Chlorhexidine use

What is the recommendation?
The Centers for Disease Control and Prevention (CDC), the Division of Healthcare Quality Promotion (DHQP) and the National Center for Emerging and Zoonotic Infectious Diseases recommend chlorhexidine usage in the hospital setting to prevent Healthcare‐Associated Infections (HAIs) (CDC, 2018). Their recommendations include chlorhexidine bathing and chlorhexidine‐impregnated dressings to prevent Central Line‐Associated Bloodstream Infections (CLABSIs). Additionally, chlorhexidine bathing alone is recommended to prevent MRSA Infections.

Chlorhexidine Use in the Hospital
Hospital-acquired infections are associated with increased monetary expenses, extensive hospital stays, and preventable mortality rates (Kaye et al, 2014).
A systematic literature was recently performed to determine if CHG can be used to reduce the risk of infections such as central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections (CAUTI); ventilator-associated pneumonia (VAP); methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile in ICU patients (Frost et al.2016). It was concluded that daily CHG usage can reduce CLABSI and MRSA infections in ICU patients, but the risk for CHG resistance and Gram-negative bacteremia should be considered. 

A study was performed to evaluate how effective chlorhexidine can be in reducing HAIs such as CLABSIs, CAUTIs, VAP, and Clostridium difficile infections in the ICU setting. The study lasted for a period of a year. During the chlorhexidine bathing study period, 55 infections occurred, compared to 60 infections during the control bathing study period. No significant improvement in HAIs was achieved based on the infection ratio reported (Noto et al, 2015).

Similarly, four ICU units in Thailand served as the setting for an open-label controlled trial, between the years 2013-2015 in which CHG usage in reducing HAIs was evaluated. Patients were randomly dived into two groups; the control group (patients being washed with a non-antimicrobial soap) and the chlorhexidine group (patients being washed with 2% chlorhexidine-impregnated washcloths). Swabs were obtained from multiple sites and on different dates. The study concluded that there was no significant difference between the groups with regards to hospital-acquired infection rates and ICU length of stay. Additionally, 2.5% of patients in the chlorhexidine group developed adverse skin reactions (Boonyasiri et al, 2016).

Chlorhexidine Related Complications
As chlorhexidine is extensively used in the hospital setting to reduce HAIs, a certain number of patients could suffer the negative effects of it. As evidenced by the presence of sensitization, contact dermatitis, allergic reactions and the most serious of all; life-threatening anaphylaxis (Guleri, Kumar, Morgan, Hartley, & Roberts, 2012). Even though chlorhexidine anaphylactic reactions are rare, there has been an increment in their presence in association with the use of multiple CHG containing products.

Chlorhexidine usage in the hospital setting has greatly increased in recent years, primarily due to efforts directed towards reducing HAIs. Chlorhexidine overexposure can have adverse effects not only for patients but for healthcare workers also; with contact dermatitis, urticaria and anaphylactic shock among them. A case was reported where septic shock was assumed to have been caused by necrotizing fasciitis, but in reality, was a life-threatening anaphylactic reaction to chlorhexidine (Hong et al, 2015). As chlorhexidine use continues to increase, additional complications could emerge, making the use of clinical judgment imperative among clinicians.

Thoughts
According to the CDC, HAIs represent a threat to patient safety. These infections include central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia (CDC, 2014). To prevent the appearance of such infections, hospitals are taking precautions in order to avoid monetary repercussions and maintain patient safety. The use of multiple chlorhexidine products to prevent infections represent one of them. However, certain considerations must be taken into account when utilizing chlorhexidine products. Including appropriateness, allergic reactions, staff compliance, and education. Based on the data presented before, chlorhexidine can certainly help decrease some HAIs such as CLABSIs, and gram-positive causing bacteria. However, CHG resistance and potential complications must be further assessed.
References

Boonyasiri, A., Thaisiam, P., Permpikul, C., Judaeng, T., Suiwongsa, B., Apiradeewajeset, N.,

Thamlikitkul, V. (2016). Effectiveness of Chlorhexidine Wipes for the Prevention of

Multidrug-Resistant Bacterial Colonization and Hospital-Acquired Infections in Intensive

Care Unit Patients: A Randomized Trial in Thailand. Infection Control and Hospital Epidemiology, 37(3), 245-53.

Centers for Disease Control and Prevention. (2014). Types of Healthcare-associated Infections. Retrieved from https://www.cdc.gov/hai/infectiontypes.html

Centers for Disease Control and Prevention. (2018). Top CDC Recommendations to Prevent

Healthcare‐Associated Infections. Retrieved from https://www.cdc.gov/HAI/pdfs/hai/top-cdc-recs-factsheet.pdf 

Frost, S. A., Alogso, M. C., Metcalfe, L., Lynch, J. M., Hunt, L., Sanghavi, R., Alexandrou, E.,

Hillman, K. M. (2016). Chlorhexidine bathing and health care-associated infections

among adult intensive care patients: a systematic review and meta-analysis. Critical care (London, England), 20(1), 379. 

Guleri, A., Kumar, A., Morgan, R. J., Hartley, M., & Roberts, D. H. (2012). Anaphylaxis to

chlorhexidine-coated central venous catheters: A case series and review of the literature. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22568873

Hong, C., Wang, S., Nather, A., Tan, J., Tay, S., & Poon, K. (2015). Chlorhexidine Anaphylaxis

Masquerading as Septic Shock. International Archives of Allergy and         Immunology, 167(1), 16-20.

Noto, M., Domenico, H, Byrne, D., Talbot, T., Rice, T., Bernard, G., & Wheeler, A. (2015).

Chlorhexidine bathing and health care-associated infections: A randomized clinical

trial. JAMA, The Journal of the American Medical Association, 313(4), 369-36978.

Kaye, K. S., Marchaim, D., Chen, T. Y., Baures, T., Anderson, D. J., Choi, Y., Sloane, R.,

Schmader, K. E. (2014). Effect of nosocomial bloodstream infections on mortality, length

of stay, and hospital costs in older adults. Journal of the American Geriatrics Society, 62(2), 306-11.