Current Practices of Antiseptic Use in Canadian Neonatal Intensive Care Units

Abstract

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.

Keywords

anti-infective agents - newborn/premature infants - skin antiseptics

• References

• 1 Jacob J, Kamitsuka M, Clark RH, Kelleher AS, Spitzer AR. Etiologies of NICU deaths. Pediatrics 2015; 135 (01) e59-e65
• 2 Stoll BJ, Hansen N, Fanaroff AA. , et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002; 110 (2 Pt 1): 285-291
• 3 Ohlin A, Björkman L, Serenius F, Schollin J, Källén K. Sepsis as a risk factor for neonatal morbidity in extremely preterm infants. Acta Paediatr 2015; 104 (11) 1070-1076
• 4 Kaplan HC, Lannon C, Walsh MC, Donovan EF. ; Ohio Perinatal Quality Collaborative. Ohio statewide quality-improvement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics 2011; 127 (03) 427-435
• 5 Payne NR, Barry J, Berg W. , et al; Stop Transmission of Pathogens (STOP) team of the St. Paul Campus; Prevent Infection Team (PIT) of the Minneapolis Campus of Children's Hospitals and Clinics of Minnesota. Sustained reduction in neonatal nosocomial infections through quality improvement efforts. Pediatrics 2012; 129 (01) e165-e173
• 6 Ting JY, Goh VS, Osiovich H. Reduction of central line-associated bloodstream infection rates in a neonatal intensive care unit after implementation of a multidisciplinary evidence-based quality improvement collaborative: A four-year surveillance. Can J Infect Dis Med Microbiol 2013; 24 (04) 185-190
• 7 Ponnusamy V, Venkatesh V, Clarke P. Skin antisepsis in the neonate: what should we use?. Curr Opin Infect Dis 2014; 27 (03) 244-250
• 8 Sathiyamurthy S, Banerjee J, Godambe SV. Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: an evidence based review. World J Clin Pediatr 2016; 5 (02) 159-171
• 9 Datta MK, Clarke P. Current practices in skin antisepsis for central venous catheterisation in UK tertiary-level neonatal units. Arch Dis Child Fetal Neonatal Ed 2008; 93 (04) F328
• 10 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 (08) 846-849
• 11 Shah D, Tracy M. Skin antisepsis survey in Australia-New Zealand neonatal nurseries. J Paediatr Child Health 2013; 49 (07) 601-602
• 12 Marschall J, Mermel LA, Fakih M. , et al; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35 (07) 753-771
• 13 Reynolds PR, Banerjee S, Meek JH. Alcohol burns in extremely low birthweight infants: still occurring. Arch Dis Child Fetal Neonatal Ed 2005; 90 (01) F10
• 14 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
• 15 Vivier PM, Lewander WJ, Martin HF, Linakis JG. Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: a complication of a culturally-based umbilical care practice. Pediatr Emerg Care 1994; 10 (02) 91-93
• 16 Milstone AM, Bamford P, Aucott SW, Tang N, White KR, Bearer CF. Chlorhexidine inhibits L1 cell adhesion molecule-mediated neurite outgrowth in vitro. Pediatr Res 2014; 75 (1-1): 8-13
• 17 Cowen J, Ellis SH, McAinsh J. Absorption of chlorhexidine from the intact skin of newborn infants. Arch Dis Child 1979; 54 (05) 379-383
• 18 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
• 19 Khashu M, Chessex P, Chanoine JP. Iodine overload and severe hypothyroidism in a premature neonate. J Pediatr Surg 2005; 40 (02) E1-E4
• 20 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 (01) F21-F28
• 21 O'Grady NP, Alexander M, Burns LA. , et al; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011; 39 (04) (Suppl. 01) S1-S34
• 22 Loveday HP, Wilson JA, Pratt RJ. , et al; UK Department of Health. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014; 86 (Suppl. 01) S1-S70
• 23 OPINIO on-line Survey software (1998–2017) Version 7.7.2. Hosted by Dalhousie University. Available at: http://www.objectplanet.com/opinio . Accessed September 1, 2016
• 24 Heron TJ, Faraday CM, Clarke P. The hidden harms of Matching Michigan. Arch Dis Child Fetal Neonatal Ed 2013; 98 (05) F466-F467
• 25 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 (01) F64
• 26 Andersen C, Hart J, Vemgal P, Harrison C. Prospective evaluation of a multi-factorial prevention strategy on the impact of nosocomial infection in very-low-birthweight infants. J Hosp Infect 2005; 61 (02) 162-167
• 27 Lilley C, Powls A, Gray A. A prospective randomised doubleblind comparison of 0.5% versus 0.05% aqueous chlorhexidine for skin antisepsis prior to line insertion in neonates. Arch Dis Child 2006; 91 (Suppl I): A17-A19
• 28 Adams D, Quayum M, Worthington T, Lambert P, Elliott T. Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant. J Hosp Infect 2005; 61 (04) 287-290
• 29 Hibbard JS, Mulberry GK, Brady AR. A clinical study comparing the skin antisepsis and safety of ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs 2002; 25 (04) 244-249
• 30 Darouiche RO, Wall Jr MJ, Itani KM. , et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362 (01) 18-26
• 31 Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002; 136 (11) 792-801
• 32 Kieran EA, O'Sullivan A, Miletin J, Twomey AR, Knowles SJ, O'Donnell CPF. 2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018; 103 (02) F101-F106
• 33 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 (02) 205-210
• 34 Huang EY, Chen C, Abdullah F. , et al; 2011 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2011; 46 (10) 2000-2011
• 35 U.S. Food and Drug Administration (FDA). 2012. Safety Labeling Changes Approved By FDA Center for Drug Evaluation and Research (CDER). Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabeling Changes/ucm307387.htm . Accessed January 2018