Yoğun Bakım Ünitelerinde MRSA ve VRE’yi Önlemede Klorheksidin Glukonat Banyo Protokolü

Öz

Sağlık hizmeti ilişkili enfeksiyonlar hastanede tedavi gören her 30 hastadan birinde (%3) görülen bir hasta güvenliği sorunudur. Antibiyotik direnci gelişimi açısından özellikle sağlık kuruluşunda yatarak tedavi gören hastalarda sağlık hizmeti ilişkili enfeksiyonlara neden olan en önemli patojenler arasında Staphylococcus aureus ve Enterococcus türleri yer almaktadır. Uluslararası kılavuz önerilerinde, bu enfeksiyonların önlenmesi ve kontrol altına alınmasında cildin antisepetik ürünlerle silinmesi/yıkanması esastır. Yoğun bakım ünitelerinde tedavi gören hastalar; hastalıkları, tedavi ve bakımları sırasında gerçekleştirilen invaziv girişimler nedeniyle enfeksiyonlar açısından yüksek risk altındadır. Bu hastalarda enfeksiyon riskini azaltmak için hijyenik bakım sağlamak hemşirenin birincil ve bağımsız rollerinden biridir ve bu uygulamalar için standart protokolleri kullanmamak, kullanılan ürünlerin uygunluğunu sorgulamamak veya doğru kullanmamak önemli sorunlar arasındadır. Klorheksidin glukonat, hastaların banyoları sırasında kullanımı kanıtlanmış güvenli ve etkili bir antimikrobiyal üründür. Bu makalede, yoğun bakım hemşireleri için önemli olan ve hastaya verilen silme yatak banyosunun doğru ve etkili bir şekilde kullanılması için gerekli müdahaleleri içeren klorheksidin glukonat banyo protokolünün basamakları, ilgili literatürün anlatı sentezi yaklaşımıyla sunulmuştur.

Anahtar Kelimeler

• Yatak banyosu
• Klorheksidin glukonat
• Sağlık hizmeti ilişkili enfeksiyonlar
• yoğun bakım hemşireliği
• hasta bakımının yönetimi

Teşekkür

Yazar, danışmanı Prof. Leyla DINC'e teşekkürlerini sunar.

Chlorhexidine Gluconate Bathing Protocol to Prevent MRSA and VRE in Intensive Care Units

Öz

Healthcare-associated infections are one of the patient safety problems seen in one out of every 30 patients (3%) under hospital treatment. Staphylococcus aureus and Enterococcus spp. are among the most important pathogens that cause healthcare-associated infections, especially in patients receiving inpatient treatment in a healthcare institution, regarding antibiotic resistance development. In international guidelines recommendations, wiping/bathing the skin with antiseptic products is essential in preventing and controlling these infections. Patients under treatment in intensive care units are at high risk of infection due to their diseases and invasive procedures performed during their treatment and care. Providing hygienic care for these patients to reduce the risk of infection is one of the nurse’s primary and independent roles, and for these practices, not using standard protocols, not questioning the suitability of the products used, or not using them correctly are among the crucial problems. Chlorhexidine gluconate is an antimicrobial product with proven use safety and effectiveness during patients’ bathing. In this article, the steps of the chlorhexidine gluconate bath protocol, which is important for critical care nurses and includes the necessary interventions for correctly and effectively performing the wiping bed bath given for patients, are presented through a narrative synthesis of the relevant literature.

Anahtar Kelimeler

• Bed bathing
• Chlorhexidine gluconate
• Healthcare-associated infections
• intensive care nursing
• Patient care management

Teşekkür

I would like to thank my supervision Prof. Leyla DINC.

