Chlorhexidine anaphylaxis: case report and review of the literature

Effect of perioperative oral care on postoperative infections in patients with cancer: A systematic review and meta-analysis

AIM

This systematic review aimed to assess the effect of non-pharmacologic perioperative oral hygiene care on reduced incidence of postoperative pneumonia (PP), surgical site infection (SSI), and the length of hospital stay in patients with cancer, and to describe the details of oral hygiene care.

METHODS

We searched seven databases. Eligibility criteria were based on perioperative oral hygiene care provided by healthcare professionals to patients aged ≥18 years who were surgically treated under general anesthesia and were evaluated for the incidence of PP and SSI. We reported risk ratios (RR) for dichotomous outcomes for PP and SSI using a fixed-effects model of meta-analysis.

RESULTS

The search resulted in 850 articles, among which two were randomized controlled trials (RCTs) and 21 were observational studies. Most studies indicated that dentists and medical care providers performed a combination of oral cleaning, and oral hygiene instructions. In RCTs, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.86; p = .60), while in observational studies, perioperative oral hygiene care significantly reduced the incidence of PP (RR, 0.55; p < .001) and SSI (RR, 0.47; p < .001). The length of hospital stay was also significantly reduced (p < .05). However, the effectiveness of nursing intervention was not clear.

CONCLUSIONS

Perioperative oral hygiene care implemented by healthcare professionals prevented PP and SSI and reduced length of hospital stays for patients after cancer surgery. As daily perioperative oral hygiene care is performed by nurses, it is necessary to research the effects of oral hygiene by nurses in the future.

Ingredients in Commercially Available Mouthwashes

OBJECTIVES

Mouthwashes, a cornerstone of oral and dental hygiene, play a pivotal role in combating the formation of dental plaque, a leading cause of periodontal disease and dental caries. This study aimed to review the composition of mouthwashes found on retail shelves in Turkey and evaluate their prevalence and side effects, if any.

METHODS

The mouthwashes examined were sourced from the 5 largest chain stores in each district of Istanbul. A comprehensive list of the constituents was meticulously recorded. The research was supported by an extensive compilation of references from scholarly databases such as Google Scholar, PubMed, and ScienceDirect. Through rigorous analysis, the relative proportions of mouthwash ingredients and components were determined.

RESULTS

A total of 45 distinctive variations of mouthwashes, representing 17 prominent brands, were identified. Amongst the 116 ingredients discovered, 70 were evaluated for potential adverse effects and undesirable side effects. The aroma of the mouthwash (n = 45; 100%), as welll as their sodium fluoride (n = 28; 62.22%), sodium saccharin (n = 29; 64.44%), sorbitol (n = 21; 46.6%), and propylene glycol (n = 28; 62.22%) content were the main undesireable features.

CONCLUSIONS

The limited array of mouthwashes found on store shelves poses a concern for both oral and public health. Furthermore, the intricate composition of these products, consisting of numerous ingredients with the potential for adverse effects, warrants serious attention. Both clinicians and patients should acknowledge the importance and unwarranted side effects of the compnents of the mouthwashes.

Assessment of Antibacterial Effects of Chlorhexidine and Two Herbal Irrigants on Disinfecting Primary Tooth Root Canals Using Central Composite Design

Background: Primary endodontic infections are caused by necrotic colonization of the pulp tissues by microorganisms. The success of endodontic treatment depends on complete debridement and disinfection of the root canal space. Maximum antibacterial effects, maximum dissolving effects on necrotic tissues, and minimum toxic effects on the periapical tissues are essential characteristics of ideal root-canal irrigants. Recently, researchers have become further interested in medicinal plants as herbal medicines due to their good antimicrobial activities and natural origins. Objectives: This study aimed to compare the antimicrobial properties of chlorhexidine solution alone and mixed with two herbal solutions in root dentine and optimize factors affecting the disinfection of primary tooth root canals. Methods: Teeth infected with pure Enterococcus faecalis suspensions were treated with chlorhexidine solution alone and mixed with chamomile and Satureja khuzestanica. After selecting the most efficient solution, factors possibly affecting the disinfection process were optimized using a central composite design. These factors were the CHX concentration, chamomile concentration, and contact time. Results: The microbial colony count showed that the minimum colony count belonged to 1% chamomile essence and 1% CHX solution, while the maximum colony count belonged to 1% S. khuzestanica and 1% CHX solution, with significant differences. In the optimization process, the best chlorhexidine concentration, chamomile concentration, and contact time were 1.13%, 1.39%, and 11.33 min, respectively. Conclusions: A combination of chlorhexidine and chamomile provided protection against oral microbial pathogens for endodontic infections. However, further comprehensive in vivo studies seem necessary.

