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Terry,
Just returned from a short period of leave, saw your query.
I am not personally aware of a formal requirement, although there may be one.
The concern is bacterial spores; they are not killed by the alcohol. That means, although a sterile manufacturing process is technically not (!) required to achieve a spore-free solution or alcohol swab, it is a definite advantage, in the case of alcohol swabs, to have them produced as sterile.
In the case of alcohol solutions, this is classically achieved by filtering the alcohol disinfectant through a bacterial exclusion filter, by which the spores are held back. In the case of alcohol swabs, manufacturers may have their proprietary ways to exclude spores from the swabs, which I am not familiar with.
In a similar context, the US FDA had a public hearing about a year or so ago, concerning liquid antiseptic products (not: swabs), whether or not they need to be produced technically sterile. The result was, if I remember this correctly, that when liquid antiseptics would be produced appropriately with good manufacturing practices, they would not need to be technically sterile, and conversely, when manufacturers would switch to sterile production, that this would increase costs very significantly.
A few years ago, I wrote a small comment for a literature evaluation service “Faculty of 1000” concerning an article reporting on contaminated alcohol swabs. I am quoting from my own comment below.
The article was:
Dolan SA, Littlehorn C, Glod MP, Dowell E, Xavier K, Nyquist AC, Todd JK. Association of Bacillus cereus Infection with Contaminated Alcohol Prep Pads. Infect Control Hosp Epidemiol. 2012 Jul; 33(7): 666-71. PMID: 22669227. DOI: 10.1086/666334
My comment was:
“This is an interesting report of a small series of infections with Bacillus cereus (a sporeforming bacterium) in one children’s hospital in the United States associated with contaminated alcohol preparation pads from one manufacturer. Two index patients were identified who had clinically relevant Bacillus cereus infections, and these infections were traced back to packaged single-use alcohol pads that were found to be contaminated with Bacillus species by microbiological investigations. These pads had not been specifically labeled as sterile. A possible route of transmission was the disinfection of vascular catheter hubs with these alcohol pads. Cultures from the pads grew a number of diverse Bacillus strains, and although the patients’ isolates did not match the ones from the pads in molecular typing, an origin from the pads appeared highly likely given that 63% of the pads were contaminated and given the diversity of the strains from the pads. The product was subsequently recalled nationwide and the hospital subsequently only used pads that were labeled as sterile. This incident is a reminder of the old microbiological wisdom that alcohol disinfectants are effectively auto-sterile with the notable exception of bacterial spores (and theoretically prions) and that all alcohol antiseptics for use on humans need to be filtered with bacterial exclusion filters during the manufacturing process (and pads would have to be sterilized separately). Of interest, the 2009 World Health Organization Hand Hygiene Guideline proposes an alternative way for end users to make their own alcohol hand rubs, by adding a small quantity of hydrogen peroxide that kills spores during storage of the alcohol hand rub.”
Regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi everyone,
I seem to recall we had a discussion on the AICA list a while back re the use of alcohol swabs for skin preparation prior to cannulation or administration of IM / SC medications and I seem to recall that the discussion may have touched on whether the swabs themselves need to be sterile or not. Problem is that I can’t find that discussion point in any of the threads were this topic was raised.
I have been looking at some of the alcohol swabs being used for IV cannulation [Day Surgery environments] and there are some brands of swabs out there that do not have the STERILE symbol [word] on the packaging.
Can anyone please tell me whether the alcohol swabs used for skin preparation need to be sterile and if so – where this requirement is stated.
Thanks in anticipation.
Kind Regards
Terry McAuley
Sterilisation & Infection Prevention and Control Consultant
STEAM Consulting
E: terry@steamconsulting.com.au
W: http://www.steamconsulting.com.au
A: PO BOX 779
Endeavour Hills
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Dear Cath,
Thank you for this piece of news, and sad to hear of Yvonne Cossart’s passing.
I would like to add that Yvonne was also famous (or probably most famous) for having discovered, in 1974, Parvovirus B19. See Wikipedia entry, and see her original article in which she described the discovery:
http://en.wikipedia.org/wiki/Parvovirus_B19
Cossart YE, Field AM, Cant B, Widdows D. Parvovirus-like particles in human sera. Lancet. 1975 Jan 11;1(7898):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/46024Parvovirus B19 is the agent of a childhood disease called erythema infectiosum, also called “slapped cheek disease”. It also causes complications in pregnancy (fetal hydrops).
I met Yvonne Cossart on a trip to Australia in the early 1990s, at a time when I was still based as a microbiologist in Germany.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387—–Original Message—–
ACIPC members and particularly those previous ICA NSW Inc members will be saddened to learn of the passing of Prof. Yvonne Cossart OA on 16/12/14. Prof. Cossart was the initial Patron of ICA NSW and subsequently AICA. Based at the University of Sydney, she was a well-respected contributor to the Australian and international microbiology, infectious diseases and infection control communities.
Perhaps most memorable were Prof. Cossart’s down to earth presentations provided to Sydney Hospital infection control participants from the late 1980s onwards. Yvonne was incredibly approachable, knowledgeable and innovative. She inspired and mentored several higher degree recipients and early infection control professionals alike. On behalf of many of those original NSW ICPs the majority of whom are now retired, I would like to extend our respect and sympathies to Yvonne’s family and professional colleagues at this sad time. RIP Prof. Cossart, Australian infection prevention is better for having known you and perhaps ACIPC Executive may wish to consider an ongoing tribute to you.
Dr Cathryn Murphy RN MPH PhD CIC
Executive Director
Infection Control Plus Pty Ltd
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Dear Jayne,
I know this may not be a nice comment — and I do apologise for this — but would it perhaps be possible in your setting to argue that it is common sense to not leave an alcohol pad on the blood culture bottle top, rather than adding to the (presumably already) high number of policy and procedure documents that are typical of most of our healthcare settings?
What saddens me — and this seems to be a global phenomenon — is that (a) good clinical instruction (e.g. someone simply showing a trainee how to take a blood culture when the trainee is supposed to do that for the first time ever), and (b) simple common sense, are increasingly replaced by formalistic rules and Policies and Procedures.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Colleagues,
Does anyone know of a standard or have a policy for taking blood for culture? I recently observed ( during hand hygiene auditing) a blood collector take the blood then insert the blood into the collection bottles with the alcohol swab still on the top? As I cannot find a policy or work directive I was hoping the brains trust could enlighten me? My own practice be it a few years ago now I would have cleaned the top with the alco wipe then discarded it and allowed the alcohol to dry before then inserting the blood, am I just behind the times? More importantly would this skew the result?
Look forward to hearing your responses
Jayne
Jayne Oconnor RN, BSc IFC, Cert V TAE
CNC IPC
Sydney Adventist Hospital
185 Fox Valley Rd,
Wahroonga,
NSW 2126Tel (02) 9487 9433
Mob 0406752685
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Dear Fiona,
Here at our institution, we are currently using this reference:
Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp Infect. 2002 Jun;51(2):79-84.
http://www.ncbi.nlm.nih.gov/pubmed/12090793Realising that it is very difficult to set and apply acceptable CFU limits, and there always will be an arbitrary component to this.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear members,
I know that air sampling in a new building is a contentious issue but we are currently undergoing it as part of the commissioning process for new operating theatres and one of the difficulties I face is people asking for the acceptable limit of certain organisms. Aside from fungal organisms I have been unable to find any references to guide me on specific organisms counts.
