Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Pediatric Eye Injuries by Hydroalcoholic Gel in the Context of the Coronavirus Disease 2019 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has made alcohol-based hand sanitizers (ABHS) widely available in public places. This may warrant determining whether cases of unintentional ocular exposure are increasing, especially in children. Objective: To describe the epidemiologic trend of pediatric eye exposures to ABHS and to report the severity of the ocular lesions. Design, Setting, and Participants: Retrospective case series conducted from April 1, 2020, to August 24, 2020. Cases were retrieved from the national database of the French Poison Control Centers (PCC) and from a pediatric ophthalmology referral hospital in Paris, France. Cases of ocular exposure to chemical agents in children younger than 18 years during the study period were reviewed. Cases of ABHS exposure were included. Exposures: The following data were collected: age, sex, circumstances of exposure, symptoms, size of the epithelial defect at first examination, time between the incident and re-epithelialization, and medical and/or surgical management. Main Outcomes and Measures: Comparison of the number of eye exposures to ABHS in children between April to August 2020 and April to August 2019. Results: Between April 1 and August 24, 2020, there were 7 times more pediatric cases of ABHS eye exposures reported in the PCC database compared with the same period in 2019 (9.9% of pediatric eye exposures in 2020 vs 1.3% in 2019; difference, 8.6%; 95% CI, 7.4-9.9; P < .001). The number of cases occurring in public places increased in 2020 (from 16.4% in May to 52.4% in August). Similarly, admissions to the eye hospital for ABHS exposure increased at the same period (16 children in 2020 including 10 boys; mean [SD] age, 3.5 [1.4] years vs 1 boy aged 16 months in 2019). Eight of them presented with a corneal and/or conjunctival ulcer, involving more than 50% of the corneal surface for 6 of them. Two cases required amniotic membrane transplant. Conclusions and Relevance: These data support the likelihood of an increasing number of unintentional ocular exposures to ABHS in the pediatric population. To maintain good public compliance with hand disinfection, these findings support that health authorities should ensure the safe use of these devices and warn the parents and caregivers about their potential danger for children.

How irritant are n-propanol and isopropanol? - A systematic review.

BACKGROUND: The use of alcoholic-based hand rubs (ABHRs) is an important tool for hand hygiene, especially in times of the COVID-19 pandemic. Possible irritant effects of ABHR may prevent their use by persons at risk of infection. METHODS: This systematic review is based on a PubMed search of articles published between January 2000 and September 2019 in English and German, and a manual search, related to the irritation potential of alcohol-based disinfectants restricted to n-propanol (1-propanol) and its structural isomer isopropanol (isopropyl alcohol, 2-propanol). RESULTS: The majority of the included studies show a low irritation potential of n-propanol alone. However, recent studies provide evidence for significant barrier damage effects of repeated exposure to 60% n-propanol in healthy, as well as atopic skin in vivo. The synergistic response of combined irritants, (ie, a combination of n-propanol or isopropanol with detergents such as sodium lauryl sulfate) is greater, compared with a quantitatively identical application of the same irritant alone. CONCLUSION: While recent studies indicate a higher risk of skin irritation for n-propanol and isopropanol than reported in the past, this risk still seems to be lower than that for frequent handwashing with detergents, as recommended by some to prevent COVID-19 infections.

Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study.

AIMS: We conducted a cross-sectional survey to estimate the prevalence and clinical manifestation of disulfiram ethanol reaction (DER) and isopropanol toxicity (IT) in patients with alcohol use disorders, on disulfiram. Alcohol-based hand rub contains either ethanol or isopropanol or both. COVID-19 pandemic has led to wide scale usage of sanitizers. Patients with alcohol use disorders, on disulfiram, might experience disulfiram ethanol like reactions with alcohol-based sanitizers. METHODS: We telephonically contacted 339 patients, prescribed disulfiram between January 2014 and March 2020. The assessment pertained to the last 3 months (i.e. third week of March to third week of June 2020). RESULT: The sample consisted of middle-aged men with a mean 16 years of alcohol dependence. Among the 82 (24%) patients adherent to disulfiram, 42 (12.3%) were using alcohol-based hand rubs. Out of these, a total of eight patients (19%; 95% CI 9-33) had features suggestive of DER; four of whom also had features indicative of IT. Five patients (62.5%) had mild and self-limiting symptoms. Severe systemic reactions were experienced by three (37.5%). Severe reactions were observed with exposure to sanitizers in greater amounts, on moist skin or through inhalation. CONCLUSION: Patients on disulfiram should be advised to use alternate methods of hand hygiene.

