Chlorhexidine
In our never-ending attempt to vanquish healthcare-associated infections, the latest
weapon to emerge is chlorhexidine gluconate (CHG). Not that CHG is exactly new: as an
antiseptic, it has been around for more than 50 years.[1] Initially a topical disinfectant,
CHG has recently crept into numerous other products and devices. We now have not only
skin antiseptic solutions but surgical scrub products, bathing cloths, oral rinses,
intravenous catheters, topical dressings, and implantable surgical mesh -- all infused with
this relatively safe, broad-spectrum antiseptic (Table). Nor is the use of CHG limited to
the hospital: CHG is increasingly added as a preservative to cosmetics and other personal
care products.
Table. Sample of Chlorhexidine Products for Healthcare Use
Product Format CHG Healthcare Uses
Concentration
Topical Sponge 2% or 3.15% With Skin preparation for surgery,
solution applicators 70% isopropyl invasive procedures, central
Swab sticks alcohol lines to prevent SSI and BSI
Ampules
Scrub Liquid detergent 2% or 4% aqueous Preoperative
solution (sudsing base) showering/bathing General
skin cleansing
Washcloth Impregnated single-use 2% aqueous Daily bathing in ICU patients
washcloth/wipe
Dental Oral rinse 0.12% Decontaminate oral cavity
solution (ventilator-associated
pneumonia prevention
protocols)
Gauze Cotton-weave gauze 0.5% with paraffin Wounds or burns
dressing dressing
Catheter CHG pad or integrated 2% gel pad or foam Peripherally inserted central
dressing with semi-permeable disk catheters Central line dressings
transparent dressing
Hand rub Waterless antiseptic 1% alcohol based Hand sanitizer for healthcare
hand gel with emollients personnel (nonsoiled hands)
BSI = bloodstream infection; CHG = chlorhexidine gluconate; ICU = intensive care
unit; SSI = surgical site infection
CHG belongs to the chemical group known as biguanides. As a biocide, its target is the
bacterial cell wall. At low concentrations, CHG binds to the negatively charged cell wall
and disrupts its osmotic equilibrium.[2] At higher concentrations, CHG attacks the
bacterial cytoplasmic membrane and denatures microbial proteins. CHG has both a rapid
onset of bactericidal action and prolonged antimicrobial efficacy through residual effects.
A common question is: against which organisms is CHG effective? The answer is nearly
all, depending on the formulation and concentration of CHG used. CHG is bactericidal,
virucidal, and fungicidal.
• At low concentrations, CHG is effective against most gram-positive bacteria;
• At higher concentrations CHG is effective against gram-negative bacteria;
• At the highest concentrations, CHG is active against yeasts;
• Virucidal activity is good against enveloped viruses (such as HIV,
cytomegalovirus, influenza, respiratory syncytial virus, and herpesvirus) but not
against "naked" viruses (such as rotavirus, adenovirus, or enterovirus);
• CHG has no sporicidal activity, so it is not effective against spores of Clostridium
difficile; and
• CHG is not active against mycobacteria.
A few months ago, Medscape posted an article about the use of CHG for routine bathing
of hospitalized patients (Can We Discard the Traditional Soap-and-Basin Bath?) This
article stimulated an influx of comments and questions about the use of CHG in
healthcare settings. Clearly, healthcare providers have a great deal of interest (and a few
misunderstandings) about CHG.
We took your questions to the following experts and leaders in the field of infection
control:
• William R. Jarvis, MD, Medscape Infectious Disease Expert Advisor, President,
Jason and Jarvis Associates, LLC, Port Orford, Oregon;
• Lynn Cromer, RN, MT, CIC, Chair, Association for Professionals in Infection
Control and Epidemiology Communications Committee and Infection Control
Consultant, Duke Infection Control Outreach Network, Durham, North Carolina;
• Rosie D. Lyles, MD, MHA, Division of Infectious Diseases, John H. Stroger Jr
Hospital of Cook County, Chicago, Illinois;
• Cindy L. Munro, RN, ANP, PhD, Professor, Adult Health and Nursing Systems,
Nursing Alumni Endowed Professor, Virginia Commonwealth University,
Richmond, Virginia; and
• Hudson Garrett Jr., PhD, MSN, MPH, APRN, FNP-BC, Director of Clinical
Affairs at Professional Disposables International; Orangeburg, New York.
