Severe allergic reactions and intra-urethral chlorhexidine gluconate

Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature

BACKGROUND

Chlorhexidine (CHL) has antiseptic and disinfectant properties used to prevent hospital-acquired infections. CHL-induced anaphylaxis is poorly reported in surgical literature despite government warnings and growing recognition. The aim of this review is to increase awareness of CHL-induced anaphylaxis in the surgical population.

METHODS

Literature review of Embase, Medline, PubMed and the Cochrane library using 'anaphylaxis (and) chlorhexidine' search terms.

RESULTS

Thirty-six articles were published on surgical patients suffering anaphylaxis to CHL. Within these, seven patients had two proven separate anaphylactic reactions and one had three separate proven anaphylactic reactions. The most commonly affected speciality was urology. The majority occurred during elective procedures. A history of atopy was surprisingly uncommon as was bronchospasm. Six patients required active chest compressions and 39.71% of patients had their surgical procedure abandoned. Unplanned intensive care admissions occurred in 27.94%.

DISCUSSION

In order to reduce abandoned procedures, unplanned intensive care unit admissions, morbidity and mortality associated with CHL-induced anaphylaxis we recommend the following: rationalization of CHL-containing products, greater vigilance regarding subtle symptoms of CHL allergy, appropriate investigation of these symptoms and a greater awareness of CHL-containing products. Lastly, we outline the appropriate investigations and highlight the need for meticulous documentation in those who are CHL allergic.

Chlorhexidine - Pharmacology and Clinical Applications

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.

Anaphylaxis to an urethral lubricant: chlorhexidine as the "hidden" allergen

We report on a severe allergic reaction during urethral catheterisation, initially erroneously attributed to natural rubber latex (NRL). However, the negative investigations for latex, the uneventful further applications of NRL, the positive skin test and basophil activation test for chlorhexidine strongly support diagnosis of chlorhexidine anaphylaxis. This case illustrates that it is not widely appreciated that "innocent" products such as urethral lubricants may elicit serious life-threatening reactions. Careful inspection of the medical records is once again re-emphasised to be mandatory in order to avert subsequent anaphylaxis.

Desquamating Vaginal Mucosa From Chlorhexidine Gluconate

BACKGROUND

Chlorhexidine gluconate is a commonly used and effective antiseptic agent for preparing patients for surgery.

CASE

A healthy premenopausal woman was taken to the operating room for a planned laparoscopically assisted vaginal hysterectomy. After vaginal, vulvar, perineal, and abdominal cleansing with chlorhexidine gluconate, the patient developed a desquamating vaginal reaction that was treated with intravenous corticosteroids, antihistamine, topical conjugated estrogen, and hydrocortisone cream. The planned surgery was aborted, and the patient recovered uneventfully overnight in the postanesthesia care unit. With continued application of conjugated estrogen cream, the patient's vaginal mucosa was well healed within 2 weeks.

CONCLUSION

Although chlorhexidine gluconate has been used effectively to minimize surgical site infection in vaginal surgery, the possibility for adverse reaction should be considered.

Chlorhexidine anaphylaxis: case report and review of the literature

Chlorhexidine is a widely used antiseptic and disinfectant. Compared to its ubiquitous use in medical and non-medical environments, the sensitization rate seems to be low. Multivarious hypersensitivity reactions to the agent have been reported, including delayed hypersensitivity reactions such as contact dermatitis, fixed drug eruptions and photosensitivity reactions. An increasing number of immediate-type allergies such as contact urticaria, occupational asthma and anaphylactic shock have been reported. In the case report, we describe anaphylaxis due to topical skin application of chlorhexidine, confirmed by skin testing and sulfidoleukotriene stimulation test (CAST(R): cellular antigen stimulation test). The potential risk of anaphylactic reactions due to the application of chlorhexidine is well known, especially that application to mucous membranes can cause anaphylactic reactions and was therefore discouraged. The use of chlorhexidine at a 0.05% concentration on wounds and intact skin was so far thought to be safe. Besides our patient, only one other case of severe anaphylactic reaction due to application of chlorhexidine on skin has been reported. Hypersensitivity to chlorhexidine is rare, but its potential to cause anaphylactic shock is probably underestimated. This review should remind all clinicians of an important potential risk of this widely used antiseptic.

Allergy to chlorhexidine gluconate in urethral gel: report of four cases and review of the literature

Chlorhexidine is a bis-biguanide molecule widely used in many preparations as a disinfectant and an antiseptic. We describe four confirmed cases of allergy to chlorhexidine gluconate in urethral gel and review the existing published reports. Pertinent issues in the treatment and investigation of these patients are discussed.

Adverse reactions associated with an alcohol-based hand antiseptic among nurses in a neonatal intensive care unit

BACKGROUND

Alcohol-based hand antiseptics are strongly recommended in the 2002 Centers for Disease Control and Prevention's hand-hygiene guideline. In a study comparing 2 hand-hygiene regimes, an alcohol-based (61% ethyl) antiseptic and a detergent containing 2% chlorhexidine gluconate in 2 neonatal intensive care units, we noted adverse reactions associated with the alcohol-based antiseptic.

METHODS

A prospective study was conducted of the skin condition of 58 nurses using an alcohol-based product from March 2001 to January 2002. Adverse reactions to the alcohol-based product were noted and the Fisher exact test was used to determine factors associated with these reactions. Nurses with reactions to the alcohol product who were available to follow-up were patch tested to the product.

RESULTS

Of 58 (1.1/100 nursing mo) nurses, 7 were evaluated by occupational health services for dermatologic symptoms that varied from mild to severe after use of the alcohol product, but 4 of 7 have resumed use. Nurses who had adverse reactions develop had been employed on the study unit and in the nursing profession for significantly less time than those with no reactions (P =.037 and P =.002, respectively), and were significantly more likely to report a history of itchy, sore skin (P =.047). A positive patch-test result was noted in 3 of 4 nurses with a previous reaction to the product.

CONCLUSION

This case series will alert users in the United States and elsewhere to the nature of reactions to alcohol products and how these reactions differ from reactions to traditional hand antiseptic products.

Effect of chlorhexidine on genital microflora, Neisseria gonorrhoeae, and Trichomonas vaginalis in vitro

BACKGROUND

Chlorhexidine is a disinfectant that has been used in skin and mouth washes and as a preservative in some vaginal lubricants. A gel containing 0.25% chlorhexidine gluconate has been found to be effective against Chlamydia trachomatis in vitro and in animal models. Applied vaginally, 5 g of this gel could achieve vaginal fluid concentrations of < or = 1250 microg/ml.

GOAL

To test the in vitro activity of chlorhexidine in a gel over a pH range of 4 to 8 in the presence or absence of blood.

STUDY DESIGN

Organisms were exposed to chlorhexidine for 30 minutes to 2 hours, and the minimum cidal concentration (MCC) was calculated.

RESULTS

The MCC for Neisseria gonorrhoeae was 25 microg/ml at 30 minutes and 12.5 microg/ml at 1 to 2 hours of exposure, whereas the MCC for Trichomonas vaginalis was 1250 microg/ml. Chlorhexidine was more active at pH 8 than pH 4, and less active in the presence of blood. The MCC for Lactobacillus crispatus was 1250 microg/ml at pH 4 and only 125 microg/ml at pH 8.

CONCLUSIONS

Based on its in vitro activity, chlorhexidine may be an appropriate topical microbicide for prevention of gonorrhea, but not for prevention of trichomoniasis. This study suggests that the presence of blood and pH affect the activity of chlorhexidine against genital pathogens and commensals.