infection control and hospital epidemiologyoctober 2008, vol. 29, no. 10
Efficacy of Adding 2% (w/v)
Chlorhexidine Gluconate to 70% (v/v)
Isopropyl Alcohol for Skin Disinfection
Prior to Peripheral Venous Cannulation
Heather Small, MSc; Debra Adams, PhD;
Anna L. Casey, PhD; Cynthia T. Crosby, BS;
Peter A. Lambert, DSc;
Thomas Elliott, FRMS, PhD, DSc, MRCP, FRCPath
We undertook a clinical trial to compare the efficacy of 2% (w/v)
chlorhexidine gluconate in 70% (v/v) isopropyl alcohol with the
efficacy of 70% (v/v) isopropyl alcohol alone for skin disinfection
to prevent peripheral venous catheter colonization and contami-
nation. We found that the addition of 2% chlorhexidine gluconate
reduced the number of peripheral venous catheters that were col-
onized or contaminated.
Infect Control Hosp Epidemiol 2008; 29:963-965
Intravenous catheters, both peripheral and central, are as-
sociated with a risk of catheter-related bloodstreaminfection.1
The role of cutaneous microorganisms in the pathogenesis
of these infections highlights the need to effectively decon-
taminate skin prior to catheterization.2,3Skin antiseptics fre-
quently utilized include povidone-iodine, alcohol, and chlor-
hexidine. The efficacy of these antiseptics has been previously
evaluated with central venous and arterial catheters.4The use
of 2% (w/v) aqueous chlorhexidine was associated with the
lowest incidence of catheter-related infection.
More recently, a solution of 2% (w/v) chlorhexidine glu-
conate in 70% (v/v) isopropyl alcohol (2% CHG in IPA)
(ChloraPrep; Enturia) has been developed for skin decon-
tamination. The 2% CHG in IPA provided more persistent
antimicrobial activity on abdominal sites than either 70% IPA
or 2% CHG alone at 24 hours.5The 2% CHG in IPA was
also superior to chloroxylenol and to an alcohol-based iodine
solution for eliminating skin microorganisms prior to an op-
eration.6In vitro studies have further confirmed that skin
antisepsis is enhanced with 2% CHG in IPA, compared with
other chlorhexidine preparations.7
The Centers for Disease Control and Prevention guidelines
recommend a 2% chlorhexidine–based preparation, tinctine
of iodine, iodophor, or 70% IPA for skin antisepsis prior to
insertion of intravascular catheters.2Evidence-based guide-
lines in the United Kingdom also recommend use of chlor-
hexidine, preferably 2% CHG in IPA, prior to the insertion
of central venous catheters.8
We evaluated the number of peripheral venous catheter
(PVC) tips that had microorganisms present on their intra-
vascular component following skin decontamination either
with 2% CHG in IPA or with 70% IPA alone, which is com-
monly used in the United Kingdom.
mitted for ablation or pacemaker insertion at University Hos-
pital Birmingham, United Kingdom. We excluded patients
who were less than 18 years of age, had skin dermatoses, had
a chlorhexidine allergy, or were unable to give informed con-
sent. Ethical approval was obtained from our local research
Patients were randomly assigned to receive skin prepara-
tion prior to PVC insertion either with the 2% CHG in IPA
solution (in a Sepp 0.67 mL applicator; Enturia) or withwipes
containing 0.6 mL of 70% IPA (Steret; Seton Prebble). Blind-
ing was not achieved because of the physical differences in
the antiseptic applicators.
The 2% CHG in IPA solution was applied using a standard
back-and-forth stroke over the entire skin insertion site for
30 seconds. The 70% IPA wipe was also applied for 30 sec-
onds, utilizing a circular movement as in routine clinical
practice. Each antiseptic was then allowedtodryfor2minutes
before a polyurethane PVC (Optiva 2, Medex Medical) was
inserted into a superficial vein of the hand. A semipermeable
dressing was applied over the insertion site. Prior to PVC
removal, the insertion sites were cleanedwith70%IPA.Clean,
nonsterile gloves, but not masks, were worn by the operator,
and the PVC tips were not handled during explantation.
Assessment of microorganisms on PVC tips.
of microorganisms present on the PVC tips was determined
by quantitative tip culture.9The distal 3 cm of each PVC tip
was vortexed in 1 mL of saline solution for 60 seconds, then
100 mL of the liquid was inoculated onto a blood agar plate
(Oxoid) that was incubated in air at 37? C for 48 hours. The
number of colony-forming units was determined, and mi-
croorganisms were identified by routine methods. Data were
compared using the Fisher exact test and Mann-Whitney U
We studied elective cardiology patients ad-
Of the 236 patients who met the trial entry criteria, 230 gave
consent and 6 declined to participate. Sixty patients were
excluded, for the following reasons: the patient was dis-
charged prior to study completion (for 1 patient), the PVC
was in situ less than 24 hours (for 10 patients), the PVC was
accidentally discarded (for 23 patients), a PVC different from
all the others in the study was used (for 1 patient), and the
explanted PVC was placed in a nonsterile dressing (for 25
patients). We analyzed PVCs from 170 patients (107 male
and 63 female), with a mean age of 61.3 years (range, 21–96
years). There were 91 patients (60 male and 31 female) in
the 2% CHG with IPA group and 79 patients (47 male and
32 female) in the IPA group. None of the patients exhibited
964infection control and hospital epidemiologyoctober 2008, vol. 29, no. 10
received skin disinfection prior to catheter insertion with 2% (w/v) chlorhexidine gluconate in 70% (v/v) isopropyl alcohol (2% CHG in
IPA) or with 70% (v/v) IPA alone. CoNS, coagulase-negative staphylococci.