Contact Dermatitis from Hand Hygiene Practices in the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) pandemic continues to spread globally at a staggering speed. At present, there is no effective treatment or vaccine for COVID-19. Hand disinfection is a cost-effective way to prevent its transmission. According to the Centres for Disease Control and Prevention (CDC) guidelines, we should wash our hands with soap and water for at least 20 seconds. If soap and water are not readily available, alcohol-based hand rubs (ABHRs) with at least 60% alcohol are the alternative. With diligent hand disinfection reinforced during COVID-19, there is an increased prevalence of contact dermatitis. This commentary highlights the fact that contact dermatitis is a readily treatable condition and should not cause any deviation of proper hand hygiene. In irritant contact dermatitis (ICD), the management strategies are selection of less irritating hand hygiene products, frequent use of moisturisers to rebuild the skin barrier, and education on proper hand hygiene practices. In allergic contact dermatitis (ACD), the identification and avoidance of the contact allergen is the key to treatment. However, ACD is less common and only accounts for 20% of the cases. The identified allergens in hand cleansers are predominantly preservative excipients and ACD attributable to ABHR are very uncommon. Alcohol-free hand rubs are widely available on the market but it is not a recommended alternative to ABHRs by the CDC.

A Case Report of Isopropanol Ingestion During the SARS-CoV-2 Pandemic.

INTRODUCTION: Patients with substance use disorder may be particularly vulnerable to withdrawal-related complications during the SARS-CoV-2 (COVID-19) pandemic. Limited availability of alcohol and other substances coupled with decreased accessibility to substance use treatment poses a substantial risk to this population. Isopropanol, the active ingredient in rubbing alcohol, is widely available; thus, it may be used in times of scarcity. CASE REPORT: We present a case of intentional isopropanol ingestion used as an ethanol surrogate within the setting of the COVID-19 pandemic. CONCLUSIONS: Toxic alcohol ingestions are imperative considerations on the differential for the intoxicated patient particularly during resource-limited times.

Safety and efficacy of 2% chlorhexidine gluconate aqueous versus 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection prior to percutaneous central venous catheter insertion in preterm neonates: the ARCTIC randomised-controlled feasibility trial protocol.

INTRODUCTION: Catheter-related sepsis is one of the most dangerous complications of neonatal intensive care and is associated with significant morbidity and mortality. Use of catheter-care 'bundles' has reduced the incidence of catheter-related sepsis, although individual components have not been well studied. Better evidence is needed to guide selection of the most appropriate antiseptic solution for skin disinfection in preterm neonates. This study will inform the feasibility and design of the first randomised controlled trial to examine the safety and efficacy of alcohol-based versus aqueous-based chlorhexidine antiseptic formulations for skin disinfection prior to percutaneous central venous catheterisation in preterm neonates. The antiseptics to be compared are 2% chlorhexidine gluconate (CHG) aqueous and 2% CHG in 70% isopropyl alcohol. METHODS AND ANALYSIS: The Antiseptic Randomised Controlled Trial for Insertion of Catheters (ARCTIC) is a two-centre randomised-controlled feasibility trial. At least 100 preterm infants born at <34 weeks' gestation and due to undergo percutaneous insertion of a central venous catheter will be randomly allocated to receive prior skin disinfection with one of the two antiseptic solutions. Outcomes include: i) recruitment and retention rates; ii) completeness of data collection; iii) numbers of enrolled infants meeting case definitions for definite catheter-related sepsis, catheter-associated sepsis and catheter colonisation and iv) safety outcomes of skin morbidity scores recorded daily from catheter insertion until 48 hours post removal. The key feasibility metrics will be reported as proportions with 95% CIs. Estimated prevalence of catheter colonisation will allow calculation of sample size for the large-scale trial. The data will inform whether it will be feasible to progress to a large-scale trial. ETHICS AND DISSEMINATION: ARCTIC has been approved by the National Health Service Health Research Authority National Research Ethics Service Committee East of England (Cambridge South) (IRAS ID 163868), was adopted onto the National Institute of Health Research Clinical Research Network portfolio (CPMS ID 19899) and is registered with an International Standard Randomised Control Trials Number (ISRCTN: 82571474; Pre-results) and European Clinical Trials Database number 2015-000874-36. Dissemination plans include presentations at scientific conferences, scientific publications and sharing of the findings with parents via the support of Bliss baby charity. TRIAL REGISTRATION NUMBER: ISRCTN82571474; Pre-results.

