This month, Chloé Schlaeppi from University Children’s Hospital Basel is reviewing:
Dramowski A, Pillay S, Bekker A, et al. Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates – A pilot clinical trial. EClinicalMedicine. 2021;37:100946. Published 2021 Jun 18.
Why is it important?
Colonization with antibiotic-resistant bacteria is frequent in hospitalized preterm neonates and increases their risk for invasive infections with those bacteria. Therefore, measures targeting skin colonization and improving skin integrity like antiseptic whole-body washing or emollients offer potential as infection prevention and control (IPC) interventions. In neonatal intensive care units (NICUs) in low- and middle-income countries, where colonization pressure is important, such easily applicable and low-cost interventions could be of benefit.
What was done?
The study was conducted in a busy neonatal unit at a tertiary hospital in Cape Town, South Africa. 80 preterm neonates, weighing 1000-1500g and on day 1-3 of life were sequentially allocated to 4 trial arms. Each arm consisted of 20 neonates, who, depending on the allocation received 1% aqueous chlorhexidine (CHG), 1% CHG followed by emollient, emollient only or standard of care (no antiseptic/emollient). All interventions were applied for 10 days and skin swabs for bacterial colony counts were taken at enrolment, during the trial intervention at day 3 and 10 as well as following the intervention at day 16 post-enrollment. In addition, regular skin condition assessments were carried out to report the effect of the intervention on skin integrity.
What did the study find?
While 1% CHG washing reduced bacterial pathogen colonization density during the intervention compared to the other three groups, it rapidly rebounded back after its cessation leading to similar colonization density in all trial arms on day 16. This effect was observed in all localizations but the nose, which the authors attributed to the washing being applied only from neck down and therefore not affecting the nose. Skin conditions improved with emollient application, either alone or in combination with 1% CHG, however those two groups also had increased S. aureus colonization rates. There were no skin reactions to 1% CHG and hypothermia following washing was rare.
Overall, all neonates were rapidly colonized with gram-negative pathogens and infection related events such as blood stream infections occurred in one third of the cohort.
Bottom line
Skin care and whole-body washing with 1% CHG are potentially highly relevant IPC interventions in preterm neonates. The rapid acquisition of pathogens suggests that such interventions should be started early and potentially continued for a longer period of time, considering the rebound of colonization density after cessation of 1% CHG application. However, in this vulnerable population of preterm neonates the optimal protocol and safe dosing of skin antisepsis remains unclear. Upon investigating these, special considerations should be given to low-and middle-income neonatal units where bacterial colonization burden is high and gram-negative pathogens are predominant.