Abstract
BackgroundSkin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence.MethodsWe performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution. ResultsIn all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines.ConclusionsPerceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.
Highlights
Skin antisepsis has been an indispensable part of medical practice for more than a century
The usual active concentrations are about 70–90% (v/v) for alcohols, 0.5–4% (w/v) for chlorhexidine gluconate (CHG), and 5– 10% (w/v) for PVI. Both CHG and PVI are available as aqueous solutions where they are the sole active ingredients, and they can be combined with alcohols, thereby creating enhanced antiseptics with two active components
For the purpose of this review, primary literature was defined as randomised clinical trials (RCTs) and non-randomised clinical studies, and secondary literature was defined as systematic reviews
Summary
Skin antisepsis has been an indispensable part of medical practice for more than a century. The most commonly used substances for skin antisepsis are (1) alcohols (ethanol, isopropanol and n-propanol), (2) chlorhexidine, commonly available as chlorhexidine gluconate (CHG), and (3) povidone-iodine (PVI), an organic iodine complex. Among these antiseptics, alcohols are microbiologically most active but have no appreciable residual activity [1,2,3]. The usual active concentrations are about 70–90% (v/v) for alcohols, 0.5–4% (w/v) for CHG, and 5– 10% (w/v) for PVI (or, instead of total PVI, 0.5–1% ‘‘available’’ iodine). We sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence
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