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Review of allergic reactions from use of chlorhexidine on medical products in clinical settings over 40 years: Risks and mitigations

Published online by Cambridge University Press:  03 June 2021

Bahgat Z. Gerges ,
Joel Rosenblatt ,
Y-Lan Truong ,
Ruth A. Reitzel  and
Isaam Raad
Bahgat Z. Gerges
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, University of Texas, MD Anderson Cancer Center, Houston, Texas
Joel Rosenblatt*
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, University of Texas, MD Anderson Cancer Center, Houston, Texas
Y-Lan Truong
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, University of Texas, MD Anderson Cancer Center, Houston, Texas
Ruth A. Reitzel
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, University of Texas, MD Anderson Cancer Center, Houston, Texas
Isaam Raad
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, University of Texas, MD Anderson Cancer Center, Houston, Texas
*
Author for correspondence: Joel Rosenblatt, E-mail: JSRosenblatt@mdanderson.org
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Abstract

Chlorhexidine is an antimicrobial agent widely used for infection prevention in medical settings. Nevertheless, allergic reactions ranging from mild to severe have been reported following its use. In this review, we analyzed all case reports published between the introduction of chlorhexidine and the end of 2019 for allergic responses associated with the use of medical devices and or other medical products containing chlorhexidine (CHX) to ascertain the prevalence of severe CHX allergic reactions and what practices might best mitigate those risks.

In total, 77 publications containing 124 reported cases of allergic reactions were grouped into 3 product categories, catheters, semisolids, and fluid products. The country, type of reaction, route of sensitization, allergy confirmation, and intervention or mitigation was extracted for each case. Overall, 30 cases were associated with catheters, 46 cases were associated with semisolid products, and 48 cases were associated with the use of other medical products. Severe cases were managed with intravenous fluids, steroids, and epinephrine (adrenaline). None of the reported cases were fatal. The allergy risks can be mitigated by better warning and training clinicians and by recording and screening patient histories for CHX presensitization from prior exposure. For patients undergoing pre-use blood tests, IgE antibody screens can also be performed. Finally, as a precaution in the event a rare severe allergic reaction occurs, procedure carts and rooms can be prestocked with injectable epinephrine and other rapidly acting anti-inflammatory medications.

Type
Review
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 6 , June 2022 , pp. 775 - 789
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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References

Liippo, J, Kousa, P, Lammintausta, K. The relevance of chlorhexidine contact allergy. Contact Dermatitis 2011;64:229–234.CrossRefGoogle ScholarPubMed
Goon, AT, White, IR, Rycroft, RJG, McFadden, JP. Allergic contact dermatitis from chlorhexidine. Dermatitis 2004;15:45–47.CrossRefGoogle ScholarPubMed
Krautheim, AB, Jermann, TH, Bircher, AJ. Chlorhexidine anaphylaxis: case report and review of the literature. Contact Dermatitis 2004;50:113–116.CrossRefGoogle ScholarPubMed
