Universal vs Targeted Chlorhexidine Bathing and Nasal Decolonization in Hospitalized Patients

The ABATE Infection trial investigated the effects of universal bacterial decolonization with chlorhexidine for patients in non-intensive care unit settings to reduce hospital-onset bacteremia and fungemia (HOB) events. Among patients with medical devices (central venous catheters, midline catheters, and lumbar drains), universal decolonization (UD) resulted in a significant and meaningful reduction in bacteremia compared with the standard of care (SOC), but cost-effectiveness is unclear.

To examine the cost-effectiveness of universal and targeted bathing strategies compared with SOC in general medical and surgical units.

A decision analytic model was constructed from June 1, 2021, to May 31, 2024, to simulate the frequency of HOB and costs under 3 strategies: SOC, UD, and targeted decolonization (TD). The model included a simulated cohort representative of the cluster-randomized ABATE Infection trial, which involved more than 500 000 participants across the US.

In TD, decolonization was administered for patients with medical devices only. Upstream costs of bathing and downstream costs of HOB, under payer and hospital perspectives were included. Parameters were informed by the ABATE Infection Trial and additional literature. Willingness-to-pay per HOB prevented was adopted as $25 000 for payers and $10 000 for hospitals. Sensitivity analyses were tailored to populations with different characteristics.

The simulated cohort, based on the population from the ABATE trial, included 529 000 adult admissions with a mean (SD) age of 63 (18) years, 54% female, and 13% with a central venous catheter, midline catheter, or lumbar drain. In the base case, the SOC was least effective and most costly. Targeted decolonization was least costly and UD resulted in the fewest HOB events. Targeted decolonization was the cost-effective strategy from payer and hospital perspectives. Compared with TD, UD had an incremental cost-effectiveness ratio of $119 700 per HOB averted from the payer perspective, and $126 600 per HOB averted from the hospital perspective. Depending on willingness-to-pay, UD may be preferred in scenarios with a higher proportion of patients with medical devices, greater reductions in HOB from decolonizing in those with devices, and lower adherence under TD.

In this decision analytic model studying universal and targeted bathing, TD was cost-effective under a broad range of scenarios for both hospital system and payer decision-makers. Universal decolonization was cost-effective in some scenarios, such as in specific units where many patients have medical devices or if it were difficult to implement a targeted approach.