I would like to hear people’s views on the isolation of skin or environmental flora when doing this sampling – how many CFU would be acceptable per air sample ?
Fiona De Sousa
Infection Prevention & Control Coordinator
Sydney Adventist Hospital
Fiona.Desousa@sah.org.au
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Hi Beth,
It seems entirely reasonable to have one unnecessary component there and use a particular preparation across the unit for the sake of standardising and rationalising the procedures.
Sorry, asking out of curiousity. While for vial tops (etc.) the small pre-packaged alcohol swabs (e.g. those used for venipuncture and blood-taking) would be sufficient in size and alcohol amount, and quite cheap (the last time I looked one cost about a cent), one would need different sizes/preparations for, e.g. inserting a central line, simply due to the greater area needing antisepsis, and the more thorough application required.
How do you manage this?
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387—–Original Message—–
Hi Kath
While acknowledging that the addition of Chlorhexidine to alcohol adds no additional benefit for the purpose of vial disinfection, having access to both combination Chlorhexidine and alcohol impregnated swabs and plain alcohol swabs increases the risk of inappropriate skin antisepsis. It is for this reason that we have removed plain alcohol based swabs completed and only stock Chlorhexidine and alcohol swabs. This does have a cost implication but on balance for considered to be insignificant compared to the risk associated with line-associated sepsis.
Regards
BethBeth Bint
Infection Prevention and Control Clinical Nurse Consultant | Infection Management and Control Service Level 1 Lawson House Wollongong Hospital Tel 02 4222 5898 |beth.bint@SESIAHS.HEALTH.NSW.GOV.AU
http://www.health.nsw.gov.au
________________________________________Dear Chris,
Dr Matthias Maiwald posted a very comprehensive response in relation to a very similar query on the list Thursday last week which you may wish to access from the archives. I have pasted a paragraph from Dr Maiwald’s post for your information:
But please bear in mind that the addition of chlorhexidine to the alcohol for swabbing the vial tops is absolutely unnecessary. The chlorhexidine adds next to nothing for the purpose of disinfecting vial tops, and pure alcohol (e.g. 70% isopropanol such in sterile prepackaged alcohol pads) is all that is needed. What the chlorhexine would add would be persistency, which is an advantage for skin antisepsis for longer procedures, but you don’t need persistent antiseptic action on vial tops.
Chlorhexidine gluconate kills a range of Gram positive and Gram negative bacteria, viruses and fungi, and binds to the top layer of the skin, which results in persistent activity. Persistence of the antimicrobial effect suppresses the regrowth of residual skin flora, as well as suppressing transient micro-organisms contacting the prepped site. Alcohol has a rapid effect but no residual effect. If you would like further information regarding appropriate uses for chlorhexidine gluconate, please refer to the CHRISP website.
The TGA recommends wiping the outer surface of the rubber stopper and injection site with a suitable disinfectant wipe/swab and allowing it to dry before inserting any device into it. Queensland Health recommend the suitable disinfectant for this purpose is a 70% alcohol impregnated swab.
Please find a copy of the related poster attached to this reply.
Kind regards,
KathCHRISP, Communicable Diseases Unit | Chief Health Officer Branch Health Service and Clinical Innovation Division | Department of Health | Queensland Government Level 1, 15 Butterfield St, Herston, QLD 4006 PO Box 2368, Fortitude Valley, QLD 4006 t. 07 33289755 e. chrisp@health.qld.gov.au | http://www.health.qld.gov.au
[cid:image001.png@01CFC2AF.19BA7870] [cid:image002.png@01CFC2AF.19BA7870] [cid:image003.png@01CFC2AF.19BA7870]
[cid:image004.png@01CFC2AF.19BA7870]——– Original Message ——–
CC:[Posted on behalf of Chris Lawson – Moderator] Hi,
Following the release of the below we have had some suggestion that only alcohol swabs should be available for use. that we should remove chlorhexidine swabs altogether from practice. Can I have some feedback fro the group please.
Regards
Chris Lawson
Caboolture Private HospitalSent from my iPad
Begin forwarded message:
Dear All
On 7 July 2014 the Therapeutic Goods Administration (TGA) updated their website to include details of the ongoing investigation into the potential contamination with Ralstonia species of some vials of propofol 1% emulsions for injection. This website update included the advice that the exterior surfaces of injection vials are not intended to be sterile and that health professionals are reminded that proper aseptic technique must be strictly followed when administering intravenous injections to a patient. This includes wiping the outer surface of the rubber stopper and injection site with a suitable disinfectant wipe/swab and allowing it to dry before inserting any device into it. http://www.tga.gov.au/safety/alerts-medicine-provive-mct-lct-140707.htm
CHRISP have developed the attached poster to assist facilities to educate clinicians that the rubber stopper of vials under the plastic flip lid is not intended to be sterile and should be wiped with a 70% alcohol impregnated swab and allowed to dry prior to accessing. This will also be published on the CHRISP website in the near future: http://www.health.qld.gov.au/chrisp/default.asp
Please disseminate to other areas of your facility as appropriate.
Kind regards, Mareeka Gray
CHRISP
(Centre for Healthcare Related Infection Surveillance and Prevention) Communicable Diseases Unit | Chief Health Officer Branch Health Service and Clinical Innovation Division | Department of Health | Queensland Government Level 3, 15 Butterfield St, Herston QLD 4006 PO Box 2368, Fortitude Valley, QLD, 4006 t. 07 33289755 e. CHRISP_TB@health.qld.gov.au | http://www.health.qld.gov.au********************************************************************************
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Dear Rachel,
In response to your question, I would first like to address the primary question, then go on to skin antisepsis for spinal procedures.
If the vials are indeed contained within a sterile package, and the sterility of the packaging can be verified, then there is absolutely no need to swab the tops of the vials, unless there is a potential contamination between unpackaging and use.
For most vials (that I know — that are NOT contained within sterile packaging) I would exactly support the TGA’s statement as cited in italics in your e-mail.
But please bear in mind that the addition of chlorhexidine to the alcohol for swabbing the vial tops is absolutely unnecessary. The chlorhexidine adds next to nothing for the purpose of disinfecting vial tops, and pure alcohol (e.g. 70% isopropanol such in sterile prepackaged alcohol pads) is all that is needed. What the chlorhexine would add would be persistency, which is an advantage for skin antisepsis for longer procedures, but you don’t need persistent antiseptic action on vial tops.
The use of skin antiseptics before spinal/epidural anaesthesia is another issue. There are a handful of reported cases of severe adhesive arachnoiditis (and permanent disability) following the use of chlorhexidine/alcohol skin antiseptic before spinal/epidural anaesthesia, some of which are discussed in Bogod’s editorial that you have attached.
As Bogod is discussing, in some cases the causation is obvious. The CHG/ALC has been confused with the anaesthetic and a significant quantity been injected in the spinal canal. The pathogenesis in these cases is very obvious. CHG is known to be neurotoxic, and 70% alcohol is a very aggressive substance when coming into contact with mucous membranes or when entering body cavities. In this regard, the alcohol probably contributed significantly to the pathogenesis. What this means is that in the cases where CHG/ALC was injected, the pathogenesis is clear, biological plausibility is established, and this would have happened with any (not just CHG-containing) skin antiseptic.