Kaynakça

1. CDC. Healthcare-Associated Infections (HAIs). Available from: https://www.cdc.gov/health-care-associated infections/index.html. [Accessed 07th November 2024].
2. Gidey K, Gidey MT, Hailu BY, Gebreamlak ZB, Niriayo YL. Clinical and economic burden of healthcare-associated infections: A prospective cohort study. Plos one. 2023;18:e0282141.
3. Manoukian S, Stewart S, Graves N, Mason H, Robertson C, Kennedy S, et al. Bed-days and costs associated with the inpatient burden of healthcare-associated infection in the UK. J Hosp Infect. 2021;114:43-50.
4. Stewart S, Robertson C, Pan J, Kennedy S, Haahr L, Manoukian S, et al. Impact of healthcare-associated infection on length of stay. J Hosp Infect. 2021;114:23-31.
5. JCI. Hospital: 2023 National Patient Safety Goals (2023). Available from: https://www.jointcom¬mission.org/-/media/tjc/documents/standards/ national-patient-safety-goals/2023/npsg_chap¬ter_hap_jul2023.pdf. [Accessed 22th May 2023].
6. Vollman K, Garcia R and Miller L. Intervention¬al patient hygiene: proactive (hygiene) strate¬gies to improve patients’ outcomes. Education. 2003;2004.
7. Vollman KM. Interventional patient hygiene: dis¬cussion of the issues and a proposed model for implementation of the nursing care basics. Inten¬sive Crit Care Nurs. 2013;29:250-255.
8. Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol. 2010;31:901-907.

