Antisepsis Bath and Oral.. Should We Change Practice? DR AZMIN HUDA ABDUL RAHIM

Transcription

1 Antisepsis Bath and Oral.. Should We Change Practice? DR AZMIN HUDA ABDUL RAHIM

2 Chlorhexidine Exposure in ICU

3 Chlorhexidine gluconate Long acting topical antiseptic In use since 1954 Water soluble Remains active for hours after application Milstone AM, et al. Clin Infec Dis 2008; 46: Lio PA, Kaye E. Inf Dis Clin North Ame;

4 Chlorhexidine gluconate Binds to negatively charged bacterial cell wall, causing osmotic changes and finally destroying the organism Activity against: Gram positive bacteria Gram negative bacteria Yeast Milstone AM, et al. Clin Infec Dis 2008; 46: Lio PA, Kaye E. Inf Dis Clin North Ame;

5 Chlorhexidine gluconate- uses For skin antisepsis: Reduction of bacterial skin burden Reduction of CLABSIs Reduction of acquisition of certain resistant organisms Pre-operative bathing and scrub Impregnated devices (vascular catheters and dressings) Oropharynx antisepsis Milstone AM, et al. Clin Infec Dis 2008; 46:274-81

6 Popovich KJ, et al. Infect Control Hosp Epidemiol 2012; 33:

7 Popovich KJ, et al. Infect Control Hosp Epidemiol 2012; 33:

8 Popovich KJ, et al. Infect Control Hosp Epidemiol 2012; 33:

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11 Why would chlorhexidine decrease CLABSIs? Safdar N, Maki DG. Intensive Care Med 2004; 30:62-67

12 Literature Review: CHLROHEXIDINE BATH

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14 Popovich KJ, et al. Infect Control Hosp Epidemiol 2009; 30:

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17 NEJM 368;6 february 7, 2013

18 A multicenter, cluster-randomized, nonblinded crossover Total 7752 patients enrolled from 9 ICU and bone marrow transplat units in 6 hospitals. Randomly assigned to bathe patients either with no-rinse 2% chlorhexidine impregnated washcloths or with nonantimicrobial washcloths for a 6-month

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22 JAMA 2015

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24 Primary outcomes in this study: Composite of CLABSI,CAUTI, VAP, C.difficile infections Secondary outcomes: Rates of positive cultures of MRO, blood culture contamination, healthcare associated BSI and rates of primary outcomes in ICU

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27 Chlorhexidine Bathing did not reduce the incidence of nosocomial infections

28 ICU staff could not be blinded to the bathing regimen, adherence to care practices was not monitored. The use of the chosen composite end point of CLABSI, VAP, CAUTI, and C difficile infection could be challenged Acquired infection rates were relatively low, and whether these results are applicable to other ICUs is unclear

29 RCT The effectiveness of chlorhexidine in preventing MDR not proven

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31 Chlorhexidine bath reduces acquisition of VRE

32 Chlorhexidine bath reduces MRSA

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35 MIC for gram positives /negatives

36 ORAL ANTISEPSIS

37 In the intensive care unit (ICU), bacterial colonization of the oropharynx is an important risk factor for VAP. AMERICAN JOURNAL OF CRITICAL CARE, January 2004, Volume 13, No. 1 25

38 Can be colonized by potential respirator pathogens such as methicillin-resistant S aureus and P aeruginosa AMERICAN JOURNAL OF CRITICAL CARE, January 2004, Volume 13, No. 1 25

39 Aspiration of oropharyngeal contents containing a large bacterial inoculum overwhelms host defenses already compromised by critical illness VAP

40 LITERATURE REVIEW ORAL ANTISEPSIS

41 JAMA, November 22/29, 2006 Vol 296, No. 20

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43 BMJ 2007

44 Rates of VAP were lower among patients receiving oral antisepsis

45 No difference in mortality

46 No difference in duration of ICU stay

47 Prevention of ventilator associated pneumonia with oral antiseptics; systematic review and meta-analysis Pre Chlrohexidine use resulted in significant reduction of VAP Lancet Infect Dis 2011

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49 Oral hygiene using Chlrohexidine effective in preventing VAP

50 Conclusion Recent trials showed that Chlorhexidine bath did not reduce incidence of nosocomial infection. However it may still be useful against MRSA and VRE.

51 Chlorhexidine bathing in icu should not be done routinely especially in the era of emerging resistance. Oral chlorhexidine 0.2% has been shown to reduce VAP in the critically ill patients, should be continued as part of VAP bundle

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