Skin anti-sepsis in PICU: guidance for correct use of Chlorhexidine Gluconate ‘ChloraPrep’

Objectives

Guidance for the use of Chloraprep in the paediatric intensive care unit.

Scope

This guideline should be followed by all healthcare professionals involved in patient care in the paediatric intensive care setting.

Audience

All healthcare professionals involved in patient care should be familiar with this guideline and the correct use of ChloraPrep as an antiseptic agent.

Background

ChloraPrep is a combination of 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA). A series of ChloraPrep products were launched, which have been given the highest recommendation by the Health Promotion Agency’s Review Panel (Health Promotion Agency)[1]

How Does it Work?

CHG maintains a persistent antimicrobial function by disrupting the cell membrane and precipitating their contents. IPA quickly destroys microorganisms by denaturing cell proteins, giving significant defence against broad-spectrum micro-organisms and rapid bactericidal action[1][2]

Comparisons of Action on Different Skin Antisepsis Agents

CHG is an effective skin antisepsis agent:

Potent broad spectrum germicidal action, thus rendering it effective against nearly all nosocomial bacteria and yeasts.
Low skin irritancy and sensitization potential.
Strong affinity for skin and shows prolonged duration of antimicrobial effect.
The antibacterial effect persists for hours after application and not neutralised by contact with proteinaceous substances, such as blood.
Bacterial resistance is rare.
Not associated with patient adverse events (with iodine, there have been reports of toxic effect on the thyroid gland in neonates[3]).

Combining CHG with another antiseptic with different mechanisms is additive and beneficial[2].

Comparison of Antimicrobial Agents used in Skin Antisepsis[2]

	Traditional Iodophors	Alcohol	Chlorhexidine
Broad spectrum	X	X	X
Rapid action		X
Residual action			X
Action on blood & other organic matter			X
No or minimal systemic absorption			X

Epic3 Guidelines

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in NHS hospitals were first published in 2001. The Department of Health (DoH) funded and endorsed an update in 2007 (epic2, Pratt et al)[4]. The DoH has since commissioned a review of further evidence to update these guidelines, concluding that the epic2 guidelines remain ‘robust, relevant and appropriate’[5], however there have been some changes and additions.

The following guidelines relate to the use of Chloraprep for intravascular devices:

Cutaneous antisepsis

IVAD14 - Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry prior to the insertion of a central venous access device. (Class A)

IVAD 15 - Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry before inserting a peripheral vascular access device. (New recommendation – Class D/GPP)

Intravenous catheter and catheter site care

IVAD23 – Use a single use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the central catheter insertion site during dressing changes, and allow to air dry. (Class A)

IVAD24 – Use a single use application of 2% chlorhexidine gluconate in 70% isopropyl alchol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the peripheral venous catheter insertion site during dressing changes, and allow to air dry. (New recommendation – Class D/GPP)

ChloraPrep Devices Available

There are a number of ChloraPrep products available: 1ml applicator, 3ml applicator, 10.5ml applicator, 26ml applicator, swabsticks, Frepp 1.5ml applicator.

The common ones used in PICU are listed below:

ChloraPrep swab – contains swab with 2% CHG in 70% IPA

Most suitable for antisepsis of catheter ports.

ChloraPrep applicator – comes in numerous sizes including 1ml, 1.5ml and 3ml, which are all easily available in PICU. The 10.5ml applicator can be found in the cardiac surgical trolley in PICU

Most suitable for skin antisepsis preparation before insertion of central venous catheter devices.

Use of ChloraPrep

Action	Rationale
Prepare the sterile field. Open dressing pack. Open all relevant equipment onto the sterile field. Perform appropriate hand washing and put on sterile gloves.	Reduce the risk of introducing infection.
Prepare ChloraPrep device: 1) ChloraPrep swab – remove from packet 2) ChloraPrep applicators squeeze wings of applicator (hold vertical) and allow solution to flow into applicator. Disinfect skin using back & forth strokes for 30seconds. Disinfect catheter ports with a rotating action for 30seconds.
Allow solution to dry for 30 seconds before proceeding.	Allows effective micro-organism killing.

Point of contact for further assistance

PICU duty red phone 84275

Last reviewed: 30/01/2025

Next review date: 31/01/2028

Author(s): Dr Christina Harry.

Author email(s): christina.harry2@nhs.scot.

Approved By: PICU Governance Group

References

1. Inwood S. Skin antisepsis: using 2% chlorhexidine gluconate in 70%isopropyl alcohol. British Journal of Nursing 2007; 16(22): 1390-4

2. Beckton, Dickinson & Company (CareFusion).

3. Linder N, Prince S, Barzilae A, Keller N, Klinger G, Shalit I, Prince T, Sirota L. Disinfection with 10% povidone-iodine versus 0.5% chlorhexidinegluconate in 70% isopropanolol in the neonatal intensive care unit. Acta Paediatrics 2004; 93: 205-10

4. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLF, McDougall C, Wilcox MH. Epic2: National evidence based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 2007; 65S:S1-65

5. Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M. Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 2014; 86S1:S1-70

6. https://www.bd.com/en-us/offerings/capabilities/infection-prevention/skin-preparation/chloraprep-patient-preoperative-skin-preparation-products/chloraprep-in-service-resources (Mar 18)