CHLORHEXIDINE GLUCONATE Chlorhexidine Gluconate: The It Antiseptic? Fran

CHLORHEXIDINE GLUCONATE Chlorhexidine Gluconate: The It Antiseptic? Fran

CHLORHEXIDINE GLUCONATE Chlorhexidine Gluconate: The It Antiseptic? Fran Canty, MA, BSN, RN, VA-BC PDI Healthcare CHLORHEXIDINE GLUCONATE Disclosure I am an employee of the clinical team of PDI Healthcare. The content of this presentation is not representative of the views of PDI or its ownership. There will be NO discussion of any PDI products and/or solutions in accordance with CE Requirements 2 2017 PDI CHLORHEXIDINE GLUCONATE

Objectives Define the mechanism of action of chlorhexidine gluconate (CHG) Understand the two modes of bacterial pathogenesis into the bloodstream from intravascular devices Define the uses of CHG to prevent central line-associated bloodstream infections (CLABSI) State the current CDC recommendations for the use of CHG to prevent CLABSI

Define the mechanism for development of CHG resistance CHLORHEXIDINE GLUCONATE CHG Mechanism of Action Broad spectrum topical anti-infective; active against gram-positive, gram-negative bacterial pathogens and fungi responsible for healthcareassociated infections (HAIs) Disrupts cytoplasmic membranes CHLORHEXIDINE GLUCONATE

CHG Mechanism of Action Bathing with no-rinse 2% CHG-impregnated cloths; patient samples processed for CHG concentration and microbial colonization Swab samples were taken from the neck, antecubital fossae and inguinal areas at 1 hour before and 1,4, and 23 hours after the bath CHG concentration correlated inversely with density of gram-positive bacteria on patients skin1

Residual antimicrobial activity persists on the skin up to 24 hours1 Popovich KJ et al. Relationship between chlorhexidine gluconate skin concentration and microbial density on the skin of critically ill patients bathed daily with CHG. Infect Control Hosp Epidemiol 2012;33(9):889-896. 1 CHLORHEXIDINE GLUCONATE Chlorhexidine Applications As An Infection Prevention Tool Uses with FDA approval and strong evidence of efficacy 1

Surgical hand scrub: an 86%-92% reduction in hand skin flora General skin cleansing: significant reduction in normal skin flora, gram-negative organisms and S. aureus Preoperative scrub: superior to other antiseptics in reducing skin flora at surgical site Central venous catheter site preparation: 49% reduction in catheter-related BSI comparing skin prep with chlorhexidine vs. povidone -iodine Vascular catheter dressings: reduction in catheter colonization

Epidural catheter dressings: reduction in catheter colonization Use for intravascular catheter maintenance to disinfect needleless connectors Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: Expanding the Armamentarium for Infection Control and Prevention. CID 2008:46; 274-281. 1 6 2017 PDI CHLORHEXIDINE GLUCONATE Chlorhexidine Applications to Reduce CLABSI Cutaneous antisepsis Catheter hub disinfection

7 2017 PDI CHLORHEXIDINE GLUCONATE Pathogenesis of Intravascular Device-Related Bloodstream Infections (BSI) Microorganisms gain access to the device surface, adhere and become incorporated into a biofilm Access to the extraluminal surface of the device Cutaneous origin from skin flora at the insertion site or from healthcare workers hands; percutaneous tract invaded

Density of skin flora at the insertion site is a major risk factor for CLABSI Access to the intraluminal surface of the device Catheter hub and lumen contamination from device manipulation CHLORHEXIDINE GLUCONATE CHG: Preventing Extraluminal Entry of Microorganisms: Cutaneous antisepsis CHG is superior to povidone-iodine indicating that CHG-containing antiseptics should be first choice for the insertion of vascular access devices Crnich, C.J., et al. Clin Infect Dis. 2002;34:1232-1242 CHLORHEXIDINE GLUCONATE

CHG: Preventing Extraluminal Entry of Microorganisms: Cutaneous antisepsis CHLORHEXIDINE GLUCONATE CDC Recommendations: CHG Use to Prevent Intravascular Catheter-Related Infections Provide evidence-based recommendations Categorized on the basis of existing scientific data and theoretical rationale Category IA. Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice e.g., aseptic technique) supported by limited evidence. Category IC. Required by state or federal regulations, rules, or standards. Category II. Suggested for implementation and supported by

suggestive clinical or epidemiologic studies or a theoretical rationale. OGrady NP et al. Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. CHLORHEXIDINE GLUCONATE CDC Recommendations: CHG Use to Prevent Intravascular Catheter-Related Infections Cutaneous antisepsis: Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.

