Current Practices of Antiseptic Use in Canadian Neonatal Intensive Care Units.

OBJECTIVE: This article assesses the degree of variability in the current practice of skin antiseptics used in Canadian neonatal intensive care units (NICUs) and different experiences related to each antiseptic used. METHODS: An anonymous survey was distributed to a clinical representative of each of the 124 Canadian level II and level III NICUs. RESULTS: One hundred and two respondents (82.2%), representing all Canadian provinces, completed the survey. Chlorhexidine gluconate with/without alcohol was the antiseptic most used (96%) and the antiseptic with the highest reported adverse effects (68% reported skin burns/breakdown). Other antiseptics used include povidone-iodine (35%) and isopropyl alcohol (22%). Specific guidelines for antiseptic use were available in only 50% of the units with many NICUs lacking gestational and/or chronological age restrictions. Only 23% of responders believed that there was awareness among health care providers of the adverse effects of antiseptics used. Less than half (43%) were completely satisfied with the antiseptics used in their units. CONCLUSION: Chlorhexidine gluconate is the most commonly used antiseptic in Canadian NICUs. The high number of associated adverse effects and the lack of guidelines regulating antiseptic use are of concern. Large clinical trials are urgently needed to guide practice and improve the safety of antiseptics.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis.

BACKGROUND: Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine-alcohol is more protective against infection than is povidone-iodine. METHODS: We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. 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. CONCLUSIONS: 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.)

2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial.

OBJECTIVE: To determine whether 2% chlorhexidine gluconate-70% isopropyl alcohol (CHX-IA) is superior to 10% aqueous povidone-iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants. DESIGN: Randomised controlled trial. SETTING: Two neonatal intensive care units (NICUs). PATIENTS: Infants <31 weeks' gestation who had a CVC inserted. INTERVENTIONS: Insertion site was cleaned with CHX-IA or PI. Caregivers were not masked to group assignment. MAIN OUTCOME MEASURES: Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction. RESULTS: We enrolled 304 infants (CHX-IA 148 vs PI 156) in whom 815 CVCs (CHX-IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX-IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX-IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX-IA 0% vs PI 5%, p=0.003). CONCLUSIONS: We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX-IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings. TRIAL REGISTRATION: This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu).

Quantification of Induced Hypothermia from Aseptic Scrub Applications during Rodent Surgery Preparation.

Laboratory mice (Mus musculus) are prone to develop hypothermia during anesthesia for surgery, thus potentially impeding anesthetic recovery, wound healing, and future health. The core body temperatures of isoflurane-anesthetized mice are influenced by the choice of supplemental heat sources; however, the contribution of various surgical scrubs on the body temperatures of mice under gas anesthesia has not been assessed. We sought to quantify the effect of using alcohol (70% isopropyl alcohol [IPA]) compared with saline to rinse away surgical scrub on the progression of hypothermia in anesthetized mice (n = 47). IPA, room-temperature saline, or warmed saline (37 °C) was combined with povidone-iodine and then assessed for effects on core (rectal) and surface (infrared) temperatures. Agents were applied to a 2×2-cm shaved abdominal area of mice maintained on a water-recirculating blanket (at 38 °C) under isoflurane anesthesia (1.5% to 2.0% at 0.6 L/min) for 30 min. Although all scrub regimens significantly decreased body temperature at the time of application, treatments that included povidone-iodine led to the coldest core temperatures, which persisted while mice were anesthetized. Compared with room-temperature saline and when combined with povidone-iodine, warming of saline did not ameliorate heat loss. IPA alone demonstrated the most dramatic cooling of both surface and core readings at application but generated an unanticipated warming (rebound) phase during which body temperatures equilibrated with those of controls within minutes of application. Although alcohol is inappropriate as a stand-alone agent for surgical skin preparation, IPA is a viable alternative to saline-based rinses in this context, and its use should be encouraged within institutional guidance for rodent surgical procedures without concern for prolonged hypothermia in mice.

