Enhanced bathing routine reduces nursing home infections

AHRQ-funded study finds ‘universal decolonization’ lowers hospital transfers

October 10, 2023

Orange, Calif. — Nursing homes that use a chlorhexidine bathing routine to clean the skin, and an over-the-counter antiseptic to clean the nose, prevent serious infections and reduce the amount of antibiotic-resistant organisms in the nursing home setting, according to findings of researchers at University of California, Irvine, Harbor-UCLA and the Centers for Disease Control and Prevention. The findings were published today in the New England Journal of Medicine..

The cleansing protocol, called universal decolonization, substantially reduced the number of nursing home residents requiring hospitalization due to infection, said senior investigator Dr. Susan Huang, MD, MPH, medical director of epidemiology and infection prevention for UCI Health, the clinical enterprise of UCI, and chancellor's professor of infectious diseases at UCI School of Medicine.

Robert Otto Valdez, PhD, MHSA, director of the U.S. Agency for Healthcare Research (AHRQ) says that for an older person “having an infection and needing to be transferred to the hospital for care can be life-threatening.”

The AHRQ-funded study, “Nursing Home Decolonization for Infection and Hospitalization Prevention,” involved nearly 14,000 residents at 28 California nursing homes in Orange and Los Angeles counties.

“Now nursing homes have another tool to help them prevent infections, reduce transfers, and keep our older adults safe,” Valdez said.

On any given day, more than 1 million people live in the nation's 15,000 nursing homes. Every year, 3 million healthcare-associated infections (HAIs) such as methicillin-resistant Staphylococcus aureus (MRSA), bloodstream and urinary tract infections occur in U.S. nursing homes. Their residents are at high risk for these infections due to age, wounds, medical devices and complex illnesses.

MRSA and other pathogens can live on a person’s skin and in their nose without making them sick. Proactively removing the potentially harmful bacteria can reduce the chances of developing an infection or spreading it to others.

During the 18-month study, Huang and her team compared 14 nursing facilities using standard bathing routines with 14 facilities using the antibacterial soap chlorhexidine and nasal swabs with povidone-iodine (iodophor) to remove pathogens from residents’ skin and nose.

Both antiseptic products have been used in healthcare for more than 60 years.

The nursing homes following the decolonization protocol saw a significant reduction in the overall prevalence of multidrug-resistant organisms, including MRSA, vancomycin-resistant Enterococci and other resistant bacteria. No change in the prevalence of multidrug resistant organisms was detected in residents of 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, MD, senior advisor for long-term care in CDC’s Division of Healthcare Quality Promotion, and technical advisory panel member for the trial.

In the routine bathing nursing homes, an average of six residents were hospitalized for infection each month per 100 occupied beds. In contrast, nursing homes using the enhanced bathing routine had two fewer residents hospitalized for infection per month per 100 occupied beds. The decolonization routine didn’t need to be perfect to prevent infection and hospitalization: 87% used the antiseptic soap as intended; 67% used the iodine-based 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,” said Huang.

“Compared to other healthcare strategies, this is a relatively simple win for nursing homes. We hope nursing homes will want to adopt it.”

Huang spearheaded the study with lead author Loren G. Miller, MD, MPH, professor and chief of the Division of Infectious Diseases in the Department of Medicine at Harbor-UCLA Medical Center and an investigator at the Lundquist Institute for Biomedical Innovation.

Huang is a nationally recognized expert on the prevention of HAIs whose protocols have been adopted in nursing homes, intensive care units and hospitals across the country.

The findings add to a growing body of Huang’s research funded by AHRQ and other U.S. 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 decreased 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 had medical devices based on the ABATE Infection Trial, also led by Huang. The CLEAR post-discharge trial showed that chlorhexidine and nasal mupirocin used after hospital discharge could reduce infection and hospitalization in those colonized with MRSA.

“Nursing Home Decolonization for Infection and Hospitalization Prevention” was published in the New England Journal of Medicine on Oct. 10, 2023. 

Learn more about the study and protocol

About the U.S. Agency for Healthcare Research and Quality

AHRQ is the lead Federal agency charged with improving the safety and quality of healthcare for all Americans. AHRQ develops the knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare professionals, and policymakers make informed health decisions. AHRQ’s mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.

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UCI Health is the clinical enterprise of the University of California, Irvine, and the only academic health system in Orange County. Patients can access UCI Health at primary and specialty care offices across Orange County and at its main campus, UCI Medical Center in Orange, Calif. The 459-bed, acute care hospital, listed among America’s Best Hospitals by U.S. News & World Report for 22 consecutive years, provides tertiary and quaternary care, ambulatory and specialty medical clinics, behavioral health and rehabilitation services. UCI Medical Center is home to Orange County’s only National Cancer Institute-designated comprehensive cancer center, high-risk perinatal/neonatal program and American College of Surgeons-verified Level I adult and Level II pediatric trauma center and regional burn center. UCI Health serves a region of nearly 4 million people in Orange County, western Riverside County and southeast Los Angeles County. Follow us on Facebook, Instagram, LinkedIn and Twitter.

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Each year, the UCI School of Medicine educates more than 400 medical students and nearly 150 PhD and MS students. More than 700 residents and fellows are trained at the UCI Medical Center and affiliated institutions. Multiple MD, PhD and MS degrees are offered. Students are encouraged to pursue an expansive range of interests and options. For medical students, there are numerous concurrent dual degree programs, including an MD/MBA, MD/MPH, or an MD/MS degree through one of three mission-based programs: the Health Education to Advance Leaders in Integrative Medicine (HEAL-IM), the Program in Medical Education for Leadership Education to Advance Diversity-African, Black and Caribbean (PRIME LEAD-ABC), and the Program in Medical Education for the Latino Community (PRIME-LC). The UCI School of Medicine is accredited by the Liaison Committee on Medical Accreditation and ranks among the top 50 nationwide for research. For more information, visit medschool.uci.edu.