Calogiuri, G, Di Leo, E, Trautmann, A, et al. Chlorhexidine hypersensitivity: a critical and updated review. J Allergy Ther 2013;4(141). doi: 10.4172/2155-6121.1000141.Google Scholar
Nagendran, V, Wicking, J, Ekbote, A, Onyekwe, T, Garvey, LH. IgE-mediated chlorhexidine allergy: a new occupational hazard? Occup Med (Lond) 2009;59:270–272.CrossRefGoogle ScholarPubMed
Rose, MA, Garcez, T, Savic, S, Garvey, LH. Chlorhexidine allergy in the perioperative setting: a narrative review. Br J Anaesth 2019;123:e95–e103.CrossRefGoogle ScholarPubMed
Opstrup, MS, Malling, H-J, Krøigaard, M,et al. Standardized testing with chlorhexidine in perioperative allergy—a large single-centre evaluation. Allergy 2014;69:1390–1396.CrossRefGoogle ScholarPubMed
Le Corre, Y, Barbarot, S, Frot, AS, Milpied, B. Allergic contact dermatitis to chlorhexidine in a very young child. Pediatr Dermatol 2010;27:485–487.CrossRefGoogle Scholar
FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. Food and Drug Administration website. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-rare-serious-allergic-reactions-skin-antiseptic. Published February 2, 2017. Accessed September 14, 2020.Google Scholar
Oda, T, Hamasaki, J, Kanda, N, Mikami, K. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Anesthesiology 1997;87:1242–1244.CrossRefGoogle ScholarPubMed
Weng, M, Zhu, M, Chen, W, Miao, C. Life-threatening anaphylactic shock due to chlorhexidine on the central venous catheter: a case series. Int J Clin Exp Med 2014;7:5930–5936.Google ScholarPubMed
Faber, M, Leysen, J, Bridts, C, Sabato, V, De Clerck, LS, Ebo, DG. Allergy to chlorhexidine: beware of the central venous catheter. Acta Anaesthesiol Belg 2012;63:191–194.Google ScholarPubMed
Guleri, A, Kumar, A, Morgan, RJM, Hartley, M, Roberts, DH. Anaphylaxis to chlorhexidine-coated central venous catheters: a case series and review of the literature. Surg Infect (Larchmt) 2012;13:171–174.CrossRefGoogle ScholarPubMed
Jee, R, Nel, L, Gnanakumaran, G, Williams, A, Eren, E. Four cases of anaphylaxis to chlorhexidine impregnated central venous catheters: a case cluster or the tip of the iceberg? Br J Anaesth 2009;103:614–615.CrossRefGoogle ScholarPubMed
Khoo, A, Oziemski, P. Chlorhexidine impregnated central venous catheter inducing an anaphylatic shock in the intensive care unit. Heart Lung Circ 2011;20:669–670.CrossRefGoogle Scholar
Kluger, M. Anaphylaxis to chlorhexidine-impregnated central venous catheter. Anaesth Intensive Care 2003;31:697–698.Google ScholarPubMed
Nakonechna, A. Chlorhexidine/Lidocaine. Reactions Wkly 2015;1548:66.Google Scholar
Pittaway, A, Ford, S. Allergy to chlorhexidine-coated central venous catheters revisited. Br J Anaesth 2002;88:304–305.Google Scholar
Qin, Z, Zeng, Z. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. Anaesth Intensive Care 2016;44:297–298.Google Scholar
Stephens, R, Mythen, M, Kallis, P, Davies, DW, Egner, W, Rickards, A. Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine–coated central venous catheter. Br J Anaesth 2001;87:306–308.CrossRefGoogle ScholarPubMed
Terazawa, E, Shimonaka, H, Nagase, K, Masue, T, Dohi, S. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Anesthesiology 1998;89:1296–1298.CrossRefGoogle Scholar
Zhou, E, Parikh, PS, Kanchuger, MS, Balsam, LB. Intraoperative anaphylaxis to chlorhexidine during LVAD and transplant surgery. J Cardiothorac Vasc Anesth 2019;33:169–172.CrossRefGoogle Scholar
