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Best products for skin antisepsis

      Application of antiseptic products to the skin plays an important role in prevention of a variety of health care–associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care–associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted.
      Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.

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      References

        • Webster J
        • Osborne S.
        Preoperative bathing or showering with skin antiseptics to prevent surgical site infection.
        Cochrane Database Syst Rev. 2015; CD004985
        • Franco LM
        • Cota GF
        • Pinto TS
        • Ercole FF
        Preoperative bathing of the surgical site with chlorhexidine for infection prevention: systematic review with meta-analysis.
        Am J Infect Control. 2017; 45: 343-349
        • Berrios-Torres SI
        • Umscheid CA
        • Bratzler DW
        • Leas B
        • Stone EC
        • Kelz RR
        • et al.
        Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017.
        JAMA Surg. 2017; 152: 784-791
        • Edmiston Jr, CE
        • Lee CJ
        • Krepel CJ
        • Spencer M
        • Leaper D
        • Brown KR
        • et al.
        Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4%, in surgical patients.
        JAMA Surg. 2015; 150: 1027-1033
        • Edmiston Jr, CE
        • Krepel CJ
        • Spencer MP
        • Ferraz AA
        • Seabrook GR
        • Lee CJ
        • et al.
        Preadmission application of 2% chlorhexidine gluconate (CHG): enhancing patient compliance while maximizing skin surface concentrations.
        Infect Control Hosp Epidemiol. 2016; 37: 254-259
        • Kapadia BH
        • Jauregui JJ
        • Murray DP
        • Mont MA
        Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total hip arthroplasty?.
        Clin Orthop Relat Res. 2016; 474: 1583-1588
        • Kapadia BH
        • Zhou PL
        • Jauregui JJ
        • Mont MA
        Does preadmission cutaneous chlorhexidine preparation reduce surgical site infections after total knee arthroplasty?.
        Clin Orthop Relat Res. 2016; 474: 1592-1598
        • Kapadia BH
        • Elmallah RK
        • Mont MA
        A randomized, clinical trial of preadmission chlorhexidine skin preparation for lower extremity total joint arthroplasty.
        J Arthroplasty. 2016; 31: 2856-2861
        • Edmiston Jr, CE
        • Krepel CJ
        • Edmiston SE
        • Spencer M
        • Lee C
        • Brown KR
        • et al.
        Empowering the surgical patient: a randomized, prospective analysis of an innovative strategy for improving patient compliance with preadmission showering protocol.
        J Am Coll Surg. 2014; 219: 256-264
        • Supple L
        • Kumaraswami M
        • Kundrapu S
        • Sunkesula V
        • Cadnum JL
        • Nerandzic MM
        • et al.
        Chlorhexidine only works if applied correctly: use of a simple colorimetric assay to provide monitoring and feedback on effectiveness of chlorhexidine application.
        Infect Control Hosp Epidemiol. 2015; 36: 1095-1097
      1. World Health Organization. Global guidelines on the prevention of surgical site infection. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/250680/9789241549882-eng.pdf?sequence=8. Accessed March 28, 2019.

        • Anderson DJ
        • Podgorny K
        • Berrios-Torres SI
        • Bratzler DW
        • Dellinger EP
        • Greene L
        • et al.
        Strategies to prevent surgical site infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 605-627
        • Tuuli MG
        • Liu J
        • Stout MJ
        • Martin S
        • Cahill AG
        • Odibo AO
        • et al.
        A randomized trial comparing skin antiseptic agents at cesarean delivery.
        N Engl J Med. 2016; 374: 647-655
        • Ngai IM
        • Van AA
        • Govindappagari S
        • Judge NE
        • Neto NK
        • Bernstein J
        • et al.
        Skin preparation for prevention of surgical site infection after cesarean delivery: a randomized controlled trial.
        Obstet Gynecol. 2015; 126: 1251-1257
        • Garry DJ
        • Ngai IM
        • Bernstein PS
        • Judge NE
        Skin preparation for prevention of surgical site infection after cesarean delivery: a randomized controlled trial.
