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Patient Safety Issues

HLORHEXIDINE

BATHING AND MICROBIAL


CONTAMINATION IN
PATIENTS BATH BASINS
By Jan Powers, RN, PhD, Jennifer Peed, RN, BSN, Lindsey Burns, RN, BSN, and
Mary Ziemba-Davis, BA

C N E 1.0 Hour
Notice to CNE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Compare the rate of bacterial contamination
on bath basins using soap to those basins
where a standardized chlorhexidine solution is
used for bathing.
2. List 3 common organisms found in patients
bath basins.
3. Describe how basin, device, infection control,
and isolation variables affect culture results
when using chlorhexidine for patient baths.
To read this article and take the CNE test online,
visit www.ajcconline.org and click CNE Articles
in This Issue. No test fee for AACN members.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012242

338

Background Research has demonstrated the hazards associated


with patients bath basins and microbial contamination. In a
previous study, soap and water bath basins in 3 acute care hospitals were found to be reservoirs for bacteria and potentially
associated with the development of hospital-acquired infections.
Bacteria grew in 98% of the basin samples; the most common
were enterococci (54%), and 32% were gram-negative organisms.
Objective To assess the presence of bacterial contaminants
in wash basins when chlorhexidine gluconate solution is used
in place of standard soap and water to wash patients.
Methods Bathing with chlorhexidine gluconate is the standard
of practice for all patients in intensive care units at St Vincent
Hospital. Specimens from 90 bath basins used for 5 days or
more were cultured for bacterial growth to assess contamination of basins when chlorhexidine gluconate is used.
Results Of the 90 basins cultured, only 4 came back positive
for microbial growth; all 4 showed growth of gram-positive
organisms. Three of the 4 organisms were identified as coagulase-negative staphylococcus, which is frequently found on
the skin. This translates into a 95.5% reduction in bacterial
growth when chlorhexidine gluconate is used as compared
with soap and water in the previous study (Fisher exact test,
P < .001). The only factor that was related to positive cultures
of samples from basins was the sex of the patient.
Discussion Compared with the previous study examining
microbial contamination of basins when soap and water was
used to bathe patients, bacterial growth in patients bath basins
decreased significantly with the use of chlorhexidine gluconate,
drastically reducing the risk for hospital-acquired infections.
Such reduced risk is especially important for critically ill patients
at high risk for bacterial infection. (American Journal of Critical
Care. 2012;21:338-343)

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5

www.ajcconline.org

atients bath basins in hospitals are a known source of microbial contamination.1,2 In a previous study,1 bath basins from which samples were cultured in 3
acute care hospitals were found to be reservoirs for bacteria and potentially associated with the development of hospital-acquired infections. Bacteria grew in 98%
of the basin samples, with the most prominent being enterococci (54%) and
gram-negative organisms (32%).1 More alarming in this study was the association between
microbes found in the bath basins and infection of patients.

Based on this and other studies of microbial


contamination of patients bath basins,2 a change in
practice eliminating the use of bath basins for hygiene
in hospitalized patients would be warranted. However, it is not yet known whether bacterial contaminants are present in patients bath basins when
chlorhexidine gluconate (CHG) solution is used for
bathing. It is known that bathing with CHG decreases
the frequency of infections with vancomycin-resistant
enterococcus and methicillin-resistant Staphylococcus
aureus3-8 and bloodstream infections.8-11 Research
studies showing the effectiveness of CHG bathing in
the reduction of hospital-acquired infections have
not clearly delineated which preparation of CHG
(impregnated cloths vs CHG solution diluted in bath
water) is most effective. Based on previous studies,
standard practice in our intensive care unit (ICU) is
bathing of all patients with 2 fl oz (60 mL) of 4%
CHG solution diluted in 3 qt (2.85 L) of water. The
purpose of this study was to assess the presence of
bacterial contaminants in wash basins when CHG
solution is used in place of standard soap and water
to wash patients.

