The impact of chlorhexidine gluconate on the skin microbiota of children and adults: A pilot study

Skin microbiota analysis in patients with anorexia nervosa and healthy-weight controls reveals microbial indicators of healthy weight and associations with the antimicrobial peptide psoriasin

Anorexia nervosa (AN), a psychiatric condition defined by low body weight for age and height, is associated with numerous dermatological conditions. Yet, clinical observations report that patients with AN do not suffer from infectious skin diseases like those associated with primary malnutrition. Cell-mediated immunity appears to be amplified in AN; however, this proinflammatory state does not sufficiently explain the lower incidence of infections. Antimicrobial peptides (AMPs) are important components of the innate immune system protecting from pathogens and shaping the microbiota. In Drosophila melanogaster starvation precedes increased AMP gene expression. Here, we analyzed skin microbiota in patients with AN and age-matched, healthy-weight controls and investigated the influence of weight gain on microbial community structure. We then correlated features of the skin microbial community with psoriasin and RNase 7, two highly abundant AMPs in human skin, to clarify whether an association between AMPs and skin microbiota exists and whether such a relationship might contribute to the resistance to cutaneous infections observed in AN. We find significant statistical correlations between Shannon diversity and the highly abundant skin AMP psoriasin and bacterial load, respectively. Moreover, we reveal psoriasin significantly associates with Abiotrophia, an indicator for the healthy-weight control group. Additionally, we observe a significant correlation between an individual's body mass index and Lactobacillus, a microbial indicator of health. Future investigation may help clarify physiological mechanisms that link nutritional intake with skin physiology.

Cutaneous Microbiome Profiles Following Chlorhexidine Treatment in a 72-Hour Daily Follow-Up Paired Design: a Pilot Study

Venous catheter-related bloodstream infections represent a significant problem in the United States. Our objective was to determine daily changes in skin microbiome profiles up to 72h postchlorhexidine treatment. Left and right forearm skin swab samples were obtained from 10 healthy volunteers over 72h at 24h intervals. Dorsal surface of left arm was treated with chlorohexidine gluconate (CHG) at initial time point (T = 0), while the right arm remained untreated (control). Swab samples were obtained shortly before (T = 0) and after CHG treatment (T = 24-48-72h). Bacterial DNA extraction, 16S rRNA gene V1-V3 sequencing and taxonomic annotation were performed using ZymoBIOMICS pipeline. PERMANOVA, linear discriminant and bacterial interaction network analyses were performed. A total of 13 total phyla, 273 genera, and 950 total species were detected across all time points, CHG-treated or CHG-untreated. Most abundant species included Cutibacterium acnes, Staphylococcus epidermidis, and Rothia Mucilaginosa. Low biomass-related inconsistent taxa detection was observed. PERMANOVA suggested a marginal difference between CHG-treated and CHG-untreated microbiome profiles (Genera: P(perm) = 0.0531; Species: P(perm) = 0.0450). Bacterial interaction network guided PERMANOVA analyses detected a microbiome change over time, suggesting a consistent CHG treatment-specific change. LEfSe identified Finegoldia magna, Bacillus pumilus, Bacillus thermoamylovorans as the only distinctive species. These species were more abundant and/or present post-CHG treatment in the CHG-treated group. These findings suggest that the skin microbiome was not significantly different 24, 48, or 72h after CHG treatment. Previous culture-based studies have found similar results after 24h. Future studies will be needed to determine the mechanisms of bacterial regrowth after CHG treatment. IMPORTANCE Annually, over 80,000 central line infections occur in the United States. Understanding the pathogenesis of these infections is crucial. Chlorhexidine is the most commonly used skin preparation before line placement. We hypothesized that the use of chlorhexidine and dressings will alter the normal arm skin microbiome over a period of 72h. We used 16S-rRNA gene next generation sequencing (NGS) to determine the forearm skin microbiome of volunteers. The left arm was swabbed with chlorhexidine and the right arm served as control. The skin microbiome returned to normal after 24h. Our NGS results confirm findings of two previous culture-based studies. Relative abundance of Bacillus spp. in the chlorhexidine-treated samples was increased, consistent with one previous study. Based on the results of this pilot study, we will need to measure viable bacteria during a 24h time course following chlorhexidine treatment to understand the source of skin microbiome replenishment.

Transitory Shifts in Skin Microbiota Composition and Reductions in Bacterial Load and Psoriasin following Ethanol Perturbation

Personal care and hygiene regimens may substantially alter the composition of the skin microbiota through direct and indirect mechanisms. An understanding of the timescales of commensal skin microbiota reestablishment following perturbation is required to inform consumer safety risk assessment, and support product development. In the current investigation, the microbiota of the volar and dorsal forearm of 10 volunteers was sampled immediately before and after wiping with 70% ethanol and at up to 24 h afterwards. Quantitative PCR and amplicon sequencing were used to measure microbial load and composition, and concentrations of the antimicrobial peptide psoriasin were measured using an enzyme-linked immunosorbent assay (ELISA). Ethanol wiping significantly reduced the total bacterial abundance at 2 h post-wipe. Recovery was observed after 6 h for total bacterial populations and for Staphylococcus epidermidis depending on the site tested. Microbiome diversity recovered by 6 h after wiping. Psoriasin concentrations were highly variable between volunteers, ranging from 42 to 1,569 ng/mL, and dorsal concentrations were significantly higher than volar concentrations (P < 0.05). For most of the volunteers, the application of ethanol decreased psoriasin concentrations, particularly for the dorsal samples, but the overall effect was not significant. This work extends observations of skin microbiome stability and demonstrates resilience in a key antimicrobial peptide.