Review of allergic reactions from use of chlorhexidine on medical products in clinical settings over 40 years: Risks and mitigations

Chlorhexidine is an antimicrobial agent widely used for infection prevention in medical settings. Nevertheless, allergic reactions ranging from mild to severe have been reported following its use. In this review, we analyzed all case reports published between the introduction of chlorhexidine and the end of 2019 for allergic responses associated with the use of medical devices and or other medical products containing chlorhexidine (CHX) to ascertain the prevalence of severe CHX allergic reactions and what practices might best mitigate those risks.In total, 77 publications containing 124 reported cases of allergic reactions were grouped into 3 product categories, catheters, semisolids, and fluid products. The country, type of reaction, route of sensitization, allergy confirmation, and intervention or mitigation was extracted for each case. Overall, 30 cases were associated with catheters, 46 cases were associated with semisolid products, and 48 cases were associated with the use of other medical products. Severe cases were managed with intravenous fluids, steroids, and epinephrine (adrenaline). None of the reported cases were fatal. The allergy risks can be mitigated by better warning and training clinicians and by recording and screening patient histories for CHX presensitization from prior exposure. For patients undergoing pre-use blood tests, IgE antibody screens can also be performed. Finally, as a precaution in the event a rare severe allergic reaction occurs, procedure carts and rooms can be prestocked with injectable epinephrine and other rapidly acting anti-inflammatory medications.

[Tolerance and effectiveness of an alcoholic solution of 2% chlorhexidine in patients with a long-term central venous route.]

Alcoholic chlorhexidine 2 % is recommended for the prevention of catheter infections. A retrospective study was conducted in a nutritional assistance unit in a cohort of patients with a long-term central venous route. The tolerance (number of skin reactions) and efficacy (number of infections/days of catheters) of this antiseptic used in repeated care in these patients were described.

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.

Curcumin-loaded Pluronic® F-127 Micelles as a Drug Delivery System for Curcumin-mediated Photodynamic Therapy for Oral Application

Antimicrobial photodynamic therapy (aPDT) is promising for oral decontamination. Curcumin has been used as photosensitizer; however, the hydrophobic properties can negatively affect aPDT. This study evaluated the aPDT efficacy using Cur-loaded Pluronic^® F-127 micelles against Streptococcus mutans and Candida albicans biofilms. Micelles characterization was performed by zeta potential, dynamic light scattering, transmission electron microscopy, absorption and fluorescence spectroscopy. Cur concentrations, cell viability by CFU mL^-1 and confocal microscopy were determined. Data were analyzed by parametric and nonparametric tests under 5%. Cur-loaded Pluronic^® F-127 exhibited spherical shape, suitable particle size (≤100 nm), adequate polydispersity index, best stability, lower photodegradation and autoaggregation compared to unloaded-Cur. Both microorganisms were sensitive to Cur-loaded Pluronic^® F-127 micelles aPDT, with minimum inhibitory concentration (MIC) of 270 μm and 2.1093 μm for S. mutans and C. albicans suspended culture, respectively. Cur-loaded Pluronic^® F-127 aPDT exhibited antibacterial/antifungal effect against the biofilms (~3 log₁₀ reduction; P ≤ 0.05); however, similar to unloaded (P ≥ 0.05). Confocal images confirmed these results. Cur-loaded Pluronic^® F-127 micelles exhibited good photo-chemical properties and may be a viable alternative to deliver Cur and to improve aPDT effect during the treatment of dental caries. Moreover, Pluronic^® micelles can enhance the solubility, stability, permeability and control the release of Cur.

