Does skin cleansing with chlorhexidine affect skin condition, temperature and colonization in hospitalized preterm low birth weight infants?: a randomized clinical trial

Safety and efficacy of whole-body chlorhexidine gluconate cleansing with or without emollient in hospitalised neonates (NeoCHG): a multicentre, randomised, open-label, factorial pilot trial

Background

Healthcare-associated infections account for substantial neonatal in-hospital mortality. Chlorhexidine gluconate (CHG) whole body skin application could reduce sepsis by lowering bacterial colonisation density, although safety and optimal application regimen is unclear. Emollients, including sunflower oil, may independently improve skin condition, thereby reducing sepsis. We aimed to inform which concentration and frequency of CHG, with or without emollient, would best balance safety and the surrogate marker of efficacy of reduction in bacterial colonisation, to be taken forward in a future pragmatic trial evaluating clinical outcomes of sepsis and mortality.

Methods

In this multicentre, randomised, open-label, factorial pilot trial, neonates in two hospital sites (South Africa, Bangladesh) aged 1-6 days with gestational age ≥ 28 weeks and birthweight 1000-1999 g were randomly assigned in a factorial design stratified by site to three different concentrations of CHG (0.5%, 1%, and 2%), with or without emollient (sunflower oil) applied on working days vs alternate working days. A control arm received neither product. Caregivers were unblinded although laboratory staff were blinded to randomisation Co-primary outcomes were safety (change in neonatal skin condition score incorporating dryness, erythema, and skin breakdown) and efficacy in reducing bacterial colonisation density (change in total skin bacterial log10 CFU from randomisation to day-3 and day-8). The trial is registered at the ISRCTN registry, ISRCTN 69836999.

Findings

Between Apr 12 2021 and Jan 18 2022, 208 infants were randomised and 198 were included in the final analysis. Skin condition scores were low with mean 0.1 (sd = 0.3; N = 208) at baseline, 0.1 (sd = 0.3; N = 199) at day 3 and 0.1 (sd = 0.3; N = 189) at day 8, with no evidence of differences between concentration (1% CHG vs 0.5% estimate = -0.3, 95% CI = (-1.2, 0.6), p = 0.55. 2% CHG vs 0.5% CHG estimate = 0.5 (-0.4, 1.4), p = 0.30), increasing frequency (estimate = -0.4; 95% CI = (-1.1, 0.4), p = 0.33), emollient (estimate = -0.5, (-1.2, 0.3), p = 0.23) or with control (estimate = -0.9, (-2.3, 0.4), p = 0.18). Mean log10 CFU was 4.9 (sd = 3.0; N = 208) at baseline, 6.3 (sd = 3.1; N = 198) at day 3 and 8.4 (sd = 2.6; N = 183) with no evidence of differences between concentration (1% CHG vs 0.5% estimate = -0.4; 95% CI = (-1.1, 0.23); p = 0.23. 2% CHG vs 0.5% CHG estimate = 0.0 (-0.6, 0.6), p = 0.96), with increasing frequency (estimate = -0.4; 95% CI = (-0.9, 0.2); p = 0.17), with emollient (estimate = 0.4, 95% CI = (-0.2, 0.9); p = 0.18) or with control (estimate = -0.2, 95% CI = (-1.3, 0.9); p = 0.73). By day-8, overall 158/183 (86%) of neonates were colonised with Enterobacterales, and 72/183 (39%) and 69/183 (9%) with Klebsiella spp resistant to third-generation cephalosporin and carbapenems, respectively. There were no CHG-related SAEs, emollient-related SAEs, grade 3 or 4 skin scores or grade 3 or 4 hypothermias.

Interpretation

In this pilot trial of CHG with or without sunflower oil, no safety issues were identified, and further trials examining clinical outcomes are warranted. The relatively late start application of emollient, at a mean of 3.8 days of life, may have reduced the impact of the intervention although no subgroup effects were detected. There was no clear evidence in favour of a specific concentration of chlorhexidine, and there was rapid colonisation with Enterobacterales with frequent antimicrobial resistance, regardless of skin application regimen.

Funding

The MRC Joint Applied Global Health award, the Global Antibiotic Research and Development Partnership (GARDP), MRC Clinical Trials Unit core funding (UKRI) and St. George's, University of London.

