: a 14 bed Medical ICU at University Hospital Nord (hospital in Marseille, France)
 Ethics: were not discussed in the article relating to this research.
Major Variables Studied  Demographic and Clinical Data
(and definition), if  Length of stay
appropriate  Length of invasive technology (catheter, ventilators, etc)
 Death
 Infection type and occurrence
Measurement tool/ Date  The hospital Lab took microbiological samples to determine patient infection.
collection method  Then there was a designated infection control team that collected the data that was produced from
the lab and the demographic and clinical data of each patient.
 The Sample size was split into a control group (soap and water) and a test group (CHG). The test
group consisted of 150 patients and the control group consisted of 175. Both groups provided data
for the study.
Data analysis Analysis was conducted using an R statistical package.
he infection control team for this hospital provided the researchers the data to analyze.
Findings/Discussion There was a significant decrease in HAI occurrence with daily use of 2% CHG impregnated wipes.

Table 1.5

APA Citation Climo, M., Yokoe, D., Warren, D., Perl, T., Bolon, M., Herwaldt, L., Weinstein, R., Sepkowitz,K., et al.
(2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of
Medicine, 368(6), 533-542. doi: 10.1056/nejmoa1113849
Author Qualifications 10 Doctors of Medicine (MD), 1 Masters of Public Health (MPH), 1 Masters of Science (MS)
Background/problem Other research has suggested that daily bathing with chlorhexidine can prevent HAIs and the development
statement of multi-drug resistant organisms.
Conceptual/Theoretical Assess whether the daily usage of CHG can have an effect of the development of HAIs and multi-drug
Framework resistant organisms.
Design/Method/Philosophica Qualitative Study – Randomized Clinical Trial
l Underpinnings
Sample/Setting/Ethical  Sample: nine ICU and bone marrow transplant unit patients between 2007-2009 to make a total of
Considerations 7735 patients.
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 Setting: ICU and Bone Marrow transplant units
 Ethics: CDC and each hospital review board granted permission to the study. Informed consent
was given to each patient. The study was also registered under clinicaltrials.gov.
Major Variables Studied  Acquisition of multidrug resistant organisms
(and definition), if  Acquisition of HAI: specifically, blood stream infections
appropriate  Utilization of daily 2% CHG bathing
 Length of stay
 Patient Demographics and Clinical history
Measurement tool/ Date  Active surveillance testing (AST) was done on each unit to identify new cases of MRSA/VRE.
collection method  Nares swabs and Peri/rectal swabs were done on each patient in the study before 48 hrs of
admission and upon discharge.
 Each hospital microbiology laboratories identified if those MRSA/VRE infections were present.
Data analysis  Poisson regression Model to calculate the number of BSIs caused by MRSA and VRE.
 Cox Proportional-Hazards regression model to understand the timeline from beginning of
hospitalization to infection.
 Sample t tests were utilized to analyze their continuous variables.
Findings/Discussion Bloodstream infections were 30% lower when utilization of CHG wipes occurred.
They confirmed that daily CHG bathing reduces the transmission of multi-drug resistant organisms and
blood stream infection risk in ICU’s and Bone Marrow transplant units.