The Use of Chlorhexidine as a Skin Preparation on the Head and Neck: A Systematic Review of Ocular and Ototoxicity

Surgical site antiseptic preparations for otolaryngology - Head and neck surgery: A current review

OBJECTIVE

To review current literature and guidelines on antiseptic surgical site preparations for preventing surgical site infections with consideration of contraindications specific to head and neck surgery.

DATA SOURCES

PubMed/MEDLINE, clinicaltrials.gov, accessdata.fda.gov, Manufacturer websites.

REVIEW METHODS

A scoping review on the literature and clinical studies comparing the efficacy of different surgical site preparations. Studies were included if they were a randomized controlled trial (RCT) comparing at least two commonly used and available antiseptic preparations. Additionally, a compilation of warnings and contraindications from manufacturer labels and articles are included. Due to the lack of randomized controlled trials concerning antiseptic preparation use in head and neck surgery specifically, an additional search was executed for articles not limited to randomized controlled trials that compared different antiseptic preparation used in surgeries concerning the head and neck.

RESULTS

Of 56,983 resulting abstracts and 3798 of them being screened, 25 RCTs were included. These RCTs included a variety of surgeries including gastrointestinal, obstetric, gynecologic, orthopedic, and vascular procedures. When searching for abstracts concerning head and neck surgeries, 9 studies were found and included.

CONCLUSIONS

To reduce surgical site infections and avoid application in situations with contraindications, practicing surgeons need to be familiar with the existing literature regarding different surgical preparations and what warnings manufacturers have listed on the products. Optimal surgical site preparation for head and neck surgery is challenging as proximity to oxygen contraindicates newer alcohol-based options that are potentially flammable. We summarize evidence-based surgical site preparation for head and neck surgery.

Intrahospital transmission and infection control of Candida auris originating from a severely infected COVID-19 patient transferred abroad

BACKGROUND

Intrahospital spread of Candida auris, which survives tenaciously in many environments, can cause sustained colonization and infection. A large outbreak of C. auris was experienced in the intensive care units (ICUs) at the study hospital during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

The index patient with severe COVID-19, who was transferred from Vietnam in January 2022, developed C. auris candidaemia 10 days after hospitalization. From mid-June 2022 to January 2023, strengthened infection prevention and control (IPC) measures were implemented in three ICUs: (1) contact precautions and isolation (CPI) for C. auris-positive cases; (2) surveillance cultures including point-prevalence (N=718) for patients or close contacts or ICU-resident healthcare workers (HCWs); (3) intensive environmental disinfection with 10-fold diluted bleach; and (4) 2% chlorhexidine bathing for all ICU patients. Environmental cultures (ECx) on surfaces and shared objects (N=276) were conducted until early September 2022, when all ECx were negative.

RESULTS

Among 53 C. auris-positive patients between February 2022 and January 2023, invasive infections resulted in seven cases of candidaemia and one case of pneumonia. C. auris was isolated from reusable tympanic thermometers (TTMs) contaminated with earwax. The isolation rate of C. auris in ECx decreased from 6.8% in June 2022 to 2.0% in August 2022, and was no longer detected in TTMs. Colonization in HCWs was remarkably rare (0.5%). The number of C. auris-positive patients peaked in July (N=10) then decreased gradually. By January 2023, no C. auris were isolated in the ICU.

CONCLUSION

Aggressive IPC measures with CPI, ECx and surveillance, decontamination of TTMs, and bathing were effective in successfully controlling this C. auris outbreak.

Incidence and Treatment of Delayed-onset Nodules After VYC Filler Injections to 2139 Patients at a Single Canadian Clinic

Background

Data suggest that hyaluronic acid (HA) fillers using VYC technology have a higher incidence of delayed‐onset nodule development at facial injection sites than earlier HA products.

Objective

To assess the incidence of delayed‐onset nodules with VYC products based on a single experienced injector.

Methods and Materials

Patients with delayed‐onset nodules after injections with VYC‐20L, VYC‐17.5L, and VYC‐15L were identified by retrospective chart review.

Results

Since 2010, 2139 patients received injections from the same physician with combinations of VYC‐20L (57.6% of patients; 2.4 syringes/patient), VYC‐17.5L (23.9%; 1.5), or VYC‐15L (18.5%; 1.5). Seven female patients (mean age, 62 years) developed delayed‐onset nodules for an overall incidence of 0.33%. A potential inflammatory trigger (reported by 6 patients) occurred 1–168 days prior to nodule development. Nodule biopsy in 1 patient confirmed a foreign‐body granuloma. The most effective treatment incorporated prednisone with or without hyaluronidase, and in 2 patients, nodules resolved spontaneously. The incidence of delayed‐onset nodules was not associated with injection technique or amount of product used.

Conclusion

VYC‐associated incidence of delayed‐onset nodules (0.33%) was lower than earlier estimates from previous studies. In the current analysis, VYC‐15L had a rate of delayed reactions comparable with non‐VYC products.

Review: Perspective on ocular toxicity of presurgical skin preparations utilizing Chlorhexidine Gluconate/Hibiclens/Chloraprep

Background:

Chlorhexidine Gluconate (CHG), Hibiclens (4% CHG with 4% Isopropyl Alcohol Detergent), and Chloraprep (i.e. labeled CHG-based solutions), utilized as preoperative surgical preparatory solutions may all cause severe oculotoxicity and ototoxicity. Alternatively, 10% Povidone-Iodine (PI) solutions without detergent demonstrate minimal toxic effects on the eyes and ears.

Methods:

Based on studies from 1984 to 2021, we compared the safety/efficacy of CHG-based versus PI-based solutions utilized for presurgical skin preparation near the cornea/eyes and ears (i.e., predominantly for cranial or cervical spine surgery).

Results:

Some studies documented that even minimal exposure (i.e., “splash risk”) during face/neck skin preparation with CHG-based solutions could result in irreversible corneal injury and ototoxicity. Within minutes to hours, CHG-based non-detergent solutions posed the risks of; corneal epithelial edema, anterior stromal edema, conjunctival chemosis, bullous keratopathy, and de-epithelialization. Notably, even occlusive dressings like Tegaderm could not protect against CHG penetration. Alternatively, PI-based solutions posed no to minimal ocular and/or ototoxicity, while often demonstrating comparable protection against surgical site infections (SSI).

Conclusion:

Chlorhexidine Gluconate (CHG), Hibiclens, and Chloraprep (i.e. CHG-based solutions) are often used as skin preparations near the face/eyes/spine (i.e., particularly anterior/posterior cervical procedures). However, if these solutions come in contact with the eyes, corneal irritation, abrasions, and even blindness may result. Alternatively, PI non-detergent solutions demonstrate safety/minimal oculotoxicity/ototoxicity, while frequently showing comparable efficacy against SSI.