Chlorhexidine gluconate–impregnated central-line dressings and necrosis in complicated skin disorder patients

doi:10.1016/j.jcrc.2014.06.001

Journal of Critical Care

Volume 29, Issue 6, December 2014, Pages 1130.e1-1130.e4

https://doi.org/10.1016/j.jcrc.2014.06.001 Get rights and content

Abstract

Although chlorhexidine gluconate (CHG) disks have been shown to help reduce the incidence of central line–associated blood stream infections, their use can result in local skin necrosis. The effects of CHG disks on patients with complex skin pathology have not been studied. We report 6 cases of dermal necrosis associated with Biopatch (Ethicon Inc, Somerville, NJ) CHG disks in adults with complex skin pathology including those with Stevens-Johnson syndrome, toxic epidermal necrolysis syndrome, graft-versus-host disease, burns, and anasarca. All patients had a CHG disk placed at a central venous catheter insertion site. Age range was from 21 to 84 years. Discovery of the reaction ranged from 4 to 14 days after disk placement. Resultant skin erosions required 2 to 10 weeks to reepithelialize. Complicated skin disorder patients represent a rare subset of the critically ill who appear prone to CHG disk necrosis. Continuous contact of CHG under occlusive dressings is speculated to predispose Stevens-Johnson syndrome, toxic epidermal necrolysis syndrome, graft-versus-host disease, and burn patients to local chemical injury secondary to loss of the epithelial tissue barrier, decreased cohesion of the epidermal-dermal junction, and increased tissue permeability. In these patients, the risk of placing the CHG disk may present more risk than using alternative antimicrobial dressings.

Introduction

Antiseptic chlorhexidine gluconate (CHG)-impregnated dressings function to reduce gram-positive and gram-negative skin colonization at the site of central venous catheter (CVC) insertion. They have been shown to decrease overall intravascular catheter or exit-site bacterial colonization from 26.9% to 14.3% and central line–associated blood stream infections from 3.8% to 2.2% in a small meta-analysis [1]. An additional study demonstrated a 60% decrease of major catheter infections [2]. One 1-in round CHG disk dressing (Biopatch; Ethicon Inc, Somerville, NJ) contains an average of 92 mg CHG per disk (Biopatch package insert). The rate of skin absorption is unknown. Skin reactions from CHG disks occur and have been termed severe CHG-impregnated sponge (disk)-associated contact dermatitis. Timsit et al [2] demonstrated occurrence at a rate of 5.3 per 1000 catheters in adult critically ill patients, and Ho and Litton [1] showed a rate of 5.6% within a meta-analysis. In a study of neonates, 5.9% (7/118) of patients developed contact dermatitis, of which 2 developed pressure necrosis [3], [4], [5], [6]. This study prompted the current contraindication of Biopatch use in premature infants. Current contraindications listed in the Biopatch package insert include usage on premature infants or on mucosal surfaces and on patients with known sensitivity to CHG. Instructions also state that, in the event of adverse reactions such as dermatitis, the disk should be discontinued immediately. Recommendations advise that the disk should be changed, a minimum of every 7 days or more frequently, in highly exudative wounds. There are currently no recommendations of usage or reports of adverse events, in patients with complex skin conditions such as burn patients or patients with severe skin reactions. Here, we report 6 patients with 7 occurrences of CHG local skin necrosis occurring at our institution, of which none of whom had contraindication for CHG disk usage.

Section snippets

Case 1

A 73-year-old woman developed Stevens-Johnson syndrome (SJS) with progression to toxic epidermal necrolysis (TENS) after a drug reaction to an antibiotic-impregnated knee implant. Stevens-Johnson syndrome and TENS are a spectrum of severe cutaneous reactions normally induced by drug or viral exposure. Clinically, patients display sloughing of their epidermis and have mucous membrane involvement and can be systemically ill. The two entities are discerned by the total body surface area (TBSA)

Discussion

Although thousands of patients in our hospital system annually receive CVC with CHG disks without adverse event(s) from the CHG disk, the 6 patients in this case series all presented with intrinsic and extrinsic risk with associated severe skin pathology. Stevens-Johnson syndrome/toxic epidermal necrolysis syndrome are severe cutaneous reactions to drug or viral exposure marked by full-thickness epidermal necrosis. Importantly, SJS/TENS are rapidly progressive, so apparently, intact tissue on

Conclusion

In an effort to decrease future CHG disk complications, our institution has amended our nursing policy with regard to dressing central-line sites in high-risk populations including SJS/TENS, GvHD, and burn patients. Per hospital policy, CHG disk dressings will not be applied to (1) open burned tissue; (2) inflammatory tissue directly surrounding burn tissue; (3) persons affected with acute GvHD, SJS/TENS with diffuse skin changes/rash/hyperpigmentation, or open tissues at catheter sites; or (4)

Acknowledgments

We thank the Brigham and Women’s Hospital Central Venous Catheter Committee and unit-based nurse educators for their assistance in effecting internal policy change for the safety of this complicated patient population. Additional appreciation is extended to the medical library staff and data coordinators for their collaboration and support.