IMPORTANCE An understanding of the timescales of commensal skin microbiota reestablishment following perturbation is required to inform consumer safety risk assessment and support product development. Following ethanol exposure, total bacterial populations and microbiome diversity recovered after 6 h. For most of the volunteers, the application of ethanol decreased psoriasin concentrations, but the overall effect was not significant. This work extends observations of skin microbiome stability and demonstrates resilience in a key antimicrobial peptide.

Chlorhexidine gluconate does not result in epidermal microbiota dysbiosis in healthy adults

BACKGROUND

Chlorhexidine gluconate (CHG) and other skin antiseptics are ubiquitous in healthcare settings and are routinely used to bathe patients' skin. The commensal epidermal microbiota is believed to provide colonization resistance and other benefits to the host; yet little is known regarding the long-term stability of the epidermal microbiota, and the impact of CHG bathing. We aimed to assess the influence of CHG exposure to the epidermal microbiota and evaluate the long-term stability of the epidermal microbiota.

METHODS

The epidermal microbiota of 5 individuals was sampled using thorough swabbing of the calf, and characterized via 16S rRNA amplicon sequencing, prior to CHG bathing, and then at 30 minutes, 3 hours, 1 day, 3 days, and 7 days postbathing. Roughly 4 months later, samples were collected from the same 5 individuals, using an identical timeline but with no CHG exposure.

RESULTS

The epidermal microbiota showed no greater change 30 minutes postexposure to CHG, than was observed in the same individuals during the recovery period, likely representing the normal sample-to-sample variability. Despite that variability, the epidermal microbiota evinced a remarkable degree of intrasubject stability, even over extended periods of time.

CONCLUSION

We conclude that single applications of CHG cause minimal, if any, disruption of the epidermal microbiota, and that long-term effects of single applications of CHG on the epidermal microbiota are unlikely.

Assessing the Potential for Unintended Microbial Consequences of Routine Chlorhexidine Bathing for Prevention of Healthcare-associated Infections

Chlorhexidine gluconate (CHG) is an antiseptic that is widely used in healthcare due to its excellent safety profile and wide spectrum of activity. Daily bathing with CHG has proven to be effective in the prevention of healthcare-associated infections and multidrug-resistant pathogen decolonization. Despite the proven benefits of CHG use, there remain concerns and unanswered questions about the potential for unintended microbial consequences of routine CHG bathing. This review aims to explore some of these questions.

Murine model of colonization with fungal pathogen Candida auris to explore skin tropism, host risk factors and therapeutic strategies

Candida auris is an emerging multi-drug-resistant human fungal pathogen. C. auris skin colonization results in environmental shedding, which underlies hospital transmissions, and predisposes patients to subsequent infections. We developed a murine skin topical exposure model for C. auris to dissect risk factors for colonization and to test interventions that might protect patients. We demonstrate that C. auris establishes long-term residence within the skin tissue compartment, which would elude clinical surveillance. The four clades of C. auris, with geographically distinct origins, differ in their abilities to colonize murine skin, mirroring epidemiologic findings. The IL-17 receptor signaling and specific arms of immunity protect mice from long-term C. auris skin colonization. We further determine that commonly used chlorhexidine antiseptic serves as a protective and decolonizing agent against C. auris. This translational model facilitates an integrated approach to develop strategies to combat the unfolding global outbreaks of C. auris and other skin-associated microbial pathogens.

Chlorhexidine Gluconate Bathing Reduces the Incidence of Bloodstream Infections in Adults Undergoing Inpatient Hematopoietic Cell Transplantation

Bloodstream infections (BSIs) occur in 20% to 45% of inpatient autologous and allogeneic hematopoietic cell transplant (HCT) patients. Daily bathing with the antiseptic chlorhexidine gluconate (CHG) has been shown to reduce the incidence of BSIs in critically ill patients, although very few studies include HCT patients or have evaluated the impact of compliance on effectiveness. We conducted a prospective cohort study with historical controls to assess the impact of CHG bathing on the rate of BSIs and gut microbiota composition among adults undergoing inpatient HCT at the Duke University Medical Center. We present 1 year of data without CHG bathing (2016) and 2 years of data when CHG was used on the HCT unit (2017 and 2018). Because not all patients adhered to CHG, patients were grouped into four categories by rate of daily CHG usage: high (>75%), medium (50% to 75%), low (1% to 49%), and none (0%). Among 192 patients, univariate trend analysis demonstrated that increased CHG usage was associated with decreased incidence of clinically significant BSI, defined as any BSI requiring treatment by the medical team (high, 8% BSI; medium, 15.2%; low, 15.6%; no CHG, 30.3%; P = .003), laboratory-confirmed BSI (LCBI; P = .03), central line-associated BSI (P = .04), and mucosal barrier injury LCBI (MBI-LCBI; P = .002). Multivariate analysis confirmed a significant effect of CHG bathing on clinically significant BSI (P = .023) and MBI-LCBI (P = .007), without consistently impacting gut microbial diversity. Benefits of CHG bathing were most pronounced with >75% daily usage, and there were no adverse effects attributable to CHG. Adherence to daily CHG bathing significantly decreases the rate of bloodstream infection following HCT.