Download PDF
Eur J Pediatr Surg 2016; 26(04): 309-315
DOI: 10.1055/s-0035-1559883
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Evaluation of Antiseptic Use in Pediatric Surgical Units in the United Kingdom—Where Is the Evidence Base?

Angela Li Ching Ng
1   Department of Paediatric Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
,
Claire Jackson
1   Department of Paediatric Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
,
Marcin Kazmierski
1   Department of Paediatric Surgery, Addenbrooke's Hospital, Cambridge, United Kingdom
› Author Affiliations
Further Information

Publication History

16 February 2015

11 June 2015

Publication Date:
17 September 2015 (online)

    Permissions and Reprints

Abstract

Aim Our aim was to conduct a survey of practice regarding skin preparation products for premature neonates (under 32 weeks gestation, below 1.5 kg) in the United Kingdom (UK) pediatric surgical units and to review the evidence on the safety and efficacy of the commonest skin preparation products used.

Methods For the survey, following Cambridge University Hospitals NHS Foundation Trust's (Addenbrooke's Hospital) approval, the UK pediatric surgical units were contacted. Each unit was asked for both unit policy and individual consultant preference for skin preparation in infants. A structured literature search was performed using Medline and EMBASE. All study types investigating skin antisepsis with povidone iodine or chlorhexidine in neonates were included. Abstracts and non-English language articles were excluded. Target outcomes related to effectiveness and potential risks of the product.

Results A total of 28 pediatric surgical units were surveyed. Overall, 14 units had a standardized policy, with 8 units using Betadine (Purdue Products L.P., Stamford, CT), 4 using alcoholic chlorhexidine, and 2 using aqueous chlorhexidine. A total of 34 articles fulfilled the criteria for inclusion. There is moderate quality evidence to support the efficacy of chlorhexidine over povidone iodine for preoperative skin antisepsis. There is evidence that povidone iodine can be absorbed, causing reactive hypothyroidism. Chlorhexidine can be absorbed but there is no evidence of this being significant. Both alcoholic and aqueous chlorhexidine can cause skin damage, including burns.

Conclusion A majority of pediatric surgical units and individual surgeons use Betadine in premature and below 1.5 kg infants despite this being outside the product license. There is no ideal product choice based on current evidence but surgeons must be aware of the inherent risks and benefits of each product.

