Residual Effect of Chlorhexidine-alcohol Compared to Triclosan-alcohol

Residual Effect of Chlorhexidine 2% / Isopropyl Alcohol 70% Compared to Triclosan 1% / Isopropyl Alcohol 70%

Currently there are few options for skin antisepsis, commercially antiseptic triclosan is mainly used. To have more options, this study is necessary, where investigators will determine the residual effect of 2% chlorhexidine in 70% isopropyl alcohol and 1% triclosan in 70% isopropyl alcohol and choose the one with the best characteristics for skin antisepsis.

2% chlorhexidine has been used as an antiseptic for invasive procedures, such as the skin preparation for surgery or insertion of intravascular catheters, thereby decreasing the incidence of infections. The preparation of the skin with antiseptics, helps mechanically clean the surface of the skin to be subjected to surgical intervention, removing fat, sweat, dead cells and kill bacteria that are in the skin. It has been shown that 2% chlorhexidine in solution with 70% isopropyl alcohol has greater activity than chlorhexidine in aqueous solution. The constant use of triclosan causes resistance of some microorganisms on some antibiotics.It has been shown that 0.5% of triclosan in 60% alcohol isopropyl chlorhexidine is more effective than alcohol. The aim of the study is to know if 2% chlorhexidine has more residual effect than triclosan 1%, both antiseptic diluted in 70% isopropyl alcohol.

The arm is composed of 135 units of measurement, it means, 540 determinations to test 2% chlorhexidine gluconate in 70% isopropyl alcohol and 1% triclosan in 70% isopropyl alcohol and two controls. The principal unit of measurement it will be four determinations of bacterial counts in a subject for antiseptics and controls to test each of the application sites, and determination as to each separately sampling for each area for each antiseptic forearm. The same subject may be assessed up to three separate occasions provided only after a minimum period of two weeks between each determination. Interventions: Biological: Bacterial culture of the prepared skin's areas with two antiseptics and two controls Other: Preparing skin's areas to be tested with two antiseptics and two controls

- Neutralizing agar (D/E neutralizing Agar, Difco TM), - Neutralizing broth (D/E Neutralizing Broth, Difco TM)

Cultures will be taken with a scrub-cup of 5 cm2 of internal area pressed over the skin previously prepared with the substances, then it added a 3 mL of culture broth (D/E Neutralizing Broth, Difco TM) containing a neutralizing agent as washing solution. The skin will scrub with a sterile rubber policeman for 1 minute and the procedure will be conducted once again. Both aliquots will gather together in a sterile tube, and a sample of 50 microliters will spread in a plate containing a neutralizing agar (D/E neutralizing Agar, Difco TM) and incubate at 35°C for 24 hrs. After incubation, the colonies will be counted.

- 2% chlorhexidine gluconate in 70% isopropyl alcohol, - 1% triclosan in 70% isopropyl alcohol, - Scrub the skin without prior application of any substance, - Deionized water redistilled

All volunteers will be provided with a neutral soap and shampoo without antiseptics for use during a period of two weeks (phase of stabilization of the skin flora). Two antiseptics (2% chlorhexidine gluconate in 70% isopropyl alcohol and 1% triclosan in 70% isopropyl alcohol) and two controls (Scrub the skin without prior application of any substance and Deionized water redistilled) will be tested as skin antiseptics. The intervention consists of preparing four skin's areas with antiseptics and controls, two in each arm of the volunteer. These ones were approximately 25 cm2 on the forearm for each antiseptic or control. The substances will be applied in an outward circular motion using a sterile swab soaked with the solutions. The solution will remain on the skin for 60 seconds, 3 hours and 24 hours before the bacterial culture will be conducted. For the control where it will be does not apply any substance, the scrub starts immediately.

135 determinations to evaluate residual effect of 2% chlorhexidine in 70% isopropyl alcohol. All volunteers was provided with a neutral soap without antiseptics for use of two weeks. 2% chlorhexidine in 70% isopropyl alcohol was tested. Were prepared the skin area of 25 cm2 randomly selected. The solution remained on the skin for 60s, 3h and 24h, everyone on different days. Cultures was taken with a scrub-cup of 5 cm2 pressed over the skin, added a 3 mL of culture broth. The skin was scrub with a sterile rubber policeman for 1 minute and the procedure conducted once again. Both aliquots came together in a sterile tube, a sample of 50 microliters were spread in a plate containing a neutralizing agar and were incubated at 35°C for 24 h.

135 determinations to test 1% triclosan in 70% isopropyl alcohol. All volunteers was provided with a neutral soap without antiseptics for use of two weeks. 1% triclosan in 70% isopropyl alcohol was tested. Were prepared the skin area of 25 cm2 randomly selected. The solution remained on the skin for 60s, 3h and 24h, everyone on different days. Cultures was taken with a scrub-cup of 5 cm2 pressed over the skin, added a 3 mL of culture broth. The skin was scrub with a sterile rubber policeman for 1 minute and the procedure conducted once again. Both aliquots came together in a sterile tube, a sample of 50 microliters were spread in a plate containing a neutralizing agar and were incubated at 35°C for 24 h.

