Summary
Chlorhexidine digluconate (CHG) is an antimicrobial agent used for different types
of applications in hand hygiene, skin antisepsis, oral care, and patient washing.
Increasing use raises concern regarding development of acquired bacterial resistance.
Published data from clinical isolates with CHG minimum inhibitory concentrations (MICs)
were reviewed and compared to epidemiological cut-off values to determine resistance.
CHG resistance is rarely found in Escherichia coli, Salmonella spp., Staphylococcus aureus or coagulase-negative staphylococci. In Enterobacter spp., Pseudomonas spp., Proteus spp., Providencia spp. and Enterococcus spp., however, isolates are more often CHG resistant. CHG resistance may be detected
in multi-resistant isolates such as extremely drug-resistant Klebsiella pneumoniae. Isolates with a higher MIC are often less susceptible to CHG for disinfection. Although
cross-resistance to antibiotics remains controversial, some studies indicate that
the overall exposure to CHG increases the risk for resistance to some antibiotic agents.
Resistance to CHG has resulted in numerous outbreaks and healthcare-associated infections.
On an average intensive care unit, most of the CHG exposure would be explained by
hand hygiene agents when liquid soaps or alcohol-based hand rubs contain CHG. Exposure
to sub-lethal CHG concentration may enhance resistance in Acinetobacter spp., K. pneumoniae, and Pseudomonas spp., all species well known for emerging antibiotic resistance. In order to reduce
additional selection pressure in nosocomial pathogens it seems to make sense to restrict
the valuable agent CHG to those indications with a clear patient benefit and to eliminate
it from applications without any benefit or with a doubtful benefit.
Keywords
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References
- 1:6-Di-4′-chlorophenyldiguanidohexane (“Hibitane”). Laboratory investigation of a new antibacterial agent of high potency.Br J Pharmacol Chemother. 1954; 9: 192-196
- The effectiveness of different concentrations of chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis.J Clin Nurs. 2014; 23: 1461-1475
- Guidelines for the prevention of intravascular catheter-related infections.Am J Infect Control. 2011; 39: S1-S34
- Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial.Lancet. 2015; 386: 2069-2077
- Epidemiology of infections acquired in intensive care units.Semin Respir Crit Care Med. 2011; 32: 115-138
- The effect of chlorhexidine bathing on rates of nosocomial infections among the critically ill population: an analysis of current clinical research and recommendations for practice.Dimensions Crit Care Nurs. 2016; 35: 84-91
- Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.New Engl J Med. 2010; 362: 18-26
- What is left to justify the use of chlorhexidine in hand hygiene?.J Hosp Infect. 2008; 70: 27-34
- Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.Lancet. 2000; 356: 1307-1312
- Does microbial resistance or adaptation to biocides create a hazard in infection prevention and control?.J Hosp Infect. 2010; 76: 200-205
- Outbreaks associated with contaminated antiseptics and disinfectants.Antimicrobial Agents Chemother. 2007; 51: 4217-4224
- Evaluation of single-use packs of hospital disinfectants.Lancet. 1973; 1: 591-593
- Do chlorhexidine patient baths prevent catheter-associated urinary tract infections?.Lancet Infect Dis. 2016; 16: 8-9
- Active efflux, a common mechanism for biocide and antibiotic resistance.J Appl Microbiol. 2002; 92: 65s-71s
- Efflux-related resistance to norfloxacin, dyes, and biocides in bloodstream isolates of Staphylococcus aureus.Antimicrob Agents Chemother. 2007; 51: 3235-3239
- Epidemiologie und Ursachen mikrobieller Biozidresistenzen.Zentralbl Hygiene Umweltmed. 1995; 197: 252-259
- Untersuchungen zur Epidemiologie mikrobieller Biozidresistenzen.Zentralbl Hygiene Umweltmed. 1995; 197: 232-251
- Plasmids and bacterial resistance to biocides.J Appl Microbiol. 1997; 83: 155-165