Several other cases remain unclear, where it is NOT obvious and/or has not been able to be clarified whether any skin antiseptic has actually been injected in the spinal canal, or whether the skin antiseptic was just (!) present on the skin surface before injection, mainly because the events leading up to the incident would not be properly reconstructed. In one of the cases (cited by Bogod) it was reconstructed that about 0.1 mL (100 uL, a non-trivial amount) was apparently accidentally injected.
For cases where CHG/ALC has been properly applied and dried (as per usual recommendations) before spinal/epidural injections, biological plausibility for linking CHG/ALC with the pathogenesis is — in my personal opinion — not clearly established.
In a hypothetical scenario where the skin antiseptic has not yet dried, I have calculated previously (that was in an earlier Infexion Connexion e-mail concerning skin antisepsis before injections) that the amount that can be brought in with a needle bore would be in the nanolitre range (one nanolitre is 0.000001 mL).
In another hypothetical scenario where the skin antiseptic has dried, the amount should be orders of magnitude lower than that.
A similar calculation (but with a bigger epidural needle bore) has been made by Tilakaratna in a letter to the editor in 2009:
http://bja.oxfordjournals.org/content/103/3/456.full/reply#brjana_el_5066
As an unexplored issue remains whether potential capillary action along the sides of the needles could suck in a solution, but this would only apply if the antiseptic has not dried.
So, these are some of my points.
Some additional points regarding CHG + ALC and/or persistency requirements on skin (see also above, concerning persistency required on vial tops) are made in our recent commentary article in JAC:
Maiwald M, Chan ESY (2014) Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother 69: 2017-21.
http://dx.doi.org/10.1093/jac/dku121It would in turn be interesting to hear what you briefly touch upon, what recommendations ANTT frameworks have in terms of alcohol + CHG, and what ANTT recommends concerning epidural/ nerve infusion management.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi all,
I am very interested in input from list subscribers to the issue surrounding use of wipes containing 70% alcohol and 2% CHG to clean the tops of vials prior to injecting or drawing up. Most subscribers would be aware of the adverse events reported in relation to injection of alcoholic CHG into an epidural that has altered practices in relation to insertion and management of epidurals. This concern has resulted; it appears, in a real concern in relation to the use of wipes on any equipment used in the management of epidurals. Please refer to the attached editorial. As the bottles of solution used are presented in a sterile form (sealed sterile packaging) we have recommended that the tops of these vials do not need swabbing prior to use. There do appear, however, to other real concerns relating to the potential for adverse events relating to both epidural and nerve infusions and possible contamination with chlorhexidine residues.
Can I ask if anyone would like to make comment on your approach to this concern?
I flag for those who may not be aware the information provided from the TGA in July 2014 when the TGA investigated a number of reported cases of an unusual infection that were associated with propofol (Ralstonia spp.). As a result of this specific investigation the TGA issued a statement which included the following general information;
“The exterior surfaces of injection vials are not intended to be sterile. Most protective lids do not guarantee sterility of the outer surface of a vial rubber stopper/aluminium crimp seal. This lid is intended to act as a shield for the rubber stopper and to keep dust and other physical contaminants away from it.
Noting this, health professionals are reminded that proper aseptic technique must be strictly followed when administering intravenous injections to a patient. This includes wiping the outer surface of the rubber stopper and its injection site with a suitable disinfectant wipe/swab and allowing it to dry before inserting any device into the vial.http://www.tga.gov.au/safety/alerts-medicine-provive-mct-lct-140707.htm#.U8h3DZSSxQE
As ANTT frameworks recommend the use of alcohol + CHG, any comments or advice pertaining to ANTT and epidural/ nerve infusion management and your organisations/ health service risk management approach would be most appreciated .
Many thanks in advance
Kind regards
Rachel……………………………………………………………………………..
Rachel Thomson
Nurse Unit ManagerInfection Prevention & Control Unit
Royal Hobart Hospital
Tasmanian Health Organisation-South
*: 03 62227882/8658Level 4, H Block
48 Liverpool Street
Hobart, 7000________________________________
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Hi Michael,
Some of the answers to your questions follow by logical extension from the 2009 WHO Hand Hygiene Guidelines (surgical hand preparation is covered in pages 54-60), although not quite in the format that you are looking for. WHO states that it is not necessary to wash hands before the surgical preparation unless they are visibly dirty (p. 56 bottom). It may then be up to an individual organisation to adapt the guidelines for its institutional use, e.g. to make sure that no one who has e.g. returned from a toilet break ‘slips through the cracks’ (i.e. to err on the stricter side).
Note that contrary to some statements that I have seen — and this should, of course, not affect the general recommendation to wash if hands are visibly dirty — it is reassuring to know that alcohol is able to cope with small (!) amounts of organic dirt/contamination:
Larson E, Bobo L. Effective hand degerming in the presence of blood. J Emerg Med. 1992 Jan-Feb;10(1):7-11.
http://www.ncbi.nlm.nih.gov/pubmed/1629595It needs to be re-emphasised that it is important to keep the hands and forearms wet with alcohol — by liberally applying it — during the entire hand preparation procedure. Recommendations by some manufacturers/organisations to use ridiculously small amounts, e.g. ~6 mL for the entire procedure, including forearms, are outright dangerous and put patients at risk.
I have discussed this aspect in a previous letter to the editor:
Maiwald M. Technique is important for alcohol-based surgical hand antisepsis. Healthcare Infection, 2012; 17: 106-107.
http://dx.doi.org/10.1071/HI12028The importance of applied volume is also being shown in a recent article by the Kampf group:
Kampf G, Ostermeyer C. Small volumes of n-propanol (60%) applied for 3 minutes may be ineffective for surgical hand disinfection. Antimicrob Resist Infect Control. 2014 Apr 24;3:15. doi: 10.1186/2047-2994-3-15. eCollection 2014.
http://www.ncbi.nlm.nih.gov/pubmed/24822090Note that due to methodological issues with testing standard EN 12791 (the one used by Kampf), the volumes in that paper are only needed to cover the hands, not the forearms (this is not well explained in the article). For a real surgical hand preparation, one needs extra volume above what is stated in the Kampf paper to cover the forearms, too.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi all
I am wondering if anyone has developed a full protocol for waterless ‘surgical scrub’ that covers issues like hand hygiene post toilet breaks, meal breaks, ward rounds, etc, prior to further waterless agent use. Our current protocol merely recommends a full social hand wash with soap and water prior to the first waterless surgical skin antisepsis of the day (or when hands are visibly dirty), but does not address any of the above scenarios. We have different observed behaviours amongst clinicians currently, but it has been difficult to find guidelines addressing these issues.
Also, does anyone enforce a social hand wash with soap and water AFTER every procedure (ie after removal of gloves and other PPE)?
I find it amazing that professional bodies for operating room professionals in Australia have not addressed these issues to date.
Thanks for any help or discussion on this.
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
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Dear Rita,
Another possibility is the Canadian-based “Webber Teleclass” series of infection control lectures:
http://www.webbertraining.com/
Some of the lectures are free (typically when sponsored, e.g. by a company, also the WHO sponsors some), other lectures require a subscription fee to listen to.
