Chlorhexidine: Case & Research Files

Ricardo Manalastas, Jr., MD

Professor, Dept of OBGYNE Philippine General Hospital College of Medicine UP Manila

Case 1: Episiotomy

MN is a 24 year-old primigravida who consulted for labor pains which started 6 hours ago. Cervix is 4 cm dilated, with intact BOW. In your admitting orders, what would you include to address the issue of prevention of infection associated with labor and delivery?

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Case 1: Episiotomy--2

Items in the admitting orders meant to prevent infections in a patient in labor: 1. Perineal prep: full, half. 2. Fleet enema 3. Full body bath 4. Start antibiotics 5. Others
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Case 1: Episiotomy--3
1.

Perineal prep:
Refers to the shaving of hair on the mons pubis and vulva, washing with antiseptic soap and rinsing with water.

Fullmons pubis and vulva Halfvulva alone

Rationale: hair is contaminated with oil, dust, sweat and organisms in the perineum.
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Case 1: Episiotomy--4
1.

Perineal prep:
Comments: Thorough washing with an antiseptic soap and water should be able to clean even the hair in the perineum. Shaving of hair as a strategy to prevent infection is no longer recommended.

Use of razors lead to microabrasions in the skin and hair follicles which could lead to higher risk of infection.

If hair needs to be removed because it interferes with the surgical procedure:

Clipping is preferred over shaving Shaving right before the procedure is less risky.

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Case 1: Episiotomy--5
2.

Fleet enema
Instilling a certain volume of liquid into the ano-rectal canal to stimulate bowel movement.

Soap suds Commercial preparations

Rationale: To prevent fecal passage and contamination during labor and delivery

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Case 1: Episiotomy---6
2.

Fleet enema
Comments:

It is impractical and embarrassing to the patient because it usually leads to passage of moist and watery stools which is more difficult to manage than formed stools during labor and delivery, leading to more contamination. Ideally, the patient should be advised to move her bowels before going to the hospital.

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Case 1: Episiotomy--7
3.

Full body bath

As with proper handwashing, a full body bath with a safe and effective antiseptic soap is known to reduce microbial contamination, and the risk of infection, e.g., chlorhexidine, triclosan. Preferably prior to hospital admission; but, if time and facilities permit, it may be done after admission.
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05Jan2011

Case 1: episiotomy--8
4.

Antibiotics
principles of surgical antibiotic prophylaxis: A single dose of an appropriate antibiotic given prior to a surgical procedure (usually at least a clean-contaminated one) can reduce significantly the risk of surgical infection. Comment Benefits are well documented in many surgical procedures, but not for vaginal delivery even with an uncomplicated episiotomy/repair. (Cite studies)

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A Randomized Controlled Trial Comparing the Efficacy, Acceptability and Safety of Chlorhexidine digluconate versus Povidone iodine and Lactic acid as an External Genital Antiseptic in Women who have Undergone Vaginal Surgery.

Manalastas, RM Jr., et al. PJOG, 2007.

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Treatment Arms & Allocation

270 participants were equally randomized to one of three groups: Group A: Chlorhexidine Antiseptic Feminine Wash Group B: Povidone iodine Feminine Wash Group C: Lactic acid Feminine Hygiene

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Summary of Results

It appeared that oral systemic antimicrobials traditionally and commonly used for patients undergoing episiotomy and episiorrhaphy were unnecessary, and that generally good outcomes in terms of preventing SSIs can be obtained with the use of a topical antiseptic solution alone, such as chlorhexidine digluconate.

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Summary of Results

Compared to Povidone iodine, and more so with Lactic acid, the number of surgical site infections (SSIs) was found to be least in participants who used Chlorhexidine digluconate as antiseptic genital wash during and after the surgical operation.

08/15/11 05Jan2011

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Case 2: Menstrual feminine hygiene

AC is a 24 year old G0 who consults because of recurrent on and off vulvar and perineal irritation associated with foul odor, most notable during and right after her menstrual periods. Using lactic acid wash affords only temporary relief yet using povidone iodine results in dryness, burning and irritation. What important messages would you impart to AC to address her problem?

05Jan2011

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Case 2: Menstrual feminine hygiene

Important messages to impart to address the problems of menstrual perineal and vulvar irritation:
1.

2.

The perineal and vulvar areas are normally colonized by a variety of microorganisms that exist in equilibrium Menstrual blood is one of several factors that disrupt the microbial ecosystem favoring overgrowth of some organisms leading to irritation

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Case 2: Menstrual feminine hygiene

3.

Judicious use of an appropriate antiseptic, along with other measures, can help prevent problems of feminine hygiene related to menstruation:
1.

