PEOPLE & OPINIONS


likely to have reduced susceptibility than in units without CHG bathing protocols (86% vs 64%, p=0.028).15


In a 2017 study,


scientists identified a high prevalence of CHG-resistant genes (67% qac, 18% smr) in organisms recovered from the skin of patients with central venous catheters who wore CHG-impregnated dressings.16 The proportion of specimens with the qac resistance genes was significantly higher from patients who had worn the dressing for >72 hours compared with those with shorter exposure (p=0.04).16 Alarmingly, reports of cross resistance between CHG and certain antibiotics, including the last-resort antibiotic colistin, have also been published.18-19


Taken to-


gether, these findings have led to a number of cautionary statements from experts in the field regarding judicious use of CHG and the need to champion “antiseptic steward- ship.”19-20


Adverse events/allergies In 2017 the FDA issued a warning about allergic reactions with use of CHG based on a growing number of cases of CHG- induced anaphylaxis (FDA).21


Although


the total number of cases is relatively small, it is widely acknowledged that they are on the rise—in fact, half of the reported anaphylaxis cases occurred since 2010 de- spite the fact that CHG has been available in the US since 1969.21


CHG can elicit other allergic reactions,


including mild contact dermatitis and delayed or immediate hypersensitivity reactions, and sensitization appears to play a role.22-23


A review of CHG allergy


found that the majority of patients who experienced a serious allergic reaction to CHG reported minor symptoms upon previous exposure to the antiseptic.23


Just


how prevalent these allergies are remains unclear—a review of adverse events with CHG published in the journal Dermatitis reported that studies of CHG allergen se- ries patch testing yield positive results in anywhere from 0.5 to 13.1% of the studied population.10


Most experts agree, however,


that cases are likely underreported and are likely to increase in frequency given the extensive use of CHG in a variety of healthcare products and applications 10,22 The perioperative setting is no exception to this trend.22-24


One Danish study found


that 9.6% of perioperative anaphylaxis cases were attributable to CHG allergy.25 A 2015 literature review of chlorhexidine- induced anaphylaxis in surgical patients published in the journal of the Royal Australasian College of Surgeons found that 39.71% of affected patients had to have their procedures canceled and 27.94% re-


sulted in unplanned ICU admissions.26 The


authors conclude that “rationalization” of CHG-containing products is needed to avoid the morbidity and mortality as- sociated with CHG-induced anaphylaxis.26


Looking to alternatives Preoperative skin antisepsis—or “skin prep”—is a well-established surgical site infection (SSI) prevention measure. Mul- tiple studies have demonstrated that anti- sepsis with an alcohol-based agent reduces the concentration of bacteria residing on the skin at the surgical site and results in significantly fewer SSIs,1,27-28


but the spec-


trum of alcohol-based agents available in the US is small. Formulations combining alcohol with PVI are currently the only alternative to CHG-alcohol products. Though CHG may have longer residual activity than PVI,29


to date there is insuf-


ficient high-quality evidence to support the superiority of either formulation in preventing SSI.1-2 The authors of the ICHE article argue


that “continued diversification of [the] topical antiseptic armamentarium” is im- perative to mitigating the upward trend in both CHG resistance and allergy.3


Cham-


pions of antiseptic stewardship similarly argue that the healthcare community must be cautious with such a valuable weapon in order to preserve its efficacy.20


many as 48 million surgical procedures performed in the US each year30


With as and the


average American undergoing 9.2 surgical procedures in their lifetime, according to a study published by the Massachusetts Chapter of the American College of Sur- geons,31


it may indeed be time to grow the


‘team’ of topical antiseptics used for pre- operative skin prep in an effort to steward existing topical antiseptics. HPN


References:


1. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017; 152: 784-91.


2. Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35 suppl2: S66-S88.


3. Crnich CJ, Pop-Vicas AE, Hedberg TG, et al. Efficacy and safety of a novel antimicrobial preoperative skin preparation. Infect Control Hosp Epidemiol 2019; article in press. doi:10.1017/ice.2019.200.


4. El-Othmani MM, Mahmood BM, Pearson L, et al. Assessment of standardization in surgical site preparation: does a compliance culture exist? Int Surg J 2016; 3:1-10.


5. Edmiston CE, Bruden B, Rucinski MC, et al. Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control 2013; 41 suppl5: S49-S55.


6. Zhang TT, Tang SS, Fu LJ. The effectiveness of different con- centrations of chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. J Clin Nurs 2014; 23:1461-1475.


7. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011; 39 suppl 1: S1-S34.


8. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-


related infection (CLEAN): an open-label, multicenter, randomized, controlled, two-by-two factorial trial. Lancet 2015; 386:2069-77.