Structured diagnostic assessment of hand eczema in cleaning workers

Hand dermatitis is a widespread problem among cleaners. In most cases, it is caused by a combination of wet work and contact with irritants, which can result in irritant (toxic) contact dermatitis. In some cases, the irritant contact eczema then evolves into allergic contact dermatitis, although not all cases of allergic contact dermatitis are preceded by irritant contact dermatitis. This mini-review proposes a two-step diagnostic algorithm based on patch testing, which can be used if allergic contact dermatitis is suspected in cleaning workers. As a first step, we recommend performing the DKG standard series (German Contact allergy research group, DKG), the DKG rubber series, both DKG "further fragrances" series as well as the DKG preservative and disinfectant series. If there are clear hints of an occupational contact dermatitis, the first step can also involve testing patients' own products alongside the standardized tests. In a second step (at the latest), if standardized tests do not suffice to identify the culprit allergen and there is well-founded suspicion, we recommend testing the patients' own products. If necessary, the second step can also include testing the individual contact allergens contained in the screening mixes that are part of the standard series.

Disinfection with single or double usage of new antiseptic olanexidine gluconate in general surgery: a randomized study

PURPOSE

Olanexidine gluconate is a newly developed solution for skin disinfection that was recently approved in Japan. We aimed to compare single and double application of the solution in preventing surgical site infection (SSI) in patients undergoing general surgery.

METHODS

This randomized study was conducted at the Tottori University Hospital. Patients scheduled to undergo gastrointestinal or hernia surgery were randomly assigned to one of two groups using either one or two Olanedine applicators for skin disinfection. The primary endpoint was the difference in SSI incidence between the two groups. The secondary endpoint was all adverse events related to olanexidine gluconate.

RESULTS

A total of 393 patients qualified for the study protocol: 193 received a single application, and 200 received a double application of Olanedine. SSI occurred in 10 patients (2.5%) overall; nine were superficial incisional SSIs, and one patient had a deep incisional SSI. Of the 10 patients who developed SSI, six (3.1%) were in the group receiving a single application, and four (2.0%) were in the group receiving a double application; there was no statistically significant difference between the two groups (P = 0.537). Allergic reactions or skin disorders related to olanexidine gluconate were not observed.

CONCLUSION

There was no difference in the SSI incidence between the use of one or two Olanedine applicators for skin preparation in elective general surgery. Therefore, a single application of Olanedine is sufficient and is recommended for general surgery as a standard disinfection precaution.

TRIAL REGISTRATION NUMBER

UMIN000027319; 5/12/2017.

Hypersensitivity reaction of the gingiva to chlorhexidine: case report and literature review

OBJECTIVE

The aim of this case report was to document a case of delayed-type hypersensitivity reaction of the gingiva to chlorhexidine and review the literature on oral mucosal hypersensitivity reactions associated to chlorhexidine-containing oral hygiene products.

STUDY DESIGN

A 58-year-old man presented with a well-demarcated erythematous area on the right upper anterior gingiva. Incisional biopsy was performed. Postoperatively, chlorhexidine digluconate gel was prescribed twice a day, but the patient did not use it because he experienced intense burning immediately after the first application. The microscopic diagnosis was nonspecific mucositis. Hypersensitivity reaction was suspected. The patient reported use of 0.004% chlorhexidine digluconate-based toothpaste twice a day in the past few years. A delayed-type hypersensitivity reaction to the toothpaste was hypothesized, and its use was discontinued. Chlorhexidine, the common ingredient of both the toothpaste and the gel, was considered the allergen. The literature was reviewed on chlorhexidine-induced oral hypersensitivity reactions.

RESULTS

Two weeks after cessation of toothpaste use, complete remission of the lesion was observed without additional intervention. Four years later, no recurrence has been reported. The literature review yielded 7 studies reporting 20 patients with intraoral manifestations of hypersensitivity reactions associated with chlorhexidine-containing oral hygiene products.

CONCLUSIONS

Clinicians should be aware that oral hygiene products containing even low concentrations of chlorhexidine might induce hypersensitivity reactions.