Early detection of cold stress to prevent hypothermia: A narrative review

Temperature monitoring is essential for assessing neonates and providing appropriate neonatal thermal care. Thermoneutrality is defined as the environmental temperature range within which the oxygen and metabolic consumptions are minimum to maintain normal body temperature. When neonates are in an environment below thermoneutral temperature, they respond by vasoconstriction to minimise heat losses, followed by a rise in metabolic rate to increase heat production. This condition, physiologically termed cold stress, usually occurs before hypothermia. In addition to standard axillary or rectal temperature monitoring by a thermometer, cold stress can be detected by monitoring peripheral hand or foot temperature, even by hand-touch. However, this simple method remains undervalued and generally recommended only as a second and lesser choice in clinical practice. This review presents the concepts of thermoneutrality and cold stress and highlights the importance of early detection of cold stress before hypothermia occurs. The authors suggest systematic clinical determination of hand and foot temperatures by hand-touch for early detection of physiological cold stress, in addition to monitoring core temperature for detection of established hypothermia, particularly in low-resource settings.

Myelin toxicity of chlorhexidine in zebrafish larvae

BACKGROUND

Chlorhexidine gluconate (CHG) is a topical antiseptic solution recommended for skin preparation before central venous catheter placement and maintenance in adults and children. Although CHG is not recommended for use in children aged <2 months owing to limited safety data, it is commonly used in neonatal intensive care units worldwide. We used zebrafish model to verify the effects of early-life exposure to CHG on the developing nervous system, highlighting its impact on oligodendrocyte development and myelination.

METHODS

Zebrafish embryos were exposed to different concentrations of CHG from 4 h post fertilization to examine developmental toxicity. The hatching rate, mortality, and malformation of the embryos/larvae were monitored. Oligodendrocyte lineage in transgenic zebrafish embryos was used to investigate defects in oligodendrocytes and myelin. Myelin structure, locomotor behavior, and expression levels of genes involved in myelination were investigated.

RESULTS

Exposure to CHG significantly induced oligodendrocyte defects in the central nervous system, delayed myelination, and locomotor alterations. Ultra-microstructural changes with splitting and fluid-accumulated vacuoles between the myelin sheaths were found. Embryonic exposure to CHG decreased myelination, in association with downregulated mbpa, plp1b, and scrt2 gene expression.

CONCLUSION

Our results suggest that CHG has a potential for myelin toxicity in the developing brain.

IMPACT

To date, the neurodevelopmental toxicity of chlorhexidine gluconate (CHG) exposure on the developing brains of infants remains unknown. We demonstrated that CHG exposure to zebrafish larvae resulted in significant defects in oligodendrocytes and myelin sheaths. These CHG-exposed zebrafish larvae exhibited structural changes and locomotor alterations. Given the increased CHG use in neonates, this study is the first to identify the risk of early-life CHG exposure on the developing nervous system.

Evidence-based review of chlorhexidine gluconate and iodine in the preoperative skin preparation of young infants

PURPOSE

The preoperative preparation of young infants' skin requires special considerations. Commonly used solutions for preparing the skin preoperatively include chlorhexidine (CHG) and iodine. The Centers for Disease Control and Prevention (CDC) has recommendations for preparing skin for surgery and other invasive procedures for adults, but they do not have recommendations for young infants' skin. The purpose of this evidence-based literature review is to synthesize the literature, compare, and inform healthcare providers about the safety and efficacy of CHG and iodine as preoperative preparation solutions for young infants' skin. For this project young infants is defined as infants less than 48 weeks' postmenstrual age and those born prematurely and less than 28 days old.

CONCLUSIONS

We analyze 19 articles that met the inclusion criteria. Three discussion themes emerge: systemic absorption, dermatologic burns, and CHG and iodine efficacy.

PRACTICE IMPLICATIONS

We need more research regarding the safety and efficacy of CHG and iodine solutions for preoperative preparation of young infants' skin. Findings suggest the cautious use of CHG and iodine solutions on patients born at or before 28 weeks' postmenstrual age, especially those less than 28 days postnatal age.

Effect of chlorhexidine cleansing on healthcare-associated infections in neonates: a systematic review and meta-analysis

BACKGROUND

Healthcare-associated infections (HAIs) have a significant impact on neonatal morbidity, mortality and long-term prognosis, which have a high incidence in neonates. Many studies have shown that chlorhexidine cleansing is effective in reducing HAIs in adults, but the effect of chlorhexidine cleansing on HAIs in neonates remains controversial.

