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NFL Infectious Disease News -- September 2013

Topical Chlorhexidine Gluconate to Prevent MRSA Infections: The Who, What, When, and Why for NFL Medical Personnel

Background

The antiseptic chlorhexidine gluconate (CHG) is routinely used for surgical skin preparation because of its broad spectrum of activity against both bacteria and viruses. Topical CHG is also used to prevent recurrent infections due to methicillin-resistant Staphylococcus aureus (MRSA), in a process called decolonization. For example, daily baths using CHG-impregnated cloths are widely used in patients in intensive care units to prevent infections caused by MRSA and other multidrug-resistant organisms. A recent study (the "REDUCE MRSA" trial) was discussed at length in our last newsletter. Briefly, this trial showed that hospitalized patients who received daily baths using CHG-impregnated cloths had a 37 percent reduction in MRSA "disease burden" compared to patients receiving routine care.

This newsletter will provide the information personnel at training facilities need to have to administer CHG safely. We will discuss recommended formulations, when and how CHG should be administered, the recommended frequency of use, duration of its effects, potential side effects, and a few other adjunctive MRSA prevention measures.

Recommended CHG formulation

CHG formulations on the market today include wipes, sprays, droppers, shampoos, mouth rinses, body rinses and toothpaste containing concentrations ranging from 0.0 percent to 36 percent. Most topical skin preparations contain CHG concentrations between 2 and 4 percent. Topical skin preparations containing 2 percent are as effective as those containing 4 percent CHG concentrations or higher.

Showering with Antiseptics containing CHG

Liquid, detergent-based preparations containing 2 to 4 percent CHG have been widely used for prevention of post-operative infections. CHG liquid soaps are supplied in unit doses ranging from 25 to 250 ml; the most commonly used commercially available unit dose is 4 ounces (approximately 120 ml). Liquid CHG preparations are typically used in the following manner: after an initial rinse in the shower, undiluted topical CHG liquid is applied to the skin, lathered, rinsed, reapplied and then rinsed a final time. Although showering with CHG is widely recommended for preoperative patients, its effectiveness remains unproven. CHG is most effective when allowed to dry on the skin. Also, it has been our and others' experience that proper and consistent application of CHG is difficult to achieve using the above protocol.

Bathing using CHG-impregnated cloths

Two percent CHG-impregnated cloths are more effective and have a lower risk of side effects than liquid CHG preparations. These cloths are commercially available in alcohol-free prepackaged unit doses sufficient for bathing a single person. Four to six 7.5 x 7.5 inch cloths are needed to bath a single adult.

No rinsing is needed after application and CHG dries on the skin. If used after showering, they should be applied only after the skin is dry and cool. Warmers can be used to heat the cloths prior to application. DICON recommends using disposable prepackaged 2 percent CHG-impregnated cloths for the following reasons:

* A track record of success in the REDUCE MRSA and other trials.

* They are available as a prepackaged product with a consistent and effective concentration of CHG

* They are disposable

* They are safe: side effects are extremely rare and minor

* Packets are relatively inexpensive (compared to other disinfectants ex: Clorox wipes) and portable

* They result in rapid killing of MRSA on skin surfaces

When and How CHG should be administered

We recommend team-wide use of topical CHG when a cluster of MRSA infections is recognized in a team training facility. Unfortunately, there is no reliable data regarding ideal time of day for CHG administration for non-hospitalized individuals. Most hospitals apply CHG during daily patient bathing as CHG is most effective when allowed to dry on the skin. We recommend applying prepackaged body wipes to athletes after the post-practice shower. CHG should not be applied to the face; we recommend instructing athletes to apply wipes to all skin surfaces below the chin.

Ideal frequency and duration to administer CHG

Two studies in military recruits using thrice weekly CHG cloths demonstrated a statistically significant reduction in acquisition of MRSA (3.3 vs. 6.5 percent) colonization. However, this reduction in colonization failed to reduce rates of skin and soft tissue infections. One study focused on duration of CHG activity on patients' skin using 2 percent chlorhexidine-impregnated cloths. In that study, CHG retained antibacterial activity in 90 percent of hospitalized patients 24 hours after administration. To our knowledge there are no studies that examine the ideal frequency to administer CHG in team settings, but based on available data, we believe that daily application is appropriate. Similarly there is no data on the duration of topical treatments in non-hospitalized patients. We recommend daily applications for a minimum of two weeks; twice weekly applications can be continued until there are no further cases of MRSA infection for at least 3 weeks.

Side effects of CHG

Descriptions of adverse reactions to topical application of CHG range in severity from local skin rash (dermatitis) to anaphylaxis. However, severe reactions are extraordinarily rare. CHG rarely has also been associated with asthma. Patients with severe reactions usually develop a simple rash before more severe reactions manifest. Therefore, CHG should be avoided in any patients who have a history of rash after administration. Direct application to mucus membranes should be avoided. Direct application of CHG over broken skin is generally considered safe, but may lead to decreased efficacy. Occasionally, topical application of CHG can result in a "sticky feeling" on skin. This sticky feeling is related to a moisturizer on CHG cloths and typically resolves completely after the skin is completely dry. Overall, side effects from CHG remain low when used appropriately.

Adjunctive Therapies

CHG is just one tool available to reduce the burden of MRSA on the field and in the locker room. It does not replace common sense or basic infection control principles. Athletes should routinely avoid sharing equipment (towels, water bottles, razors, bar soap) that can transmit bacterial infections. Hand hygiene and protection against body fluids with gloves and bandages are standard infection prevention methods. Common areas such as weight lifting rooms should be kept clean. Broken or damaged equipment should be repaired or replaced. We do not recommend therapies such as silver impregnated towels, prophylactic decolonization, mupirocin or special laundry services. Athletes and family members with suspected MRSA infection should seek medical care and keep any wounds covered until advised further by a physician. MRSA, even when managed correctly, can be fatal. Mistakes may cost you more than a few extra days "on the bench."

Summary

* Topical chlorhexidine gluconate, in conjunction with general infection control principles, should be used by all team members when there is a cluster of MRSA infections in a training facility.

* Prepackaged 2 percent CHG-impregnated cloths are currently the best formulation for practical use.

* CHG-impregnated cloths should be applied to all skin surfaces below the chin, for a minimum of 5 days and then repeated twice weekly until the training facility has had no further MRSA cases for 2 to 3 weeks.

* Side effects from topically applied CHG are low when used appropriately.

* CHG is not a substitute for good hygiene and infection control practices.

* DICON can assist athletic trainers or physicians who have additional questions regarding chlorhexidine or management of clusters or outbreaks of infections due to MRSA. Contact DICON physicians at 919-684-4596.

-- Daniel J. Sexton, MD
Professor of Medicine
Division of Infectious Diseases
Medical Director Co-Medical Director
Duke Infection Control Outreach Network
Duke University Medical Center
daniel.sexton@duke.edu

Deverick J. Anderson, MD, MPH
Associate Professor of Medicine
Division of Infectious Diseases
Duke Infection Control Outreach Network
Duke University Medical Center
deverick.anderson@duke.edu

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