Chlorhexidine Allergy: Current Challenges and Future Prospects

Chlorhexidine is a synthetic bisbiguanide antiseptic and was introduced in healthcare use in 1954. Allergy to chlorhexidine has been increasingly reported particularly in the perioperative and medical procedural settings. The hypersensitivity reactions range from mild cutaneous reactions to anaphylaxis or death. There are many products and medical devices containing chlorhexidine that sometimes lack standardized labeling. With the various routes of chlorhexidine exposure, accidental or recurrent reactions in chlorhexidine-allergic patients have been reported. Therefore, we aim to review the most recent evidence in clinical manifestations, diagnostic methods, management, and preventive measures with a focus on the unique features of chlorhexidine allergy.

Combination of Beta Glucan, Honey and Chlorhexidine in the Wound Management in a Cat a Case Report

Wound management is one of the oldest and one of the most frequent therapeutic activities in medicine. Over the centuries there has been described and tested many therapeutic substances for the treatment of wounds with various effects. Due to the discovery of antibiotics, a wound management regime used to be limited only to a local application. Over years, it has been shown, that comprehensive therapy which uses only antibacterial preparations, also may contain some negative points (resistance of aggressive pathogens, toxicity, allergic reactions, etc.). According to studies, the best solution to this problem is a local application, using preparations that ensure the sterility of the affected parts of the skin, and the utilization of agents that are able to accelerate the granulation and lead to the healing process of the wound. Products that contain beta glucan combined with a gentle but effective antiseptics (chlorhexidine digluconate), or natural substance with antiseptic and also nourishment effect (honey), are very beneficial in wound management. A good penetration of active agents, the ability to moisturize defective tissues, and to make a protective film that hinder the intersection of impurities and decrease secondary contamination, are the benefits of a gel formulation, that is the most appropriate external form of application in veterinary practice that can improve and accelerate a successful healing process of wounds in animals.

Antimicrobial and antibiofilm effects of abietic acid on cariogenic Streptococcus mutans

Dental caries is a type of oral microbiome dysbiosis and biofilm infection that affects oral and systemic conditions. For healthy life expectancy, natural bacteriostatic products are ideal for daily and lifetime use as anti-oral infection agents. This study aimed to evaluate the inhibitory effects of abietic acid, a diterpene derived from pine rosin, on the in vitro growth of cariogenic bacterial species, Streptococcus mutans. The effective minimum inhibitory concentration of abietic acid was determined through observation of S. mutans growth, acidification, and biofilm formation. The inhibitory effects of abietic acid on the bacterial membrane were investigated through the use of in situ viability analysis and scanning electron microscopic analysis. Cytotoxicity of abietic acid was also examined in the context of several human cell lines using tetrazolium reduction assay. Abietic acid was found to inhibit key bacterial growth hallmarks such as colony forming ability, adenosine triphosphate activity (both planktonic and biofilm), acid production, and biofilm formation. Abietic acid was identified as bacteriostatic, and this compound caused minimal damage to the bacterial membrane. This action was different from that of povidone-iodine or cetylpyridinium chloride. Additionally, abietic acid was significantly less cytotoxic compared to povidone-iodine, and it exerted lower toxicity towards epithelial cells and fibroblasts compared to that against monocytic cells. These data suggest that abietic acid may prove useful as an antibacterial and antibiofilm agent for controlling S. mutans infection.

Health care worker sensitivity to chlorhexidine-based hand hygiene solutions: A cross-sectional survey

BACKGROUND

Health service hand hygiene programs have seen widespread use of chlorhexidine solutions. Reports of both immediate and delayed hypersensitivity to chlorhexidine are increasing among health care workers. This study examined the prevalence of self-reported symptoms of sensitivity to chlorhexidine solutions among health care workers.

METHODS

This study was a cross-sectional online anonymous survey of all workers at a single health service.

RESULTS

Of the 1,050 completed responses, 76.3% were female, 35.3% were nurses and midwives, 28% were medical staff, and 8.7% were working in nonclinical areas. Over 95% used chlorhexidine-based hand hygiene products in their workplace. Nurses and midwives most frequently reported asthma (13.7%), contact dermatitis (27.8%), and previous testing for allergy to chlorhexidine (4.9%). There was a correlation between both the presence of atopy, eczema, or dermatitis and the self-reporting of dry skin, eczema, or dermatitis attributed to chlorhexidine use.

DISCUSSION

Occupational chlorhexidine allergy is an important risk to health care workers. Self-reported symptoms of sensitivity to chlorhexidine solutions revealed high reported use and presence of skin symptoms among health care workers.