References (16)

M. Lissia et al.
Toxic epidermal necrolysis (Lyell’s disease)
Burns
(2010)
S.R. Hymes et al.
Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease
J Am Acad Dermatol
(2012)
S.R. Hymes et al.
Graft-versus-host disease: part I. Pathogenesis and clinical manifestations of graft-versus-host disease
J Am Acad Dermatol
(2012)
V.A. Harpin et al.
Barrier properties of the newborn infant’s skin
J Pediatr
(1983)
K.M. Ho et al.
Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis
J Antimicrob Chemother
(2006)
J.F. Timsit et al.
Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults
Am J Respir Crit Care Med
(2012)
J.S. Garland et al.
Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants
Pediatr Infect Dis J
(1996)
J.S. Garland et al.
A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates
Pediatrics
(2001)

There are more references available in the full text version of this article.

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The methodology for determining this diagnosis was not reported. Wall, Divito and Talbot (2014) reported skin necrosis associated with the use of a CHG sponge dressing in 6 patients with complex skin disorders including burns and graft vs. host disease. The possibility that some chemotherapeutics (specifically 5-FU and taxanes) act synergistically with CHG to create skin damage has been proposed (Kutzscher, 2012).
Chlorhexidine-impregnated gel dressing compared with transparent polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients: A pilot randomised controlled trial
2019, Australian Critical Care
Citation Excerpt :
Other studies have reported skin irritation or damage for both dressings.18–22 A few case reports showed erosive contact dermatitis and skin necrosis from chlorhexidine-impregnated dressings.23,24 Repeated application and removal of dressings damage the skin integrity, lead to inflammatory skin reactions, and increase rates of CRBSI.25
In patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections.
The objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC.
One hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip.
Of 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes.
Our preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.
Skin complications associated with vascular access devices: A secondary analysis of 13 studies involving 10,859 devices
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Signs and symptoms include itch, erythema, and pain, (McNichol et al., 2013; Thayer, 2012). While these conditions and symptoms are significant, and frequently reported in the literature (Kutzscher, 2012; LeBlanc and Baranoski, 2011; McNichol et al., 2013; Thayer, 2012; Ullman et al., 2015b; Wall et al., 2014), robust, systematic evidence concerning vascular access-associated skin complication incidence and modifiable risk factors, are sparse. Single site, observational studies in mixed settings (Farris et al., 2015; Konya et al., 2010) have reported overall medical adhesive-related skin injury prevalence (across all types of exposure to medical adhesive) of 3–25%, with the highest risk in elderly patients (Farris et al., 2015), and those with vascular access devices (Konya et al., 2010).
Vascular access devices are widely used in healthcare settings worldwide. The insertion of a vascular access device creates a wound, vulnerable to irritation, injury and infection. Vascular access-associated skin complications are frequently reported in the literature, however very little evidence is available regarding the incidence and risk factors of these conditions to inform practice and technology development.
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Three groups consisting of 48 healthy volunteers were included. Age range was 23 to 54 years old and 60% of participants were male. Each subject had 1 knee serve as the test and the contralateral as the control. The test site was prepared with either 2% chlorhexidine, 4% chlorhexidine, or a silver-zinc bioelectric dressing and after 24 hours skin cultures were taken and examined for bacterial growth.
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Basic Science – Microbiology.
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^☆: Disclosures: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

^☆☆: No funding sources were used in the preparation of this manuscript.

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Electronic ArticleChlorhexidine gluconate–impregnated central-line dressings and necrosis in complicated skin disorder patients☆,☆☆

Abstract

Introduction

Section snippets

Case 1

Discussion

Conclusion

Acknowledgments

Burns

J Am Acad Dermatol

J Am Acad Dermatol

J Pediatr

Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis

J Antimicrob Chemother

Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults

Am J Respir Crit Care Med

Local reactions to a chlorhexidine gluconate-impregnated antimicrobial dressing in very low birth weight infants

Pediatr Infect Dis J

A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates

Pediatrics

Electronic Article
Chlorhexidine gluconate–impregnated central-line dressings and necrosis in complicated skin disorder patients☆,☆☆