Category 1A CHLORHEXIDINE GLUCONATE CDC Recommendations: Best Practices Checklist CHLORHEXIDINE GLUCONATE CDC Recommendations: CLIP Adherence Monitoring CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub Disinfection of hubs before every access is recommended to reduce hub contamination Optimal disinfectant and hub scrub time are not known CHLORHEXIDINE GLUCONATE

CDC Recommendations: CHG Use to Prevent Intravascular Catheter-Related Infections Needleless Intravascular Catheter Systems: Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. Category 1A CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub 17 2017 PDI H. P. Loveday et al. / Journal of Hospital Infection(2014) S1S70 CHLORHEXIDINE GLUCONATE

Summary of US Clinical Guidelines for Disinfection of Needleless Access Devices Data on file, PDI, Orangeburg, New York. CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Catheter Hub Disinfection Current Evidence Published In Vitro and Clinical Studies 19 2017 PDI CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub Hong H et al. Am J Infect Control 2013:41

CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub Background: Methods: 21 Inadequate needleless connector decontamination can result

in microbial contamination of the internal lumen of the central venous access device resulting in colonization and CLABSI Microbial in vitro study investigating the comparative efcacy of 3 needleless connector decontamination methods and 3 connector types with different durations of application; 648 procedures; S. aureus, S. epidermidis, Pseudomonas aeruginosa, and Candida albicans as test organisms. 324 connectors pre-coated with sterile human serum Findings: Even a 5-sec CHG swabbing (2% CHG/70% alcohol) outperformed other methods with or without human serum exposure: ideal method is 30 seconds with CHG swabs

Poor compliance with swabbing may negate the efficacy 2017 PDI Flynn JM et al. Infect Control Hosp Epidemiol 2017; 38: 617-619 CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: A pediatric single center before/after study on a hemopoietic stem cell transplant ward Methods: 22 Observational before/after study;

change from catheter connector antisepsis with 70 % alcohol to 2% CHG/70% alcohol Primary outcome of CRBSI CRBSI rate declined from 12/1000 CL days to 3/1000 CL days (p= 0.004) Similar declines seen with introduction on other wards 2017 PDI

Soothill JS et al. Am J Infect Control 2009; 37:626-30 CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Scrub the Hub Prospective, randomized, blinded crossover clinical trial in a 24-bed MICU Findings: 113/509 (22%) hubs contaminated Use of a 3.15% CHG/70% IPA prep pad was associated with less CVC hub contamination compared to disinfection with 70% IPA alone Statistical significance only for a shorter scrub time Hayden, M. K., et. al. . A Randomized Cross-Over Clinical Trial to Compare 3.15% Chlorhexidine/70% Isopropyl Alcohol (CHG) vs 70% Isopropyl Alcohol Alone (Alcohol) and 5s vs 15s Scrub for Routine Disinfection of Needleless Connectors (NCs) on Central Venous Catheters (CVCs) in an Adult Medical Intensive Care Unit (ICU), Oral Abstract Presented at 2014 ID Week Conference, October 11, 2014, Philadelphia, PA.

CHLORHEXIDINE GLUCONATE CHG: Preventing Intraluminal Entry of Microorganisms: Catheter Hub Disinfection Quality Improvement Projects presented at Professional Meetings CHLORHEXIDINE GLUCONATE Changing Port/Hub Disinfection Product Decreases Catheter Related Bloodstream Infections in a Pediatric Intensive Care Unit Shannon Duffy, RN, BSN; Childrens Hospital, St. Louis, MO. BACKGROUND The pediatric intensive care unit (PICU) unable to obtain a zero CLABSI rate. PICU using 70% isopropyl alcohol (IPA) swab for 15-seconds for each central line access; practice not consistent with the NICU where a 3.15% chlorhexidine/70% isopropyl alcohol (CHG/IPA) swab with a 15second scrub duration was implemented. Approval sought from key stakeholders for trial of the CHG/IPA swab in the PICU. METHODS Implemented the CHG/IPA swab for a 6-month trial; historical 12-month CLABSI rates used for the preintervention baseline dataset.