CONCLUSIONS

Screening programs need to identify nurses who develop chlorhexidine sensitivity due to occupational exposure. Strategies to mitigate risk should provide alternatives for those with sensitization.

Entrapment of Drugs within Metallic Platinum and Their Delivery

Platinum has been a widely used metal for a variety of implanted medical devices, because of its inertness, low corrosion rate, high biocompatibility, high electric conductivity, and good mechanical stability. A highly desirable property still in need to be addressed is the tailoring of drug-delivery ability to that metal. This is needed in order to treat infections due to the process of implanting, to treat postoperation pain, and to prevent blood clotting. Can Pt itself serve as a delivery matrix? A review on metallic implants (Lyndon, J. A.; Boyd, B. J.; Birbilis, N. Metallic implant drug/device combinations for controlled drug release in orthopaedic applications. J. Control. Release 2014, 179, 63-75) proposes that "Metals themselves can be used for delivering pharmaceutics" but adds that "there has been no current research into [that] possibility" despite its advantages. Here we present a solution to that challenge and show a new method of using an inert metal as a 3D matrix from within which entrapped drug molecules are released. This new type of drug-delivery system is fabricated by the methodolodgy of entrapment of molecules within metals, resulting in various drugs@Pt. Specifically the following drugs have been entrapped and released: the pain-killer and platelet-inhibitor nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen and naproxen, the antibiotic ciprofloxacin, and the antiseptic chlorhexidine. The delivery profiles of all biocomposites were studied in two forms, powders and pressed discs, showing, in general, fast followed by slow first order release profiles. It is shown that the delivery kinetics can be tailored by changing the entrapment process, by applying different pressures in the disc preparation, and by changing the delivery temperature. The latter was also used to determine the activation energy for the release. Full characterization of the metallic biomaterials is provided, including X-ray diffraction (XRD), scanning electron microscopy (SEM), energy-dispersive X-ray (EDAX), thermogravimetric analysis (TGA), and surface area/porosity analysis.

Induction and inhibition of oral malodor

Volatile sulfur compounds (VSCs) such as hydrogen sulfide (H₂ S) and methyl mercaptan (CH₃ SH) are the main components of oral malodor, and are produced as the end products of the proteolytic processes of oral microorganisms. The main pathway of proteolysis is the metabolism of sulfur-containing amino acids by gram-negative anaerobic bacteria. Gram-positive bacteria may promote VSC production by gram-negative anaerobes by cleaving sugar chains from glycoproteins and thus providing proteins. A large variety of bacteria within the oral microbiota are thought to be involved in the complex phenomenon of halitosis. Oral microbiota associated with a lack of oral malodor, oral microbiota associated with severe and H₂ S-dominant oral malodor, and oral microbiota associated with severe and CH₃ SH-dominant oral malodor have been distinguished through molecular approaches using the 16S rRNA gene. Pathological halitosis may primarily be addressed through treatment of causative diseases. In all cases, plaque control is the basis of oral malodor control, and dentifrices, mouthwashes, and functional foods play a supplementary role in addition to brushing. Recently, the use of natural ingredients in products tends to be favored due to the increase in antibiotic-resistant strains and the side effects of some chemical ingredients. In addition, probiotics and vaccines are expected to offer new strategies for improving the oral conditions through mechanisms other than antibacterial agents.

Chlorhexidine allergy in the perioperative setting: a narrative review

Chlorhexidine is an antiseptic with a broad spectrum of activity and a persistent effect on skin. Consequently, it has become an ubiquitous antiseptic in healthcare and the community. As use has become widespread, increasing numbers of cases of allergy have been reported in the literature, including cases of anaphylaxis to chlorhexidine gels used on mucous membranes, chlorhexidine-impregnated devices such as central venous catheters, chlorhexidine preparations used on wounds and broken skin, and cases after dental procedures. Numerous governmental warnings have been issued over recent decades to warn of the risk of allergy to chlorhexidine on mucosal surfaces or in medical devices. Whilst the number of published cases likely underestimates the true prevalence of reactions, we retrospectively surveyed clinics with experience in investigating perioperative chlorhexidine allergy. Despite differences in investigation practice before the survey took place, 13 clinics responded which together had diagnosed 252 cases of anaphylaxis to chlorhexidine, and cases of delayed allergy. In eight of 13 clinics, chlorhexidine was within the top four most commonly diagnosed causes of perioperative anaphylaxis. Despite this, the incidence of anaphylaxis to chlorhexidine is low given that patients are very commonly exposed. Sensitisation of healthcare workers can occur, but is uncommon. Before exposing patients to this antiseptic, consideration of the potential risk vs benefit should be undertaken, particularly for higher risk exposures, such as mucosal exposure or i.v. exposure via impregnated lines. Difficulties exist in protecting patients with known allergies from re-exposure to chlorhexidine, which would be improved with uniform labelling and chlorhexidine product registers.