These individuals contributed to the responses found below.
General Questions About Effectiveness of Chlorhexidine
"Are all of the chlorhexidine products equally effective?" Although CHG is an
effective bactericidal ingredient, differences in the product formulations will influence
how they should be used. To date, few studies have compared the efficacy of CHG soap
vs impregnated washcloths. The wipes have a theoretical advantage over the liquid soap
because the CHG in the wipes is not rinsed from the skin and the residual CHG extends
the potential for activity.
The antiseptic products (used for prepping skin for procedures or surgery) contain
alcohol, which increases the product's effectiveness. Alcohol begins to kill bacteria and
inactivate viruses immediately. The aqueous products, which contain only CHG, rely on
a cumulative effect for maximum bactericidal activity. This is why patients must begin
bathing or showering with aqueous CHG 72 hours before surgery and repeat the bath or
shower 2 days and then 1 day before their procedure.
"How cost effective is using CHG compared with soap/water or other agents?" The
answer is obvious if you consider the cost savings of more effective antisepsis. Consider
these facts:
• One surgical site infection (SSI) costs $25,546[3];
• For elderly patients, each SSI costs $40,000[4];
• Patients who develop an SSI are twice as likely to die,[5] and they spend 7-10
additional days in the hospital[6]; and
• 2.6%-5.0% of surgical procedures result in surgical site infections.[6,7]
Of course, to be cost-effective, a product must first be clinically effective. Many studies
have compared the effectiveness of CHG with that of soap and water, povidone-iodine
(most studies have assessed the use of povidone-iodine without alcohol), and alcohol, for
various healthcare indications.
Vernon and colleagues compared bathing patients by using CHG-saturated wipes with
conventional soap-and-water bathing.[8] They showed that the use of CHG resulted in a 3-
fold greater reduction in gram-positive bacteria, a 2-fold greater reduction in
vancomycin-resistant enterococci and yeasts, and a 1-fold greater reduction in gram-
negative bacteria.
Many studies have documented the effectiveness of CHG bathing and scrubbing in
reducing colonization of the skin. However promising these observations, to date they
have largely failed to translate into measurable reductions in surgical site infections,
although most of the studies have been underpowered to make this determination.[9]
Research demonstrating the effectiveness of CHG for intravascular catheter management
has been more positive.[2] A meta-analysis found that the incidence of bloodstream
infections was reduced by 49% in patients with central vascular lines who receive CHG
vs povidone-iodine (without alcohol) for insertion-site skin antisepsis. [10] Although CHG
costs more than povidone-iodine, it is cost-effective when the reduction in costs
associated with catheter-related bloodstream infections are considered.[11]
CHG has also been found to be superior to povidone-iodine for skin cleansing
immediately before surgery.[12] Darouchie and colleagues found that after clean-
contaminated surgery, a CHG-alcohol skin antisepsis product was significantly
moreprotective than povidone-iodine (without alcohol) against both superficialincisional
SSIs (4.2% vs 8.6%; P = .008) and deep incisional SSIs (1% vs 3%; P = 0.05), but not
against organ-space SSIs (4.4% vs 4.5%).[12]
Questions About Bathing With Chlorhexidine
"Our ICU staff gives soap and water baths before CHG baths because CHG will not
eliminate visible dirt. Is this really necessary?" Not always. CHG will eliminate
visible dirt, according to our experts, and routine "pre-bathing" with soap and water is not
needed unless a patient is significantly soiled. In that sense, CHG will never entirely
replace soap and water cleaning. The greater the bioburden on the skin, the less any
antiseptic will be able to penetrate, so if you really want to reduce the skin microflora,
you may need to perform conventional cleaning. Although CHG is effective in the
presence of biologic substances such as blood, serum proteins, and pus, its activity is
marginally reduced. So a trauma patient, for example, may have to be cleaned with
conventional methods first.