Also, sometimes there are SHEA/ECCMID/(ASID) courses in infection control; one may watch out for such course advertisements.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Bug Control do seminars for Leading Age Services in Sydney- Prevention and Control of an outbreak in Residential Care , Infection Control in Residential Aged Care Day 1 & 2. Contact phone number for LASA is 02 9291 1117
We also do onsite education and have attached a flyer for your perusal.
Kind Regards
Mandy Bain
Office Administration[Description: High Res – Screen]
Bug Control (Aust) Pty Ltd
Infection Control Advisory Service
PO Box 406 GORDON NSW Australia 2072
Phone 9418 1917
Fax 9499 6786
info@bugcontrol.com.au
http://www.bugcontrol.com.auDear All,
Can you recommend some courses that can be attended by staff who have either newly entered into infection control or may have been working as infection control nurses for a couple of years.
Thank you for your time,
Rita
PS We are in the Northern Sydney Local Health District
Rita RoyClinical Nurse Consultant | Infection Control
Hornsby Ku ring gai Health Service, Palmerston Road, Hornsby NSW 2077
Tel (02) 9477 9232 | Fax (02) 9477 9013 | Mob 0422 930 370 | Rita.Roy@health.nsw.gov.au
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Hi Glenys,
There is certainly a point to be made to use something that is commonly used and/or mentioned in guidelines. Just bear in mind that guidelines do not operate in a “vacuum”, and in the Scottish recommendation that you cite, based on the literature that they analysed and cited within the document, the support for >>EXACTLY<< 2% chlorhexidine and 70% isopropanol is underwhelming, to say it mildly.
Based on the published antimicrobially active concentration ranges of antiseptics and what is usually used in products for this purpose, the 2% chlorhexidine 70% isopropanol combination is clearly an excellent choice — with this I agree wholeheartedly — but there are also other possible and reasonable concentration choices. Also, again, bear in mind that the question of chlorhexidine + alcohol versus povidone-iodine + alcohol for surgical skin antisepsis (which is what we are talking about) is unresolved.
As mentioned in my earlier comment, the focus on exactly 2% chlorhexidine was also part of a recent US healthcare scandal.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women's and Children's Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Michael,
This may be the case in terms of what is available in Australia. Hence hospital using either of these products for surgical skin preparation would be wise to undertake an "offline risk assessment" until the manufacturer/supplier has the correct TGA registration as this may take some time as a significant amount of data is required for such registration.
In addition hospital would also be wise to stick with a preparation that is recommended in the current literature (all be there is some debate about the methodology of these studies) and a product that is has been recommended by others rather than a preparation that at this point in time is recommended for skin antisepsis prior to insertion of intravascular devices.
I see the NHS recommended 2% Chlorhexidine and Alcohol for surgical skin preparation in there "High Impact Intervention Care Bundle to Prevent Surgical Site Infection" link below
Ensure that 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is used for skin preparation (if patient sensitive, use povidone-iodine)
http://www.documents.hps.scot.nhs.uk/hai/infection-control/evidence-for-care-bundles/key-recommendations/ssi/ssi-rec-6.pdfRegards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Hi Glenys
Agreed. The main problem is that the only formulations of chlorhexidine and alcohol that are tinted red (both 0.5% and 2% chlorhexidine content) available in Australia are all from the same manufacturer and all only licensed by TGA for hard surface disinfection. The red tint is a specific requirements for some surgeons to enable them to easily visualise where the skin has been prepped.
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email5th May 2014
Hi Michael,
Until companies have their products correctly registered with the TGA (inclusive of the purpose of use and labelling) users (i.e. hospitals/surgeons) assume liability for any injuries resulting from any “off-label use”.
As it is difficult to find any recommendations or publications supporting the use of >0.5% chlorhexidine and Alcohol for surgical skin preparation at this point in time hospitals would be wise to undertake an “offline risk assessment” and have it endorsed by their Infection Control committee before proceeding.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Hi Matthias
I believe the labelling of the solution in question is more about TGA licensing than the actual formulation of the solution. That has been discussed here previously on this list. The manufacturer of that product has never explicitly stated you cannot use this solution for skin antisepsis, only that it is not current licensed for this use. A vexing issue indeed.
Cheers
MichaelMichael Wishart
Infection Control Coordinator
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@svha.org.au
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email5th May 2014
Hi Glenys,
Thank you very much for these additional points.
I would like to add a few points for clarification.
It is indeed the case that the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be automatically inferred to surgical skin preparation. Apart from the IHI document that you cited (apparently specifying 2%; I have not yet seen the document), there does not seem to be a widely specified CHG percentage (supported by data) to be added to the alcohol that is available in guidelines.
The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for surgical skin preparation that the combination of 1% iodine and 70% alcohol (i.e. two antiseptics) performs better than a combination of 0.5% CHG and 70% alcohol (i.e. two antiseptics). Note that the type of iodine and the alcohol types have not been specified in that study. These results seem congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC versus CHG+ALC).
The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two antiseptics) performs better than 10% povidone-iodine alone (i.e. only one antiseptic). For anyone who has followed the microbiological literature on antiseptics (which spans many decades), the outcome of this trial was hardly surprising, because this is a massively unequal comparison: two antiseptics against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it indeed looks like the scientific part of the Darouiche trial is solid (as you state).
The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol is any inferior to 2% CHG with alcohol (or vice versa).
I have not suggested to use alcohol alone for surgical skin preparation; the combinations of either CHG+ALC or PVI+ALC have clear benefits of being combination antiseptics with enhanced activity. What I was suggesting is that people should get less hung up about the role of CHG in the CHG+ALC combination. The microbiological properties of skin antiseptics have been studied for over 100 years (e.g. Harrington and Walker. Boston Medical and Surgical Journal. 1903; 148: 548-52), and a wealth of information particularly came from studies done in the 1970s and 1980s. From this branch of the literature, the microbiological properties of the various skin antiseptics are well defined. Alcohols are known to be far superior in their immediate antimicrobial activity than either CHG or PVI. While evidence from clinical trials is clearly the best evidence, this evidence CANNOT be assessed in isolation, and it is necessary — while assessing evidence — to have a holistic picture with taking the necessary scientific background (in this case: microbiological background) and the principles of biological plausibility into account. That this was not commonly done in evidence assessments for skin antisepsis — and people focussed blindly on clinical trial outcomes — is presumably the reason for the massive, large-scale medical literature error that we described in our PLoS One (2012) article and subsequently commented upon further in our recent J Antimicrob Chemother (2014) article.
The advice “Do not use to disinfect surfaces likely to come in contact with broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you mention presumably simply means that alcohol-containing antiseptics are unsuitable to be used on wounds (also mucous membranes).
The range of CHG concentrations that I have seen in CHG+ALC combinations for surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one particular manufacturer. The 4% CHG concentration would be typical of aqueous CHG antiseptics (as John Ferguson states).
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Matthias,
To access IHI information – you just need to register and then you can get access to information such as the How to Guides – it’s free.
We should clarify for those following this thread that the CDC reference to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol…………….” is referring to skin preparation for intravascular devices not surgical (preoperative) skin preparation – extract from guidelines below.
Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
* “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives [82, 83]. Category IA”
While there may be supportive evidence for >0.5% chlorhexidine and alcohol preparations for the prevention of catheter-related bloodstream infections we shouldn’t assume that this will necessarily be the case for reducing surgical site infections(SSIs). Hence until we see the studies that clearly demonstrate that alcohol alone is better that CHG and alcohol, Iodine and alcohol, CHG alone or Iodine alone for surgical (preoperative) skin preparation to prevent surgical site infections we should be cautious about what we suggest people focus on.
This recent publication from St Vincent’s Hospital, Melbourne may be of interest to those considering a 0.5% CHG and alcohol preparation for surgical (preoperative) skin preparation
The study showed that patients who received skin prep with 0.5% chlorhexidine and alcohol prior to orthopaedic surgical procedures were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.
Carroll K. et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection, Volume 20, Issue 2, pages 130-135, February 2014
* “The study was performed over an 18-month period (January 2011 to June 2012) and included 964 patients undergoing prosthetic hip or knee replacement surgery
* In the multivariable logistic regression analysis patients who received skin prep with 0.5% chlorhexidine and alcohol were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.
* The authors acknowledge findings may reflect surgeon preference and experience and that skin prep requires more evaluation/RCT”.
*
Thanks for forwarding the ProPublica scandal publication, very interesting reading.I see the US company concerned settled with the US Dept of Justice avoiding criminal charges for allegations of fraud against the government and the product is now approved by the FDA as outlined in a US Department of Justice Press Release titled “CareFusion to Pay the Government $40.1 Million to Resolve Allegations That Include More Than $11 Million in Kickbacks to One Doctor” on Thursday, January 9, 2014:
* ” The settlement resolves allegations that, under agreements entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses and recommends standardized health care performance measures and practices. The government contends that the purpose of those payments was to induce Denham to recommend, promote and arrange for the purchase of ChloraPrep by health care providers. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
* “This settlement also resolves allegations that, during the period between September 2009 and August 2011, CareFusion knowingly promoted the sale of ChloraPrep for uses that were not approved by the Food and Drug Administration, some of which were not medically accepted indications, and made unsubstantiated representations about the appropriate uses of ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
http://www.justice.gov/opa/pr/2014/January/14-civ-021.html
http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdfIn addition the product concerned has also been registered with the TGA in Australia and is on the ARTG list for use as “Sterile tinted antiseptic applied to patient’s skin prior to invasive medical procedures”.
While the FDA discredited the NEJM publication in court proceedings as outlined at the ProPublica link I don’t see where the publication it has been discredited by the NEJM nor the U.S. National Institutes of Health, Clinical Trials Unit who approved the trail?
Given that the allegations of impropriety and kickbacks where towards Dr. Charles Denham, who was not an author of the NEJM publication and the trail was a randomized, double-blind, placebo-controlled trial and conflicts of interest were disclosed the results and conclusion below may still be valid.
Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.
Results
“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P 0.008) and deep incisional infections (1% vs. 3%, P 0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups”.
Conclusion
“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)
In addition I think you will find in the US that there are only 2 concentrations of CHG and alcohol available for surgical (preoperative) skin preparation – 2% or 4 % – happy to be corrected.
In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that I think jenny is referring to states the following on their users product guide:
* Do not use to disinfect therapeutic devices.
* Do not use to disinfect surfaces likely to come in contact with broken skin.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Hi Glenys,
Interesting. I had not yet seen the IHI Project JOINTS website. Some of the contents seem to be behind a login-wall, though.
The “2%” CHX specified percentage brings up an interesting issue; there was a recent US healthcare scandal in which it is alleged that an ex committee member of the US National Quality Forum (NQF) inappropriately influenced the NQF towards a 2% CHG-containing solution, at a time when only one manufacturer provided that particular percentage (meaning a 2% endorsement would direct consumers towards that manufacturer’s product) and at a time when there was no clear evidence to prefer a particular CHX percentage over another (as John Ferguson states).
http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group
People should not get so focused on the CHX component; as I have often emphasised, it is known from many decades of microbiological testing both in vitro and on human skin that alcohols, when well formulated, are about 10 times more microbiologically effective than CHX.
Interesting, the second reference (2014 Update) lists routine preoperative CHX showering/bathing/wiping as an unresolved issue. While this practice is supported by a good microbiological rationale (and those who know me know that I like microbiological rationales), it is not yet quite established whether this translates into better clinical outcomes. Note, this is different from specific preoperative decolonisation of MSSA/MRSA cariers, which seems indeed to translate into better outcomes. Also, for classical skin antisepsis (‘skin prep’) as discussed above, it is also well established that this translates into outcomes.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Jenny,
Sorry to join the discussion in relation to surgical preoperative skin preparation late.
Your surgeons request may relate to the Institute of Healthcare Improvement (IHI) Project JOINTS.
http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.aspxIn addition to the interventions recommended by the Surgical Care Improvement Project (SCIP) (i.e. appropriate use of prophylactic antibiotics, appropriate hair removal…..and so on) Project JOINTS recommends the following interventions for elective hip and knee arthroplasty procedures:
1. Use of an alcohol-containing antiseptic agent for preoperative skin preparation.
Hospitals participating in the IHI Project JOINTS are using one of the following surgical preoperative skin preparations (personal communication):
o 2% CHG plus alcohol
* 10% Iodophor plus alcohol
You can find additional information in the IHI Project JOINTS, “How to Guide” including the following.* IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty: “The combination of a long-acting agent (either an iodophor or CHG) is better than povidone iodine alone for preventing SSI. There is insufficient evidence to support recommending the use of one combination agent over another”.
2. Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery – most are using CHG wipes (personal communication).
3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers.In addition the recent publication from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update – Intervention number one is a Grade 1 (high) level of evidence recommendation and may be worth a read.
“Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (quality of evidence: I).
a. Alcohol is highly bactericidal and effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with chlorhexidine gluconate or an iodophor.115
i. Alcohol is contraindicated for certain procedures, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
b. The most effective disinfectant to combine with alcohol is unclear…….”.The publication is freely available online at the following link: http://www.jstor.org/stable/10.1086/676022
Your surgeon may want a tinted product so he/she can see where it has been applied, although any staining (tinted CHG or Idophor) may obscure signs of inflammation post-operatively.
regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426thankyou to everyone who responded to my question – its given me a great basis for discusssion with the ortho surgeon !!
________________________________
Hi John,I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.
One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Jenny
The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.
The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstractKind regards
JohnDr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this
Thanks
Jenny McCarthy
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Hi Glenys,
Thank you very much for these additional points.
I would like to add a few points for clarification.
It is indeed the case that the CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 state to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol” and that this cannot be automatically inferred to surgical skin preparation. Apart from the IHI document that you cited (apparently specifying 2%; I have not yet seen the document), there does not seem to be a widely specified CHG percentage (supported by data) to be added to the alcohol that is available in guidelines.
The Carroll et al. 2014 study (from Melbourne) shows (in a non-RCT) for surgical skin preparation that the combination of 1% iodine and 70% alcohol (i.e. two antiseptics) performs better than a combination of 0.5% CHG and 70% alcohol (i.e. two antiseptics). Note that the type of iodine and the alcohol types have not been specified in that study. These results seem congruent with those of Swenson et al. ICHE 2009; 30: 964-71 (iodine+ALC versus CHG+ALC).
