Chlorhexidine Gluconate (CHG) as we know it in the medical fraternity, is an antimicrobial agent that is commonly used in the preoperative preparation of skin to prevent postoperative infections, dental plaque prevention, and the prevention of ventilator-associated pneumonia. Numerous studies and research have shown that due to its cationic nature, CHG has been shown to be effective in killing enveloped viruses. As SARS-CoV-2 is an enveloped virus, CHG has been shown to be effective against SARS-CoV-2. CHG has been included as a simple and safe addition to the current Covid-19 prevention guidelines. It has been found that when CHG is used with vaccination, proper social distancing, mask wearing, and hand hygiene, CHG may contribute to a more robust disease prevention regimen. This article shows some evidence on how CHG was used as a topical antimicrobial agent against SARS-CoV-2 through an oral rinse and how it may be used in reducing disease spread. This article is about our awareness of the effectiveness of Chlorhexidine Gluconate as an antimicrobial agent whether it is in a bath wipe or oral rinse.
Use of chlorhexidine to eradicate oropharyngeal SARS-CoV-2 in COVID-19 patients
(An extract)
Prevention of coronavirus disease 2019 (COVID-19) relies on minimizing spread. In this study, chlorhexidine gluconate was investigated as a topical antimicrobial agent against SARS-CoV-2. This was a randomized, prospective cohort study using chlorhexidine as an oral rinse and posterior oropharyngeal spray in hospitalized COVID-19 patients. The primary outcome was presence or absence of laboratory-confirmed SARS-CoV-2 in the oral and oropharyngeal cavities after 4 days of chlorhexidine use and standard of care (study group) or standard of care only (control group). SARS-CoV-2 was eliminated from the oropharynx in 62.1% of patients who used chlorhexidine as an oral rinse, versus 5.5% of the control group patients. Among patients who used a combination of oral rinse and oropharyngeal spray, 86.0% eliminated oropharyngeal SARS-CoV-2, versus 6.3% of control patients.
Background
Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019, there have been over 113 million confirmed cases of coronavirus disease 2019 (COVID-19) worldwide resulting in over 2.5 million deaths.1, 2In the absence of effective systemic antimicrobial agents, prophylaxis is crucial for disease control. The gold standard of epidemic disease prophylaxis is a combination of vaccine immunization, use of prophylactic antimicrobial agents, and isolation from the causal microorganism. As public distribution of a SARS-CoV-2 vaccine is underway, prophylactic recommendations currently focus on isolation from the virus via social distancing, mask wearing, hand washing, and disease tracing.3 There is emerging evidence that topical antimicrobial agents may also be useful in preventing COVID-19 disease spread.4, 5In this study, the authors investigated the use of chlorhexidine gluconate as an oropharyngeal antimicrobial agent against SARS-CoV-2 infection.
Materials and Methods
This was a prospective cohort study performed at four community hospitals in Los Angeles, CA (East Los Angeles Doctors Hospital, Community Hospital of Huntington Park, Alhambra Hospital Medical Center, and Garfield Medical Center). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committees of the Pipeline Health and AHMC Healthcare hospital systems. Informed consent was obtained from all subjects involved in the study. COVID-19 patients who were admitted to the COVID 19 wards at the above hospitals between May 20, 2020, and December 15, 2020 were identified for the study. All COVID-19 diagnoses were confirmed via detection of SARS-CoV-2 in nasopharyngeal swab specimens by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) by WestPac Labs with the use of the cobas 6800 SARS-CoV-2 test (Roche Molecular Systems). The study population included patients who were able to follow instructions to use chlorhexidine as an oral rinse. Patients with nasogastric or endotracheal tubes placed were excluded from the study. Patients who were symptomatic for over a week before admission were also excluded.
From this population, patients were randomly assigned to the study and control groups. Both groups received the standard of care in their treatment plans. The study group was given chlorhexidine to use as an oropharyngeal rinse while the control group was not. For each administration of chlorhexidine, a unit dose cup containing 0.5 ounces (15 ml) of commercially available chlorhexidine gluconate (0.12%) was provided to each patient.
Patients were then observed to self-administer the solution as a thorough oral rinse for 30 s twice a day. After 4 days, the oropharynx was swabbed and tested for the presence of SARS CoV-2 by rRT-PCR.
Since an oral rinse alone would not reach the posterior oropharynx effectively, a chlorhexidine spray was added to the oral rinse regimen in the second study group. After the patient used chlorhexidine as an oral rinse as stated above, a provider used a spray applicator to deliver three sprays (a total of approximately 1.5 ml) of the chlorhexidine solution to the posterior oropharynx. To open the posterior pharynx, the patient was instructed to vocalize “ah” for 5 s while the solution was sprayed. This process was performed twice a day for 4 days. After 4 days of chlorhexidine administration, the oropharynx was swabbed and tested for presence of SARS-CoV-2 by rRT-PCR. A paired t-test was used to compare findings, with a significance level of .05.
Fourteen nurses and one physician in the hospitals where this study was conducted followed the above chlorhexidine oral rinse with oropharyngeal spray regimen twice a day in addition to social distancing, mask wearing, and hand washing to prevent contracting COVID-19. The healthcare workers were followed for the duration of the study, and adherence to the chlorhexidine regimen and COVID-19 status was self-reported. The rate of SARS-CoV-2 infection among this group was compared to the rate of infection among all healthcare workers in their respective hospitals.
Results
684 patients with positive SARS-CoV-2 infection were identified (Figure 1). The mean onset of symptoms was 5.6 days before admission (standard deviation, 2.3; range, 1–16). 390 patients were excluded for symptom onset of greater than 6 days before admission, placement of nasogastric or endotracheal tubes, or inability to follow instructions to use chlorhexidine. 58% of the study population was male, 42% was female, and the median age was 62 years (range, 23–89). 294 patients were included in analysis, with 159 patients in the study group receiving chlorhexidine and 135 patients in the control group. All patients received the standard of care for COVID-19, which included remdesivir, anticoagulation, steroids, and oxygen therapy. There was no significant difference in response to treatment between the two groups.
Figure 1
Participant flow in a randomized control trial of chlorhexidine in hospitalized COVID-19 patients
Use of chlorhexidine in healthcare workers
A group of 15 healthcare workers (14 nurses and 1 physician) used chlorhexidine as an oral rinse and oropharyngeal spray twice a day as described above for the duration of the study. None were observed to develop SARS-CoV-2 infection during the course of this study. In contrast, the rate of COVID-19 among all healthcare workers in their respective hospitals during the same time period was near 50%.
Adverse effects
No adverse effects of using chlorhexidine as outlined were observed.
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