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.

Toxic alcohol diagnosis and management: an emergency medicine review.

Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.

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.

The Activation Effects of Low Level Isopropyl Alcohol Exposure on Arterial Blood Pressures Are Associated with Decreased 5-Hydroxyindole Acetic Acid in Urine.

PURPOSES: The objectives of this paper are to study the impact of low level isopropyl alcohol exposure on blood pressure and to explore its potential mechanism. METHODS: This cross-sectional study was based on a prospective occupational cohort in south China, which focusing on occupational risk factors related cardiovascular health problems. A total of 283 participants (200 low isopropyl alcohol exposed workers and 83 controls) was finally enrolled in this study. Linear regression models were used to analyze the relationship between arterial blood pressures and low level isopropyl alcohol exposure. We used mediation method to explore possible mediated roles of neurogenic factors. RESULTS: Systolic blood pressure (SBP, 123±10 vs. 118±11), diastolic blood pressure (DBP, 79±7 vs. 74±7) and mean blood pressure (MBP, 93±8 vs. 89±9) were different between the exposed group and the control group (p < 0.01). After adjusting for covariates, the difference was still significant. Besides, isopropyl alcohol and smoking had an interactive effect on DBP and MBP (p < 0.05). Furthermore, we observed a mediated effect of 5-hydroxyindole acetic acid (5-HIAA) on isopropyl alcohol exposure induced arterial blood pressure increase, which accounted for about 25%. CONCLUSIONS: Our results suggest that low level isopropyl alcohol exposure is a potential risk factor for the increased arterial blood pressure and 5-HIAA partly mediates the association between low level isopropyl alcohol exposure and arterial blood pressures.

Differences in Cutaneous Irritation of Five Commonly Used Topical Products.

INTRODUCTION: Irritation, such as burning and stinging, on the site of application, is a common side effect of topical dermatologic products including creams, lotions, sprays, and foams. This effect may be more pronounced when applying products to atopic or psoriatic skin. The composition of the vehicle may affect the extent of the irritation. This study compared the irritation and erythema potential of 7 different topical dermatologic products to determine the products with the least likelihood of causing discomfort when applied.
METHODS: Seven sites on the anterior leg of 30 subjects were dry shaven with 10 upward strokes. Subjects rated the stinging of petrolatum (negative control), isopropyl alcohol (positive control), Cetaphil Lotion, triamcinolone 0.1% cream, triamcinolone 0.2% spray, betamethasone foam, and clobetasol 0.05% spray, 1 minute after product application, using a scale of 0 (no symptoms) to 10 (intolerable stinging/burning). The investigator assessed erythema at the sites 30 minutes after application of the products using a scale of 0 (none) to 4 (severe).
RESULTS: Stinging rating score of each product was statistically significant from one another. Petrolatum produced the least stinging (0) and isopropyl alcohol the most (10). Stinging with triamcinolone spray, Cetaphil Lotion, and triamcinolone cream ranked in the lower half of the rating scale (all below 5). Betamethasone foam and clobetal spray ranked the highest at >7. When corrected for the erythema caused by shaving, triamcinolone spray and Cetaphil Lotion produced the least amount of erythema of all the products tested.
DISCUSSION: Rapid evaporation of the volatile vehicle of triamcinolone spray and the non-irriating nature of the medication left behind may contribute to its low erythema and stinging. This product may be an appropriate choice for patients with compromised skin but who require the advantages and conveniences of a spray vehicle.

J Drugs Dermatol. 2016;15(7):870-873.