Chlorohexidine has been in medical use for decades. The World Health Organization even put it on their List of Essential Medicines, which is a list of the safest and most effective medicines needed in a health system (1). Chlorohexidine is often referred to as chlorhexidine gluconate (CHG), which is a disinfectant and antiseptic used for cleaning wounds, preventing dental plaque, disinfecting skin before surgery and to sterilize surgical instruments (2). In recent years, medical supply manufacturers have started introducing CHG into dressings used to secure vascular access devices, and disks that cover the insertion site of vascular access catheters. In this post, we will breakdown the history of CHG, its introduction into the vascular access space, and Center for Disease Control (CDC) recommendations regarding its use.
Chlorhexidine gluconate is active against gram-positive and gram-negative organisms, facultative anaerobes, aerobes, and yeasts. More simply put, it is effective against a wide range of bacterial organisms. It is such a popular antiseptic that in 2016 it was the 230th most prescribed medication in the United States with more than 2 million prescriptions (2 ). One of the more common medical uses for CHG is in the form of an oral rinse, where it can help combat gingivitis (4). For preoperative skin prep, povidone iodine had been the standard of care for years. Povidone iodine and CHG have very similar functions, and there have been a number of studies comparing the efficacy of the two against each other. The broad consensus of this research is that they are very comparable, with scant evidence suggesting that CHG is more effective than povidone iodine. One study in particular found that the incidence of surgical site infections (SSI) was lower with the use of CHG, although the reduction in SSI was not large enough to be considered statistically significant (3).
As the use of CHG-impregnated (C-I) dressings and disks became more prevalent, the CDC released an updated document that outlines recommendations for their use in the prevention of intravascular catheter-related infections. The FDA cleared C-I dressings based on bench testing data, noting that they demonstrated effectiveness as a barrier to bacterial penetration to the catheter site, and in the reduction of bioburden within the dressing during use. The FDA also cleared a subset of these dressings with the specific indication for preventing catheter-related blood stream infection (CRBSI) based on results from clinical testing data. C-I dressings are clinically indicated for patients over 18 years of age, however they are not recommended to protect the sites of patients less than 18 years of age due to risk of serious adverse skin reactions.
The CDC document further outlines that there is a lack of sufficient evidence from published, high quality studies about safety and efficacy of C-I dressings in patients under 18 years of age. When commenting on the limitation of the evidence for patients 18 years and older, the CDC noted that three of the five Randomized Controlled Trials (RCT) did not use insertion site skin antisepsis methods such as alcoholic chlorhexidine recommended for CVCs by the 2011 guidelines. Whether the benefits of C-I dressings over standard dressings would be observed or achieve the same magnitude if skin antisepsis with alcoholic chlorhexidine were used for all patients is unclear (5 ).
Additionally, the CDC noted increasing reports of anaphylactic reactions to chlorhexidine skin preparations and contended that those reports raised questions about C-I dressings. The CDC recommends that health care professionals always ask patients if they have ever had an allergic reaction to any antiseptic before recommending or prescribing a chlorhexidine gluconate product.
While it is clear that more high-quality research on the topic of C-I dressings is needed in all age groups, there is currently sufficient evidence suggesting it has a positive impact on catheter-related blood stream infections in patients over 18 years of age. With the increased attention placed on preventing peripheral IV catheter bloodstream infections and CHG’s ability to fight infection, the use of CHG disks and dressings needs to be confirmed in additional independent studies. We need to fully understand the safety and efficacy of C-I dressings for all types of vascular access devices and patients.
1. BIOPATCH Protective Disk with CHG | Ethicon EMEA. (n.d.). Retrieved April 25, 2019, from https://www.ethicon.com/emea/products/vascular-access-infection-control/biopatch-protective-disk-chg
2. Chlorhexidine (Topical Application Route) Description and Brand Names. (2019, February 01). Retrieved May 9, 2019, from https://www.mayoclinic.org/drugs-supplements/chlorhexidine-topical-application-route/description/drg-20070874
3. Chlorhexidine Gluconate Oral Rinse: What Is It? (n.d.). Retrieved April 25, 2019, from https://www.colgate.com/en-us/oral-health/conditions/gum-disease/chlorhexidine-gluconate-oral-rinse--what-is-it-
4. Rao, D. M. (2017). Comparison of the Efficacy of Chlorhexidine Gluconate versus Povidone Iodine as Preoperative Skin Preparation for the Prevention of Surgical Site Infections. Journal of Medical Science And Clinical Research,05(04).
5. Schmalz, G., & Arenholt-Bindslev, D. (2009). Biocompatibility of dental materials. Berlin: Springer.
6. Updated Recommendations on Chlorhexidine-Impregnated (C-I) Dressings | Infection Control | CDC. (n.d.). Retrieved April 25, 2019, from https://www.cdc.gov/infectioncontrol/guidelines/bsi/c-i-dressings/index.html
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