9. Upadhyay S and Smith DG. Healthcare Associated Infections, Nurse Staffing, and Financial Performance. Inquiry. 2023;60:469580231159315.
10. Sağlık Hizmetleri Genel Müdürlüğü SK, Akreditasyon ve Çalışan Hakları Dairesi Başkanlığı [General Directorate of Health Services Health Quality, Accreditatıon and Employee Rights Department]. Sağlıkta Kalite Standartları Hastane (Sürüm 6.1) [Quality Standards in Health Hospital (Version 6.1)]. Available from: https://dosyamerkez.sag-lik.gov.tr/Eklenti/41258/0/skshastane-seti-s-61- -09082021pdf.pdf. [Accessed 20th May 2023].
11. WHO. Global Strategy on Infection Prevention and Control. Available from: https://www.who. int/news/item/28-05-2022-seventy-fifth-world-health-assembly---daily-update--28-may-2022. [Accessed 22th May 2023].
12. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014; 70:1198- 1208.
13. CDC. CDC’s Core Infection Prevention and Control Practicesfor Safe Healthcare Delivery in All Settings. Available from: https://www.cdc.gov/ infectioncontrol/guidelines/core-practices/index.html. [Accessed 9th January 2023].
14. Yokoe DS, Anderson DJ, Berenholtz SM, Calfee DP, Dubberke ER, Ellingson KD, et al. A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates. Am J Infect Control. 2014;42:820-828.
15. CDC. Antibiotic Resistance Threats In The United States 2021. Available from: https://www.cdc. gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. [Accessed 23th January 2023].
16. Ogston A. Report upon Micro-Organisms in Surgical Diseases. Br Med J 1881;1:369-375.
17. Kirby WM. Extraction of a Highly Potent Penicillin Inactivator from Penicillin Resistant Staphylococci. Science. 1944;99:452-453.
18. Cookson B. Five decades of MRSA: controversy and uncertainty continues. The Lancet. 2011;378:1291-1292.
19. CDC. Methicillin-resistant Staphylococcus au¬reus (MRSA). Available from: https://www.cdc. gov/mrsa/community/index.html. [Accessed 13th December 2021].
20. CDC. 2020 National and State Healthcare-Associated Infections Progress Report. Available from: https://www.cdc.gov/hai/data/portal/ progress-report.html#. . [Accessed 13th Decem¬ber 2021].
21. Hekimoğlu HC, Batır E, Yıldırım Gözel E, Altun D. Ulusal Sağlık Hizmeti İlişkili Enfeksiyonlar Sürveyans Ağı Özet Raporu 2024 [National Healthcare Associated Infections Surveillance Network Summary Report 2024]. Available from: https://hsgm. saglik.gov.tr/media/attachments/2025/06/23/ ek_ulusal-saglik-hizmeti-ile-Iliskili-enfeksiyon-lar-surveyans-agi-ushIesa-Ozet-raporu-2024.pdf [Accessed 23th October 2023].
22. Thiercelin M and Jouhaud L. Sur un diplocoque saprophyte de l’intestin susceptible de devenir pathogene. C R Soc Biol. 1899;51:269-271.
23. Schleifer KH and Kilpperbalz R. Transfer of Strep¬tococcus-Faecalis and Streptococcus-Faecium to the Genus Enterococcus Nom Rev as Enterococcus-Faecalis Comb-Nov and Enterococcus-Faecium Comb-Nov. International Journal of Systematic Bacteriology. 1984;34:31-34.
24. Uttley AH, Collins CH, Naidoo J, George RC. Vancomycin-resistant enterococci. The Lancet. 1988;1:57-58.
25. Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4:416-420.
26. Horan TC, Andrus M and Dudeck MA. CDC/ NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309-332.
27. Coia JE, Wilson JA, Bak A, Marsden GL, Shimonovich M, Loveday HP, et al. Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect. 2021;118S:S1-S39.
28. Siegel JD, Rhinehart E, Jackson M, Chiarello L, HICPAC. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2024. Available from: https://www.cdc.gov/infection-control/ hcp/isolation-precautions/index.html. [Accessed 17th January 2025].
29. Lee YJ, Chen JZ, Lin HC, Liu HY, Lin SY, Lin HH, et al. Impact of active screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization on MRSA infections, mortality and medical cost: a quasi-experimental study in surgical intensive care unit. Critical Care. 2015;19:1- 10.
30. Derde LPG, Cooper BS, Goossens H, Malhotra-Kumar S, Willems RJL, Gniadkowski M, et al. Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial. Lancet Infect Dis. 2014;14:31-39.
31. Huang SS, Septimus E, Kleinman K, Moody J, Hickok J, Avery TR, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
32. Robotham JV, Graves N, Cookson BD, Barnett AG, Wilson JA, Edgeworth JD, et al. Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation. BMJ. 2011;343:d5694.
33. McDonnell G and Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev. 1999;12:147-179.
34. Hines AG, Nuss S, Rupp ME, Lyden E, Tyner K, Hewlett A. Chlorhexidine bathing of hospitalized patients: beliefs and practices of nurses and patient care technicians, and potential barriers to compliance Infect Control Hosp Epidemiol. 2015;36:993-994.
35. Eigsti JE. Innovative solutions: beds, baths, and bottoms: a quality improvement initiative to standardize use of beds, bathing techniques, and skin care in a general critical-care unit. Dimens Crit Care Nurs. 2011;30:169-176.
36. Musuuza JS, Roberts TJ, Carayon P, Safdar N. Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran’s Hospital by examining nurses’ perspectives and experiences. BMC Infect Dis. 2017;17:75.