"I always thought you couldn't beat soap and water for bathing." Any skin antiseptic
(CHG, povidone-iodine, alcohol, or a mixture of CHG or povidone-iodine with alcohol)
will reduce the microbial burden on the skin better than regular soap and water. The one
situation for which soap and water might be indicated is the patient with Clostridium
difficile infection/colonization because none of the skin antiseptics currently on the
market will kill C difficile spores. Neither does soap and water, but it does dilute the
numbers of spores. To date, this is only a theoretical rationale for soap and water in such
patients because no one has documented an increase in C difficile infections when skin
antiseptics are used rather than soap and water.
With the rise of antibiotic-resistant microbes in healthcare institutions, the traditional
basin bath can be part of the problem, with both basin and water playing roles. Studies
have shown that the reusable basin can be a reservoir of contamination, harboring a wide
range of organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococci (VRE).[13] Furthermore, the hospital water supply can
be a source of contamination, perhaps one of the most overlooked sources of
contamination in the hospital, particularly with gram-negative bacteria and
nontuberculous mycobacteria.[14] CHG-impregnated wipes or washcloths are single-use
and disposable, and they require no rinsing, thus eliminating the need for basin and water.
Although popular primarily in patients in the intensive care unit (ICU), who need to be
bathed in bed, the no-water, no-basin bath is probably a good idea for all patients who are
immunocompromised, have fresh surgical wounds, or are otherwise at high risk for
infection.
"So, do you see chlorhexidine replacing the soap and basin bath for all hospitalized
patients, especially nonambulatory patients (from neonatal to geriatric) in the near
future?" This is hard to predict. To date, most studies have been limited to ICU patients
(daily bathing) or surgical patients (daily bathing for several days before surgery, and an
application with the CHG-impregnated cloth, which is not washed off, right before
surgery).[4,6] The effect of CHG bathing in other patient groups has not been well
assessed, and even the existing evidence comes mostly from before/after studies, not
randomized, controlled trials.
No studies of the use of CHG as a bathing agent in neonates or children have been
published, although anecdotally, some neonatal intensive care units (NICUs) are using
CHG bathing for all admissions regardless of birthweight. In the future, CHG might
replace soap and basin bathing, but more data are needed in a variety of populations.
"We are told to avoid the face when bathing patients with CHG -- either cloths or
solution. Are there any other special precautions?" Manufacturers of CHG-
impregnated bathing wipes and skin antiseptics state that you should not use the products
in the periorbital or eyelid areas. If CHG solutions come into contact with eyes, wash
them out promptly and thoroughly with water. You also should avoid contact with the
meninges or the middle ear. CHG is toxic to nerve tissues with direct contact, although
this has not been reported with currently used agents. In patients with head or spinal
injuries or perforated tympanic membrane, the benefit of use in preoperative preparation
should be balanced against the risk of contact with these body areas.
"Can CHG be used on the perineum? For example, can we use it on the patient with
a Foley catheter?" The best approach is to consult the specific product instructions for
use to determine whether the product is safe to use on mucous membranes. Some
products will specify that they are not to be used in the genital area.
In general, CHG is not recommended for contact with mucous membranes. The Centers
for Disease Control and Prevention (CDC), Society for Healthcare Epidemiology of
America, and the Infectious Diseases Society of America, in their compendium of
guidelines for prevention of catheter-related urinary tract infection, recommend that
"cleaning the meatal area with antiseptic solutions is unnecessary; routine hygiene is
appropriate."[15]
One expert responded that if you are bathing with CHG, you can clean the Foley (gently)
and the perineum with CHG, but only the external genital region should be cleaned with
CHG.