Judicious 1. Used only during periods of high risk e.g., during and a few days after menses 2. Routinely used on the vulva and perineum; not as an intra-vaginal douche.

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Case 2: Menstrual feminine hygiene

3.

Judicious use of an appropriate antiseptic, along with other measures, can help prevent problems of feminine hygiene related to menstruation:
2.

Appropriate antiseptic
1. 2.

3. 4.

Neither too mild transient effect: symptoms recurrent Nor too harsh dryness and irritation: kills off even the healthy flora Acts rapidly relief comes sooner Longer duration of action relief is lasting

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Case 2: Menstrual feminine hygiene

3 Judicious use of an appropriate antiseptic, along
.

with other measures, can help prevent problems of feminine hygiene related to menstruation:
3.
.

Other measures
Cotton underwear Loose-fit pants Non-heavily scented products Wash instead of wipe Wipe from back-to-front.

1. 2. 3. 4. 5.

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Local StudyManalastas, RM 2010 unpublished

COMPARATIVE RANDOMIZED CONTROLLED DOUBLE-BLIND TRIAL ON THE EFFICACY, ACCEPTABILITY AND SAFETY OF CHLORHEXIDINEDIGLUCONATE VERSUS POVIDONE IODINE AND LACTOSERUM FEMININE WASHES IN PREVENTING INFECTION, IRRITATION AND FOUL ODOUR AMONG FILIPINAS DURING MENSTRUATION AND DURING REGULAR EVERY-OTHER-DAY USE FOR THREE WEEKS

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Local StudyManalastas, RM 2010 unpublished

significant and safe reductions in bacterial colonization of the vulvar area with regulated use of the antiseptic during menstruation and continuing until the next cycle

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Local StudyManalastas, RM 2010 unpublished

successfully improved odour levels, and with prolonged use (1 menstrual cycle) leading to stably neutral odours. demonstrated high levels of safety, in particular, 100% safety at immediate use, with a few isolated cases of itchiness with longer use.

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Local StudyManalastas, RM 2010 unpublished

Trends in the density of bacterial growth:

povidone iodine seems less effective against bacteria in moderate growth patterns, apparently exhibiting a transient effect or a short-acting capacity such that bacteria start to re-grow in moderate amounts.

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Local StudyManalastas, RM 2010 unpublished

Trends in the density of bacterial growth:

lactic

acid seems to take longer (slower acting) to reduce bacteria in light and more than light growth patterns

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Local StudyManalastas, RM 2010 unpublished

Trends in the density of bacterial growth:

chlorhexidine

seems to achieve the fastest (by 6 hours after use) sterilizing (no growth) effect on the bacteria compared to the other two products

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Case 3: Caesarean Section

GB is a 32 year old G3P2 on her 38th week AOG, with 2 previous CS. She is scheduled for elective repeat CS with BTL. What measures would you take to minimize the risk of surgical infection?

05Jan2011

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Case 3: Caesarean Section

Measures to minimize the risk of surgical infection: 1. Full body bath 2. Abdomino-perineal prep 3. Bowel prep 4. Antibiotic prophylaxis 5. Good surgical technique

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Case 3: Caesarean Section

Good surgical technique Minimize tissue trauma

-- Eliminate dead space

Do not compromise blood supply No unnecessary foreign body Achieve & maintain asepsis/antisepsis

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Case 3: Caesarean Section

Achieve & maintain asepsis/antisepsis

Proper use of safe & effective disinfectant Disinfect the operative field

Abdomino-perineal skin Vaginal canal

Proper surgical scrub of all members of the team Minimize talking & traffic in the OR Exclude members of the staff with respiratory or skin infections from the team

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Local StudyFuentes-Fallarme, AT & Manalastas, RM, 2008

Comparison of Efficacy between Chlorhexidine and Povidone Iodine as Abdominal Skin Preparation Among Women Undergoing Caesarean Section & Exploratory Laparotomy for Ectopic Pregnancy: A Randomized Trial

05Jan2011

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Objective

To compare the efficacy of chlorhexidine and povidone iodine for cleansing the operative field for abdominal deliveries and exploratory laparotomies for ectopic pregnancies.