The Darouiche et al. NEJM 2010 study clearly shows (in an RCT) for surgical skin preparation that a combination of 2% CHG with 70% isopropanol (i.e. two antiseptics) performs better than 10% povidone-iodine alone (i.e. only one antiseptic). For anyone who has followed the microbiological literature on antiseptics (which spans many decades), the outcome of this trial was hardly surprising, because this is a massively unequal comparison: two antiseptics against one, and the isopropanol in the 2%CHG/70%IPA trial arm outperforms either CHG alone or PVI alone by a factor of 10 (!). Apart from that, it indeed looks like the scientific part of the Darouiche trial is solid (as you state).
The Carroll et al. 2014 study and the Darouiche et al. 2010 study — even in synospsis — genuinely CANNOT be taken to infer that 0.5% CHG with alcohol is any inferior to 2% CHG with alcohol (or vice versa).
I have not suggested to use alcohol alone for surgical skin preparation; the combinations of either CHG+ALC or PVI+ALC have clear benefits of being combination antiseptics with enhanced activity. What I was suggesting is that people should get less hung up about the role of CHG in the CHG+ALC combination. The microbiological properties of skin antiseptics have been studied for over 100 years (e.g. Harrington and Walker. Boston Medical and Surgical Journal. 1903; 148: 548-52), and a wealth of information particularly came from studies done in the 1970s and 1980s. From this branch of the literature, the microbiological properties of the various skin antiseptics are well defined. Alcohols are known to be far superior in their immediate antimicrobial activity than either CHG or PVI. While evidence from clinical trials is clearly the best evidence, this evidence CANNOT be assessed in isolation, and it is necessary — while assessing evidence — to have a holistic picture with taking the necessary scientific background (in this case: microbiological background) and the principles of biological plausibility into account. That this was not commonly done in evidence assessments for skin antisepsis — and people focussed blindly on clinical trial outcomes — is presumably the reason for the massive, large-scale medical literature error that we described in our PLoS One (2012) article and subsequently commented upon further in our recent J Antimicrob Chemother (2014) article.
The advice “Do not use to disinfect surfaces likely to come in contact with broken skin” for the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that you mention presumably simply means that alcohol-containing antiseptics are unsuitable to be used on wounds (also mucous membranes).
The range of CHG concentrations that I have seen in CHG+ALC combinations for surgical skin preparation is 0.5% to 3.15% (the latter an odd number by one particular manufacturer. The 4% CHG concentration would be typical of aqueous CHG antiseptics (as John Ferguson states).
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Matthias,
To access IHI information – you just need to register and then you can get access to information such as the How to Guides – it’s free.
We should clarify for those following this thread that the CDC reference to “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol…………….” is referring to skin preparation for intravascular devices not surgical (preoperative) skin preparation – extract from guidelines below.
Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
* “Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives [82, 83]. Category IA”
While there may be supportive evidence for >0.5% chlorhexidine and alcohol preparations for the prevention of catheter-related bloodstream infections we shouldn’t assume that this will necessarily be the case for reducing surgical site infections(SSIs). Hence until we see the studies that clearly demonstrate that alcohol alone is better that CHG and alcohol, Iodine and alcohol, CHG alone or Iodine alone for surgical (preoperative) skin preparation to prevent surgical site infections we should be cautious about what we suggest people focus on.
This recent publication from St Vincent’s Hospital, Melbourne may be of interest to those considering a 0.5% CHG and alcohol preparation for surgical (preoperative) skin preparation
The study showed that patients who received skin prep with 0.5% chlorhexidine and alcohol prior to orthopaedic surgical procedures were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.
Carroll K. et al. Risk factors for superficial wound complications in hip and knee arthroplasty. Clinical Microbiology and Infection, Volume 20, Issue 2, pages 130-135, February 2014
* “The study was performed over an 18-month period (January 2011 to June 2012) and included 964 patients undergoing prosthetic hip or knee replacement surgery
* In the multivariable logistic regression analysis patients who received skin prep with 0.5% chlorhexidine and alcohol were at higher risk of superficial infection than those who received 1% iodine and alcohol, p0.012.
* The authors acknowledge findings may reflect surgeon preference and experience and that skin prep requires more evaluation/RCT”.
*
Thanks for forwarding the ProPublica scandal publication, very interesting reading.I see the US company concerned settled with the US Dept of Justice avoiding criminal charges for allegations of fraud against the government and the product is now approved by the FDA as outlined in a US Department of Justice Press Release titled “CareFusion to Pay the Government $40.1 Million to Resolve Allegations That Include More Than $11 Million in Kickbacks to One Doctor” on Thursday, January 9, 2014:
* ” The settlement resolves allegations that, under agreements entered into in 2008 by CareFusion’s predecessor, CareFusion paid $11.6 million in kickbacks to Dr. Charles Denham while Denham served as the co-chair of the Safe Practices Committee at the National Quality Forum, a non-profit organization that reviews, endorses and recommends standardized health care performance measures and practices. The government contends that the purpose of those payments was to induce Denham to recommend, promote and arrange for the purchase of ChloraPrep by health care providers. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
* “This settlement also resolves allegations that, during the period between September 2009 and August 2011, CareFusion knowingly promoted the sale of ChloraPrep for uses that were not approved by the Food and Drug Administration, some of which were not medically accepted indications, and made unsubstantiated representations about the appropriate uses of ChloraPrep. ChloraPrep has been approved by the Food and Drug Administration for the preparation of a patient’s skin prior to surgery or injection”.
http://www.justice.gov/opa/pr/2014/January/14-civ-021.html
http://www.ag.ny.gov/pdfs/Settlement_Agreement.pdfIn addition the product concerned has also been registered with the TGA in Australia and is on the ARTG list for use as “Sterile tinted antiseptic applied to patient’s skin prior to invasive medical procedures”.
While the FDA discredited the NEJM publication in court proceedings as outlined at the ProPublica link I don’t see where the publication it has been discredited by the NEJM nor the U.S. National Institutes of Health, Clinical Trials Unit who approved the trail?
Given that the allegations of impropriety and kickbacks where towards Dr. Charles Denham, who was not an author of the NEJM publication and the trail was a randomized, double-blind, placebo-controlled trial and conflicts of interest were disclosed the results and conclusion below may still be valid.
Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.
Results
“A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P 0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P 0.008) and deep incisional infections (1% vs. 3%, P 0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups”.
Conclusion
“Preoperative cleansing of the patient’s skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)
In addition I think you will find in the US that there are only 2 concentrations of CHG and alcohol available for surgical (preoperative) skin preparation – 2% or 4 % – happy to be corrected.
In Australia the supplier/manufacturer of the CHLORHEXIDINE 0.5% IN ALCOHOL 70% TINTED RED that I think jenny is referring to states the following on their users product guide:
* Do not use to disinfect therapeutic devices.
* Do not use to disinfect surfaces likely to come in contact with broken skin.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426Hi Glenys,
Interesting. I had not yet seen the IHI Project JOINTS website. Some of the contents seem to be behind a login-wall, though.
The “2%” CHX specified percentage brings up an interesting issue; there was a recent US healthcare scandal in which it is alleged that an ex committee member of the US National Quality Forum (NQF) inappropriately influenced the NQF towards a 2% CHG-containing solution, at a time when only one manufacturer provided that particular percentage (meaning a 2% endorsement would direct consumers towards that manufacturer’s product) and at a time when there was no clear evidence to prefer a particular CHX percentage over another (as John Ferguson states).
http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group
People should not get so focused on the CHX component; as I have often emphasised, it is known from many decades of microbiological testing both in vitro and on human skin that alcohols, when well formulated, are about 10 times more microbiologically effective than CHX.
