Chlorhexidine Bathing Routine Reduces Infections in Nursing Homes

A new study funded by the Agency for Healthcare Research and Quality (AHRQ) found that nursing homes using a chlorhexidine bathing routine to clean the skin and nose with over-the-counter antiseptic solutions prevents serious infections and reduces the amount of antibiotic resistant organisms in the nursing home, such as methicillin-resistant Staphylococcus aureus (MRSA). The study was published today in the New England Journal of Medicine.

In nursing homes using the bathing routine, known as decolonization, two residents per month avoided transfers to the hospital due to infections. These nursing homes also significantly reduced transfers to the hospital for other causes. Nearly 14,000 residents were included in the study.

"For an older person, having an infection and needing to be transferred to the hospital can be life-threatening. Now nursing homes have another tool to help them prevent infections, reduce transfers, and keep our older adults safe," said AHRQ Director Robert Otto Valdez, Ph.D., M.H.S.A.

More than 1 million people reside in one of the Nation’s 15,000 nursing homes on any given day. Each year, 3 million healthcare-associated infections (HAIs) such as MRSA, bloodstream infections, and urinary tract infections occur in U.S. nursing homes, causing 150,000 hospital admissions and 350,000 deaths. Nursing home residents are at high risk for HAIs due to age, wounds, medical devices, and other illnesses.

MRSA and other pathogens can live on a person’s skin and in their nose without making them sick. However, proactively removing these potentially harmful bacteria can reduce the chance that a person develops an infection.

In this 18-month study of 28 nursing homes in California, researchers compared 14 facilities that continued their usual bathing routines (control group) to 14 facilities that used decolonization for all residents (intervention group). Decolonization included using a special soap called chlorhexidine and a nasal swab with povidone-iodine (iodophor) to remove pathogens from residents’ skin and nose. These two products have been used in healthcare for over 60 years.

Nursing homes that used decolonization also saw significant reduction in the overall prevalence of multidrug-resistant organisms (MDROs) including MRSA, vancomycin-resistant Enterococci, and other resistant bacteria. No change in MDRO prevalence was detected in residents who lived in the nursing homes that used routine bathing.

"CDC is excited to see the results of a nursing home-focused infection prevention intervention being published. Given the growing concern of harm from antimicrobial-resistant germs in nursing homes, the impact of this decolonization bathing program is quite important and provides a concrete action that facilities can use to protect nursing home residents," said Nimalie Stone, M.D., M.S., Senior Advisor for Long-Term Care in CDC’s Division of Healthcare Quality Promotion, and technical advisory panel member for the trial.

Adherence to the decolonization bathing routine didn’t need to be perfect to prevent hospitalization and resistant organisms: 87 percent of nursing home staff used the antiseptic soap as intended and 67 percent used the nasal swab as intended.

"Our findings suggest that changing to an antiseptic soap and cleaning the nose with iodophor is a highly effective way to prevent dangerous infections in nursing homes. Compared with other healthcare strategies, this is a relatively simple win for nursing homes, and we hope nursing homes will want to adopt it," said the study’s senior investigator, Susan S. Huang, M.D., M.P.H., of the Division of Infectious Diseases, University of California Irvine School of Medicine. Dr. Huang spearheaded the study along with lead author Loren G. Miller, M.D., M.P.H., of the Division of Infectious Diseases, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center.

This study's findings add to a growing body of research funded by AHRQ and other Department of Health and Human Services agencies that show universal decolonization can be an effective tool to prevent infections for at-risk populations in the healthcare system. The REDUCE MRSA Trial found that decolonizing all intensive care unit (ICU) patients with chlorhexidine and nasal mupirocin reduced all-cause bloodstream infections by nearly half. More recently, AHRQ published a toolkit that expands the decolonization protocol to non-ICU hospital patients who have indwelling medical devices.

The study, "Nursing Home Decolonization for Infection and Hospitalization Prevention," was published in the New England Journal of Medicine on October 10, 2023. It, and the decolonization protocol used by the intervention group, are available at www.nejm.org/doi/full/10.1056/NEJMoa2215254.