AIM

The purpose of this study was to conduct a systematic review and meta-analysis of the effect of chlorhexidine cleansing on HAIs in neonates. The protocol of this review has been registered with the PROSPERO international prospective register of systematic reviews.

METHODS

A systematic literature search was performed on five medical literature databases, namely MEDLINE, Web of Science, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL), published up until 3 March 2021. In the end, six studies were eligible for inclusion, including four randomised controlled trials and two quasi-experimental studies. Version 2 of the Cochrane tool for assessing risk of bias in randomised trials and the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies were used for quality assessment. Pooled risk ratios (RRs) and their associated 95% CIs were calculated using the fixed effects model (I² <50%) or the random effects model (I² ≥50%).

FINDINGS AND CONCLUSIONS

The results of the meta-analysis revealed that chlorhexidine cleansing had no significant effect on neonatal sepsis (RR: 0.49, 95% CI 0.18 to 1.38, p=0.18, I²=0%), but significantly reduced neonatal skin bacterial colonisation (RR: 0.61, 95% CI 0.42 to 0.90, p=0.01, I²=50%). In addition, this systematic review showed that chlorhexidine cleansing could significantly reduce central line-associated bloodstream infection in neonates based on large-sample studies. However, more studies are needed to determine the optimal concentration and frequency of chlorhexidine cleansing. PROSPERO registration number CRD42021243858.

SHEA Neonatal Intensive Care Unit (NICU) White Paper Series: Practical approaches for the prevention of central-line-associated bloodstream infections

This document is part of the "SHEA Neonatal Intensive Care Unit (NICU) White Paper Series." It is intended to provide practical, expert opinion, and/or evidence-based answers to frequently asked questions about CLABSI detection and prevention in the NICU. This document serves as a companion to the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) Guideline for Prevention of Infections in Neonatal Intensive Care Unit Patients. Central line-associated bloodstream infections (CLABSIs) are among the most frequent invasive infections among infants in the NICU and contribute to substantial morbidity and mortality. Infants who survive CLABSIs have prolonged hospitalization resulting in increased healthcare costs and suffer greater comorbidities including worse neurodevelopmental and growth outcomes. A bundled approach to central line care practices in the NICU has reduced CLABSI rates, but challenges remain. This document was authored by pediatric infectious diseases specialists, neonatologists, advanced practice nurse practitioners, infection preventionists, members of the HICPAC guideline-writing panel, and members of the SHEA Pediatric Leadership Council. For the selected topic areas, the authors provide practical approaches in question-and-answer format, with answers based on consensus expert opinion within the context of the literature search conducted for the companion HICPAC document and supplemented by other published information retrieved by the authors. Two documents in the series precede this one: "Practical approaches to Clostridioides difficile prevention" published in August 2018 and "Practical approaches to Staphylococcus aureus prevention," published in September 2020.

Chlorhexidine bathing of the critically ill for the prevention of hospital-acquired infection

BACKGROUND

Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications, permanent disability or death. Whilst all hospital-based patients are susceptible to infections, prevalence is particularly high in the ICU, where people who are critically ill have suppressed immunity and are subject to increased invasive monitoring. People who are mechanically-ventilated are at infection risk due to tracheostomy and reintubation and use of multiple central venous catheters, where lines and tubes may act as vectors for the transmission of bacteria and may increase bloodstream infections and ventilator-associated pneumonia (VAP). Chlorhexidine is a low-cost product, widely used as a disinfectant and antiseptic, which may be used to bathe people who are critically ill with the aim of killing bacteria and reducing the spread of hospital-acquired infections.

OBJECTIVES

To assess the effects of chlorhexidine bathing on the number of hospital-acquired infections in people who are critically ill.

SEARCH METHODS

In December 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared chlorhexidine bathing with soap-and-water bathing of patients in the ICU.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data and undertook risk of bias and GRADE assessment of the certainty of the evidence .