Surgical field and skin preparation

Surgical site infection (SSI) is the third most frequent healthcare-associated infection in France. SSI rates in total hip or knee replacement are around 2%. The main bacteria implicated in SSI in clean surgery are those of the skin flora, whence the importance of skin preparation to eliminate transient flora and reduce resident flora. Guidelines for the prevention of SSI have progressed in recent years in France: firstly in 2013, and then in 2016. That preoperative hair removal and scrubbing of clean skin ahead of cutaneous asepsis is non-contributive was confirmed in 2013. A shower with normal soap taken as close to the beginning of surgery as possible is still recommended, as is use of alcoholic antiseptics for cutaneous asepsis. The debate remains open between chlorhexidine and povidone-iodine in several surgical specialties in the absence of any multicenter studies. Future choices of antiseptic may need to take account of resistance, especially to chlorhexidine, and possible side-effects. Finally, antimicrobial skin sealants and adhesive surgical drapes are not recommended for the prevention of infection.

An Unexpected Cause of an Acute Hypersensitivity Reaction during Recovery from Anaesthesia

Acute hypersensitivity reactions to chlorhexidine in the operating room are probably more likely to occur during the early phases of anaesthesia because chlorhexidine is often used for cleaning the surgical field or during placement of indwelling catheters. We report a case of an acute hypersensitivity reaction that occurred in the post anaesthetic care unit. Subsequent skin testing suggested sensitivity to chlorhexidine, which had been applied over the vaginal mucosa at the end of surgery. Relevant issues in the investigation of acute hypersensitivity reactions in the post anaesthetic period are discussed.

Chlorhexidine-related anaphylaxis in urological practice

Introduction:

There have been numerous case reports highlighting the risk of anaphylactic reactions when using chlorhexidine-containing urethral gels. However, there is no evidence that the inclusion of chlorhexidine in urethral gels reduces the risk of catheter associated urinary tract infection.

Methods:

Pubmed and Medline were searched for the keywords anaphylaxis (and) chlorhexidine. Case reports were reviewed and information regarding year, patient demographics, country, chlorhexidine administration route, signs, symptoms encountered and the presence of subsequent allergy testing were analysed.

Results:

In terms of clinical features, 89% (32/36) of patients were noted to have skin changes recorded as either urticaria, flushing, rash, erythema or wheals. Respiratory changes were recorded in 67% (24/36), which included those described as bronchospasm, chest tightness, wheeze or cough. Hypotension was documented in 92% of reports (33/36) while hypoxia was recorded in half of the reports (18/36) and a quarter (8/36) had periorbital angioedema or documented oral or tongue swelling. Only four out of 36 patients required formal cardiopulmonary resuscitation and no patients died.

Conclusion:

Chlorhexidine-related anaphylaxis is a relatively frequently reported entity. Despite this, there appears to be no compelling evidence that chlorhexidine mitigates the risk of catheter-associated urinary tract infection.

Level of evidence:

Level 4 evidence.

Chlorhexidine-induced anaphylaxis occurring in the workplace in a health-care worker: case report and review of the literature

BACKGROUND

Chlorhexidine has been widely used in the occupational field as an effective antiseptic and disinfectant, especially in the health-care services. Several cases of allergic reactions to chlorhexidine have been reported, both in the general population and in workers.

OBJECTIVES

To describe a case of occupational chlorhexidine-induced severe anaphylaxis that occurred in the workplace in a health-care worker (HCW) and to update the literature on chlorhexidine as a possible occupational allergen.