135 units of measurement to test two controls. Principal unit of measurement: four determinations of bacterial counts in a subject for antiseptics and controls to test each of the application sites. All volunteers was provided with a neutral soap without antiseptics for use of two weeks. Deionized water redistilled (Control 2: Control with scrub) and Scrub the skin without prior application of any substance (Control1: Control without scrub) was tested. Were prepared two skin's areas of 25 cm2 randomly selected. The solution remained on the skin for 60s, 3h and 24h. Cultures was taken with a scrub-cup of 5 cm2 pressed over the skin, added a 3 mL of culture broth. The skin was scrub with a sterile rubber policeman for 1 minute and the procedure conducted once again. Both aliquots came together in a sterile tube, a sample of 50 microliters were spread in a plate containing a neutralizing agar and were incubated at 35°C for 24 h.

135 units of measurement to test two antiseptics and two controls. Principal unit of measurement: four determinations of bacterial counts in a subject for antiseptics and controls to test each of the application sites. All volunteers was provided with a neutral soap without antiseptics for use of two weeks. 2% chlorhexidine in 70% isopropyl alcohol and 1% triclosan in 70% isopropyl alcohol, Deionized water redistilled and Scrub the skin without prior application of any substance was tested. We prepared four skin's areas of 25 cm2, two in each forearm. The solution remained on the skin for 60s, 3h and 24h. Presence of allergy or any skin reaction at 24 hours after the antiseptic application.

Inclusion Criteria: Healthy adult volunteers Volunteers who have completed the stabilization phase of skin flora. Volunteers who does not taken a shower or bath 24 hours before the test. Exclusion Criteria: Volunteers with a score below 100 Colony Forming Unit per square centimeter (CFU/cm2) of forearm skin surface in the control after the stabilization of the skin flora. History of skin allergies or atopy, as well as reactions to alcohol, soaps, iodine, chlorine or latex.

Karpanen TJ, Worthington T, Hendry ER, Conway BR, Lambert PA. Antimicrobial efficacy of chlorhexidine digluconate alone and in combination with eucalyptus oil, tea tree oil and thymol against planktonic and biofilm cultures of Staphylococcus epidermidis. J Antimicrob Chemother. 2008 Nov;62(5):1031-6. doi: 10.1093/jac/dkn325. Epub 2008 Aug 13.

McDonnell G, Russell AD. Antiseptics and disinfectants: activity, action, and resistance. Clin Microbiol Rev. 1999 Jan;12(1):147-79. doi: 10.1128/CMR.12.1.147. Erratum In: Clin Microbiol Rev 2001 Jan;14(1):227.

Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7;362(1):18-26. doi: 10.1056/NEJMoa0810988.

Edmiston CE Jr, Seabrook GR, Johnson CP, Paulson DS, Beausoleil CM. Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to surgery. Am J Infect Control. 2007 Mar;35(2):89-96. doi: 10.1016/j.ajic.2006.06.012.

Swenson BR, Hedrick TL, Metzger R, Bonatti H, Pruett TL, Sawyer RG. Effects of preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin preparation protocols. Infect Control Hosp Epidemiol. 2009 Oct;30(10):964-71. doi: 10.1086/605926.

Newman JL, Kaiser NE. Extended activity of healthcare antiseptic products: Manivannan G. Disinfection and decontamination, Principles, applications and related issues. 1st Edition, St. Louis, Missouri, USA. CRC Press Editorial, 2007, Oct: 155-152

Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002 Dec;30(8):S1-46. doi: 10.1067/mic.2002.130391.

Macias JH, Arreguin V, Munoz JM, Alvarez JA, Mosqueda JL, Macias AE. Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect. Am J Infect Control. 2013 Jul;41(7):634-7. doi: 10.1016/j.ajic.2012.10.002. Epub 2013 Feb 4.

Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev. 2004 Oct;17(4):863-93, table of contents. doi: 10.1128/CMR.17.4.863-893.2004.

Adams D, Quayum M, Worthington T, Lambert P, Elliott T. Evaluation of a 2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant. J Hosp Infect. 2005 Dec;61(4):287-90. doi: 10.1016/j.jhin.2005.05.015. Epub 2005 Oct 10.

Milstone AM, Passaretti CL, Perl TM. Chlorhexidine: expanding the armamentarium for infection control and prevention. Clin Infect Dis. 2008 Jan 15;46(2):274-81. doi: 10.1086/524736.

Karpanen TJ, Worthington T, Conway BR, Hilton AC, Elliott TS, Lambert PA. Penetration of chlorhexidine into human skin. Antimicrob Agents Chemother. 2008 Oct;52(10):3633-6. doi: 10.1128/AAC.00637-08. Epub 2008 Aug 1.