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MATERIALS AND METHODS

Randomized controlled trial Sample size: 552 subjects Study population: women who underwent cesarean section and exploratory laparotomy for ectopic pregnancy Study period: March to August 2008 Randomization: using computer generated random numbers Exclusion: known allergy to chlorhexidine or povidone iodine Informed consent was obtained Demographic data were obtained and recorded on the Patient Registry Form
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Skin preparation using chlorhexidine

Liberal application of 0.2% solution over the skin of operative field Vigorous scrubbing for 2 minutes Area was dried with a sterile towel Done twice
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Skin preparation using Povidone Iodine

Application of 7% povidone Iodine solution mixed with NSS over the skin Vigorous scrubbing for 2 minutes Drying using sterile towel Application of 10% povidone Iodine solution on the operative field
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Surgeons also use the same agent for hand scrubbing as was used in skin disinfection of the patient. Post-operative care: Patients were monitored for presence of febrile morbidity and wound infection while in the wards. The agent used during the pre-operative antiseptic was continued during the postoperative wound dressing.

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Outpatient follow up

7 days and 14 days after discharge Examined for the presence of surgical site infection and fever Asked if there is occurrence of such outcomes during discharge Patient registry forms completed

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SUMMARY AND CONCLUSION

There was a significant difference in the incidence of surgical site infection (SSI) 7 days postoperatively, occurring in 7.63% and 2.75% under the complete data (p=.0132), 6.9% and 2.6% under the positive outcome assumption (p=.0168) and in 16.6% and 7.6% under the negative outcome assumption (p=.0013) for povidone iodine and chlorhexidine group, respectively.
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Other findings

2 patients under povidone iodine group developed deep SSI with organ space involvement SSI cases under chlorhexidine arm are all superficial in category

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Additional Back-up Slides

Antiseptics

Most commonly used skin antiseptic agents

iodophors 2. alcohol-containing products 3. chlorhexidine gluconate
1.

2% aqueous chlorhexidine was superior to either 10% povidone iodine or 10% alcohol in preventing infection

CDC, 1996

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Advantages of Chlorhexidine

1.

Good persistence against bacteria (duration of action of 5-6 hours)

2. Blood, serum, and other protein-rich biomaterials can deactivate the microbicidal effect of povidone iodine but not chlorhexidine.

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Advantages of Chlorhexidine

3. Better than povidone iodine at reducing colony counts of coagulase-negative staphylococci12, which is the most common skin contaminant organism (81%)15 4. Good safety profile

12

15

Maki DG, Ringer M, et al. Prospective randomized trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338(8763):339-343 Suwanpimolkul G, Pongkumpai M, et al. A randomized trial of 2% chlorhexidine in 70% alcohol compared with 10% povidone-iodine for venipuncture site disinfection: effects on blood culture contamination rates. 17th European Congress of Clinical Microbiology and Infectious Diseases, Germany. 31 Mar-o4 April 2007

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Reported side effects of Povidone Iodine

irritation and discoloration of skin iodine overload in newborn infants caused by the use of povidone iodine for perineal preparation of the mother in vaginal delivery1 causing transient hypothyroidism

Ansotegui AJ, Knorr EJI, et al. Iodine overload in newborn infants caused by the use of PVP-iodine for perineal preparation of the mother in vaginal delivery. An Esp Pediatr 1989 Jan;30(1):23-Bondar V, Rago C, et al. Chlorhexidine lavage in the treatment of experimental intra-abdominal infection. Arch surg. 2000;135:309314

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Reported side effects of Povidone Iodine

systemic iodine absorption after preoperative antisepsis in cataract surgey2 transcutaneous iodine absorption in infants undergoing cardiac operation causing renal failure, metabolic acidosis, and thyroid suppression3

2
3

Below H, Behrens-Baumann W, et al. Systemic iodine absorption after preoperative antisepsis using povidone-iodine in cataract surgeryan open controlled study. Dermatology.2006;212 Suppl 1:41-6. Mitchell IM, Pollock JC, et al. Transcutaneous iodine absorption in infants undergoing cardiac operation. Ann Thorac Surg. 1991 Nov;52(5):1138-40.

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Reported side effects of Povidone Iodine

can be absorbed through healthy skin4, most especially in cases of extensive burns, producing lethal results5

4 5

Tomoda C, Kitano H, et al. Transcutaneous iodine absorption in adult patients with thyroid cancer disinfected with povidone-iodine at operation. Thyroid. 2005 Jun; 15(6):600-3. Steen M. review of the use of povidone-iodine (PVP-I) in the treatment of burns. Postgrad Med J. 1993;69 Suppl 3:S84-92.

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Other reasons why many authors recommend chlorhexidine over povidone iodine

more acceptable to patients produced less waste less expensive

1 0

Wellard S, Palater L. An evaluation of two methods of pre-cannulation skin disinfection. Aust J of Advanced Nursing. 1996. 14(1):3-7

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Chlorhexidine: Case and Research Files

Thank You!