Comparison of the microorganisms isolated from peripheral vascular catheter (PVC) tips following removal from patients who
evidence of infection and no chlorhexidine hypersensitivity
was observed. The mean indwell period of the PVC tips was
2.3 days (range, 1–6 days) for the 2% CHG in IPA group
and 2.2 days (range, 1–4 days) for the IPA group (
Antibiotic prophylaxis for the cardiologic procedure (flu-
cloxacillin) was given for 24 hours to 16 patients in the 2%
CHG in IPA group and to 18 patients in the IPA group. No
patients received antibiotics for treatment of infection during
The use of 2% CHG in IPA was associated with a reduced
number of PVC tips with microorganisms present on their
surface, compared with the use of 70% IPA alone (Figure).
Microorganisms were present on 39 (49.4%) of 79 PVC tips
in the 70% IPA group, compared with 18 (19.8%) of 91 PVC
tips in the 2% CHG in IPA group (
[95% confidence interval, 2.0–7.8]). With the achieved sam-
ple sizes, the study had a 90% power to detect a difference
between a 50% rate with 70% IPA and a 25% rate with 2%
CHG in IPA; the level of significance was set at .05. Of the
16 PVCs from patients who received antibiotics in the 2%
CHG in IPA group, 6 yielded microorganisms on culture; of
the 18 PVCs from patients who received antibiotics in the
70% IPA group, 12 yielded microorganisms on culture.
The mean number of colony-forming units yielded from
each culture-positive PVC tip was 4 in the 2% CHG in IPA
group, compared with 2 in the IPA group (
than one type of microorganism was present on 5 tips from
the CHG in IPA group and on 8 tips from the IPA group.
P p .7
; odds ratio, 4.0
P ! .001
). MoreP p .57
Skin disinfection with 2% CHG in IPA prior to PVC insertion
resulted in a significant reduction in the number of PVC tips
that had microorganisms present on their surface, compared
with skin disinfection with 70% IPA alone. The number of
microorganisms detected could have been the result of con-
tamination from the skin, although early colonization could
not be ruled out. Both contamination and colonization are,
however, likely prerequisites for the subsequent development
of infection in patients with either a peripheral or a central
intravenous catheter. These results concur with previous find-
ings that demonstrated the superiority of 2% CHG in IPA in
reducing skin microbial counts, compared with 70% IPA or
with 2% CHG alone.5
IPA provides a rapid reduction in the number of skin mi-
croorganisms but does not have any residual activity. In com-
parison, CHG has residual activity on the skin for as long as
24 hours.10This offers a further explanation for the findings
in this current study. CHG at a concentration of 2% (w/v)
with 70% (v/v) IPA, therefore, may not only be an effective
skin antiseptic but may also provide continued protection of
the PVC from microbial ingress from the skin.
The results of the current study may have also been influ-
enced by the applicators used. The different types of appli-
cation may have resulted in differences in the removal of
epithelial cells and bacterial commensals and may have in-
fluenced the penetration of antiseptic into the skin. A similar
number of patients received antibiotic prophylaxis in each
efficacy of skin decontamination prior to cannulation 965 Download full-text
study group, and there was no correlation between the use
of these antibiotics and the presence of microorganisms on
the catheter surfaces. However, the use of flucloxacillin may
have decreased the overall contamination rate in both groups.
This study suggests that the use of 2% CHG in IPA for
skin decontamination prior to PVC insertion may reduce the
risk of subsequent PVC contamination or colonization, com-
pared with the use of 70% IPA alone.
We thank the cardiology staff for support.
Potential conflicts of interest.
uted to the study design. All other authors report no conflicts of interest
relevant to this study.
This study was supported by aneducationalgrantfrom
C.T.C. is employed by Enturia and contrib-
From the Department of Clinical Microbiology and Infection Control,
University Hospital Birmingham NHS Foundation Trust, The Queen Eliz-
abeth Hospital, Edgbaston (H.S., D.A., A.L.C., T.E.), and the Department of
Pharmaceutical and Biological Sciences, Aston University, Aston Triangle
(P.A.L.), Birmingham, England; and Enturia, Leawood, Kansas (C.T.C.).
Address reprint requests to Thomas Elliott, PhD, Selly Oak Hospital,
Raddlebarn Rd., Selly Oak, Birmingham, B29 6JD, England (tom.elliott
Presented in part: 6th International Intravenous Therapy Home and Hos-
pital Conference; Oxford, England; March 8 and 9, 2006.
Received February 26, 2008; accepted June 5, 2008;electronicallypublished
September 4, 2008.
? 2008 by The Society for Healthcare Epidemiology of America. All rights
reserved. 0899-823X/2008/2910-0012$15.00.DOI: 10.1086/590664
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