9. ChlorhexidineFacts.com About chlorhexidine: history of chlorhexidine. Available from: https://chlorhexidinefacts.com/ history-of-chlorhexidine.html. Accessed 11 June 2019.


10. Silvestri DL, McEnery-Stonelake M. Chlorhexidine: uses and adverse reactions. Dermatitis 2013; 24(3): 112-18.


11. Adapted from GHX Database; Global Healthcare Exchange Market Intelligence Medical/Surgical Product Schema 2017.


12. Wang JT, Sheng WH, Wang JL, et al. Longitudinal analysis of chlorhexidine susceptibilities of nosocomial methicillin-resis- tant Staphylococcus aureus isolates at a teaching hospital in Taiwan, J Antimicrob Chemother 2008; 62(3): 514-17.


13. Batra R, Cooper BS, Whitely C, et al. Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis 2010; 50(2): 210-7.


14. Zhang M, O’Donoghue MM, Hiramatsu K, et al. Prevalence of antiseptic-resistance genes in Staphylococcus aureus and coagulase-negative staphylococci colonizing nurses and the gen- eral population in Hong Kong. J Hosp Infect 2011; 78(2): 113-7.


15. Suwantarat N, Carroll KC, Tekle T, et al. High prevalence of reduced chlorhexidine susceptibility in organisms causing central line-associated bloodstream infections. Infect Control Hosp Epide- miol 2014; 35(9): 1183-186.


16. Choudhury MA, Sidjabat HE, Rathnayake IU, et al. Culture-independent detection of chlorhexidine resistance genes qacA/B and smr in bacterial DNA recovered from body sites treated with chlorhexidine-containing dressings. J Med Microbiol 2017; 66: 447-453.


17. Addetia A, Greninger AL, Adler A, et al. A novel, wide- spread qacA allele results in reduced chlorhexidine susceptibility in staphylococcus epidermis. Antimicrob Agents Chemother 2019; 63(6): e02607-18.


18. Wand ME, Bock LJ, Bonney LC, et al. Mechanisms of increased resistance to chlorhexidine and cross-resistance to colistin following exposure of Klebsiella pneumoniae clinical isolates to chlorhexidine. Antimicrob Agents Chemother 2016; 61: e01162-16.


19. Horner C, Mawer D, Wilcox M. Reduced susceptibility to chlorhexidine in staphylococci” is it increasing and does it matter? J Antimicrob Chemother 2012; 67(11): 2547-559.


20. Kampf G. Acquired resistance to chlorhexidine—is it time to establish an “antiseptic stewardship” initiative? J Hosp Infect 2016; 94:213-27.


21. U.S. Food and Drug Administration. FDA drug safety com- munication: FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. 2017. Available from: https://www.fda.gov/drugs/drug-safety-and-availability/ fda-drug-safety-communication-fda-warns-about-rare-serious- allergic-reactions-skin-antiseptic. Accessed 6 June 2019.


22. Moka E, Argyra E, Siafaka I, et al. Chlorhexidine: hypersen- sitivity and anaphylactic reactions in the perioperative setting. J Anaesthesiol Clin Pharmacol 2015; 31:145-48.


23. Abdallah C. Perioperative chlorhexidine allergy: is it serious? J Anaesthesiol Clin Pharmacol 2015; 31(2): 152-154.


24. Krishna MT, York M, Chin T, et al. Multi-centre retrospective analysis of anaphylaxis during general anaesthesia in the United Kingdom: aetiology and diagnostic performance of acute serum tryptase. Clin Exp Immunol 2014; 178:399-404.


25. Opstrup MS, Malling HJ, Kroigarrd M, et al. Standardized test- ing with chlorhexidine in perioperative allergy--a large single-centre evaluation. Allergy. 2014;69(100):1390.


26. Sharp G, Green S, Rose M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg 2016; 86(4): 237-43.


27. Tuuli MG, Liu J, Stout MJ, et al. A randomized trial compar- ing skin antiseptic agents at cesarean delivery. New Eng J Med 2016; 374: 647-55.


28. Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. New Eng J Med 2010; 362: 18-26.


29. Maiwald M, Chan ESY. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012; 7(9): e44277.


30. Stanford Healthcare. General Surgery: surgery statistics. Available from: https://stanfordhealthcare.org/medical-clinics/ surgery-clinic/patient-resources/surgery-statistics.html. Accessed 25 September 2019.


31. American College of Surgeons, Massachusetts Chapter. How many surgical procedures will Americans experience in an average lifetime? Evidence from three states. Available from: https://mcacs.org/abstracts/2008/P15.cgi. Accessed 25 September 2019.


hpnonline.com • HEALTHCARE PURCHASING NEWS • January 2020 49


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56