Use Of A 2 Percent Chlorhexidine Solution example essay topic

Background It stands to reason that some type of preparation needs to occur before an IV needle is inserted into a vein. For one thing, even as sterile as the needle might be, this is still a foreign object being introduced into the body -- and as such, the body will likely bring its defenses to do everything it can to reject the foreign object. For another thing, the skin itself is a breeding ground for microorganisms. Once a puncture is made into the skin and vein, this is a excellent entry point for skin flora and microorganisms to invade the body, creating all types problems such as bloodstream infections.

Because of this, specific medical guidelines among Western countries insist that the entry site of an IV catheter be adequately prepared before the needle is actually inserted. Preparation generally includes a swabbing of the entry site with an antibacterial, antiseptic solution. The theory behind such an action is that preparing the skin within antiseptic solution greatly reduces the amount of microorganisms and / or skin flora that could enter the wound. Such preparation would cut down on the instance of infection, which is an important consideration what one is trying to treat a patient. The topical solutions used tend to contain either an alcohol base or a base of povidone-iodine, which is marketed under the name of Betadine.

For many years, either or both of these solutions have been used as a topical preparations solution before insertion of an IV. But despite best efforts, it appears that more than 90 percent of all intravascular device-related septicemia come from either central venous or arterial catheters (Maki and Ringer, 1991). The belief is that depending on the strength of the antiseptic used prior to insertion of any type of venous or arterial catheter can have an impact on potential infection (Maki and Ringer, 1991). This is important, because life-threatening complications in patients with vascular catheters is septicemia (Maki and Ringer, 1991). In the United States, is estimated -- or at least it was more than ten years ago -- that approximately 50,000 patients and hospitals acquired some type of catheter-related septicemia each year (Maki and Ringer, 1991).

Such septicemia tends to start with invasion in the insertion tract by microorganisms originating from a patient's skin flora (Maki and Ringer, 1991). In the United States, disinfected in the insertion site with some type of chemical antiseptic -- such as alcohol or Betadine -- is considered an important method to prevent intravascular device-related infection (Maki and Ringer, 1991). In the United States, Betadine -- which is the brand-name for povidone-iodine -- is commonly used while another topical antiseptic of a chlorhexidine basis has been commonly used throughout Europe (Maki and Ringer, 1991). The question we need to try to answer therefore is which is more effective in terms of site preparation prior to IV insertion -- Betadine or alcohol? Even more important, what studies have addressed this issue and what have the conclusions been?

In this paper, we will do a brief review of studies that have been conducted on povidone-iodine as the topical agent to prevent or reduce infection caused by a IV usage. As we will see throughout the paper, such literature tends to be scarce on this issue, although more and more researchers are beginning to take a closer look at this problem. Literature Review The literature available determining which antiseptic is more effective -- povidone-iodine or alcohol -- is somewhat lacking, possibly because it has only been recently that studies and research on these two topical antiseptics have been conducted. Furthermore, finding any mention of using pure alcohol as a topical antiseptic prior to starting an IV is also difficult to find. There have been some studies performed however on povidone-iodine and other topical antiseptics such as chlorhexidine. In addition, finding any research that addressed the use of alcohol vs. povidone-iodine in use as preparation before starting an IV was extremely difficult as well.

The literature in this area is extremely spotty. What we will do in this section is determine and examine a few studies that have been done that compare povidone-iodine with other types of topical antiseptics. We will also examine a few studies that use povidone-iodine in IV-like settings such as drawing blood. One study compared povidone-iodine with chlorhexidine to prevent central venous catheter infections in neonates -- in other words, premature infants. The reason for this particular trial was a concern that neonates requiring a central venous catheter (CVC) tended to experience high rates of catheter-related bloodstream infection without any obvious source (Garland et al, 2001). The authors of the study questioned if the source could possibly be the pre-catheter insertion method; especially as pertaining to topical antiseptic solution used (Garland et al, 2001).

In this trial, 705 neonates were randomized to receive at their catheter sites either at 10 percent of povidone-iodine skin scrub or a 70 percent alcohol scrub, which was followed by placement of a chlorhexidine-impregnated disk placed over the catheter insertion site (Garland et al, 2001). It was found that the chlorhexidine-impregnated dressing (as long as it was replaced on weekly basis) was as effective as the cutaneous disinfection using the povidone-iodine to solution (Garland et al, 2001). There was concern however, that using a chlorhexidine dressing was likely not the best method for certain low-birth weight infants, as the contact of the antiseptic with the skin could cause local contact dermatitis (Garland et al, 2001). But overall, it was determined that use of alcohol application before catheter insertion did tend to reduce the incidence of infection (Garland et al, 2001). Another similar study -- this one conducted among adults -- also compared povidone-iodine, alcohol and chlorhexidine for prevention of infection that was associated with central venous and arterial catheters (Maki and Ringer, 1991).