Keywords

skin antisepsis - povidone iodine - chlorhexidine - infants safety
 

  • References

  • 1 Darouiche RO, Wall Jr MJ, Itani KM , et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med 2010; 362 (1) 18-26
    CrossrefPubMedGoogle Scholar
  • 2 Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 2010; 97 (11) 1614-1620
    CrossrefPubMedGoogle Scholar
  • 3 Davenport M, Doig CM. Wound infection in pediatric surgery: a study in 1,094 neonates. J Pediatr Surg 1993; 28 (1) 26-30
    CrossrefPubMedGoogle Scholar
  • 4 Chwals WJ, Blakely ML, Cheng A , et al. Surgery-associated complications in necrotizing enterocolitis: A multiinstitutional study. J Pediatr Surg 2001; 36 (11) 1722-1724
    CrossrefPubMedGoogle Scholar
  • 5 Mitchell IM, Pollock JC, Jamieson MP, Fitzpatrick KC, Logan RW. Transcutaneous iodine absorption in infants undergoing cardiac operation. Ann Thorac Surg 1991; 52 (5) 1138-1140
    CrossrefPubMedGoogle Scholar
  • 6 Pyati SP, Ramamurthy RS, Krauss MT, Pildes RS. Absorption of iodine in the neonate following topical use of povidone iodine. J Pediatr 1977; 91 (5) 825-828
    CrossrefPubMedGoogle Scholar
  • 7 Gordon CM, Rowitch DH, Mitchell ML, Kohane IS. Topical iodine and neonatal hypothyroidism. Arch Pediatr Adolesc Med 1995; 149 (12) 1336-1339
    CrossrefPubMedGoogle Scholar
  • 8 Yilmaz D, Teziç HT, Zorlu P, Firat S, Bilaloğlu E, Kutlu AO. Single dose povidone-iodine on thyroid functions and urinary iodine excretion. Indian J Pediatr 2003; 70 (8) 675-677
    CrossrefPubMedGoogle Scholar
  • 9 Smerdely P, Lim A, Boyages SC , et al. Topical iodine-containing antiseptics and neonatal hypothyroidism in very-low-birthweight infants. Lancet 1989; 2 (8664) 661-664
    PubMedGoogle Scholar
  • 10 Brown RS, Bloomfield S, Bednarek FJ, Mitchell ML, Braverman LE. Routine skin cleansing with povidone-iodine is not a common cause of transient neonatal hypothyroidism in North America: a prospective controlled study. Thyroid 1997; 7 (3) 395-400
    CrossrefPubMedGoogle Scholar
  • 11 Linder N, Davidovitch N, Reichman B , et al. Topical iodine-containing antiseptics and subclinical hypothyroidism in preterm infants. J Pediatr 1997; 131 (3) 434-439
    CrossrefPubMedGoogle Scholar
  • 12 Parravicini E, Fontana C, Paterlini GL , et al. Iodine, thyroid function, and very low birth weight infants. Pediatrics 1996; 98 (4 Pt 1) 730-734
    PubMedGoogle Scholar
  • 13 AvRuskin TW, Greenfield E, Prasad V, Greig F, Juan CS. Decreased T3 and T4 levels following topical application of povidone-iodine in premature neonates. J Pediatr Endocrinol Metab 1994; 7 (3) 205-209
    PubMedGoogle Scholar
  • 14 Whitehouse JS, Gourlay DM, Masonbrink AR , et al. Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function. J Pediatr Surg 2010; 45 (6) 1192-1197
    CrossrefPubMedGoogle Scholar
  • 15 Jackson HJ, Sutherland RM. Effect of povidone-iodine on neonatal thyroid function. Lancet 1981; 2 (8253) 992
    PubMedGoogle Scholar
  • 16 Lyen KR, Finegold D, Orsini R, Herd JE, Parks JS. Transient thyroid suppression associated with topically applied povidone-iodine. Am J Dis Child 1982; 136 (4) 369-370
    PubMedGoogle Scholar
  • 17 Cosman BC, Schullinger JN, Bell JJ, Regan JA. Hypothyroidism caused by topical povidone-iodine in a newborn with omphalocele. J Pediatr Surg 1988; 23 (4) 356-358
    CrossrefPubMedGoogle Scholar
  • 18 Pinsker JE, McBayne K, Edwards M, Jensen K, Crudo DF, Bauer AJ. Transient hypothyroidism in premature infants after short-term topical iodine exposure: an avoidable risk?. Pediatr Neonatol 2013; 54 (2) 128-131