Saliva as an alternate for blood to measure concentrations of acetone under exposure to isopropanol.

OBJECTIVES: In occupational medicine, blood concentrations are often measured to judge the internal burden of workers at work-place during exposure to a potentially hazardous substance. However, blood-withdrawals are invasive and can often not be taken at work-place due to hygienic reasons. Sampling of saliva is non-invasive and easy to perform even at workplace. In order to substitute blood analysis, analysis of saliva has to be as specific and sensitive as blood investigations. Therefore acetone-concentrations in blood and in saliva during exposure to isopropanol were compared. METHODS: 18 healthy non-smokers were exposed to 360 ppm isopropanol in an exposure chamber over 4 h. Once an hour during exposure and 30 min after, blood and saliva were sampled. Saliva was collected by a cotton plug over 10 minutes and stored in an airtight closed headspace tube. Concentrations of the metabolite acetone were measured by gas chromatography. - RESULTS: The concentrations of acetone in blood and saliva rose continually during exposure and dropped after exposure-cessation. High correlations between concentrations of acetone in blood and saliva were found for each individual and the entire group (entire group: r = 0.8568, p <0.0001, y = 0.8374x - 0.4404). CONCLUSIONS: Acetone-measurement in saliva is a non-invasive, easily conductable and reliable method for estimating the internal burden of isopropanol-exposure. Further studies for the standardization and validation are necessary to impose a threshold limit value on work-place isopropanol-exposure.

Allergic contact dermatitis from iodine preparations: a conundrum.

Iodine preparations are widely used antiseptics, yet limited information exists on their irritant potential and threshold for diagnostic patch testing. We examine this issue by using iodine in different preparations and concentrations. A total of 24 fair-skinned, healthy volunteers without a history of iodine allergy, ranging in age from 18 to 65 years (mean age 49.5 + 10.7 SD), were recruited. Concentrations of 0.5%, 1%, 5% and 10% iodine in petrolatum (pet.), 0.5%, 0.75% and 1% iodine in 70% isopropyl alcohol (IPA) and 1%, 5%, 7.5% and 10% of povidone-iodine (PVP-I) were applied for 2 days to the intrascapular area on the back or to the volar forearm between cubital fossa and wrist using Finn Chambers on Scanpor. Test sites were read 2 days (D2) and 4 days (D4) after patch application. Skin reactions were graded according to the following scheme: 0 = no reaction, + = questionable erythema, 1 = definite erythema, 2 = erythema and induration and 3 = vesiculation. Mild-to-moderate reactions (+ to 2) were observed in 75% of the subjects patched with 5% iodine in pet. at 2-4 days after application. Almost all subjects reacted to 10% iodine at D2 and D4, with 65% exhibiting erythema and induration or vesiculation. A large number (33%) of the subjects developed some reactions to the low concentration (0.5%) of iodine in 70% IPA at D2. Vesicles were seen in 54% of the subjects patched with 1% iodine in 70% IPA at D4. Only 1 subject reacted to 7.5% and 10% PVP-I. Iodine can be irritant to normal skin in pet. and in 70% IPA. Pet. possibly enhances skin contact with iodine, thus increasing its irritant capacity. Alcohol removes sebum from the skin surface, and it might increase iodine penetration into the skin, causing a higher degree of irritation. PVP-I is relatively non-irritant, because its iodine is complexed in an iodophor. For diagnostic patch testing, we recommend using iodine at less than 1% in pet. and at less than 0.5% in 70% IPA. For PVP-I, 10% appears non-irritant. With the variation in patch-test irritant response, interpretation of the patch-test response in the light of clinical history is mandatory.

Contact dermatitis to alcohol swabs masquerading as vaccine allergy.

A 14-year-old girl developed an eruption on her upper arm of pruritic, follicular papules each time she received a vaccination. This was initially thought to be a local reaction to the vaccines. After a similar rash appeared at a venepuncture site, a contact allergy to the alcohol swabs used before the procedures was postulated. A repeated open application test clarified this observation.