Some CHG products have been safely used for vaginal antisepsis. Recently, CHG was
used investigationally in pregnant women as an intravaginal wash, gel, or wipe in an
attempt to prevent the vertical transmission of vaginal organisms and reduce neonatal
infections.[16] One of the manufacturers of an aqueous CHG 4% product states that
"irritation, sensitization, and generalized allergic reactions have been reported with
chlorhexidine-containing products, especially in the genital areas."[17]
"Can CHG be used more than once per day? If not, we still need traditional
cleansers for incontinent patients." CHG can be applied repeatedly in a single day or
sequentially over several days. The manufacturer of a widely used CHG
antiseptic/antimicrobial skin cleanser states that the product can be used many times per
day without causing irritation, dryness, or discomfort. Studies show that for surgical
patients, the application of a CHG bath (applying, letting it dry, and then washing it off)
for several days reduces the bacterial load on the skin.[12] Once-daily applications reduce
the bacterial load less than twice daily or sequential daily applications. Similarly, single-
day applications have a reduced effect on bacterial load compared with multiple-day
applications. The best regimens for all patients in all situations (eg, ICU, surgical prep)
are still unknown.
Questions About Resistance, Sensitization, and Toxicity of Chlorhexidine
"Can microbial resistance, or reduced effectiveness, develop with prolonged use of
chlorhexidine?" Emerging resistance and decreasing susceptibility are always concerns
with antimicrobials, antiseptics, and decolonizing agents, and research to monitor the
development of these effects is ongoing. Resistance to antiseptics is analogous to
antibiotic resistance, and the 2 share some common resistance mechanisms.[18] A
manufacturer of CHG products states that "after 50 years of research and experience
[there is] still no development of bacterial resistance to CHG." [19] Milstone and
colleagues[2] explain that "although decreasing susceptibility to chlorhexidine has been
reported, it has not been convincingly shown to be associated with repeated exposure to
chlorhexidine." No case of a patient becoming resistant to the antimicrobial effects of
CHG has been documented.
Resistance, if it develops, is most likely to be associated with inappropriate use.
Resistance to CHG has been demonstrated readily in the laboratory, notably when low
concentrations of CHG are used. Whether the residual amount of CHG left on a surface
after CHG use could facilitate emerging resistance is not known. However, until now,
most bacteria exhibiting an increased level of resistance to a particular biocide in a
laboratory situation have remained susceptible to high concentrations of that biocide.
Gram-negative organisms resistant to CHG have been retrieved from dispensers
containing germicidal hand soap with CHG, used for routine hand antisepsis in hospitals.
[20]
Bacterial contamination with pan-resistant Acinetobacter species or Klebsiella species,
multidrug-resistant Pseudomonas species, or MRSA was noted on the surfaces of
dispensers of hand soap which contained 2% CHG.[21]
Some strains of MRSA carry genes that confer increased minimum bactericidal
concentrations to antiseptics, meaning that it takes a higher concentration of the antiseptic
to kill them. However, these concentrations are still well below the concentration of CHG
used in clinical practice, so the antisepsis should still be effective. The prevalence of the
gene for CHG resistance varies widely in countries around the world, but is still very low
considering how long CHG has been used in western Europe. Still, concerns have been
expressed that the selective stress exerted by biocides, such as CHG, could favor the
growth and dissemination of bacteria expressing resistance mechanisms.[18] It is not
known whether the MRSA strains with resistance to CHG are also found in the United
States.