- Klebsiella oxytoca with reduced sensitivity to chlorhexidine isolated from a diabetic foot ulcer.Int J Infect Dis. 2015; 34: 112-116
- Recurrent methicillin-resistant Staphylococcus aureus cutaneous abscesses and selection of reduced chlorhexidine susceptibility during chlorhexidine use.J Clin Microbiol. 2015; 53: 3677-3682
- Evaluation of epidemiological cut-off values indicates that biocide resistant subpopulations are uncommon in natural isolates of clinically-relevant microorganisms.PLoS One. 2014; 9: e86669
- Comparative susceptibility of hospital isolates of gram-negative bacteria to antiseptics and disinfectants.J Hosp Infect. 1987; 9: 255-264
- Antibiotic resistance as an indicator of bacterial chlorhexidine susceptibility.J Hosp Infect. 2002; 51: 106-113
- QacEdelta1 gene frequency and biocide resistance in extended-spectrum beta-lactamase producing Enterobacteriaceae clinical isolates.Revista de investigacion clinica. 2012; 64: 535-540
- Antiseptic and antibiotic resistance in gram-negative bacteria causing urinary tract infection in spinal cord injured patients.Paraplegia. 1981; 19: 50-58
- Reduced susceptibility to chlorhexidine among extremely-drug-resistant strains of Klebsiella pneumoniae.J Hosp Infect. 2012; 81: 15-19
- Klebsiella pneumoniae susceptibility to biocides and its association with cepA, qacDeltaE and qacE efflux pump genes and antibiotic resistance.J Hosp Infect. 2012; 81: 87-91
- Disinfectant susceptibility of different Salmonella serotypes isolated from chicken and egg production chains.J Appl Microbiol. 2016; 121: 672-681
- Antiseptic and antibiotic resistance in gram-negative bacteria causing urinary tract infections.J Clin Pathol. 1980; 33: 288-296
- In vitro induction of chlorhexidine- and benzalkonium-resistance in clinically isolated Pseudomonas aeruginosa.Kansenshogaku Zasshi. 1993; 67: 202-206
- Isolation of chlorhexidine-resistant Pseudomonas aeruginosa from clinical lesions.J Clin Microbiol. 1982; 1: 166-168
- Comparative sensitivity and resistance of some strains of Pseudomonas aeruginosa and Pseudomonas stutzeri to antibacterial agents.J Clin Pathol. 1974; 27: 463-466
- The relationship and susceptibilities of some industrial laboratory and clinical isolates of Pseudomonas aeruginosa to some antibiotics and biocides.J Appl Microbiol. 2001; 91: 972-984
- Correlation between reduced susceptibility to disinfectants and multidrug resistance among clinical isolates of Acinetobacter species.J Antimicrob Chemother. 2010; 65: 1975-1983
- Effect of daily chlorhexidine bathing on acquisition of carbapenem-resistant Acinetobacter baumannii (CRAB) in the medical intensive care unit with CRAB endemicity.Am J Infect Control. 2015; 43: 1171-1177
- Resistance to antibiotics and biocides among non-fermenting Gram-negative bacteria.Clin Microbiol Infect. 2001; 7: 308-315
- Outbreak of nosocomial urinary tract infections caused by Serratia marcescens.J Clin Microbiol. 1984; 20: 691-695
- Chlorhexidine resistance in Proteus mirabilis.J Clin Pathol. 1974; 27: 284-287
- High rate of qacA- and qacB-positive methicillin-resistant Staphylococcus aureus isolates from chlorhexidine-impregnated catheter-related bloodstream infections.Antimicrob Agents Chemother. 2012; 56: 5693-5697
- Antimicrobial resistance characteristics of and disinfectant-resistant gene distribution in Staphylococcus aureus isolates from male urogenital tract infection.Zhonghua nan ke xue. 2014; 20: 630-636
- Prevalence of antiseptic-resistance genes in Staphylococcus aureus and coagulase-negative staphylococci colonising nurses and the general population in Hong Kong.J Hosp Infect. 2011; 78: 113-117
- Chlorhexidine and mupirocin susceptibilities in methicillin-resistant Staphylococcus aureus isolates from bacteraemia and nasal colonisation.J Glob Antimicrob Resist. 2016; 4: 65-69
- Longitudinal analysis of chlorhexidine susceptibilities of nosocomial methicillin-resistant Staphylococcus aureus isolates at a teaching hospital in Taiwan.J Antimicrob Chemother. 2008; 62: 514-517
