Neonatal skin antisepsis with alcohol-based compared to aqueous 2% chlorhexidine, used in moderate preterm infants or extremely preterm infants after the first week of life, is safe and may be associated with a reduced incidence of catheter-related bloodstream infections.

Summary

In a double-cohort comparison across two 3-year periods with a 1-year washout, alcohol-based 2% chlorhexidine for neonatal skin antisepsis reduced CRBSI incidence density by about half (OR 0.45) versus aqueous 2% chlorhexidine, without increasing skin lesions. Absolute risk reduction was 3.9% (NNT 25).

Key Findings

• Alcohol-based 2% chlorhexidine reduced CRBSI incidence density versus aqueous 2% (4.03 vs 9.05 per 1000 line-days; OR 0.45, 95% CI 0.29–0.68).
• Absolute risk reduction was 3.9% with a number needed to treat of 25.
• Skin lesion rates were similar between periods; erythema was most common (5.1% vs 4.2%).
• In extremely preterm infants within the first week, the reduction was similar in magnitude but not statistically significant.

Clinical Implications

Consider adopting alcohol-based 2% chlorhexidine for neonatal line antisepsis beyond the first week of life, with ongoing skin monitoring, to reduce CRBSI.

Limitations

• Nonrandomized before–after design susceptible to temporal and practice changes
• Extremely preterm infants in first week continued aqueous chlorhexidine, limiting generalizability for this subgroup

Future Directions

Prospective randomized trials or interrupted time series with adjustment for secular trends; evaluate optimal timing in extremely preterm infants and skin safety profiling.