Baird, PA, Cokis, CJ. A case series of anaphylaxis to chlorhexidine-impregnated central venous catheters in cardiac surgical patients. Anaesth Intensive Care 2019;47:85–89.CrossRefGoogle ScholarPubMed
Wang, ML Chang, CT, Huang, HH, Yeh, YC, Lee, TS, Hung, KY. Chlorhexidine-related refractory anaphylactic shock: a case successfully resuscitated with extracorporeal membrane oxygenation. J Clin Anesth 2016;34:654–657.CrossRefGoogle ScholarPubMed
Chen, P, Huda, W, Levy, N. Chorhexidine anaphylaxis: Implications for post-resuscitation management. Anaesthesia 2016; 71:242–243.CrossRefGoogle Scholar
Ho, A, Zaltzman, J, Hare, GMT, et al. Severe and near-fatal anaphylactic reactions triggered by chlorhexidine-coated catheters in patients undergoing renal allograft surgery: a case series. Can J Anaesth 2019;66:1483–1488.CrossRefGoogle Scholar
Zheng, X, Fang, X, Cai, X. Two episodes of anaphylaxis caused by a chlorhexidine sulfadiazine-coated central venous catheter. Chin Med J (Engl) 2014;127:2395–2397.Google ScholarPubMed
Beatty, P, Kumar, N, Ronald, A. A complicated case of chlorhexidine-associated anaphylaxis. Anaesthesia 2011;66:60–61.CrossRefGoogle ScholarPubMed
Rutkowski, K, Wagner, A. Chlorhexidine: a new latex? Eur Urol 2015;68:345–347.CrossRefGoogle ScholarPubMed
Jayathillake, A, Mason, DF, Broome, K. Allergy to chlorhexidine gluconate in urethral gel: report of four cases and review of the literature. Urology 2003;61:837.CrossRefGoogle ScholarPubMed
Lasa, EM, González, C, García-Lirio, E, Martínez, S, Arroabarren, E, Gamboa, PM. Anaphylaxis caused by immediate hypersensitivity to topical chlorhexidine in children. Ann Allergy Asthma Immunol 2017;118:118–119.CrossRefGoogle Scholar
Nakonechna, A, Dore, P, Dixon, T. Immediate hypersensitivity to chlorhexidine is increasingly recognised in the United Kingdom. Allergol Immunopathol (Madr) 2014;42:44–49.CrossRefGoogle ScholarPubMed
Parkes, AW, Harper, N, Herwadkar, A, Pumphrey, R. Anaphylaxis to the chlorhexidine component of Instillagel: a case series. Br J Anaesth 2009;102:65–68.CrossRefGoogle Scholar
Pham, NH, Weiner, JM, Reisner, GS, Baldo, BA. Anaphylaxis to chlorhexidine. Case report. Implication of immunoglobulin E antibodies and identification of an allergenic determinant. Clin Exp Allergy 2000;30:1001–1007.CrossRefGoogle ScholarPubMed
Sijbesma, T, Röckmann, H, van der Weegen, W. Severe anaphylactic reaction to chlorhexidine during total hip arthroplasty surgery. A case report. Hip Int 2011;21:630–632.CrossRefGoogle ScholarPubMed
Stables, GI, Turner, WH, Prescott, S, Wilkinson, SM. Generalized urticaria after skin cleansing and urethral instillation with chlorhexidine-containing products. Br J Urol 1998;82:756–757.CrossRefGoogle ScholarPubMed
Bergqvist-Karlsson, A. Delayed and immediate-type hypersensitivity to chlorhexidine. Contact Dermatitis 1988;18:84–88.CrossRefGoogle ScholarPubMed
Dyer, JE, Nafie, S, Mellon, JK, Khan, MA. Anaphylactic reaction to intraurethral chlorhexidine: sensitisation following previous repeated uneventful administration. Ann Roy Coll Surg Engl 2013;95(6):e105–e118.Google ScholarPubMed
Garvey, LH, Roed-Petersen, J, Husum, B. Anaphylactic reactions in anaesthetised patients—four cases of chlorhexidine allergy. Acta Anaesthesiol Scand 2001;45:1290–1294.CrossRefGoogle ScholarPubMed
Knight, BA, Puy, R, Douglass, J, O’Hehir, RE, Thien, F. Chlorhexidine anaphylaxis: a case report and review of the literature. Intern Med J 2001;31:436–437.CrossRefGoogle Scholar
Koch, A, Wollina, U. Chlorhexidine allergy. Allergo J Int 2014;23:84–86.CrossRefGoogle Scholar