METHODS

We report a case of a severe anaphylactic reaction that occurred in the workplace in a 63-year-old man, who had worked as a dentist for over 20 years. We also carried out a systematic review of the literature according to the PRISMA guidelines. No time or language filters were applied. Only occupational case-reports and case-series were included.

RESULTS

The causative role of chlorhexidine was suspected owing to the presence of chlorhexidine-containing products in the workplace. Positive results on the Basophil Activation Test confirmed the diagnosis of immediate chlorhexidine-induced hypersensitivity reaction and excluded a role of other disinfectants. No other causes of anaphylaxis were suspected. Our systematic literature review identified 14 cases of occupational chlorhexidine-induced allergy among HCWs; in these cases, the clinical presentation was mild and the symptoms resolved. No cases of systemic reactions in the workplace were reported.

CONCLUSIONS

This is the first report of chlorhexidine-induced severe anaphylaxis occurring in the workplace. This case report underlines the importance of investigating and being aware of individual and environmental risk factors in the occupational field, which can cause, albeit infrequently, severe reactions with serious consequences.

Comparative evaluation of the effect of different disinfecting agents on bond strength of composite resin to dentin using two-step self-etch and etch and rinse bonding systems: An in-vitro study

Objective

This study was carried out to examine the effect of the application of different disinfecting agents on the shear bond strength (SBS) of an etch-and-rinse system.

Materials and Methods

A total of 120 dentin surfaces of human molars were taken. Sixty samples were taken for immediate (testing was done after 24 h) and delayed (testing was done after 6 months) each. Further, they were divided into three subgroups (n = 20) according to the disinfectant used: Group I: control (no disinfectant); Group II: chlorhexidine based; and Group III: Aloe barbadensis miller (Aloe vera) based. Dentine bonding agent was applied, and resin composite build-ups were done for SBS testing. Samples were examined under scanning electron microscope for observing the gap formation for dentin-restoration interface. SBS results were statistically analyzed.

Results

The results of the study showed that both chlorhexidine and aloe vera had improved bond strength as compared to the control group both for immediate and delayed SBSs.

Conclusion

Thus, aloe vera can be used as an alternative to chlorhexidine for cavity disinfection.

Australian and New Zealand Anaesthetic Allergy Group Perioperative Anaphylaxis Investigation Guidelines

These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf .

National Athletic Trainers' Association Position Statement: Management of Acute Skin Trauma

OBJECTIVE

  To present recommendations for the cleansing, debridement, dressing, and monitoring of acute skin trauma in patients.

BACKGROUND

  Acute skin trauma is common during participation in athletic and recreational activities. Clinical decisions and intervention protocols after injury vary among athletic trainers and are often based on ritualistic practices. An understanding of cleansing, debridement, and dressing techniques; clinical features of infection and adverse reactions; and monitoring of acute skin trauma is critical for certified athletic trainers and other allied health and medical professionals to create a local wound environment that promotes healing and lessens the risk of complications.

RECOMMENDATIONS

  These guidelines are intended to provide the certified athletic trainer and others participating in athletic health care with specific knowledge about and recommendations for the management of acute skin trauma.

Aqueous Chlorhexidine for Intravitreal Injection Antisepsis: A Case Series and Review of the Literature

PURPOSE

To determine the incidence of endophthalmitis in a large clinical series using aqueous chlorhexidine for antisepsis before intravitreal injection and to review the ophthalmic literature regarding chlorhexidine efficacy and safety.

DESIGN

Multicenter retrospective case series.

PARTICIPANTS

All patients receiving intravitreal injections from 7 retinal specialists.

METHODS

An audit of intravitreal injections performed by retinal specialists who exclusively used aqueous chlorhexidine 0.05% or 0.1% for prophylaxis of infective endophthalmitis was undertaken. The incidence of endophthalmitis was determined from August 1, 2011, to February 28, 2015. A literature review was performed to critically appraise the ocular safety and efficacy of aqueous chlorhexidine.

MAIN OUTCOME MEASURES

Incidence of endophthalmitis after intravitreal injections.

