Universal ICU Decolonization: An Enhanced Protocol

The following is a nursing protocol for adult ICUs implementing Universal Decolonization. The REDUCE MRSA Trial found a 44 percent reduction in all-cause bloodstream infections and a 37 percent reduction in MRSA clinical cultures when using this protocol as it is written. Modifications to this protocol may be done; however, variations may not achieve the same results as in the trial.

Key Elements

1. Daily chlorhexidine (CHG) bathing for duration of ICU stay.
2. 5-day mupirocin administration during ICU stay.
3. Cessation of ICU screening (if not required by law).

Detailed Protocol

For each adult ICU patient, each day:

1. Stop admission ICU screening (if not required by law).
2. Determine if any CHG exclusion criteria exist.
   1. CHG allergy.
3. Determine if any mupirocin exclusion criteria exist.
   1. Mupirocin allergy.
   2. Nasal packing or physical inability to use mupirocin.
4. Bathe patient with CHG daily, starting on day 1 of ICU admission, for entire ICU stay.
5. Administer mupirocin to patient twice a day, starting on day 1 of ICU admission, for 5 days or until ICU discharge (if prior to 5 days).
6. If patient is readmitted, restart the protocol for both CHG and mupirocin.
7. Stop protocol upon discharge or transfer from the ICU.

Mupirocin Application

1. Place patient's bed at 30 degrees, if tolerated.
2. Apply 0.5 grams (about the size of a blueberry) of mupirocin onto a sterile cotton swab.
3. Apply the swab directly into nostril. Ensure coating of the sides of the nostril.
4. Repeat for other nostril.
5. Press nostrils together and massage gently for 60 seconds.
6. Do this twice a day for 5 days.
7. Avoid contact with eyes and other intranasal products.
8. If nasal devices are in place (e.g., nasal intubation, NG tubes), place mupirocin around tubing and massage gently to distribute ointment.

Chlorhexidine (CHG) 2% Bathing Cloths

1. A CHG bathing wall poster (Appendix E) is available to print for patient rooms, which outlines the CHG bathing process.
2. After routine washing of face and hair, remove one batch of CHG cloths (three bundled packages of two cloths each = six cloths).
3. You may use a warmer to warm up the cloths. Warming is for patient comfort, it is not required. Cold cloths are active and can be used if patient desires a cool cloth.
4. CHG removes bacteria from the skin during bathing. Cloths should be used to bathe the skin with firm massage.
5. Do not use CHG above the jawline^a Chlorhexidine should not come in contact with eyes or ear canals.
6. CHG should be used for all bathing purposes, including once a day full-body bathing, incontinence care, or for any other reasons for additional cleaning.
7. CHG replaces soap and water baths. It should not be used as a "top coat" after bathing. Rather, it is the soap and cleansing process for removing bacteria and binding to skin for persistent antibacterial activity lasting 24 hours.
8. Use the six cloths for bathing all body areas below the jawline:
   • Cloth 1: Neck, shoulders and chest.
   • Cloth 2: Both arms, hands, web spaces, and axilla.
   • Cloth 3: Abdomen and then groin/perineum.
   • Cloth 4: Right leg, foot, and web spaces.
   • Cloth 5: Left leg, foot, and web spaces.
   • Cloth 6: Back of neck, back and then buttocks.
9. Use additional CHG bathing cloths, if necessary, to thoroughly cleanse the body.
10. After application to each body site, clean tubing from Foleys, drains, G-tube/J-tubes, rectal tubes, chest tubes within 6 inches of the patient.
11. Ensure thorough cleaning, with special attention to commonly soiled areas such as the neck, skin folds, and perineal areas. CHG is safe to use on perineal areas, including external mucosa. CHG is also safe for superficial wounds, including stage 1 and stage 2 decubitus ulcers.
12. Pay special attention to cleaning skin areas surrounding lines and other devices to ensure removal of bacteria from skin. CHG is safe on devices and can be used over semi-occlusive dressings.
13. If incontinence occurs, rinse the affected area with water and clean with chux. Then clean skin with CHG cloths. Use CHG-compatible barrier products if needed.
14. Skin may feel sticky for a few minutes after application.
15. Do not rinse with water or wipe off. Allow to dry naturally.
16. CHG cloths have moisturizers. If additional moisturizer or lotion is needed, only use lotions that are known to be compatible with chlorhexidine. CHG compatibility should be assessed by the product's manufacturer.
17. Do not place CHG cloths directly on bedding, as contact with bleach can create a brown stain.
18. Dispose of CHG cloths in the trash. Do not flush.

^a. Chlorhexidine has been safely used on the face and hair in several studies with special attention to avoid the eyes and ear canals. Risk is if chlorhexidine comes in direct contact with nerves, as may be the case with a perforated ear drum or with direct contact with the eyes. In the REDUCE MRSA trial, we avoided the skin above the jawline to ensure chlorhexidine did not contact these areas.