Methods
Bathing Procedure
Before the start of the study, standardized procedures for patient hygiene and storage of wash basins
were in place. ICU nurses bathe patients with 2 fl
oz (60 mL) CHG to 3 qt (2.85 L) water in bath
About the Authors
Jan Powers is director of clinical nurse specialists and a
clinical nurse specialist in the trauma intensive care unit
at St Vincent Hospital in Indianapolis, Indiana. Jennifer
Peed and Lindsey Burns are staff nurses in the medical
intensive care unit at St Vincent Hospital. Mary ZiembaDavis is a research scientist on the clinical nurse specialist
team at St Vincent Hospital.
Corresponding author: Jan Powers, RN, PhD, Director of
Clinical Nurse Specialists and Nursing Research, Trauma
Intensive Care Unit Clinical Nurse Specialist, St Vincent
Hospital, 2001 West 86th Street, Indianapolis, Indiana
46260 (e-mail: jmpowers@stvincent.org).

www.ajcconline.org

basins, using a new washcloth for each body part


bathed. Initial bathing occurs within 6 hours of
ICU admission and daily thereafter. After completion
of bathing, basins are wiped with a paper towel to
eliminate standing water and then placed upside
down on a storage table to air dry. Basins are
labeled and designated solely for CHG bathing and
are discarded if contamination with vomit or other
bodily fluids occurs. An additional basin is labeled
for the storage of bath supplies.
Study Procedure
Samples from 90 basins used to wash 90 patients
in a 40-bed mixed medical surgical ICU at a large
Midwestern tertiary care hospital (St Vincent Hospital, Indianapolis, Indiana) were cultured for microbial contamination. Study enrollment continued
until a sample of 90 basins was
achieved. All bath basins were
dated when the patient was admitted to the ICU, and only basins that
had been in use for 5 days were
included in the sample. Approval
was obtained from the institutional
review board before the start of the
study. Once enrolled, bath basins
were assigned a unique identification number to
ensure that basin duplication did not occur. A data
tracking sheet was completed, with the data being
entered into a Microsoft Excel spreadsheet by a trained
investigator. The data collection tool recorded:
Patients demographics: sex, medical vs surgical
admission diagnosis, age, length of stay in the hospital, and length of stay in the ICU;
Basin variables: the number of days that basins
had been in use when the culture samples were
obtained and the number of days since the patients
last bath when the basins were sampled;
Device variables: presence of central catheters,
arterial catheters, peripherally inserted central catheters,
endotracheal tubes, tracheostomy tubes, ventilators,
urinary catheters, and fecal containment devices;

Patients hospital
bath basins are
a known source
of microbial
contamination.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5

339

Table 1
Bath basin study comparisonsa
No. (%) of patients
Cleaning agent used
Chlorhexidine (current study)
Soap and water (Johnson et al., 2009)1
a

Bacterial
growth

No bacterial
growth

4 (4.4)

86 (95.6)

90 (97.8)

2 (2.2)

Fisher exact test: P < .001.

Infection and isolation variables: Infection(s)


at latest laboratory culture (yes vs no), antibiotics
(yes vs no), and isolation (yes vs no).
Basin Cultures
Basins were allowed time to dry thoroughly
before samples were obtained for culture. A culture
swab for each study basin was obtained from the
hospital laboratory. The culture swab was saturated
with sterile saline before culture and rolled along
the bottom of the basin perimeter around all corners and sides in a continuous motion. The swab
was then rolled along the center of the basin. A laboratory requisition form was completed by using
identification numbers for each study patient/bath
basin that were known only to the first author.
Swab specimens labeled with the same identifier
were submitted for analysis. Laboratory findings
were entered into the Excel spreadsheet and filed in
regulatory study binders.
Statistical Analysis
Univariate tests rather than logistic regression
were used to assess the extent to which independent
variables were predictive of bacterial growth on
basins because of the small number
of observed bacterial events compared
with the number of nonevents. Pearson 2 tests were used for all nominal
variable comparisons with a Fisher
exact test applied to all 2 2 tables.
The nonparametric 2-sample Wilcoxon
rank sum test for median differences
was used in place of 2 independent
sample t tests for mean differences.
Mintab Version 15 was used for statistical analysis with an of .05 or less as the criterion for statistically significant differences. P values
adjusted for ties are reported for 2-sample Wilcoxon
rank sum tests.

The intensive care


unit has standardized procedures
for patient hygiene
and storage of
wash basins.

Results
Ninety bath basins from ICU patients were
examined, 42 from female (46.7%) and 48 (53.3%)
from male patients. Patients were from 24 to 88 years

