Chlorhexidine structure

Preoperative use of chlorhexidine

Chlorhexidine

The following is a summary of notes that I collected on use of chlorhexidine for reduction in surgical site infections.

What is it?

A chemical antiseptic that has been commonly used by dentists for oral hygiene. Lately it has found wider acceptance as a presurgical skin and hand scrub.

Mouthwash

Sold under the brand name Peridex for oral care

Skin disinfectant

Due to inactive ingredients added to the skin formulations these cannot be used in the mouth

Brands

  1. Hibiclens for body wash
  2. Avagard, a personal hand antiseptic (1% chlorhexidine and 61% ethyl alcohol)
  3. Chloraprep for minor procedures (2% chlorhexidine and 70% isopropyl alcohol)
  4. BIOPATCH for central line exit sites

Advantages of chlorhexidine

  1. Effective against MRSA and VRE
  2. Rapid onset of activity but slower than alcohol same as povidone
  3. Active for at least 6 hours after application much better than povidone
  4. Not inactivated by blood and body fluids
  5. Less flammable than alcohol
  6. No skin staining
  7. No evidence of development of resistance
  8. Repeated applications have cumulative advantage

So what is the evidence to support its use?

  1. When used preoperatively for skin antisepsis in clean contaminated surgery. A study by Darouiche et al evaluated 849 subjects. They randomized patients to receive either chlorhexidine or povidone-iodine as preoperative scrub. The patients were followed for post operative infection rates.1
    1. They found surgical site infection rates of 9% for patients treated with chlorhexidine versus 16% for those treated with povidone iodine.
    2. Number of superficial and deep surgical incisional infections also dropped in the group treated with chlorhexidine.
    3. No effect on organ space infection was seen in this study.
  2. Garibaldi et al demonstrated that preoperative antiseptic shower with chlorhexidine as opposed to povidone-iodine or triclosan reduces skin colonization at surgical sites. 2

    In this study patients were randomized to either of the three agents. Intraoperative surgical site cultures were nine fold lower in the group treated with chlorhexidine as opposed to 1.3 fold lower for povidone-iodine group.

  3. A small study by Paulson et al Evaluated the effect of 4% chlorhexidine on five volunteers. They had five shower washed and were sampled after the shower then 3 and 6 hours later then on days 1,2 and 5. The study arm demonstrated reduced colony counts up to 5 days. 3
  4. A randomized trial by Hayek et al enrolled 1989 patients using either chlorhexidine, placebo or conventional bar soap on two occasions in the 24 hours prior to surgery. 4

Infection rates Chlorhexidine Bar soap Placebo
All surgery 9% 12.8% 11.7%
Clean surgery 7.2% 10.2% 10%

This study demonstrated a decrease in post operative surgical site infections for the chlorhexidine group. Notice that in this study bar soap was no better than placebo.


What are the contraindications for use?

  1. Do not use on meninges
  2. Age <2 months
  3. Body cavities
  4. Eyes or ears

How is it available?

  1. 2% cloth
  2. Soap

Summary points

  1. Rinse free
  2. Alcohol free
  3. Effective against MRSA, VRE and acinetobacter
  4. Active for up to 6 hours after application

Instructions for patients

  1. Wash hair as usual and body with regular soap
  2. Wet clean wash cloth and turn off shower
  3. Put chlorhexidine soap on washcloth
  4. Apply to whole body from neck down- do not get into eyes or mouth
  5. Soap does not lather
  6. Wash body gently for 5 minutes with the wash cloth- Do not scrub too hard
  7. Do not use regular soap after using chlorhexidine
  8. Turn shower back on and rinse
  9. Pat dry with clean dry towel
  10. Do not use any lotion, moisturizer or makeup on skin

References


  1. Darouiche, Rabih O, Matthew J Wall, Kamal M F Itani, Mary F Otterson, Alexandra L Webb, Matthew M Carrick, Harold J Miller, et al. 2010. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. The New England journal of medicine 362, no. 1 (January 7): 18-26.
  2. Garibaldi, R A. “Prevention of intraoperative wound contamination with chlorhexidine shower and scrub.” The Journal of hospital infection 11 Suppl B (April 1988): 5-9.
  3. Paulson, D S. “Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash.” American journal of infection control 21, no. 4 (August 1993): 205-9.
  4. Hayek, LJ, J M Emerson, and A M Gardner. “A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates.” The Journal of hospital infection 10, no. 2 (September 1987): 165-72.

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