        Obstet Gynecol. 2017; 129: 751
        • Springel EH
        • Wang XY
        • Sarfoh VM
        • Stetzer BP
        • Weight SA
        • Mercer BM
        A randomized open-label controlled trial of chlorhexidine-alcohol vs povidone-iodine for cesarean antisepsis: the CAPICA trial.
        Am J Obstet Gynecol. 2017; 217: 463
        • Uppal S
        • Bazzi A
        • Reynolds RK
        • Harris J
        • Pearlman MD
        • Campbell DA
        • et al.
        Chlorhexidine-alcohol compared with povidone-iodine for preoperative topical antisepsis for abdominal hysterectomy.
        Obstet Gynecol. 2017; 130: 319-327
        • Davies BM
        • Patel HC.
        Systematic review and meta-analysis of preoperative antisepsis with combination chlorhexidine and povidone-iodine.
        Surg J (N Y). 2016; 2: e70-e77
        • Morrison TN
        • Chen AF
        • Taneja M
        • Kucukdurmaz F
        • Rothman RH
        • Parvizi J
        Single vs repeat surgical skin preparations for reducing surgical site infection after total joint arthroplasty: a prospective, randomized, double-blinded study.
        J Arthroplasty. 2016; 31: 1289-1294
        • Al-Niaimi A
        • Rice LW
        • Shitanshu U
        • Garvens B
        • Fitzgerald M
        • Zerbel S
        • et al.
        Safety and tolerability of chlorhexidine gluconate (2%) as a vaginal operative preparation in patients undergoing gynecologic surgery.
        Am J Infect Control. 2016; 44: 996-998
        • Haas DM
        • Morgan S
        • Contreras K
        • Enders S
        Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.
        Cochrane Database Syst Rev. 2018; 7CD007892
        • Jeppson PC
        • Balgobin S
        • Rahn DD
        • Matteson KA
        • Dieter AA
        • Ellington DR
        • et al.
        Comparison of vaginal hysterectomy techniques and interventions for benign indications: a systematic review.
        Obstet Gynecol. 2017; 129: 877-886
        • Boyce JM
        • Pittet D
        Healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Guideline for hand hygiene in health-care settings.
        MMWR. 2002; 51: 1-45
        • Tanner J
        • Dumville JC
        • Norman G
        • Fortnam M
        Surgical hand antisepsis to reduce surgical site infection.
        Cochrane Database Syst Rev. 2016; CD004288
        • Macinga DR
        • Edmonds SL
        • Campbell E
        • McCormack RR
        Comparative efficacy of alcohol-based surgical scrubs: the importance of formulation.
        AORN J. 2014; 100: 641-650
        • Hennig TJ
        • Werner S
        • Naujox K
        • Arndt A
        Chlorhexidine is not an essential component in alcohol-based surgical hand preparation: a comparative study of two handrubs based on a modified EN 12791 test protocol.
        Antimicrob Resist Infect Control. 2017; 6: 96
        • Kampf G
        • Kramer A
        • Suchomel M
        Lack of sustained efficacy for alcohol-based surgical hand rubs containing ‘residual active ingredients’ according to EN 12791.
        J Hosp Infect. 2017; 95: 163-168
        • Popovich KJ
        • Hota B
        • Hayes R
        • Weinstein RA
        • Hayden MK
        Effectiveness of routine patient cleansing with chlorhexidine gluconate for infection prevention in the medical intensive care unit.
        Infect Control Hosp Epidemiol. 2009; 30: 959-963
        • Climo MW
        • Yokoe DS
        • Warren DK
        • Perl TM
        • Bolon M
        • Herwaldt LA
        • et al.
        Effect of daily chlorhexidine bathing on hospital-acquired infection.
        N Eng J Med. 2013; 368: 533-542
        • Dicks KV
        • Lofgren E
        • Lewis SS
        • Moehring RW
        • Sexton DJ
        • Anderson DJ
        A multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate bathing in community hospital intensive care units.
        Infect Control Hosp Epidemiol. 2016; 37: 791-797
        • Huang SS
        • Septimus E
        • Kleinman K
        • Moody J
        • Hickok J
        • Avery TR
        • et al.
        Targeted versus universal decolonization to prevent ICU infection.