340

old (mean, 61.6 years; SD, 14.0 years). Mean lengths


of stay in the hospital and in the ICU were 11.1
(SD, 7.1; range, 5-41) days and 9.8 (SD, 6.6; range,
4-42) days, respectively. Eighty-two percent of patients
(n = 74) were admitted to the ICU for medical diagnoses and 18% (n = 16) were postsurgical patients.
Of the 90 bath basins cultured, only 4 (4.4%)
were positive for microbial growth. All microbes
were gram-positive organisms, with 3 identified as
coagulase-negative staphylococcus, which is frequently found on the skin. One culture yielded grampositive cocci. The median number of days that basins
had been in use when they were cultured did not
differ between basins that showed bacterial growth
(median, 7.5 days) and basins that showed no bacterial growth (median, 7.0 days; W = 3879.5; P = .51).
Median days since patients last baths with the study
basins were equivalent for basins that showed bacterial growth (median = 1.0 day) and basins that
showed no bacterial growth (median = 1.0 days;
W = 3906.5; P = .90).
Table 1 compares bacterial growth of samples
from bath basins in the current study with CHG to
the existing basin study1 in which soap and water
were used to bathe patients. A 95.5% reduction in
basin cultures positive for bacteria was observed
when CHG was used (4.4% growth vs 97.8% growth;
Fisher exact test, P < .001).
Relationships between patients demographics,
device variables, infection and isolation variables,
and bacterial growth in study basins are presented
in Table 2. The only significant main effect was
between the patients sex and bacterial growth. All
basins positive for bacterial growth were associated
with female patients (Fisher exact test, P = .04).
None of the other independent variables were significantly related to bacterial growth in study basins.

Discussion
In dramatic contrast to an existing study1 that
showed 97.8% bacterial growth in 92 bath basins
when soap and water was used to bathe patients,
we observed 4.4% bacterial growth in 90 basins
when CHG solution was used for patients baths.
Our finding reflects a 95.5% reduction in cultures
of bath basins positive for bacteria, indicating that
patient bath basins may not be inevitable sources
of bacterial growth when CHG is used. The
patients sex was the only factor that was associated with positive cultures; other patients characteristics, length of basin use, the presence of
indwelling devices, identified infections, antibiotic
use, and isolation status were not related to positive culture results.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5

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Table 2
Bacterial growth in bath basins by patient,
device, and infection/isolation characteristics
No. (%) of patientsa
Characteristic

Bacterial growth

No bacterial growth

Sex
Female
Male

4 (100.0)
0 (0.0)

38 (44.2)
48 (55.8)

Diagnosis
Medical
Surgical

3 (75.0)
1 (25.0)

71 (82.6)
15 (17.4)

Pb
.04

.55

Age, median, y
Length of stay, median, d
In hospital
In intensive care unit

68.0

60.5

.64c

7.5
7.5

9.0
7.5

.36d
.87e

Central catheter
Yes
No

3 (75.0)
1 (25.0)

43 (50)
43 (50)

.62

Arterial catheter
Yes
No

1 (25.0)
3 (75.0)

12 (14.0)
74 (86.0)

Peripherally inserted central catheter


Yes
No

2 (50.0)
2 (50.0)

47 (54.7)
39 (45.3)

Endotracheal tube
Yes
No

3 (75.0)
1 (25.0)

45 (52.3)
41 (47.7)

Tracheostomy tube
Yes
No

0 (0.0)
4 (100.0)

20 (22.2)
70 (77.8)

Ventilator
Yes
No

2 (50)
2 (50)

52 (60.5)
34 (39.5)

Foley catheter
Yes
No

4 (100.0)
0 (0.0)

76 (88.4)
10 (11.6)

Fecal containment device


Yes
No

1 (25.0)
3 (75.0)

16 (18.6)
70 (81.4)

Infection shown by latest culture


Yes
No

2 (50.0)
2 (50.0)

52 (60.5)
34 (39.5)

Antibiotics
Yes
No

2 (50.0)
2 (50.0)

65 (75.6)
21 (24.4)

Isolation
Yes
No

0 (0.0)
4 (100.0)

20 (23.3)
66 (76.7)

.47

>.99

.62

.57

>.99

>.99

.57

>.99

.27
.57

aUnits

for age and length of stay are as specified in first column; all other values are No. (%) of patients.
P values based on Fisher exact test, unless W value indicated in footnote.
cWilcoxon rank sum test, W = 3888.5.
dWilcoxon rank sum test, W = 3960.5.
eWilcoxon rank sum test, W = 3922.0.
bMost

Our study was limited to 90 CHG bath basins by


design to make accurate comparison to the 92 soap
and water bath basins cultured by Johnson et al.1

www.ajcconline.org

Like Johnson et al, basins in the current study were


sampled from a medical/surgical ICU. Unlike the
study by Johnson et al, our study did not include

