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A baby sustained extensive skin burns after the use of a skin preparation (alcoholic chlorhexidine). Following this event the hospital started using an aqueous preparation of chlorhexidine 0.05%. Was this the right choice and what is the evidence for the use of this or any other skin preparation in preterm infants?
Structured clinical question
In preterm infants of <28 weeks’ gestation [patient] what is the choice of skin preparation prior to invasive procedures on the unit [intervention] in terms of safety or least complications and prevention of infection [outcome]?
Search strategy and outcome
Primary source: Medline (1956–2005), MeSH terms were used. An advance search was carried out and close matches from mapping were chosen and another search was carried out using explode and major subheadings. Secondary sources: Cochrane and EMBASE.
Search terms: Premature and anti-infective agents and invasive procedures and safety and complications.
Search outcome: Only four hits matched all our search criteria. We further searched for trials that looked at the safety and efficacy of different antimicrobials with out restricting the age group. We found two hits that specifically answered our question.1,2 See table 2.
Care of the preterm infant in neonatal units is challenging and involves a lot of support. Placement of central lines is an important aid in delivering this care and it is a common practice to use an alcohol based skin preparation (0.5% chlorhexidine in 70% methanol) prior to this procedure. However, this preparation has the potential to cause skin burns.7
Burns in this population of infants may be associated with increased mortality and morbidity. There is also the possible impact of burns (pain and stress) on neuronal migration and hence long-term outlook.4
Evidence for the use of an appropriate agent in this population of infants in sparse; this is understandable because of the ethical issues related to carrying out research in these patients. A considerable proportion of the evidence that we found was in the form of case reports.3
A clinical study comparing skin antisepsis and the safety of different skin preparations1 in adults showed that aqueous chlorhexidine, chlorhexidine in isopropyl alcohol or isopropyl alcohol alone had good immediate antimicrobial activity but that chlorhexidine in alcohol had more persistent activity; all had an excellent safety profile. Unfortunately, we cannot apply adult data to our population as has been highlighted by cases such as ours.
A review article examined analyses comparing the activity and safety of current antiseptics.2 Six randomised, controlled, single blind, parallel group clinical trials were assessed to determine the best preoperative skin preparation. The agents examined included chlorhexidine with isopropyl alcohol (chlorhexidine gluconate with 70% isopropyl alcohol, or another combination of the two) 2% chlorhexidine alone, 4% chlorhexidine alone, 70% isopropyl alcohol alone and 10% povidone iodine alone. An antiseptic containing a combination of two antiseptics with different mechanisms of action consistently and significantly demonstrated better antimicrobial activity than a single antiseptic alone. It was also demonstrated that chlorhexidine or povidone iodine alone did not in some studies qualify as a suitable antiseptic agent. Again, all of these trials were on adults and no side effects were noted.
One paper looked at an alternative agent, octenidine, and reported it to be safe.5 However, this study examined a small population of infants (24) and on further enquiry we found that the preparation contained arachis oil and hence is not a viable alternative in the UK.
The EPIC project updating the national evidence based guidelines for preventing health care-associated infections in NHS hospitals in England reported that both alcoholic and aqueous preparations of chlorhexidine provide concentrations of chlorhexidine that are higher than the minimal inhibitory concentration for most nosocomial bacteria and yeasts. Both 0.5% and 1% alcoholic solutions and 0.5% and 2% aqueous solutions were examined.8 However, there is no mention of its safety in preterm infants.
We also contacted the manufacturer (Seton Health Care Group, Oldham, Uk) seeking more information but did not learn anything new. It was evident to us from our search that the currently used agents have the potential to cause considerable harm to infants. However, no safer alternative is supported by evidence and this reinforces the need to examine this issue more closely. Research must be carried out to find a safe and effective agent if we are to not make things more difficult for an already challenged population.
CLINICAL BOTTOM LINE
Extremely preterm infants are at risk of burns from the use of alcoholic skin preparations, but no comparative data are available to suggest the best preparation for this group of patients. (Grade C)
Making sure there is no pooling seems to be the most effective method of avoiding problems related to skin burns in infants. (Grade C)
Alcohol based preparations have good antibacterial activity in adults and have an excellent safety profile. (Grade C)
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