    CrossrefPubMedGoogle Scholar
  • 19 Khashu M, Chessex P, Chanoine JP. Iodine overload and severe hypothyroidism in a premature neonate. J Pediatr Surg 2005; 40 (2) E1-E4
    PubMedGoogle Scholar
  • 20 Bryant WP, Zimmerman D. Iodine-induced hyperthyroidism in a newborn. Pediatrics 1995; 95 (3) 434-436
    PubMedGoogle Scholar
  • 21 Lashkari HP, Chow P, Godambe S. Aqueous 2% chlorhexidine-induced chemical burns in an extremely premature infant. Arch Dis Child Fetal Neonatal Ed 2012; 97 (1) F64
    CrossrefPubMedGoogle Scholar
  • 22 Bringué Espuny X, Soria X, Solé E , et al. Chlorhexidine-methanol burns in two extreme preterm newborns. Pediatr Dermatol 2010; 27 (6) 676-678
    CrossrefPubMedGoogle Scholar
  • 23 Reynolds PR, Banerjee S, Meek JH. Alcohol burns in extremely low birthweight infants: still occurring. Arch Dis Child Fetal Neonatal Ed 2005; 90 (1) F10
    CrossrefPubMedGoogle Scholar
  • 24 Mannan K, Chow P, Lissauer T, Godambe S. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Acta Paediatr 2007; 96 (10) 1536-1537
    CrossrefPubMedGoogle Scholar
  • 25 Krautheim AB, Jermann TH, Bircher AJ. Chlorhexidine anaphylaxis: case report and review of the literature. Contact Dermat 2004; 50 (3) 113-116
    CrossrefPubMedGoogle Scholar
  • 26 Cowen J, Ellis SH, McAinsh J. Absorption of chlorhexidine from the intact skin of newborn infants. Arch Dis Child 1979; 54 (5) 379-383
    CrossrefPubMedGoogle Scholar
  • 27 O'Brien CA, Blumer JL, Speck WT , et al. Effect of bathing with a 4 per cent chlorhexidine gluconate solution on neonatal bacterial colonisation. J Hosp Infect 1984; 5 (Suppl. 01) 141
    PubMedGoogle Scholar
  • 28 Wilson CM, Gray G, Read JS , et al. Tolerance and safety of different concentrations of chlorhexidine for peripartum vaginal and infant washes: HIVNET 025. J Acquir Immune Defic Syndr 2004; 35 (2) 138-143
    CrossrefPubMedGoogle Scholar
  • 29 O'Neill J, Hosmer M, Challop R , et al. Percutaneous absorption potential of chlorhexidine in neonates. Curr Ther Res 1982; 31: 485-489
    PubMedGoogle Scholar
  • 30 Aggett PJ, Cooper LV, Ellis SH, McAinsh J. Percutaneous absorption of chlorhexidine in neonatal cord care. Arch Dis Child 1981; 56 (11) 878-880
    CrossrefPubMedGoogle Scholar
  • 31 Chapman AK, Aucott SW, Gilmore MM, Advani S, Clarke W, Milstone AM. Absorption and tolerability of aqueous chlorhexidine gluconate used for skin antisepsis prior to catheter insertion in preterm neonates. J Perinatol 2013; 33 (10) 768-771
    CrossrefPubMedGoogle Scholar
  • 32 Sankar MJ, Paul VK, Kapil A , et al. Does skin cleansing with chlorhexidine affect skin condition, temperature and colonization in hospitalized preterm low birth weight infants?: a randomized clinical trial. J Perinatol 2009; 29 (12) 795-801
    CrossrefPubMedGoogle Scholar
  • 33 Darmstadt GL, Hossain MM, Choi Y , et al. Safety and effect of chlorhexidine skin cleansing on skin flora of neonates in Bangladesh. Pediatr Infect Dis J 2007; 26 (6) 492-495
    CrossrefPubMedGoogle Scholar
  • 34 Garland JS, Alex CP, Mueller CD, Cisler-Kahill LA. Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants. Pediatr Infect Dis J 1996; 15 (10) 912-914
    CrossrefPubMedGoogle Scholar
  • 35 Garland JS, Alex CP, Mueller CD , et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001; 107 (6) 1431-1436
    CrossrefPubMedGoogle Scholar
  • 36 Visscher M, deCastro MV, Combs L , et al. Effect of chlorhexidine gluconate on the skin integrity at PICC line sites. J Perinatol 2009; 29 (12) 802-807