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5

341

basins from a cardiac ICU and rehabilitation unit,


which potentially limits the comparability and generalizability of our findings. It is relevant to note,
however, that infection-control bathing practices
and care and storage of bath basins were standardized throughout the study ICU.
We cannot rule out that potential differences in
bathing practices and basin care and storage techniques alone account for disparities in bacterial contamination in these 2 studies.
Although universal precautions were
followed, bathing methods were not
observed in the comparison study,
and basin care and storage were highlighted as a potentially significant
source of the high rate of basin bacterial contamination.1 In our study, we
had already implemented standardized bathing practices along with the
implementation of CHG bathing. It is
therefore unknown whether it was
our standardized techniques for
bathing patients and for care of wash basins or the
CHG in the basin that made the significant difference in microbial contamination. Additionally, the
current study is limited by the lack of a control
group; multisite research with a control group controlling for bathing and basin storage techniques is
recommended to resolve this important question.
Evidence has established that hospital tap water
is a source of bacterial contamination.12 In a systematic review of 18 randomized controlled trials,
experimental studies, and meta-analyses conducted
since 2006, researchers concluded that CHG bathing
is acceptable and useful for the reduction of central catheterassociated bloodstream infections, the
acquisition or decolonization of multidrug-resistant
organisms, and surgical site infections.13 On the evidence grading scale
used, CHG bathing was supported by
fair to good evidence, with the weight
of the evidence and expert opinion
not strongly in favor.13 It is unknown
whether efficacy is improved with the
use of CHG-impregnated cloths versus
liquid CHG solution in bath water,
which remains an area for future
research. Establishment of evidencebased bathing procedures for hospitalized patients is
required to ensure best practice and potentially
reduce the incidence of nosocomial infections. Our
findings of minimal microbial contamination of
bath basins when CHG is used to bathe patients suggest that it may be premature to conclude that bath

Patients bath
basins may not
be inevitable
sources of bacterial growth
when chlorhexidine is used.

It may be premature to conclude


that bath basins
are a potential
source of hospitalacquired infections.

342

basins are a potential source of hospital-acquired


infections.
FINANCIAL DISCLOSURES
None reported.
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REFERENCES
1. Johnson D, Lineweaver L, Maze L. Patients bath basins as
potential sources of infection: a multicenter sampling study.
Am J Crit Care. 2009;18:31-40.
2. Marchaim D, Abreu-Lanfranco O, Taylor AR, et al. Hospital
bath basins are frequently contaminated with multi-drug
resistant human pathogens. Poster presented as part of the
40th Annual Critical Care Congress of the Society of Critical
Care Medicine, January 15-19, 2011, San Diego, California.
http://www.sageproducts.com/documents/pdf/education
/symposia/skin/21529_Marchaim_SHEA_poster.pdf.
Accessed June 8, 2012.
3. Batra R, Cooper B, Whiteley C, et al. Efficacy and limitation of
a chlorhexidine-based decolonization strategy in preventing
transmission of methicillin-resistant Staphylococcus aureus
in an intensive care unit. Clin Infect Dis. 2010;50:210-217.
4. Ridenour G, Lampen R, Pederspiel J, et al. Selective use of
intranasal mupirocin and chlorhexidine bathing and the
incidence of methicillin-resistant Staphylococcus aureus
colonization and infection among intensive care unit
patients. Infect Control Hosp Epidemiol. 2007;28:1155-1161.
5. Sandri A, Dalarosa M, Ruschel de Alcantara L, et al. Reduction in incidence of nosocomial methicillin-resistant
Staphylococcus aureus (MRSA) infection in an intensive
care unit: role of treatment with mupirocin ointment and
chlorhexidine baths for nasal carriers of MRSA. Infection
Control Hosp Epidemiol. 2006;27:185-187.
6. Vernon M, Kayden M, Trick W, et al. Chlorhexidine gluconate
to cleanse patients in a medical intensive care unit: the
effectiveness of source control to reduce the bioburden of
vancomycin-resistant enterococci. Arch Intern Med. 2006;
166:306-312.
7. Kassakian SZ, Mermel LA, Jefferson JA, Parenteau SL,
Machan JT. Impact of chlorhexidine bathing on hospitalacquired infections among general medical patients. Infect
Control Hosp Epidemiol. 2011;32:238-243.
8. Climo M, Sepkowitz K, Zuccotti G, et al. The effect of daily
bathing with chlorhexidine on the acquisition of methicillinresistant Staphylococcus aureus, vancomycin-resistant
enterococcus, and healthcare-associated bloodstream
infection: results of a quasi-experimental multicenter trial.
Crit Care Med. 2009;37:1858-1865.
9. Bleasdale S, Trick W, Gonzalez I, et al. Effectiveness of
chlorhexidine bathing to reduce catheterassociated bloodstream infections in medical intensive care unit patients.
Arch Intern Med. 2007;167(19):2073-2079.
10. Munoz-Price L, Hota B, Stemer A, et al. Prevention of bloodstream infections by use of daily chlorhexidine baths for
patients at a long-term acute care hospital. Infect Control
Hosp Epidemiol. 2009;30(11):1031-1035.
11. Popovich K, Hota B, Hayes R, et al. Effectiveness of routine
patient cleansing with chlorhexidine gluconate for infection
prevention in the medical intensive care unit. Infect Control
Hosp Epidemiol. 2009;30(10):959-963.
12. Clark AP, John LD. Nosocomial infections and bath water:
any cause for concern? Clin Nurse Spec. 2006;20:119-123.
13. Sievert D, Armola R, Halm MA. Chlorhexidine gluconate
bathing: does it decrease hospital-acquired infections? Am
J Crit Care. 2011;20:166-170.