"Should we be worried about the toxicity of chlorhexidine?" CHG is not absorbed
through intact adult skin. When used properly, adverse reactions to CHG are rarely
[Link] of its cationic nature, CHG binds strongly to skin, mucosa, and other
tissues and is thus very poorly absorbed by any route -- skin or gastrointestinal tract. No
detectable blood levels have been found in humans after oral use. Percutaneous
absorption, if it occurs at all, is insignificant. CHG essentially remains on the skin and is
shed with the skin. Therefore, most effects noted with CHG use have been local,
consisting primarily of mild skin irritation.[21] Organ damage has been described from
accidental exposures; these cases are extremely rare, but the following have been
reported:
• Corneal injuries and permanent corneal scarring have occurred after inadvertent
exposure of the eyes to 4% CHG;
• An esophageal burn occurred after ingestion of a large quantity of highly
concentrated CHG;
• Ulcerative colitis was reported after an enema was given with 4% CHG; and
• Contact with the inner ear has caused deafness.[21]
"Are many patients allergic to CHG?" Generalized allergic reactions to CHG have
been reported but are extremely rare. Contact dermatitis, urticaria, and anaphylaxis have
occurred after repeated skin exposures to this agent.[21] Nodata from western Europe,
where CHG has been used for much longer than in the United States, have yet shown that
allergic reactions are more common or are increasing. However, if a patient verbalizes a
previous allergic reaction to CHG, this should be prominently noted and CHG products
avoided in that patient, and patients should always be questioned about previous
experiences before using any substance for the first time.
Irritative skin reactions can occasionally occur, but these do not necessarily indicate
allergy. It is important to remember that when CHG topical antiseptic is used, the skin
must be dry at the time it is applied and the CHG must be permitted to dry. Dressings
placed over wet CHG can increase the risk for adverse skin reactions, particularly in low-
birthweight infants.
"Why must we use only certain lotions on hands or patients after washing with a
CHG product?" The antibacterial activity of CHG depends upon the chemical
deposition of the CHG cationic (positively charged) molecule on the skin, where it binds
to the stratum corneum.[22] The cationic nature of the CHG molecule helps it to persist on
the skin and continue its antibacterial activity, but it is also subject to possible
inactivation if an anionic (negatively charged) substance is encountered. It has long been
known that anionic-based substances have this diminishing effect on residual CHG. Hand
lotions or creams that contain anionic emulsifying agents will reduce the antibacterial
effect of CHG.[23] With this information, most healthcare facilities have purchased lotions
that are cationic or nonionic (neutral), making them compatible with CHG used by staff
or patients.
Questions About Other Uses of Chlorhexidine in Healthcare
"Can you address the use of CHG for vascular catheter insertion preparation?"
This is one of the most common uses of CHG products in healthcare settings today. The
Infectious Diseases Society of America and The Society for Healthcare Epidemiology of
American guidelines recommend the use of a > 0.5% CHG and 70% isopropyl alcohol
product for skin antisepsis before vascular catheter insertion to prevent catheter-related
infections.[24] This practice can reduce catheter colonization and catheter-related
bloodstream infections. It has been found to be superior to povidone-iodine (without
alcohol) solutions or plain alcohol. In a randomized, controlled trial of 631 catheter
insertions, the incidence of catheter colonization was significantly lower after skin
antisepsis with 2% CHG-70% alcohol than with aqueous povidone-iodine (14.2% vs
24.7%; relative risk, 0.5 [95% confidence interval, 0.3-0.8]; P < .01]).[25] Skin antisepsis
before vascular catheter insertion is also one of the only currently approved indications
for CHG use in the neonate.
Antiseptics such as CHG-alcohol should be applied with sufficient friction to ensure that
the solution reaches into the invisible cracks and fissures in the skin. No evidence
supports the use of the traditional concentric prepping technique, although this technique
is still widely employed.
"Are CHG-transparent dressings effective for central lines?" The skin can never be
completely sterilized. At least 80% of resident and transient skin flora is found in the first
5 epidermal layers of the skin. About 20% of skin flora remains on the skin, even after
antisepsis, and bacterial re-growth begins immediately (back to the original level by 24
hours). The objective of CHG-impregnated dressings is to continue to suppress bacterial
re-growth and to protect the area at the point of catheter insertion, from where it is
believed that microorganisms migrate along the catheter insertion tract, to infect the
catheter tip.