        N Engl J Med. 2013; 368: 2255-2265
        • O'Horo JC
        • Silva GL
        • Munoz-Price LS
        • Safdar N
        The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: a meta-analysis.
        Infect Control Hosp Epidemiol. 2012; 33: 257-267
        • Frost SA
        • Alogso MC
        • Metcalfe L
        • Lynch JM
        • Hunt L
        • Sanghavi R
        • et al.
        Chlorhexidine bathing and health care-associated infections among adult intensive care patients: a systematic review and meta-analysis.
        Crit Care. 2016; 20: 379
        • Afonso E
        • Blot K
        • Blot S
        Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomised crossover trials.
        Euro Surveill. 2016; 21
        • Huang HP
        • Chen B
        • Wang HY
        • He M
        The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adult intensive care units.
        Korean J Intern Med. 2016; 31: 1159-1170
        • Noto MJ
        • Domenico HJ
        • Byrne DW
        • Talbot T
        • Rice TW
        • Bernard GR
        • et al.
        Chlorhexidine bathing and health care-associated infections: a randomized clinical trial.
        JAMA. 2015; 313: 369-378
        • Urbancic KF
        • Martensson J
        • Glassford N
        • Eyeington C
        • Robbins R
        • Ward PB
        • et al.
        Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug-resistant organism acquisition.
        Crit Care Resusc. 2018; 20: 109-116
        • Donskey CJ
        • Deshpande A.
        Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: a review of the literature.
        Am J Infect Control. 2016; 44: e17-e21
        • Popovich KJ
        • Hota B
        • Hayes R
        • Weinstein RA
        • Hayden MK
        Daily skin cleansing with chlorhexidine did not reduce the rate of central-line associated bloodstream infection in a surgical intensive care unit.
        Intensive Care Med. 2010; 36: 854-858
        • Rhee Y
        • Palmer LJ
        • Okamoto K
        • Gemunden S
        • Hammouda K
        • Kemble SK
        • et al.
        Differential effects of chlorhexidine skin cleansing methods on residual chlorhexidine skin concentrations and bacterial recovery.
        Infect Control Hosp Epidemiol. 2018; 39: 405-411
        • Edmiston Jr, CE
        • Krepel CJ
        • Seabrook GR
        • Lewis BD
        • Brown KR
        • Towne JB
        Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission?.
        J Am Coll Surg. 2008; 207: 233-239
        • Edmiston Jr, CE
        • Seabrook GR
        • Johnson CP
        • Paulson DS
        • Beausoleil CM
        Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to surgery.
        Am J Infect Control. 2007; 35: 89-96
        • Kassakian SZ
        • Mermel LA
        • Jefferson JA
        • Parenteau SL
        • Machan JT
        Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients.
        Infect Control Hosp Epidemiol. 2011; 32: 238-243
        • Lowe CF
        • Lloyd-Smith E
        • Sidhu B
        • Ritchie G
        • Sharma A
        • Jang W
        • et al.
        Reduction in hospital-associated methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus with daily chlorhexidine gluconate bathing for medical inpatients.
        Am J Infect Control. 2017; 45: 255-259
        • Rupp ME
        • Cavalieri RJ
        • Lyden E
        • Kucera J
        • Martin M
        • Fitzgerald T
        • et al.
        Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections.
        Infect Control Hosp Epidemiol. 2012; 33: 1094-1100
        • Huang SS
        • Septimus E
        • Kleinman K
        • Moody J
        • Hickok J
        • Heim L
        • et al.
        Daily chlorhexidine bathing in general hospital units-results of the ABATE infection trial (Active BAThing to Eliminate infection).
        Open Forum Infect Dis. 2017; 4: 35-36
        • O'Grady NP
        • Alexander M
        • Burns LA
        • Dellinger EP
        • Garland J
        • Heard SO
        • et al.
        Guidelines for the prevention of intravascular catheter-related infections.
        Clin Infect Dis. 2011; 52: e162-e193
        • Marschall J
        • Mermel LA
        • Fakih M
        • Hadaway L
        • Kallen A
        • O'Grady NP
        • et al.
        Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 753-771
        • 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: F101-F106
        • Mimoz O
        • Lucet JC
        • Kerforne T
        • Pascal J
        • Souweine B
        • Goudet V
        • et al.
        Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial.
        Lancet. 2015; 386: 2069-2077
        • Ullman AJ
        • Cooke ML
        • Mitchell M
        • Lin F
        • New K
        • Long DA
        • et al.
        Dressings and securement devices for central venous catheters (CVC).
        Cochrane Database Syst Rev. 2015; CD010367
        • Righetti M
        • Palmieri N
        • Bracchi O
        • Prencipe M
        • Bruschetta E
        • Colombo F
        • et al.
        Tegaderm CHG dressing significantly improves catheter-related infection rate in hemodialysis patients.
        J Vasc Access. 2016; 17: 417-422
        • Apata IW
        • Hanfelt J
        • Bailey JL
        • Niyyar VD
        Authors’ response to: reducing tunneled catheter-related infection in hemodialysis patients with nationwide standardization of catheter care protocol.
        J Vasc Access. 2018; 19: 112
        • Guzman-Pruneda FA
        • Husain SG
        • Jones CD
        • Beal EW
        • Porter E
        • Grove M
        • et al.
        Compliance with preoperative care measures reduces surgical site infection after colorectal operation.
        J Surg Oncol. 2019; 119: 497-502
        • Deery SE
        • Cavallaro PM
        • McWalters ST
        • Reilly SR
        • Bonnette HM
        • Rattner DW
        • et al.
        Colorectal surgical site infection prevention kits prior to elective colectomy improve outcomes.
        Ann Surg. 2019 Jan 24; ([Epub ahead of print])
        • Andiman SE
        • Xu X
        • Boyce JM
        • Ludwig EM
        • Rillstone HRW
        • Desai VB
        • et al.
        Decreased surgical site infection rate in hysterectomy: effect of a gynecology-specific bundle.
        Obstet Gynecol. 2018; 131: 991-999
        • Carter EB
        • Temming LA
        • Fowler S
        • Eppes C
        • Gross G
        • Srinivas SK
        • et al.
        Evidence-based bundles and cesarean delivery surgical site infections: a systematic review and meta-analysis.
        Obstet Gynecol. 2017; 130: 735-746
        • Kawakita T
        • Iqbal SN
        • Landy HJ
        • Huang JC
        • Fries M
        Reducing cesarean delivery surgical site infections: a resident-driven quality initiative.
        Obstet Gynecol. 2019; 133: 282-288
        • Pronovost P
        • Needham D
        • Berenholtz S
        • Sinopoli D
        • Chu H
        • Cosgrove S
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
      2. Food and Drug Administration. FDA drug safety podcast: FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. 2017. Available from: https://www.fda.gov/Drugs/DrugSafety/DrugSafetyPodcasts/ucm540654.htm. Accessed March 28, 2019.

        • Bhardwaj P
        • Ziegler E
        • Palmer KL
        Chlorhexidine induces VanA-type vancomycin resistance genes in enterococci.
        Antimicrob Agents Chemother. 2016; 60: 2209-2221
        • Wand ME
        • Bock LJ
        • Bonney LC
        • Sutton JM
        Mechanisms of increased resistance to chlorhexidine and cross-resistance to colistin following exposure of Klebsiella pneumoniae clinical isolates to chlorhexidine.
        Antimicrob Agents Chemother. 2017; 61
        • Williamson DA
        • Carter GP
        • Howden BP
        Current and emerging topical antibacterials and antiseptics: agents, action, and resistance patterns.
        Clin Microbiol Rev. 2017; 30: 827-860
        • Hayashi M
        • Kawamura K
        • Matsui M
        • Suzuki M
        • Suzuki S
        • Shibayama K
        • et al.
        Reduction in chlorhexidine efficacy against multi-drug-resistant Acinetobacter baumannii international clone II.
        J Hosp Infect. 2017; 95: 318-323
        • Batra R
        • Cooper BS
        • Whiteley C
        • Patel AK
        • Wyncoll D
        • Edgeworth JD
        Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit.
        Clin Infect Dis. 2010; 50: 210-217
        • Kampf G.
        Acquired resistance to chlorhexidine: is it time to establish an ‘antiseptic stewardship’ initiative?.
        J Hosp Infect. 2016; 94: 213-227