Noel, J, Temple, A, Laycock, GJ. A case report of anaphylaxis to chlorhexidine during urinary catheterisation. Ann R Coll Surg Engl 2012;94:e159–e160.CrossRefGoogle ScholarPubMed
Ramselaar, CG, Craenen, A, Bijleveld, RT. Severe allergic reaction to an intraurethral preparation containing chlorhexidine. Br J Urol 1992;70:451–452.CrossRefGoogle Scholar
Weitz, NA, Lauren, CT, Weiser, JA, et al. Chlorhexidine gluconate–impregnated central access catheter dressings as a cause of erosive contact dermatitis: a report of 7 cases. JAMA Dermatol 2013;149:195–199.CrossRefGoogle ScholarPubMed
Wicki, J, Deluze, C, Cirafici, L, Desmeules, J. Anaphylactic shock induced by intraurethral use of chlorhexidine. Allergy 1999;54:768–769.CrossRefGoogle ScholarPubMed
Stewart, M, Lenaghan, D. The danger of chlorhexidine in lignocaine gel: a case report of anaphylaxis during urinary catheterisation. Australas Med J 2015;8:304–306.CrossRefGoogle ScholarPubMed
Thong, CL, Lambros, M, Stewart, MG, Kam, PCA. An unexpected cause of an acute hypersensitivity reaction during recovery from anaesthesia. Anaesth Intensive Care 2005;33:521–524.CrossRefGoogle Scholar
Totty, J, Forsyth, J, Mekako, A, Chetter, I. Life-threatening intraoperative anaphylaxis as a result of chlorhexidine present in Instillagel. BMJ Case Rep 2017. doi: 10.1136/bcr-2017-221443.CrossRefGoogle Scholar
Wittczak, T, Dudek, W, Walusiak-Skorupa, J, Świerczyńska-Machura, D, Pałczyński, C. Chlorhexidine—still an underestimated allergic hazard for healthcare professionals. Occup Med (Lond) 2013;63:301–305.CrossRefGoogle Scholar
Evans, RJ. Acute anaphylaxis due to topical chlorhexidine acetate. BMJ 1992;304:686.CrossRefGoogle ScholarPubMed
Porter, BJ, Acharya, U, Ormerod, AD, Herriot, R. Latex/chlorhexidine-induced anaphylaxis in pregnancy. Allergy 1998;53:455–457.CrossRefGoogle Scholar
Mushtaq, U, Tan, A, Tan, JA, Smith, WB. Acute allergic reaction after intravenous saline injection: an unusual presentation of chlorhexidine allergy. Med J Aust 2014;200:599–600.CrossRefGoogle ScholarPubMed
Ebo, DG, Stevens, WJ, Bridts, CH, Matthieu, L. Contact allergic dermatitis and life-threatening anaphylaxis to chlorhexidine. J Allergy Clin Immunol 1998;101:128–129.CrossRefGoogle Scholar
Russ, BR, Maddern, PJ. Anaphylactic reaction to chlorhexidine in urinary catheter lubricant. Anaesth Intensive Care 1994;22:611–612.CrossRefGoogle Scholar
Fisher, AA. Contact urticaria from chlorhexidine. Cutis 1989;43:17–18.Google ScholarPubMed
Bahal, S, Sharma, S, Garvey, LH, Nagendran, V. Anaphylaxis after disinfection with 2% chlorhexidine wand applicator. BMJ Case Rep 2017. doi: 10.1136/bcr-2017-219794.CrossRefGoogle ScholarPubMed
Conraads, VM, Jorens, PG, Ebo, DG, Claeys, MJ, Bosmans, JM, Vrints, CJ. Coronary artery spasm complicating anaphylaxis secondary to skin disinfectant. Chest 1998;113:1417–1419.CrossRefGoogle Scholar
Doolan, BT, Crilly, HM. Chlorhexidine wipes: time to stop and think about allergy. Anaesth Intensive Care 2019;47:90–95.CrossRefGoogle Scholar
Khan, RA, Kazi, T, O’Donohoe, B. Near fatal intraoperative anaphylaxis to chlorhexidine—is it time to change practice? BMJ Case Rep 2011. doi: 10.1136/bcr.09.2009.2300.CrossRefGoogle ScholarPubMed
McEnery-Stonelake, M, Silvestri, DL. Allergic contact dermatitis to chlorhexidine after oral sensitization. Dermatitis 2013;24:92–93.CrossRefGoogle ScholarPubMed