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AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5

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CNE Test Test ID A1221052: Chlorhexidine Bathing and Microbial Contamination in Patients Bath Basins.
Learning objectives: 1. Compare the rate of bacterial contamination on bath basins using soap to those basins where a standardized chlorhexidine solution is used
for bathing. 2. List 3 common organisms found in patients bath basins. 3. Describe how basin, device, infection control, and isolation variables affect culture
results when using chlorhexidine for patient baths.
1. What was the purpose of the study described in this article?
a. To assess bath basins for bacterial contamination when chlorhexidine was
used in place of soap
b. To assess bath basins for bacterial contamination when soap was used in
place of chlorhexidine
c. To assess bath basins for bacterial contamination based on patient length
of stay
d. To assess bath basins for bacterial contamination in all ICU patients
2. Which of the following methods was used to determine study
eligibility?
a. Patients had to be admitted to the unit following a surgical procedure.
b. Patients had to use bath basins for at least 5 days.
c. Patients had to be bathed within 6 hours of admission.
d. Patients had to have bath basins changed out every 5 days during admission.
3. Which of the following was considered part of the standardized
bathing practice in the study hospital?
a. Using the bath basin for storing patient supplies
b. Using the bath basin as an emesis basin as needed
c. Using a paper towel to dry the basin following the bath
d. Using a new bath basin for each bath
4. Which of the following was considered a device variable in the study?
a. Time the culture was obtained in relation to time since last bath
b. Isolation status at the time the culture was obtained
c. Presence of a central venous catheter when the culture was obtained
d. Length of stay at the time the culture was obtained
5. How were cultures obtained from the basins in this study?
a. Culture swabs were rolled around the corners and bottom of the basin
when it was dry.
b. Culture swabs were rolled around the corners of the basin after wetting it
with tap water.
c. Culture swabs were rolled around the corners and bottom of the basin
prior to drying it following the bath.
d. Culture swabs were wetted with sterile saline and rolled around the corners
and bottom of the basin.

6. How was the 95% infection reduction calculated?


a. The study group was compared to a group in another unit that used soap
instead of chlorhexidine.
b. The present study group was compared to a past study group by Johnson
et al that used soap.
c. The study hypothesis stated all patients with bath basins would have infections.
d. The study groups infection rate was compared to the hospitals historical data.
7. Which of the following percentages of bath basin samples grew
bacteria in the previous study by Johnson et al?
a. 32%
c. 95%
b. 54%
d. 98%
8. Which of the following demographic characteristics was statistically
signif icant in the basins with positive cultures?
a. Age
b. Length of stay
c. Gender
d. Diagnosis
9. Which of the following percentages of patients with a positive
culture was in isolation?
a. 0%
c. 50%
b. 25%
d. 100%
10. Which of the following was the most common organism found on
the study cultures?
a. Gram-negative rods
b. Gram-positive cocci
c. Coagulase-positive staphylococcus
d. Clostridium difficile
11. Which of the following factors may have affected the study results?
a. The standardized bathing practice was implemented prior to the study
b. The study had too many control groups
c. The use of tap water for the baths
d. The patient length of stay prior to the cultures

Test ID: A1221052 Contact hours: 1.0 Form expires: September 1, 2014. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. a
b
c
d

2. a
b
c
d

3. a
b
c
d

4. a
b
c
d

5. a
b
c
d

6. a
b
c
d

8. a
b
c
d

7. a
b
c
d

10. a
b
c
d

9. a
b
c
d

11. a
b
c
d

Fee: AACN members, $0; nonmembers, $10 Passing score: 8 correct (73%) Category: A Test writer: Marylee Bressie, RN, MSN, CCRN, CCNS, CEN.

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