Interesting, the second reference (2014 Update) lists routine preoperative CHX showering/bathing/wiping as an unresolved issue. While this practice is supported by a good microbiological rationale (and those who know me know that I like microbiological rationales), it is not yet quite established whether this translates into better clinical outcomes. Note, this is different from specific preoperative decolonisation of MSSA/MRSA cariers, which seems indeed to translate into better outcomes. Also, for classical skin antisepsis (‘skin prep’) as discussed above, it is also well established that this translates into outcomes.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Jenny,
Sorry to join the discussion in relation to surgical preoperative skin preparation late.
Your surgeons request may relate to the Institute of Healthcare Improvement (IHI) Project JOINTS.
http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.aspxIn addition to the interventions recommended by the Surgical Care Improvement Project (SCIP) (i.e. appropriate use of prophylactic antibiotics, appropriate hair removal…..and so on) Project JOINTS recommends the following interventions for elective hip and knee arthroplasty procedures:
1. Use of an alcohol-containing antiseptic agent for preoperative skin preparation.
Hospitals participating in the IHI Project JOINTS are using one of the following surgical preoperative skin preparations (personal communication):
o 2% CHG plus alcohol
* 10% Iodophor plus alcohol
You can find additional information in the IHI Project JOINTS, “How to Guide” including the following.* IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty: “The combination of a long-acting agent (either an iodophor or CHG) is better than povidone iodine alone for preventing SSI. There is insufficient evidence to support recommending the use of one combination agent over another”.
2. Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery – most are using CHG wipes (personal communication).
3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers.In addition the recent publication from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update – Intervention number one is a Grade 1 (high) level of evidence recommendation and may be worth a read.
“Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (quality of evidence: I).
a. Alcohol is highly bactericidal and effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with chlorhexidine gluconate or an iodophor.115
i. Alcohol is contraindicated for certain procedures, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
b. The most effective disinfectant to combine with alcohol is unclear…….”.The publication is freely available online at the following link: http://www.jstor.org/stable/10.1086/676022
Your surgeon may want a tinted product so he/she can see where it has been applied, although any staining (tinted CHG or Idophor) may obscure signs of inflammation post-operatively.
regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426thankyou to everyone who responded to my question – its given me a great basis for discusssion with the ortho surgeon !!
________________________________
Hi John,I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.
One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Jenny
The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.
The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstractKind regards
JohnDr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this
Thanks
Jenny McCarthy
Maryvale Private HospitalMaryvale Private Hospital Confidentiality and Privacy Notice
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Hi Glenys,
Interesting. I had not yet seen the IHI Project JOINTS website. Some of the contents seem to be behind a login-wall, though.
The “2%” CHX specified percentage brings up an interesting issue; there was a recent US healthcare scandal in which it is alleged that an ex committee member of the US National Quality Forum (NQF) inappropriately influenced the NQF towards a 2% CHG-containing solution, at a time when only one manufacturer provided that particular percentage (meaning a 2% endorsement would direct consumers towards that manufacturer’s product) and at a time when there was no clear evidence to prefer a particular CHX percentage over another (as John Ferguson states).
http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group
People should not get so focused on the CHX component; as I have often emphasised, it is known from many decades of microbiological testing both in vitro and on human skin that alcohols, when well formulated, are about 10 times more microbiologically effective than CHX.
Interesting, the second reference (2014 Update) lists routine preoperative CHX showering/bathing/wiping as an unresolved issue. While this practice is supported by a good microbiological rationale (and those who know me know that I like microbiological rationales), it is not yet quite established whether this translates into better clinical outcomes. Note, this is different from specific preoperative decolonisation of MSSA/MRSA cariers, which seems indeed to translate into better outcomes. Also, for classical skin antisepsis (‘skin prep’) as discussed above, it is also well established that this translates into outcomes.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Jenny,
Sorry to join the discussion in relation to surgical preoperative skin preparation late.
Your surgeons request may relate to the Institute of Healthcare Improvement (IHI) Project JOINTS.
http://www.ihi.org/engage/initiatives/completed/projectjoints/Pages/default.aspxIn addition to the interventions recommended by the Surgical Care Improvement Project (SCIP) (i.e. appropriate use of prophylactic antibiotics, appropriate hair removal…..and so on) Project JOINTS recommends the following interventions for elective hip and knee arthroplasty procedures:
1. Use of an alcohol-containing antiseptic agent for preoperative skin preparation.
Hospitals participating in the IHI Project JOINTS are using one of the following surgical preoperative skin preparations (personal communication):
o 2% CHG plus alcohol
* 10% Iodophor plus alcohol
You can find additional information in the IHI Project JOINTS, “How to Guide” including the following.* IHI Project JOINTS How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty: “The combination of a long-acting agent (either an iodophor or CHG) is better than povidone iodine alone for preventing SSI. There is insufficient evidence to support recommending the use of one combination agent over another”.
2. Preoperative bathing or showering with chlorhexidine gluconate (CHG) soap for at least three days before surgery – most are using CHG wipes (personal communication).
3. Staphylococcus aureus screening and use of intranasal mupirocin and CHG bathing or showering to decolonize Staphylococcus aureus carriers.In addition the recent publication from the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Practice Recommendations “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update – Intervention number one is a Grade 1 (high) level of evidence recommendation and may be worth a read.
“Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (quality of evidence: I).
a. Alcohol is highly bactericidal and effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with chlorhexidine gluconate or an iodophor.115
i. Alcohol is contraindicated for certain procedures, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
b. The most effective disinfectant to combine with alcohol is unclear…….”.The publication is freely available online at the following link: http://www.jstor.org/stable/10.1086/676022
Your surgeon may want a tinted product so he/she can see where it has been applied, although any staining (tinted CHG or Idophor) may obscure signs of inflammation post-operatively.
regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
infexion@ozemail.com.au
ABN 47533508426thankyou to everyone who responded to my question – its given me a great basis for discusssion with the ortho surgeon !!
________________________________
Hi John,I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.
One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Jenny
The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.
The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstractKind regards
JohnDr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this
Thanks
Jenny McCarthy
Maryvale Private HospitalMaryvale Private Hospital Confidentiality and Privacy Notice
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Hi John,
I was actually considering remaining in the background for this particular discussion. You make very good points. The (potentially) increased incidence of skin reactions is interesting information that may be worth publishing if you can.
One may want to bear in mind that different applications of skin antisepsis (e.g. blood culture collection, surgical skin prep, vascular catheter insertion) have different functional and physiological characteristics and requirements, and for surgical skin preparation (Jenny’s question), the question of chlorhexidine/alcohol versus povidone-iodine/alcohol is unresolved. Chlorhexidine/alcohol is an excellent choice, but iodine/alcohol should not be discounted for this purpose.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Jenny
The critical point is that when chlorhex is mixed with alcohol , there is no apparent benefit from exceeding 0.5%.
The old literature on 2% C and lines related to an aqueous preparation.
