Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: An evidence based review

Table 1 Characteristics of topical antiseptic agents used in neonates (World Health Organization 2009)

Antiseptic agent	Mechanism of action	Advantages	Disadvantages	Preparations/compounds
Chlorhexidine	Disruption of cytoplasmic membranes	Broad spectrum antimicrobial activity	Non-sporicidal	0.25%, 0.5%, 1%, 2%, 4% - aqueous and alcohol based
	Denaturation of proteins	Kills yeasts	Not effective against mycobacteria
		Intermediate onset of action	Local dermatitis
		Activity not affected by organic material	Neurotoxicity
		Residual activity	Non-sporicidal
Alcohols	Damages cell membrane	Broad spectrum antimicrobial activity	Not active in presence of organic material	Ethanol, isopropyl alcohol, methanol
	Denaturation of proteins	Faster onset of action	No residual activity
			Skin reactions
			Systemic absorption
Iodine	Forms complexes with proteins and lipids	Broad spectrum antimicrobial activity	Skin irritation	10% povidone-iodine
	Impaired protein synthesis and alteration of cell membranes	Sporicidal	Systemic absorption with hypothyroidism
		Effective against mycobacteria
		Has some residual activity
Hexachlorophene	Inactivates essential enzyme systems	Good activity against gram positive, weak against gram negative	Residual activity	Currently not recommended for bathing neonates
			Neurotoxicity

Table 2 Studies reporting adverse effects of chlorhexidine use in neonates

Ref.	Design/type	Patient characteristics (n)	Type of antiseptic used	Purpose of antisepsis	Adverse reaction	Systemic effects	Comments
Garland et al[78]	Prospective study	Neonates (n = 111)	0.5% CHG in 70% IPA	PICC insertion	None reported	Not reported	GA not reported
Garland et al[79]	RCT	Neonates (n = 335, including 98 babies < 1000 g)	0.5% CHG and 70% IPA, CHG impregnated dressing after cleansing	PICC insertion	19 cases of contact dermatitis of which 15 are < 1000 g	Not reported	Occlusive dressing could be the cause of contact dermatitis
Bührer et al[102]	Prospective study	Preterm < 27 wk GA (n = 24)	2% phenoxyethanol and 0.1% octenidine	Skin care	Transient erythema in a 23 wk gestation baby	Absorbed systemically but no adverse effects reported
Pezzati et al[57]	RCT	Preterm < 34 wk (n = 101)	4% CHG aqueous solution	Umbilical cord care	None	Not reported	Mostly above 28 wk
Andersen et al[37]	Prospective study	VLBW < 1500 g (n = 36)	2% aqueous CHG	PICC, cannula insertion	Skin erythema and burn	Not reported	Recommended alternative safer agent
Visscher et al[22]	Pilot study	Neonates (n = 40; 14 of which < 30 wk )	2% CHG in 70% IPA	PICC insertion	Erythema and dryness	Not reported	Could be from dressing
Schick et al[98]	Case report	Preterm < 28 wk GA (n = 2)	IPA	Umbilical catheterisation	Skin burn (2nd/3rd degree burn)	Not reported
Harpin et al[95]	Case report	Preterm 27 wk GA (n = 1)	Methylated spirit (95% ethanol and 5% wood naptha)	Umbilical catheterisation	Haemorrhagic skin necrosis	Very high ethanol and methanol levels in blood	Use of alcohol antiseptics in preterm neonates potentially dangerous
Watkins et al[99]	Case report	Extreme LBW babies (n = 2)	Iso propyle alcohol	Umbilical catheterisation	Skin burns	Not reported	Care must be taken in selection of such solutions
Brayer et al[100]	Case report	Preterm at 35 wk (n = 1)	Isopropyl alcohol	Umbilical catheterisation	Severe skin burn	Not reported
Reynolds et al[96]	Case report	Preterm infants 24 wk (n = 2)	0.5% CHG + 70% methanol	Umbilical catheterisation	Extensive abdominal skin burns	Not reported	Avoid pooling of the antiseptic solution and use Saline for cleaning to wash antiseptic
Mannan et al[101]	Case report	Preterm 26 wk GA (n = 1)	0.5% CHG + 70% alcohol	Umbilical catheterisation	Extensive abdominal skin burns	Not reported	Alcohol containing preparations should be avoided in NICUs
Bringué Espuny et al[97]	Case report	Preterm 26 wk (n = 2)	0.5% CHG + methanol	Umbilical catheterisation	Skin burns	Not reported	Use of alcoholic preparations should be avoided in preterm
Lashkari et al[103]	Case report	Preterm 25 wk GA (n = 1)	2% aqueous CHG	Umbilical catheterisation	Skin burn	Not reported	Cleansing with Normal saline could potentially reduce the exposure and burns

CHG: Chlorhexidine; GA: General availability; NICU: Neonatal intensive care unit; IPA: Iso propyle alcohol; PICC: Peripherally inserted central venous catheter; VLBW: Very low birth weight infants; RCT: Randomized controlled trial.