In this particular study, 668 catheters were randomized with use of the 10 percent povidone-iodine solution; a solution with 70 percent alcohol or a solution with 2 percent chlorhexidine (Maki and Ringer, 1991). The antiseptics were used on the sites before insertion of catheter and on the site every day after the catheter was inserted (Maki and Ringer, 1991). In the study, it was found that chlorhexidine was associated with the lowest incidents of local catheter-related infection; at 2.3 per 100 catheters (Maki and Ringer, 1991). This is compared to a catheter-related infection of 7.1 per 100 catheters for alcohol and 9.3 per 100 catheters for povidone-iodine (Maki and Ringer, 1991). From the study, the authors concluded that use of a 2 percent chlorhexidine solution rather than a 10 percent povidone-iodine solution or a 70 percent alcohol solution for cutaneous disinfection before insertion of an IV could reduce the incidence of device-related infection (Maki and Ringer, 1991). When it came to comparing the alcohol-based solution with the povidone-iodine solution, the authors of the study also realized that both were approximately the same when it came to protecting against infection -- but stressed the point that both were less effective than the chlorhexidine solution (Maki and Ringer, 1991).

A more recent study works to compare, povidone-iodine and another solution called DuraPrep -- which is an iodophor-in-isopropyl alcohol solution (Birnbach et al, 2003). For purposes of our paper, this study was an interest, because the povidone-iodine solution was being tested against a specific alcohol solution. While this particular study actually tested the two topical antiseptics on pregnant women in connection with issuing an epidural during labor, the results of the test are still interesting to compare whether Betadine or alcohol is a better topical antiseptic before preparing an IV. This test -- or study -- involved 60 women in active labor who had requested an epidural (Birnbach et al, 2003).

The women were randomly selected to receive skin preparation either with povidone-iodine or DuraPrep solution (Birnbach et al, 2003). It was found following the study that the proportion of subjects demonstrating positive skin cultures immediately after skin disinfection had differed between the two groups (Birnbach et al, 2003). The group receiving the povidone-iodine solution reported 30.3 percent of positive skin cultures -- with the number of subjects with positive skin cultures at the time of catheter removal also greater in the povidone-iodine group (Birnbach et al, 2003). In this particular study, it was found that the DuraPrep solution provided a greater decrease in the number of positive skin cultures -- especially immediately following disinfection of the skin (Birnbach et al, 2003). Another study -- this one dealing with obtaining blood cultures -- questioned the appropriate antiseptic that should be used when drawing blood (Huffman, 2000). The concern in this particular study revolved around blood culture contamination, which could be traced directly to the antiseptic used prior to inserting the needle (Huffman, 2000).

According to the preliminary research of the study, there is a rather high rate of blood culture contamination, which has caused 35 to 50 percent of all positive blood cultures (Huffman, 2000). Needless to say, the study indicated that disinfection was necessary to avoid any type of false-positive results (Huffman, 2000). In this particular study, ante cubital venipuncture samples were taken from a random selection of patients who had their skin cite disinfected with either povidone-iodine (10 percent solution) or iodine tincture (2 percent) (Huffman, 2000). What makes the study particularly germane to our particular paper was that before the iodine tincture was applied, it was preceded by an application of a 70 percent isopropyl alcohol solution (Huffman, 2000). In both cases, the solutions were allowed to dry for two minutes prior to the phlebotomy (Huffman, 2000). The blood cultures were considered positive if either culture through any type of bacteria or fungus (Huffman, 2000).

Following that, positive cultures were classified as true positive or false positive; with the conclusion being that false positive cultures for those growing skin microflora (Huffman, 2000). In the study, it was found that nearly 10 percent of all the blood cultures were positive -- and of the 10 percent, 32 percent of those were determined to be false positives (Huffman, 2000). Furthermore, it was found that povidone-iodine Group had more skin contamination (3.8 percent of that group) than the iodine tincture group that use the alcohol (2.4 percent) (Huffman, 2000). The true positive culture rate was not impacted by either one (Huffman, 2000). The authors of the study speculated that, based on results, the drying time of antiseptic solution was probably the reason why the iodine tincture produced less skin contamination (Huffman, 2000). As mentioned above, povidone-iodine requires a two- to three-minute drying time (Huffman, 2000).