Education provided to the nursing staff prior to and four months following the implementation. Outcome metric: CLABSI rates; Process metric: compliance with scrub duration; Qualitative assessment of nursing satisfaction with the product. Presented at the 41st Annual Association for Professionals in Infection Control and Epidemiology Conference; June 7-9,2014; Anaheim, CA. Abstract 9-286. CHLORHEXIDINE GLUCONATE Changing Port/Hub Disinfection Product Decreases Catheter Related Bloodstream Infections in a Pediatric Intensive Care Unit Shannon Duffy, RN, BSN; Childrens Hospital, St. Louis, MO. 294 days FINDINGS CLABSI rates decreased from 2.8 infections/ 1000 CL days to 0.48 infections/1000 CL days PICU CLABSIs without a CLABSI

in the PICU Scrubbing compliance consistent throughout the trial. CHG/IPA swab implemented as standard practice for hub disinfection; PICU went 294 days without a CRBSI. CONCLUSIONS Collaboration with key stakeholders and implementing a new catheter maintenance protocol supported by the literature led to acceptance of the practice change. Presented at the 41st Annual Association for Professionals in Infection Control and Epidemiology Conference; June 7-9,2014; Anaheim, CA. Abstract 9-286. Two (2) Catheter Associated Bloodstream Infections within the 18 months since practice change within the PICU CHLORHEXIDINE GLUCONATE

Changing Port/Hub Disinfection Product Decreases Catheter Related Bloodstream Infections in a Pediatric Intensive Care Unit Shannon Duffy, RN, BSN; Childrens Hospital, St. Louis, MO. NURSING FEEDBACK HOW EFFECTIVELY DO YOU FEEL YOU CAN SCRUB THE HUB ? Presented at the 41st Annual Association for Professionals in Infection Control and Epidemiology Conference; June 7-9,2014; Anaheim, CA. Abstract 9-286. DO YOU LET THE HUB DRY AFTER SCRUBBING? CHLORHEXIDINE GLUCONATE Our NICU Journey to Zero Central Line-Associated Bloodstream Infections: Special Patients Require

Special Interventions Janet Pettit, MSN, NNP-BC, CNS, Neonatal Nurse Practitioner, Doctors Medical & Kaiser Permanente Medical Center BACKGROUND - Neonates at high-risk for central line-associated bloodstream infections - Challenge is lack of well documented, evidence-based practice guidelines. - Use of chlorhexidine gluconate (CHG) solutions are best practice for skin antisepsis for central line insertion and maintenance in the adult population, but no CHG containing solutions have FDA approval for infants <2 months of age. - The extended antimicrobial persistence of CHG/ALC beneficial in reducing the number of potential dressing changes preserving the integrity of the neonates skin. - Cost per CLABSI in NICU estimated at $40K. METHODS - Internal assessment of practices: catheter insertion, catheter site and hub maintenance. - 3.15% CHG /70% IPA implemented for skin preparation for catheter insertion/dressing changes and hub and connector set disinfection.

Presented at the Association for Professionals in Infection Control and Epidemiology Annual Conference, June 27-29, 2011. Baltimore, MD. Abstract 7-062 CHLORHEXIDINE GLUCONATE Our NICU Journey to Zero Central Line-Associated Bloodstream Infections: Special Patients Require Special Interventions Janet Pettit, MSN, NNP-BC, CNS, Neonatal Nurse Practitioner, Doctors Medical & Kaiser Permanente Medical Center BSI & CLABSI RESULTS Sustained zero CLABSI for twenty (24) months consecutively 40 Zero incidence of skin breakdown or erythema associated with the use of the CHG

CONCLUSIONS CLABSIs can be prevented and is sustainable in the NICU The CHG/ALC swab for disinfecting hubs and needleless connectors was the crucial intervention. Evolving clinical evidence suggests the use of CHG/ALC as best practice for needleless connectors 30 Incidence of BSI

Work Work Teams Teams Formed Formed 35 25 20 CHG CHG Needleless Needleless Connectors 15 10

5 CHG CHG Skin Skin Antisepsis Antisepsis 0 Staff buy-in along with clinical best practices make zero possible. Presented at the Association for Professionals in Infection Control and Epidemiology Annual Conference, June 27-29, 2011. Baltimore, MD. Abstract 7-062 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 BSI criteria per VON & CLABSI per CDC Criteria for diagnosis BSI CLABSI