Small H, Adams D, Casey AL, Crosby CT, Lambert PA, Elliott T. Efficacy of adding 2% (w/v) chlorhexidine gluconate to 70% (v/v) isopropyl alcohol for skin disinfection prior to peripheral venous cannulation. Infect Control Hosp Epidemiol. 2008 Oct;29(10):963-5. doi: 10.1086/590664.

Hibbard JS, Mulberry GK, Brady AR. A clinical study comparing the skin antisepsis and safety of ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs. 2002 Jul-Aug;25(4):244-9. doi: 10.1097/00129804-200207000-00007.

Jones RD, Jampani HB, Newman JL, Lee AS. Triclosan: a review of effectiveness and safety in health care settings. Am J Infect Control. 2000 Apr;28(2):184-96.

D'Arezzo S, Lanini S, Puro V, Ippolito G, Visca P. High-level tolerance to triclosan may play a role in Pseudomonas aeruginosa antibiotic resistance in immunocompromised hosts: evidence from outbreak investigation. BMC Res Notes. 2012 Jan 19;5:43. doi: 10.1186/1756-0500-5-43.

Bedoux G, Roig B, Thomas O, Dupont V, Le Bot B. Occurrence and toxicity of antimicrobial triclosan and by-products in the environment. Environ Sci Pollut Res Int. 2012 May;19(4):1044-65. doi: 10.1007/s11356-011-0632-z. Epub 2011 Nov 5.

McMurry LM, Oethinger M, Levy SB. Triclosan targets lipid synthesis. Nature. 1998 Aug 6;394(6693):531-2. doi: 10.1038/28970. No abstract available.

Levy CW, Roujeinikova A, Sedelnikova S, Baker PJ, Stuitje AR, Slabas AR, Rice DW, Rafferty JB. Molecular basis of triclosan activity. Nature. 1999 Apr 1;398(6726):383-4. doi: 10.1038/18803. No abstract available.

Queckenberg C, Meins J, Wachall B, Doroshyenko O, Tomalik-Scharte D, Bastian B, Abdel-Tawab M, Fuhr U. Absorption, pharmacokinetics, and safety of triclosan after dermal administration. Antimicrob Agents Chemother. 2010 Jan;54(1):570-2. doi: 10.1128/AAC.00615-09. Epub 2009 Oct 12.

Russell AD. Whither triclosan? J Antimicrob Chemother. 2004 May;53(5):693-5. doi: 10.1093/jac/dkh171. Epub 2004 Apr 8.

Bartzokas CA, Gibson MF, Graham R, Pinder DC. A comparison of triclosan and chlorhexidine preparations with 60 per cent isopropyl alcohol for hygienic hand disinfection. J Hosp Infect. 1983 Sep;4(3):245-55. doi: 10.1016/0195-6701(83)90025-7.

Hobson DW, Bolsen K. Methods of testing oral and topical antiseptics and antimicrobials. In: Block SS, editor. Disinfection, Sterilization, and Preservation. 5th Ed, Philadelphia [PA]: Lippincott Williams & Wilkins; 2001. p.1329-1359.

Alvarez JA, Macias JH, Macias AE, Rodriguez E, Munoz JM, Mosqueda JL, Ponce de Leon S. Povidone-iodine against sodium hypochlorite as skin antiseptics in volunteers. Am J Infect Control. 2010 Dec;38(10):822-5. doi: 10.1016/j.ajic.2010.05.019.

Williamson P, Kligman AM. A new method for the quantitative investigation of cutaneous bacteria. J Invest Dermatol. 1965 Dec;45(6):498-503. doi: 10.1038/jid.1965.164. No abstract available.

Hanski I, von Hertzen L, Fyhrquist N, Koskinen K, Torppa K, Laatikainen T, Karisola P, Auvinen P, Paulin L, Makela MJ, Vartiainen E, Kosunen TU, Alenius H, Haahtela T. Environmental biodiversity, human microbiota, and allergy are interrelated. Proc Natl Acad Sci U S A. 2012 May 22;109(21):8334-9. doi: 10.1073/pnas.1205624109. Epub 2012 May 7.

Malhotra S, Dharmadasa A, Yentis SM. One vs two applications of chlorhexidine/ethanol for disinfecting the skin: implications for regional anaesthesia. Anaesthesia. 2011 Jul;66(7):574-8. doi: 10.1111/j.1365-2044.2011.06706.x. Epub 2011 May 24.

Sogawa Y, Kobayashi H, Kajiura T, Nishihara Y. Comparison of residual antimicrobial activity of chlorhexidine-containing antiseptics: An express report. J Healthc Infect 2010;2:32-36.

Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthop Nurs. 2009 May-Jun;28(3):141-5. doi: 10.1097/NOR.0b013e3181a469db.

Levy SB. Antibacterial household products: cause for concern. Emerg Infect Dis. 2001;7(3 Suppl):512-5. doi: 10.3201/eid0707.017705.