Skin antisepsis survey in Australia–New Zealand neonatal nurseries


  • Conflict of interest: None declared.

Dear Editor,

Central line-associated blood stream infections are responsible for 20–40% of health-care-associated infection in both paediatric and adult patients,[1] placing a strain on limited resources in terms of staff and cost. A recent study in the USA showed an increase of 4–7 days in length of stay associated with nosocomial bacteraemia.[2] Chlorhexidine (CHG)-based antiseptic for skin preparation before central line insertion and dressing changes has been recommended for use in infants over 2 months of age.[3] There is a lack of uniformity regarding usage of skin antisepsis in newborn infant, and its usage is currently not approved by the US Food and Drug Administration for infants less than 2 months. However, a national US survey of neonatology program directors revealed that 78% of neonatal intensive care units use CHG[4] with wide variation in preparations used. Our intention was to survey and identify the extent of usage of CHG and other skin antiseptic solutions and its adverse effects in various neonatal nurseries including neonatal transport services and surgical units across Australia–New Zealand (ANZ). The survey was sent by using the web-based software Survey Monkey (Survey Monkey Inc., Palto Alto, CA, USA) in December 2011 to the unit directors and the nursing unit manager if no response was obtained. All the responses were anonymous.

Of the 31 tertiary units in ANZ, 29 units responded (93%). Over half of the units (52%) responded that nosocomial infection was a serious concern in the last 18–24 months, and six units responded that skin antisepsis policy was a concern as well. The type (Table 1) and concentration (Table 2) of CHG used in the neonatal intensive care unit varied considerably. Alcohol-based CHG was commonly used in term infants, whereas majority of units (72%) used aqueous CHG in preterm infants. Three units reported using iodine first with a secondary use of CHG. Most units used CHG of a strength >0.1% with a range between 0.1% and 2.0%. In terms of indications of CHG, peripheral intravenous access, central vascular access and umbilical catheterisations and maintenance were the commonly used procedures. Daily bathing of newborns (three units) and Methicillin Resistant Staphylococcus Aureus decolonisation (five units) were other less often indications.

Table 1. Antiseptic solutions used in Australia and New Zealand Level III neonatal intensive care unit
SolutionChlorhexidine (aqueous)Chlorhexidine (alcohol based)Iodine
Policy for term infants (n = 28)12 (43%)16 (56%)0
Policy for preterm infants (n = 29)21 (72%)5 (17%)3 (11%)
Table 2. Strength of the chlorhexidine solutions in preterm infants
Strength of chlorhexidine in preterm infants(<0.1%)(0.1–0.5%)(0.5–2.0%)
Peripheral intravenous catheter insertion policy (n = 23)5 (22%)8 (35%)10 (43%)
Central and umbilical line insertion policy (n = 23)6 (26%)7 (30%)10 (44%)

Adverse effects of CHG were reported by 12 units, in form of skin erythema or burns or blisters. Six out of 10 units who reported the adverse effects were using higher concentration of CHG (>0.5%). Seventeen units (59% of respondent) reported using iodine in the past and hypothyroidism was common side effect observed then.

In contrast to the US national survey by Tamma et al.,[4] all respondents from ANZ in our survey used CHG in some form for term infants and almost 90% in preterm infants as well. Victor Yu[5] surveyed 20 neonatal intensive care units in Australia more than two decades ago and identified lack of uniformity with regard to skin antisepsis policy including intravascular access. Our survey showed that while most units used CHG in their neonatal nurseries, there was a 20-fold range in concentration, indicating a lack of consensus. CHG has been used in various invasive procedures like central/umbilical line insertions, central line maintenance and bathing of newborn infants as well. The use of alcohol or aqueous base and the addition of iodine is an additional concern. The literature in adults suggests that aqueous CHG is as effective as alcohol base and safe, although alcohol may provide longer antiseptic effect.[6] Adverse effects of CHG are reported in form of skin burns, erythema and blisters,[7] although more so in preterm infants. Although CHG is clearly effective as skin antiseptic solution, a further research and data into its optimal strength, type and associated skin adverse effects needs to be established.