RESULTS

A total of 40 535 intravitreal injections were performed by 7 retinal specialists across 3 centers. Chlorhexidine was well tolerated, and only 1 patient with a suspected allergic reaction was noted. Three cases of endophthalmitis were identified with 1 culture-positive case. The 0.0074% (1 in 13 512) per-injection rate of endophthalmitis in this series compares favorably with previous series in which povidone-iodine has been used.

CONCLUSIONS

Aqueous chlorhexidine was associated with a low rate of postinjection endophthalmitis and was well tolerated by patients.

Acute generalised exanthematous pustulosis and other severe drug eruptions from over the counter medications: A case report and review of the literature

We present a case of acute generalised exanthematous pustulosis in an 11-year-old girl who used Duro-Tuss, an over-the-counter cough mixture containing pholcodine, and present a comprehensive review of the literature on severe drug reactions resulting from using non-prescription medications. This case reinforces the importance of taking a complete medication history.

In vitro Effect of Mouthrinse Containing Essential Oils on Proliferation and Migration of Gingival Epithelial Cells

We aimed to investigate in vitro the effects of mouthrinses containing essential oils (EOs) on proliferation and migration of gingival epithelial cells. Human gingival epithelial cells were treated with predetermined dilutions of commercially available EO mouthrinses with or without ethanol and a mouthrinse containing cetyl pyridinium chloride (CPC) for 60 s. Cell proliferation was evaluated using WST-1 assay. Cell migration was assessed using a wound closure model. Within 10 s of exposure to EO mouthrinse without ethanol, the epithelial cells became aberrant and shrank. No statistically significant difference in cell migration or proliferation was observed among cells pretreated by the EO mouthrinse with ethanol, CPC mouthrinse and control (phosphate buffered saline). In contrast, the EO mouthrinse without ethanol significantly reduced cell proliferation (p < 0.001) to approximately 20% relative to control. As for the EO mouthrinse without ethanol, it was not possible to assess its effect on cell migration using this model, because treated cells could be easily detached from the culture plate upon scratch, possibly because of the surfactant ingredient in the formulation. Within the limitations of the study, the EO mouthrinse with ethanol exerted no inhibitory effect on proliferation and migration of the gingival epithelial cells. Copyright © 2016 John Wiley & Sons, Ltd.

Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature

BACKGROUND

Chlorhexidine (CHL) has antiseptic and disinfectant properties used to prevent hospital-acquired infections. CHL-induced anaphylaxis is poorly reported in surgical literature despite government warnings and growing recognition. The aim of this review is to increase awareness of CHL-induced anaphylaxis in the surgical population.

METHODS

Literature review of Embase, Medline, PubMed and the Cochrane library using 'anaphylaxis (and) chlorhexidine' search terms.

RESULTS

Thirty-six articles were published on surgical patients suffering anaphylaxis to CHL. Within these, seven patients had two proven separate anaphylactic reactions and one had three separate proven anaphylactic reactions. The most commonly affected speciality was urology. The majority occurred during elective procedures. A history of atopy was surprisingly uncommon as was bronchospasm. Six patients required active chest compressions and 39.71% of patients had their surgical procedure abandoned. Unplanned intensive care admissions occurred in 27.94%.

DISCUSSION

In order to reduce abandoned procedures, unplanned intensive care unit admissions, morbidity and mortality associated with CHL-induced anaphylaxis we recommend the following: rationalization of CHL-containing products, greater vigilance regarding subtle symptoms of CHL allergy, appropriate investigation of these symptoms and a greater awareness of CHL-containing products. Lastly, we outline the appropriate investigations and highlight the need for meticulous documentation in those who are CHL allergic.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for preventing hospital-acquired (nosocomial) surgical site infections.

SEARCH METHODS

For this fifth update we searched the Cochrane Wounds Group Specialised Register (searched 18 December 2014); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014 Issue 11); Ovid MEDLINE (2012 to December Week 4 2014), Ovid MEDLINE (In-Process & Other Non-Indexed Citations December 18, 2014); Ovid EMBASE (2012 to 2014 Week 51), EBSCO CINAHL (2012 to December 18 2014) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in people undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for selection, risk of bias and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We did not identify any new trials for inclusion in this fifth update. Seven trials involving a total of 10,157 participants were included. Four of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub/Riohex). Three trials involving 7791 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The smaller studies found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

AUTHORS' CONCLUSIONS

This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.