While this works well in theory, it is likely that in the real world, very few health-care providers actually wait that amount of time to allow an antiseptic solution to dry before proceeding with an IV (Huffman, 2000). It was postulated by the authors that because the iodine tincture solution dried more rapidly than did the povidone-iodine, it likely acted more rapidly to decrease skin microbe activity (Huffman, 2000). Discussion We can draw some conclusions from the above the literature / studies. First, povidone-iodine doesn't dry as quickly as alcohol-based solutions. As we saw in one of the studies, the result of this characteristic meant a more likelihood of contamination at the puncture site.

This is a particular concern when it comes to inserting an IV -- the recommendation is that Betadine be allowed to dry for at least a couple minutes before a needle is inserted; but there is a question as to whether this actually happens. Second, it seems as though a direct comparison between alcohol-based solutions and those using Betadine don't tend to differ quite so much in the long run. In fact, the studies that happened to focus on povidone-iodine actually tested this topical agent with chlorhexidine -- and in most cases, the chlorhexidine was actually more effective in reducing instances of positive skin cultures. Another point to consider is that saying one or the other is more effective than the other doesn't take into account the situations in which they are used.

For example, in reviewing the study of Betadine and its use among catheters used on neonates has shown that chlorhexidine with alcohol preparation has actually been more effective; as long as the neonatal does not suffer from contact dermatitis. For those neonates who do have this problem, povidone-iodine is probably the better choice. Finally, we don't find too many instances in which pure alcohol is used as a topical agent -- it is typically mixed in with some sort of other aqueous solution to provide a topical cleansing agent prior to IV insertion. Although chlorhexidine has been proving to be effective in terms of skin preparation before insertion of an IV, a report in the U.S. Center for Disease Control's Morbidity and Morality Weekly Report has indicated that it isn't so much the chemical of chlorhexidine that helps as much as what the chemical is combined with (O'Grady, 2002). The report mentions, for example, that tincture of chlorhexidine gluconate of 0.5 percent is no more effective in preventing any type of infection or CVC colonization as the standard 10 percent povidone-iodine (O'Grady, 2002).

The report also states that a povidone-iodine and ointment applied at the insertion site of hemodialysis catheters ended up actually reducing the incidence of exit-site infections, catheter tip colonization and blood stream infection (O'Grady, 2002). Conclusion As we mentioned earlier in this paper, research is still pretty sketchy in the area of which is more effective in preventing infection when it comes to IV insertion and exit. What is interesting is that according to the studies quoted in this paper, povidone-iodine, which is the most widely used solution in terms of topical preparation before IV insertion, actually seems to be the least effective of the solutions tested. Chlorhexidine, on the other hand, in many studies, seem to do a very good job of reducing positive skin cultures and potential blood infections. Another issue that has not necessarily been touched on (but that we alluded to in this paper) is that sometimes topical ointment is useful -- as we saw above, a topical ointment with the percentage of povidone-iodine actually ended up decreasing the instances of infection at an IV exit site. The question we were trying to answer at the beginning of this paper doll with which is the more effective chemical -- Betadine or alcohol.

In researching the issue, it was found that both, and random studies, actually ended up demonstrating the same effectiveness. However, when you throw chlorhexidine into the mix, you have another result -- namely, that the chlorhexidine happens to be the most effective antiseptic among studies and trials in various situations. As of now, there have been very few studies performed on the effectiveness of povidone-iodine as a preventative infection agent for use at IV sites. It is uncertain why more attention has not been paid to this particular topical agent -- as we saw in the beginning of the paper, many hospitals use povidone-iodine in their IV preparation. Yet according to the studies that have been performed, Betadine may not necessarily be the most effective antiseptic to be used for the site of entry. How this antiseptic stacks up to others is something that the medical community will need to consider in years to come.

Bibliography

Birnbach DJ et al (2003).
Comparison of povidone iodine and DuraPrep, an iodophor-in-isopropyl alcohol solution, for skin disinfection prior to epidural catheter insertion in parturient's. Anesthesiology 98 (1), 164-169. Garland, Jeffrey S. et al (2001).
A randomized trial comparing povidone-iodine to a chlorhexidine for prevention of central venous catheter infections in neonates. Pediatrics 107 (6), 1431-1438. Huffman, Grace Brooke (2000).
Which antiseptic to use when obtaining blood cultures? American Family Physician 61 (4), 1120-1121. Maki, D.G. and Ringer, M. (1991).
Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 338 (8763), 339-344. O'Grady, Naomi P. et al (2002, August 9).