MAIN RESULTS

We included eight studies in this review. Four RCTs included a total of 1537 individually randomised participants, and four cluster-randomised cross-over studies included 23 randomised ICUs with 22,935 participants. We identified one study awaiting classification, for which we were unable to assess eligibility.The studies compared bathing using 2% chlorhexidine-impregnated washcloths or dilute solutions of 4% chlorhexidine versus soap-and-water bathing or bathing with non-antimicrobial washcloths.Eight studies reported data for participants who had a hospital-acquired infection during the ICU stay. We are uncertain whether using chlorhexidine for bathing of critically ill people reduces the rate of hospital-acquired infection, because the certainty of the evidence is very low (rate difference 1.70, 95% confidence interval (CI) 0.12 to 3.29; 21,924 participants). Six studies reported mortality (in hospital, in the ICU, and at 48 hours). We cannot be sure whether using chlorhexidine for bathing of critically-ill people reduces mortality, because the certainty of the evidence is very low (odds ratio 0.87, 95% CI 0.76 to 0.99; 15,798 participants). Six studies reported length of stay in the ICU. We noted that individual studies found no evidence of a difference in length of stay; we did not conduct meta-analysis because data were skewed. It is not clear whether using chlorhexidine for bathing of critically ill people reduced length of stay in the ICU, because the certainty of the evidence is very low. Seven studies reported skin reactions as an adverse event, and five of these reported skin reactions which were thought to be attributable to the bathing solution. Data in these studies were reported inconsistently and we were unable to conduct meta-analysis; we cannot tell whether using chlorhexidine for bathing of critically ill people reduced adverse events, because the certainty of the evidence is very low.We used the GRADE approach to downgrade the certainty of the evidence of each outcome to very low. For all outcomes, we downgraded evidence because of study limitations (most studies had a high risk of performance bias, and we noted high risks of other bias in some studies). We downgraded evidence due to indirectness, because some participants in studies may have had hospital-acquired infections before recruitment. We noted that one small study had a large influence on the effect for hospital-acquired infections, and we assessed decisions made in analysis of some cluster-randomised cross-over studies on the effect for hospital-acquired infections and for mortality; we downgraded the evidence for these outcomes due to inconsistency. We also downgraded the evidence on length of stay in the ICU, because of imprecision. Data for adverse events were limited by few events and so we downgraded for imprecision.

AUTHORS' CONCLUSIONS

Due to the very low-certainty evidence available, it is not clear whether bathing with chlorhexidine reduces hospital-acquired infections, mortality, or length of stay in the ICU, or whether the use of chlorhexidine results in more skin reactions.

The Effect of Education on Chlorhexidine Use in the NICU

BACKGROUND

Neonates are at greater risk for central line-associated bloodstream infection (CLABSI) because of prolonged vascular access for nutrition and medications. Skin antisepsis using chlorhexidine gluconate (CHG), particularly the formulation with alcohol (CHG/alcohol), during central line insertion and maintenance activities is a key clinical care process associated with CLABSI reduction. One area of ongoing confusion for many clinicians is whether to adhere to the manufacturer's recommendations that CHG remain on the skin following the procedure to promote persistent microbicidal effects or to foster product removal in hopes of preventing skin-related complications.

PURPOSE

Determine the effect of a targeted education program on the knowledge and attitudes of nurses who place peripherally inserted central catheters in the NICU regarding the use and removal of CHG antiseptic.

METHODS

A quasi-experimental presurvey/postsurvey quality improvement project (QI project) recruited participants from the electronic mailing list of a national neonatal nursing organization.

RESULTS

There was a statistically significant deficiency in knowledge or misinformation related to the use of CHG/alcohol on the presurvey assessment. Eight questions reflecting knowledge consistent with most recent evidence were answered correctly only 11.4-25.7 percent of the time, all of which were considered statistically significant. Following completion of the education program, a nearly 100 percent correct response rate on all but three postsurvey questions resulted.

CONCLUSIONS

This quality improvement project demonstrated success in the ability to change knowledge surrounding the removal of CHG/alcohol from the skin of babies in the NICU following completion of a targeted education program and the effectiveness of targeted web-based educational programs.

Bathing and Beyond: Current Bathing Controversies for Newborn Infants

BACKGROUND

Bathing the newborn infant is controversial, ranging from how and when to give the newborn their first bath, whether to bathe newborns at all in the initial days of life, and how to approach bathing the hospitalized premature and full-term infant in the neonatal intensive care unit (NICU).

PURPOSE

To review relevant literature about bathing newborn infants, as well as examine the controversies about bathing NICU patients including the use of daily chlorhexidine gluconate (CHG) baths.