The CDC and Healthcare Infection Control Practices Advisory Committee recently
completed a review of the existing data on the use of the CHG-impregnated sponge
(BioPatch®, Ethicon 360, Somerville, New Jersey) and 3M Tegaderm™ CHG (3M, St.
Paul, Minnesota). They found no published clinical data on the efficacy of the 3M
Tegaderm CHG, and the US Food and Drug Administration (FDA) indication is that this
product is a dressing (for securement), without an indication for reducing infection. Thus,
the CDC's updated guidelines for the prevention of intravascular catheter-related
infections, released in draft form in November 2009,[26] did not mention this product, and
the final version of the guideline (to be published soon) will not make a recommendation
to use this product for prevention of infection. In contrast, the committee found sufficient
evidence to confirm the efficacy of the BioPatch® for the 3 FDA-approved indications:
reducing central venous catheter-related bloodstream infections, reducing local site
reactions, and reducing skin bioburden. [27-30]
"I've heard conflicting rules about the use of chlorhexidine in the operating room.
What is the actual recommendation?" CHG-based antiseptics are widely used for
surgical skin preparation in the operating room. The concern about the use of CHG with
alcohol (or any alcohol-based product) in theoperating room is the potential for a fire in
the presence of the triad of oxygen, electrocautery, and alcohol.
Most such fires occur in the patient's head and neck region because of the proximity to
oxygen and the potential for pooling of flammable liquids in the patient's hair or drapes.
This situation has occurred most often with the use of the larger, 26-mL antiseptic
applicators because a larger volume of antiseptic is used and the drying time is
prolonged.[31] Safety measures to prevent an operating room fire include the following:[32]
• Use the smallest-volume CHG applicator practical, especially for head and neck
surgeries, and prep carefully, avoiding run-off of liquid into hair or drapes;
• Do not allow the solution to pool on or under drapes or body areas; remove any
wet materials from the area;
• Do not drape or use an ignition source until the antiseptic has dried completely
and vapors have dissipated (a minimum of 3 minutes -- hair soaked with
antiseptic can take up to an hour to dry); and
• Make certain that all operating room personnel are educated about the
flammability of CHG-alcohol antiseptics and how to prevent a fire; in
preoperative briefings and time-outs, remind team of use of CHG.
"How effective is oral CHG, and are there any special precautions for using the oral
CHG rinses?" The use of CHG for oral decontamination follows decades of use of this
product by dentists in patients with gingivitis and periodontitis.[2] The recent increased
use in hospitals has been primarily as an intervention to reduce ventilator-associated
pneumonia (VAP) by reducing the number of bacteria able to colonize or infect the upper
and lower airways. Several studies have assessed efficacy of this approach, and it has
been included in most VAP prevention bundles, although current evidence does not
conclusively support the routine use of CHG in mechanically ventilated patients, except
in cardiac surgery patients.[33]
CHG is deactivated by anionic compounds, including the anionic surfactants commonly
used as detergents in toothpastes and mouthwashes. For this reason, CHG mouth rinses
should be used at least 30 minutes after other dental products.[16] For best effectiveness,
food, drink, smoking, and mouth rinses should be avoided for at least 1 hour after oral
CHG use.
Anionic substances, such as sodium lauryl sulfate, commonly found in toothpaste, also
disrupt CHG's cationic activity. For this reason, a time delay between brushing and
gargling is advisable.
The most common unwanted effect of using oral chlorhexidine is staining of the teeth. A
yellow-brown stain, similar to what occurs with excessive coffee or tobacco use, occurs
in about half of patients exposed to the oral solution. However, the staining is highly
variable in different individuals, and the cause is not known with certainty. Patients
should be advised that this is a normal cosmetic and temporary effect. The stain can be
removed with standard professional dental cleaning.