    CrossrefPubMedGoogle Scholar
  • 37 Nuntnarumit P, Sangsuksawang N. A randomized controlled trial of 1% aqueous chlorhexidine gluconate compared with 10% povidone-iodine for topical antiseptic in neonates: effects on blood culture contamination rates. Infect Control Hosp Epidemiol 2013; 34 (4) 430-432
    CrossrefPubMedGoogle Scholar
  • 38 Linder N, Prince S, Barzilai A , et al. Disinfection with 10% povidone-iodine versus 0.5% chlorhexidine gluconate in 70% isopropanol in the neonatal intensive care unit. Acta Paediatr 2004; 93 (2) 205-210
    CrossrefPubMedGoogle Scholar
  • 39 Abdeyazdan Z, Majidipour N, Zargham-Boroujeni A. Comparison of the effects of povidone-iodine and chlorhexidine solutions on skin bacterial flora among hospitalized infants. J Educ Health Promot 2014; 3: 16
    PubMedGoogle Scholar
  • 40 Garland JS, Buck RK, Maloney P , et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J 1995; 14 (6) 510-516
    CrossrefPubMedGoogle Scholar
  • 41 Rooman RP, Du Caju MV, De Beeck LO, Docx M, Van Reempts P, Van Acker KJ. Low thyroxinaemia occurs in the majority of very preterm newborns. Eur J Pediatr 1996; 155 (3) 211-215
    CrossrefPubMedGoogle Scholar
  • 42 Reuss ML, Leviton A, Paneth N, Susser M. Thyroxine values from newborn screening of 919 infants born before 29 weeks' gestation. Am J Public Health 1997; 87 (10) 1693-1697
    CrossrefPubMedGoogle Scholar
  • 43 van Wassenaer AG, Kok JH, Dekker FW, de Vijlder JJ. Thyroid function in very preterm infants: influences of gestational age and disease. Pediatr Res 1997; 42 (5) 604-609
    CrossrefPubMedGoogle Scholar
  • 44 Biswas S, Buffery J, Enoch H, Bland JM, Walters D, Markiewicz M. A longitudinal assessment of thyroid hormone concentrations in preterm infants younger than 30 weeks' gestation during the first 2 weeks of life and their relationship to outcome. Pediatrics 2002; 109 (2) 222-227
    CrossrefPubMedGoogle Scholar
  • 45 Frank JE, Faix JE, Hermos RJ , et al. Thyroid function in very low birth weight infants: effects on neonatal hypothyroidism screening. J Pediatr 1996; 128 (4) 548-554
    CrossrefPubMedGoogle Scholar
  • 46 Bagnoli F, Farmeschi L, Peruzzi L , et al. Altered thyroid function in small for gestational age newborns: study based on screening test for congenital hypothyroid. Journal of Pediatric Sciences 2010; 4: e55
    PubMedGoogle Scholar
  • 47 Aitken J, Williams FL. A systematic review of thyroid dysfunction in preterm neonates exposed to topical iodine. Arch Dis Child Fetal Neonatal Ed 2014; 99 (1) F21-F28
    CrossrefPubMedGoogle Scholar
  • 48 Mullany LC, Darmstadt GL, Tielsch JM. Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. Pediatr Infect Dis J 2006; 25 (8) 665-675
    CrossrefPubMedGoogle Scholar
  • 49 Lee A, Harlan R, Breaud AR , et al. Blood concentrations of chlorhexidine in hospitalized children undergoing daily chlorhexidine bathing. Infect Control Hosp Epidemiol 2011; 32 (4) 395-397
    CrossrefPubMedGoogle Scholar
  • 50 Watkins AM, Keogh EJ. Alcohol burns in the neonate. J Paediatr Child Health 1992; 28 (4) 306-308
    CrossrefPubMedGoogle Scholar
  • 51 Tamma PD, Aucott SW, Milstone AM. Chlorhexidine use in the neonatal intensive care unit: results from a national survey. Infect Control Hosp Epidemiol 2010; 31 (8) 846-849
    CrossrefPubMedGoogle Scholar
  • 52 Chapman AK, Aucott SW, Milstone AM. Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. J Perinatol 2012; 32 (1) 4-9
    CrossrefPubMedGoogle Scholar