FINDINGS

Despite studies showing that temperature can be maintained when the first bath was at 1 hour after delivery, there are benefits from delaying the bath including improved breastfeeding. Tub or immersion bathing improves temperature, and is less stressful. It is not necessary to bathe infants every day, and premature infants can be bathed as little as every 4 days without an increase in skin colonization. No differences have been reported in skin parameters such as pH, transepidermal water loss, and stratum corneum hydration whether the first and subsequent baths are given using water alone or water and a mild baby cleanser. Concerns about systemic absorption suggests caution about widespread practice of daily CHG bathing in the NICU until it is known whether CHG crosses the blood-brain barrier, particularly in premature infants.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Research regarding bathing practices for NICU patients should be evidence-based whenever possible, such as the benefits of immersion bathing. More evidence about the risks and benefits of daily CHG bathing is needed before this practice is widely disseminated.

Potential NICU Environmental Influences on the Neonate's Microbiome: A Systematic Review

OBJECTIVE

To identify how the neonatal intensive care unit (NICU) environment potentially influences the microbiome high-risk term and preterm infants.

DATA SOURCES

Electronic databases utilized to identify studies published in English included PubMed, Google Scholar, Cumulative Index for Nursing and Allied Health Literature, and BioMedSearcher. Date of publication did not limit inclusion in the review.

STUDY SELECTION

Two hundred fifty articles were assessed for relevance to the research question through title and abstract review. Further screening resulted in full review of 60 articles. An in-depth review of all 60 articles resulted in 39 articles that met inclusion criteria. Twenty-eight articles were eliminated on the basis of the type of study and subject of interest.

DATA EXTRACTION

Studies were reviewed for information related to environmental factors that influence microbial colonization of the neonatal microbiome. Environment was later defined as the physical environment of the NICU and nursery caregiving activities.

DATA SYNTHESIS

Studies were characterized into factors that impacted the infant's microbiome—parental skin, feeding type, environmental surfaces and caregiving equipment, health care provider skin, and antibiotic use.

CONCLUSIONS

Literature revealed that various aspects of living within the NICU environment do influence the microbiome of infants. Caregivers can implement strategies to prevent environment-associated nosocomial infection in the NICU such as implementing infection control measures, encouraging use of breast milk, and decreasing the empirical use of antibiotics.

Efficacy and safety of whole body skin cleansing with chlorhexidine in neonates--a systemic review

BACKGROUND

Cord cleansing with chlorhexidine has been shown to reduce the risk of neonatal mortality in low-resource settings. The effect of whole body skin cleansing with chlorhexidine in neonates is, however, not clear.

METHODS

We searched MEDLINE and other databases and included all studies that evaluated the effect of chlorhexidine cleansing on neonatal mortality rate (NMR) and/or the incidence of neonatal sepsis. We estimated the pooled relative risks by fixed effect and random-effects models and also explored the sources of heterogeneity by subgroup meta-analysis.

RESULTS

Seven randomized trials and 2 before-and-after studies that evaluated single cleansing with chlorhexidine were included in the review. Pooled analysis showed no significant effect on NMR in either the fixed effect (5 studies; relative risk: 0.91; 95% confidence interval: 0.80 to 1.04) or random-effects model (0.83; 0.63 to 1.08). On subgroup analysis, the before-and-after study conducted in high-NMR setting showed significant reduction in mortality (0.68; 0.50 to 0.93) but the randomized controlled trials from low-NMR settings did not show any benefit (0.97; 0.84 to 1.13). Pooled analysis of 5 studies that reported the rates of sepsis revealed substantial heterogeneity (I = 80.2%). Pooled result by random-effects model as well as the sensitivity analysis including only the randomized trials found no significant effect (0.65; 0.40 to 1.05 and 0.97; 0.80 to 1.18, respectively).

CONCLUSIONS

There is no conclusive evidence for any beneficial effect after single skin cleansing with chlorhexidine. However, given the heterogeneity in the major outcomes it seems prudent to generate more evidence from randomized trials in high-NMR settings. Until such time, this intervention cannot be recommended in any settings.

Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant

Chlorhexidine gluconate (CHG) is a widely used topical antiseptic that is recommended by the Centers for Disease Control and Prevention for skin cleansing before central venous catheter insertion in adults and children. Because of limited safety data, CHG is not recommended for use in children <2 months of age. CHG is, however, frequently used in Neonatal Intensive Care Units across the United States. Here, we will review the safety of CHG use in preterm infants.