37. Climo MW, Sepkowitz KA, Zuccotti G, Fraser VJ, Warren DK, Perl TM, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009;37:1858-1865.
38. Petlin A, Schallom M, Prentice D, Sona C, Mantia P, McMullen K, et al. Chlorhexidine gluconate bathing to reduce methicillin-resistant Staphylococcus aureus acquisition. Crit Care Nurse. 2014;34:17-25.
39. Ritz J, Pashnik B, Padula C, Simmons K. Effectiveness of 2 methods of chlorhexidine bathing. J Nurs Care Qual. 2012;27:171-175.
40. Boonyasiri A, Thaisiam P, Permpikul C, Judaeng T, Suiwongsa B, Apiradeewajeset N, et al. Effectiveness of Chlorhexidine Wipes for the Prevention of Multidrug-Resistant Bacterial Colonization and Hospital-Acquired Infections in Intensive Care Unit Patients: A Randomized Trial in Thailand. Infect Control Hosp Epidemiol. 2016;37:245-253.
41. Pallotto C, Fiorio M, De Angelis V, Ripoli A, Franciosini E, Quondam Girolamo L, et al. Daily bathing with 4% chlorhexidine gluconate in intensive care settings: A randomized controlled trial. Clin Microbiol Infect 2019; 25: 705-710.
42. Burnham CA, Hogan PG, Wallace MA, Deych E, Shannon W, Warren DK, et al. Topical Decolonization Does Not Eradicate the Skin Microbiota of Community-Dwelling or Hospitalized Adults. Antimicrob Agents Chemother. 2016;60:7303- 7312.
43. Swan JT, Ashton CM, Bui LN, Pham VP, Shirkey BA, Blackshear JE, et al. Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial. Crit Care Med. 2016;44:1822-1832.
44. Hankins RJ, Handke L, Fey PD, Cavalieri RJ, Caw¬cutt KA, Van Schooneveld T, et al. Prospective, crossover, comparative study of two methods of chlorhexidine bathing. Infect Control Hosp Epidemiol 2025; 46: 1-6.
45. Knapp L, Amezquita A, McClure P, Stewart S, Maillard JY. Development of a protocol for predicting bacterial resistance to microbicides. Appl Environ Microbiol. 2015;81:2652-2659.
46. Bajaj TI, Loh C and Borgstrom D. Diluting chlorhexidine gluconate: One scrub or two? Surg Infect (Larchmt). 2014;15:544-547.
47. Edmiston CE, Lee CJ, Krepel CJ, Spencer M, Leaper D, Brown KR, et al. Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients. JAMA Surgery 2015; 150: 1027-1033.
48. Alserehi H, Filippell M, Emerick M, Cabunoc MK, Preas MA, Sparkes C, et al. Chlorhexidine gluconate bathing practices and skin concentrations in intensive care unit patients. Am J Infect Control. 2018;46:226-228.
49. Popovich KJ, Lyles R, Hayes R, Hota B, Trick W, Weinstein RA, et al. Relationship between Chlorhexidine Gluconate Skin Concentration and Microbial Density on the Skin of Critically Ill Patients Bathed Daily with Chlorhexidine Gluconate. Infect Control Hosp Epidemiol. 2012;33:889-896.
50. Rhee Y, Simms AT, Schoeny M, Baker AW, Baker MA, Gohil S, et al. Relationship between chlor-hexidine gluconate concentration and microbi¬al colonization of patients’ skin. Infect Control Hosp Epidemiol 2024; 45: 1-6.
51. Chang HL, Liu TY, Huang PS, Chen CH, Yen CW, Chen HZ, et al. Implementation of 2% Chlorhexidine Bathing to Reduce Healthcare-Associated Infections Among Patients in the Intensive Care Unit. Microorganisms 2025; 13: 65. 20250102.
52. Chen WS, Lin JZ, Zhang K, Fang XP, Wang R, Sun QM, et al. Bathing with 2% chlorhexidine gluconate versus routine care for preventing surgical site infections after pancreatic surgery: a single-centre randomized controlled trial. Clin Microbiol Infect 2025; 31: 825-831.
53. Reis MAO, de Almeida MCS, Escudero D, Medeiros EA. Chlorhexidine gluconate bathing of adult patients in intensive care units in Sao Paulo, Brazil: Impact on the incidence of health-care associated infection. Braz J Infect Dis 2022; 26: 101666.
54. Rhee Y, Palmer LJ, Okamoto K, Gemunden S, Hammouda K, Kemble SK, et al. Differential effects of chlorhexidine skin cleansing methods on residual chlorhexidine skin concentrations and bacterial recovery. infection control & hospital epidemiology 2018; 39: 405-411.
55. Berman A, Snyder S and Frandsen G. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process and Practice. 10 ed. Edinburgh Gate, Harlow: Pearson Education Limited, 2016.
56. Taylor C, Lillis C, Lemone P, et al. Fundamentals of Nursing: The Art And Science of Nursing Care. 7 ed. Philadelphia: LippincotWilliams&Wilkins., 2011.
57. Hsu JE, Whitson AJ, Van Dyke R, Wu JC, Matsen FA, Long DR. Dynamics of Cutibacterium repopulation onto the skin surface of the shoulder after chlorhexidine application. Int Orthop 2023; 47: 1511-1515.
58. Abraham D, Ravindran V, and Joseph M. Effec¬tiveness of Chlorhexidine Bath, Saline Bath, and Standard Bath on Skin Health Status. Indian Journal of Public Health Research & Development 2019; 10.
59. Vanhoozer G, Lovern Bs I, Masroor N, Abbas S, Doll M, Cooper K, et al. Chlorhexidine gluconate bathing: Patient perceptions, practices, and barriers at a tertiary care center. Am J Infect Control 2019; 47: 349-350.
60. Wiemken TL and Ericsson AC. Chlorhexidine gluconate does not result in epidermal microbiota dysbiosis in healthy adults. Am J Infect Control 2021; 49: 769-774.
61. Klassert TE, Zubiria-Barrera C, Denkel LA, Lopez M, Neubert R, Keles Slevogt A, et al. Short- and long-term impact of aseptic bathing strategies on the skin microbiome in ICU patients. Med Microbiol Immunol 2025; 214: 34.