Furthermore, we found an increase in skin reactions to the more concentrated products (went to a poster).Matthias M will comment no doubt – he has recently published this piece that is of relevance – Maiwald M, Chan ESY. Pitfalls in evidence assessment: the case of chlorhexidine and alcohol in skin antisepsis (Leading Article). J. Antimicrob. Chemother. (2014) Advance Access.
http://jac.oxfordjournals.org/content/early/2014/04/28/jac.dku121.abstractKind regards
JohnDr John Ferguson
Infectious Diseases & Microbiology
+61 428 885573Hi Jenny,
There is lots of supportive evidence for 2%CHG in 70%IPA, particularly for invasive device skin preparation (CVC/PICC/PIVC,ICC/Epidural, etc,etc..)
Here is a link to Dr William Jarvis discussing the differences of various skin preps.
http://www.medscape.com/viewarticle/761489
There is both a video of the discussion..
To cut to the conclusion;
The findings were very interesting. Of greatest importance, the investigators found that all products (0.5% chlorhexidine with ethanol, 1% chlorhexidine with ethanol, and 2% chlorhexidine with isopropyl alcohol) were equally effective. This will be very helpful information when you are trying to select a product for preparation of the insertion site for intravascular catheters or for a preoperative surgical antiseptic. Chlorhexidine is effective, and different concentrations of chlorhexidine are equally effective, with no statistically significant difference in colony counts. All of these products should be equally beneficial to patients in preventing central line-associated bloodstream infections or surgical site infections.Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition Service
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
President, Australian Vascular Access Society
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital, Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 | Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.au“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve Jobs
________________________________Hi all – not sure if this has already been discussed and apologies if it has – one of the orthopaedic surgeons here is requesting Chlorhexidine 2% with 70% alcohol (tinted red) as opposed to the 0.5% with 70% alcohol for skin prep. Firstly, is there an advantage to using the 2% as opposed to the 0.5% and if so would anyone have any literature to support this
Thanks
Jenny McCarthy
Maryvale Private HospitalMaryvale Private Hospital Confidentiality and Privacy Notice
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Dear Yuk Yin,
The chlorhexidine-alcohol combination would seem a good choice for peripheral IV line insertion, because the main thing that chlorhexidine adds to the mix is persistency on skin, which is a benefit for anything that stays in place for a while. On the other hand, applications that do not require persistency (such as one-time venipuncture, ports access, etc.) do well with just alcohol. As has been discussed (I believe here on this forum?), it may make sense in terms of handling IV devices if a unit uses chlorhexidine-alcohol also for port access — in terms of streamlining procedures — because then staff handling IV devices have to remember only one type of antiseptic and it is less complicated.
Injections, venipuncture and blood culture bottle diaphragm disinfection will do well with just alcohol; no chlorhexidine required.
A while ago (I think early 2013) there has been a public hearing by the US FDA if skin antiseptics should generally manufactured to the level of being sterile. For simple alcohol pads (as you mention), this is apparently an easy process, but for more complex skin antiseptics, the manufacturing process (to the formal level of “sterile”) apparently becomes quite cumbersome and more expensive. I can’t quite remember what the outcome was, but several people who have exellent knowledge in the area told me that this is not necessary if the manufacturer ensures in the manufacturing process that bacterial spores are excluded/avoided during manufacturing, and has quality processes in place to monitor this. The reason is that alcohol is basically “autosterile” except for bacterial spores. If that can be verified with a manufacturer, then I think it would be safe to use chlorhexidine-alcohol.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear Matthias,
Thanks for your advice.
Sterile Alcohol wipe is common in my hospital for injection, venous puncture or IV ports access. Recently, we review and consider to introduce wipe of 2% chlorhexidine and 70% v/v isopropyl alcohol for IV peripheral line insertion. We found that the products available in the market is not sterile because chlorhexidine cannot undergo sterilization. Since it is not “sterile”, I have hesitation if it can also be used to disinfect IV ports or diaphragm of blood culture bottles.
Regards,
Ho Yuk Yin, APN/ICN
Infection Control Unit,
Tung Wah HospitalDear Ms/Mr Ho,
It can be used, provided that:
(a) the alcohol is in a sufficient concentration (at least 70% v/v ethanol or isopropanol would be required), and
(b) the alcohol wipes have been manufactured in a way that this excludes bacterial spore contamination.
Please note that for the purposes you describe, i.e. (i) to disinfect injection ports, and (ii) the diaphragms of blood culture bottles, the alcohol is the important component, not the chlorhexidine. For both purposes, alcohol wipes/swabs alone without the chlorhexidine would be sufficient.
The reason why bacterial spores need to be excluded is that the alcohol does not kill spores (actually none of the common antiseptics kills spores, also chlorhexidine does not), and this has to be taken care of during the manufacturing process. It helps if the swabs/wipes are specifically labelled as “sterile”, otherwise you may want to contact the manufacturer for further information.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear All,
I wonder if antiseptic wipe ” alcohol based 2% Chlorhexidine” that indicated for skin disinfection can be used to disinfect injection ports or diaphragm of blood culture bottles. Please advise.
Regards,
Ho Yuk Yin, APN/ICN
Infection Control Unit
Tung Wah Hospital________________________________
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Dear Ms/Mr Ho,
It can be used, provided that:
(a) the alcohol is in a sufficient concentration (at least 70% v/v ethanol or isopropanol would be required), and
(b) the alcohol wipes have been manufactured in a way that this excludes bacterial spore contamination.
Please note that for the purposes you describe, i.e. (i) to disinfect injection ports, and (ii) the diaphragms of blood culture bottles, the alcohol is the important component, not the chlorhexidine. For both purposes, alcohol wipes/swabs alone without the chlorhexidine would be sufficient.
The reason why bacterial spores need to be excluded is that the alcohol does not kill spores (actually none of the common antiseptics kills spores, also chlorhexidine does not), and this has to be taken care of during the manufacturing process. It helps if the swabs/wipes are specifically labelled as “sterile”, otherwise you may want to contact the manufacturer for further information.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Dear All,
I wonder if antiseptic wipe ” alcohol based 2% Chlorhexidine” that indicated for skin disinfection can be used to disinfect injection ports or diaphragm of blood culture bottles. Please advise.
Regards,
Ho Yuk Yin, APN/ICN
Infection Control Unit
Tung Wah Hospital________________________________
***************************************************************************
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Although this Email and any attachments are believed to be free of virus or other defects that might affect any computer system into which it is received and opened, it is the responsibility of the recipient to ensure that it is virus free, and no responsibility is accepted by the Hospital Authority for any loss or damage in any way arising from its use.
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Dear Fiona,
There was an earlier thread about this in Infexion Connexion and also in OzBug where this was discussed. Not sure when, but it might have been about 1-2 years ago. The gist was, and my take on it was, that scepticism is warranted.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387I have received a query regarding electrolysed water for use as a sanitising and cleaning agent for hand washing, environmental cleaning as well as food rinsing/cleaning. Apparently there are facilities that use this product so am wondering if anyone has a) heard about it and b) uses it for hand hygiene and environmental cleaning etc.
Regards
Fiona Wilson I CNC, Infection Control, TIPCU
Population Health Services I Department of Health and Human Services
Post GPO Box 125 Hobart Tas 7001 | Email tipcu@dhhs.tas.gov.au
Phone (03) 6222 7684 | Fax (03) 6233 0553
A fair and healthy Tasmania________________________________
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