Ohtoshi, T, Yamauchi, N, Tadokoro, K, et al. IgE antibody-mediated shock reaction caused by topical application of chlorhexidine. Clin Allergy 1986;16:155–161.CrossRefGoogle ScholarPubMed
Snellman, E, Rantanen, T. Severe anaphylaxis after a chlorhexidine bath. J Am Acad Dermatol 1999;40:771–772.CrossRefGoogle ScholarPubMed
Teixeira de Abreu, AP, Ribeiro de Oliveira, LR, Teixeira de Abreu, AF, et al. Perioperative anaphylaxis to chlorhexidine during surgery and septoplasty. Case Rep Otolaryngol 2017. doi: 10.1155/2017/9605804.CrossRefGoogle Scholar
Toletone, A, Dini, G, Massa, E, et al. Chlorhexidine-induced anaphylaxis occurring in the workplace in a healthcare worker: case report and review of the literature. Med Lav 2018;109:68–76.Google Scholar
Bae, YJ, Park, CS, Lee, JK, et al. A case of anaphylaxis to chlorhexidine during digital rectal examination. J Korean Med Sci 2008;23:526–528.CrossRefGoogle ScholarPubMed
Gu, JQ, Liu, S, Zhi, YX. Provocation test-confirmed chlorhexidine-induced anaphylaxis in dental procedure. Chin Med J (Engl) 2018;131:2893–2894.Google Scholar
Magdaleno-Tapial, J, Martínez-Doménech, A, Valenzuela-Oñate, C, Ferrer-Guillén, B, Esteve-Martínez, A, Zaragoza-Ninet, V. Allergic contact dermatitis to chlorhexidine in pediatric patients. Pediatr Dermatol 2019;36:540–541.CrossRefGoogle Scholar
Mitchell, DJ, Parker, FC. Anaphylaxis following urethral catheterisation. Br J Urol 1993;71:613.CrossRefGoogle ScholarPubMed
Okano, M, Nomura, M, Hata, S, et al. Anaphylactic symptoms due to chlorhexidine gluconate. Arch Dermatol 1989;125:50–52.CrossRefGoogle ScholarPubMed
Peutrell, JM. Anaphylactoid reaction to topical chlorhexidine during anaesthesia. Anaesthesia 1992;47:1013.CrossRefGoogle ScholarPubMed
Reynolds, NJ, Harman, RR. Allergic contact dermatitis from chlorhexidine diacetate in a skin swab. Contact Dermatitis 1990;22:103–104.CrossRefGoogle Scholar
Roberts, DL, Summerly, R, Byrne, JP. Contact dermatitis due to the constituents of Hibiscrub. Contact Dermatitis 1981;7:326–328.CrossRefGoogle Scholar
Shoji, A. Contact dermatitis to Aloe arborescens . Contact Dermatitis 1982;8:164–167.CrossRefGoogle Scholar
Vu, M, et al. Immediate hypersensitivity to chlorhexidine. Australas J Dermatol 2018;59:55–56.CrossRefGoogle Scholar
Hong, CC, Wang, SM, Nather, A, Tan, JH, Tay, SH, Poon, KH. Chlorhexidine anaphylaxis masquerading as septic shock. Int Arch Allergy Immunol 2015;167:16–20.CrossRefGoogle ScholarPubMed
Lieberman, P, Nicklas, RA, Oppenheimer, J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010;126:477–480.CrossRefGoogle ScholarPubMed
Sharp, G, Green, S, Rose, M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg 2016;86:237–243.CrossRefGoogle ScholarPubMed
Chiewchalermsri, C, Sompornrattanaphan, M, Wongsa, C, Thongngarm, T. Chlorhexidine allergy: current challenges and future prospects. J Asthma Allergy 2020;13:127–133.CrossRefGoogle Scholar
Harper, NJN, Cook, TM, Garcez, T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth 2018;121:159–171.CrossRefGoogle Scholar
Dyer, JE, Taktak, SY, Parkes, AW, Garcez, T, Gall, Z. Chlorhexidine-related anaphylaxis in urological practice. J Clin Urol 2019;12:32–38.CrossRefGoogle Scholar
Raad, I, Chaftari, AM. Advances in prevention and management of central line-associated bloodstream infections in patients with cancer. Clin Infect Dis 2014;59 suppl 5:S340–S343.CrossRefGoogle ScholarPubMed
Johansson, SG. ImmunoCAP Specific IgE test: an objective tool for research and routine allergy diagnosis. Expert Rev Mol Diagn 2004;4:273–279.CrossRefGoogle Scholar