CHLORHEXIDINE GLUCONATE Getting to Zero: Outpatient Hemodialysis Catheter-Associated Bloodstream Infections Bren,Virginia R., et al. Altru Health System,Grand Forks, ND, BACKGROUND - Relative risk for bacteremia for patients with permanent (cuffed) hemodialysis catheters is sevenfold the risk for patients with AV fistulas. - High utilization of catheter use -72% - exceeding regional and national percentages. - In 2007, 11 CLABSIs : 1.7 per 100 patient months; increased to 2.4 BSIs per 100 patient months in first 4 months of 2008. - Multi-drug resistant organism (MDRO) colonization increasing (8% in 2005 to >35% in 2007) - Noncompliance with the CDCs 2001 recommendations for prevention of infection in hemodialysis observed. hand hygiene was omitted between touching machines or when performing non-invasive procedures. environmental surfaces were not cleaned between patients.

catheter manipulations performed without hub disinfection. METHODS A bundle of best practices were applied simultaneously: Catheter hub disinfection prior to each accession with CHG 3.15%/70% IPA, hand hygiene plus gloving prior to patient care and machines, chlorhexidine gluconate impregnated sponge dressings on exit sites of those catheters deemed high risk Presented at the Fifth Decennial International Conference on Healthcare-Associated Infections; March 18-22, 2010; Atlanta, GA. Abstract 181 CHLORHEXIDINE GLUCONATE Getting to Zero: Outpatient Hemodialysis Catheter-Associated Bloodstream Infections Bren,Virginia R., et al.Altru Health System, Grand Forks, ND, RESULTS CLABSI

2.4 Catheter associated BSI rate dropped from 2.4 per 100 patient months to 0, which was sustained for 15 months. 24 BSIs were prevented during that period with an estimated $480,000 in cost savings. CONCLUSIONS A bundle of best practices was effective in reducing and sustaining CLABSIs. No change in MDRO prevalence. Dialysis catheter care is challenging because guidelines are somewhat inconsistent.

Sustaining the infection rate at zero is directly related to reduced utilization of catheter accesses. 0 PREVENTED 24 BSIs = $480,000 41% FISTULA UTLIZATION BY 2009 Presented at the Fifth Decennial International Conference on Healthcare-Associated Infections; March 18-22, 2010; Atlanta, GA. Abstract 181 FOR 15 MONTHS COST SAVINGS

MDRO COLONIZATION RATE STABILIZED CHLORHEXIDINE GLUCONATE CHG Resistance 32 2017 PDI CHLORHEXIDINE GLUCONATE CHG Resistance Clinical significance? In vitro studies suggest that chlorhexidine exposure may cause reduced susceptibility to antibiotics and biocides via intrinsic or acquired mechanisms of resistance.1 Strains of K. pneumoniae with increased tolerance to CHG acquired by genetic mutations identified; these mutations also resulted in increased tolerance to colistin.2

At present, insufficient scientific evidence exists to evaluate these risks and additional studies are needed. McDonnell G, Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev. 1999;12(1):147-179. Wand ME. et al. Mechanisms of increased resistance to chlorhexidine and cross-resistance to colistin following exposure of Klebsiella pneumoniae clinical isolates to chlorhexidine. Antimicrob Agents Chemother. 2016 Dec 27;61(1). 1 2 CHLORHEXIDINE GLUCONATE CHG Resistance Healthcare-associated S. aureus bloodstream isolates prior to and after implementation of facility-wide CHG bathing tested for chlorhexidine susceptibility over a 7.5 year period Bed baths with 4% CHG: 2 time periods preceded by at least a year of non-CHG use

No decrease in CHG susceptibility observed: minimal inhibitory concentration (MIC) testing using CLSI guidelines None of the isolates tested contained resistance-promoting genes (qacA or qacB): PCR detection method Concluded that the broad use of chlorhexidine in hospitalized patients does not easily prompt the development of resistance Marolf CT, Alter R, Lyden E, Fey PD, Rupp M. Susceptibility of Nosocomial S. aureus to Chlorhexidine After Implementation of a Hospital-Wide Antiseptic Bathing Regimen. ICHE Jul 2017; 38(7). CHLORHEXIDINE GLUCONATE

Summary Chlorhexidine gluconates broad spectrum of antimicrobial activity makes it an ideal agent for many infection prevention applications The rapid antimicrobial activity of CHG with alcohol in addition to the persistent and residual antibacterial effect on the skin has led to strong recommendations for its use as a cutaneous antiseptic and catheter hub disinfectant More research is needed to evaluate the clinical significance of CHG resistance to antibiotics CHLORHEXIDINE GLUCONATE Questions? Thanks for your attention!

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