Monday, March 18, 2013
Enamored with chlorhexidine, but is it justified?
Regular readers of our blog understand how smitten we are with chlorhexidine gluconate (CHG).
For use in lines, dressings and the oropharynx, we have controlled trial data. However, for CHG bathing (a.k.a. "source control"), the data have consisted of quasi (before-after) studies without concurrent control groups. So we take note this week of two multicenter, cluster-randomized crossover trials, one published in the New England Journal of Medicine (adult ICUs) and one published in Lancet (pediatric ICUs). Both studies were partially supported by Sage, the manufacturer of the no-rinse 2% CHG wipes used, and both had the same design: randomization to 6 months of daily CHG or nonantimicrobial bathing, followed by 6 months of the opposite. The adult (NEJM) study was interrupted by a several month recall of the CHG cloths, but the investigators handled that problem well (and analyzed the data with and without the interruption data included).
The adult ICU investigators examined the outcomes of health care-associated BSI and MRSA/VRE acquisition, finding significant reductions in both during CHG use. I'm most impressed with the CLABSI numbers: a 53% reduction during CHG use (1.6 vs. 3.3 per 1000 cath days). The Lancet (PICU) study is underwhelming by comparison, possibly due to the focus on longer-stay kids and the fact that written informed consent was required (which resulted in many subjects not being included; a waiver of informed consent was obtained from every center in the adult study, resulting in more complete enrollment).
The primary outcome in the pediatric study was any bloodstream infection (actually, any positive blood culture) and by intent-to-treat analysis, the reduction in "bacteremia" (in quotes because some of the positive blood cultures were likely contaminants) was not statistically significant, whereas by "per-protocol" analysis the 33% reduction was significant (3.3 vs. 4.9 per 1,000 patient days, P=0.04). CHG was safe in both studies, with no increase in skin reactions, no major adverse events.
A sample of MRSA and VRE were collected and subjected to CHG susceptibility testing in the NEJM study, and the results were what would be expected, but who knows how to interpret CHG MICs anyway?
Now for the caveat, the sobering note, the but, but, but, the impact of CHG was among the gram-positive organisms, almost entirely coagulase-negative staphylococci (the yeast (Candida) findings in the adult study are of interest, but the numbers are small). A published table combines the results of both studies by organism group. Not such an exciting story for the gram negative rods, or for S. aureus, which as we know are the more problematic, virulent bugs.
And to finish, a poorly constructed haiku about chlorhexidine:
reduce the infection risk
not for the bad bugs?
Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
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Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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One of the most popular anonymous blogs written by an emergency room physician.