Some patients complain that the use of CHG rinse makes food taste metallic. The
alteration in taste should disappear when the oral rinse is discontinued. Clinicians may
want to emphasize that use of CHG as a mouthwash without scrubbing or brushing the
teeth has minimal impact on the biofilm on teeth. If used with brushing, it removes the
biofilm on teeth and reduces oral infection and VAP.
"Can CHG be used on open wounds?" The potential benefits of using CHG and other
antiseptics to cleanse wounds is of great interest. Microbial colonization and infection are
thought to delay wound healing and even cause wound [Link] might
theoretically reduce the bacterial load of the wound; compared with topical antibiotics,
CHG is less likely to encounter bacterial resistance in the wound.[34] On the other hand,
concerns about toxicity to local wound healing factors and possible reduced activity in
the presence of wound exudate or blood remain to be addressed.[34]
In the limited human research to date, CHG appears to be safe and does not interfere with
wound healing. CHG may favor healing of open wounds at risk for infection. However,
the evidence to date has not sufficiently assessed the efficacy and safety of CHG for
wound care, so no conclusions can be drawn.[34]
The topical antiseptic, which contains alcohol, should not be used on open wounds
because it could burn the tissues. Aqueous CHG has been used, in very low
concentrations (0.012%), to clean superficial wounds. In this manner, CHG will neither
cause additional tissue injury nor delay healing.[3]Product information for a popular brand
of aqueous CHG states that wounds that involve more than the superficial layers of the
skin should not be routinely treated with the product.[35] For superficial wounds, the area
should first be rinsed with water, then the wound area should be covered with the
minimum amount of solution necessary, and rinsed thoroughly afterward.[35]
"Have any studies been conducted on the use of CHG in neonates?" Most CHG
products are approved for use only in patients over the age of 2 months; therefore, this
excludes neonates. The only indication for the use of CHG in neonates is preparation of
skin before intravascular catheter placement
That said, anecdotally we know that CHG is widely used in NICUs across the country. A
recent comprehensive review concluded that some percutaneous absorption of CHG
occurs in neonates at trace levels, particularly in preterm infants.[29]
Therefore, the safe use of CHG on neonates with underdeveloped stratum corneum has
not been established. One of the few published studies of neonatal use is a randomized,
controlled trial in a NICU looking at CHG-impregnated sponge dressings for the
prevention of catheter-related bloodstream infections. Although the patches did reduce
bloodstream infections, local infections, and skin bioburden, many adverse skin reactions
to CHG occurred in very-low-birthweight infants.[29]
Use of this product should probably be delayed until about 1 week of age (when the skin
has matured) in infants who are very premature or low birthweight. This CHG-
impregnated sponge dressing also has been tested in older infants and children without
demonstrating any adverse events.[30]
With respect to perinatal use, if CHG has been used for cleansing the mother's skin, the
mother's nipples should be washed thoroughly with water before breast-feeding. One
neonate was reported to develop multiple episodes of bradycardia and cyanosis, with
serum chlorhexidine concentrations of 11 ng/mL after oral exposure when CHG was used
on the mother's breasts to prevent mastitis.[36]
"Is chlorhexidine bathing for VRE-/MRSA-positive patients recommended in long-
term care?" This is a difficult question. To date, the studies done in ICU patients
suggest that daily CHG bathing will reduce the risk for VRE colonization and of VRE
bloodstream infection. These same studies have not shown a significant reduction in
MRSA colonization or MRSA bloodstream infection (probably because the CHG is not
placed intranasally, where MRSA usually resides). Studies also show that CHG bathing
used prophylactically before surgery or as a surgical prep (on the day of surgery) reduces
the surgical site infection rate. Hopefully, data looking specifically at long-term care
patients will be forthcoming.
References