- Epidemiology and susceptibilities of methicillin-resistant Staphylococcus aureus in Taiwan: emphasis on chlorhexidine susceptibility.Diagn Microbiol Infect Dis. 2009; 63: 309-313
- Chlorhexidine and mupirocin susceptibilities of methicillin-resistant Staphylococcus aureus from colonized nursing home residents.Antimicrob Agents Chemother. 2013; 57: 552-558
- Prevalence of resistance to antiseptics and mupirocin among invasive coagulase-negative staphylococci from very preterm neonates in NICU: the creeping threat?.J Hosp Infect. 2013; 83: 333-336
- Susceptibility to chlorhexidine amongst multidrug-resistant clinical isolates of Staphylococcus epidermidis from bloodstream infections.Int J Antimicrob Agents. 2016; 48: 86-90
- Biocide and copper tolerance in enterococci from different sources.J Food Prot. 2013; 76: 1806-1809
- Antibiotic and biocide resistance in methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus.J Hosp Infect. 1999; 43: 281-291
- High prevalence of biocide resistance determinants in aureus isolates from three African countries.Antimicrob Agents Chemother. 2015; 60: 678-681
- Effects of ortho-phthalaldehyde, glutaraldehyde and chlorhexidine diacetate on Mycobacterium chelonae and Mycobacterium abscessus strains with modified permeability.J Antimicrob Chemother. 2003; 51: 575-584
- Biocide use and antibiotic resistance: the relevance of laboratory findings to clinical and environmental situations.Lancet Infect Dis. 2003; 3: 794-803
- Development of resistance to chlorhexidine diacetate in Pseudomonas aeruginosa and the effect of a “residual” concentration.J Hosp Infect. 2000; 46: 297-303
- Sensitivity of urine-grown cells of Providencia stuartii to antiseptics.J Clin Pathol. 1978; 31: 929-932
- The resistance of urinary tract pathogens to chlorhexidine bladder washouts.J Hosp Infect. 1987; 10: 28-39
- Chlorhexidine resistance in antibiotic-resistant bacteria isolated from the surfaces of dispensers of soap containing chlorhexidine.Infect Control Hosp Epidemiol. 2002; 23: 692-695
- Varying activity of chlorhexidine-based disinfectants against Klebsiella pneumoniae clinical isolates and adapted strains.J Hosp Infect. 2016; 93: 42-48
- Microbial contamination of disinfectants and antiseptics in four major hospitals in Trinidad.Pan Am J Publ Health. 2003; 14: 193-200
- Characterization of antibiotic and disinfectant susceptibility profiles among Pseudomonas aeruginosa veterinary isolates recovered during 1994–2003.J Appl Microbiol. 2015; 118: 326-342
- Responses of Pseudomonas aeruginosa to antimicrobials.Front Microbiol. 2014; 4: 422
- MexCD-OprJ multidrug efflux system of Pseudomonas aeruginosa: involvement in chlorhexidine resistance and induction by membrane-damaging agents dependent upon the AlgU stress response sigma factor.Antimicrob Agents Chemother. 2008; 52: 4478-4482
- Induction of mexCD-oprJ operon for a multidrug efflux pump by disinfectants in wild-type Pseudomonas aeruginosa PAO1.J Antimicrob Chemother. 2003; 51: 991-994
- Outer membrane changes in Pseudomonas stutzeri resistant to chlorhexidine diacetate and cetylpyridinium chloride.Int J Antimicrob Agents. 2000; 16: 233-238
- Cytological changes in chlorhexidine-resistant isolates of Pseudomonas stutzeri.J Antimicrob Chemother. 2000; 45: 145-152
- Efficacy of common hospital biocides with biofilms of multi-drug resistant clinical isolates.J Med Microbiol. 2008; 57: 966-973
- Sensitivity of Providencia to antiseptics and disinfectants.J Clin Pathol. 1976; 29: 815-823
- Resistance of Providencia stuartii to chlorhexidine: a consideration of the role of the inner membrane.J Appl Bacteriol. 1986; 60: 361-367
- Exposure of Acinetobacter baylyi ADP1 to the biocide chlorhexidine leads to acquired resistance to the biocide itself and to oxidants.J Antimicrob Chemother. 2011; 66: 319-322
- Increase in chlorhexidine minimal inhibitory concentration of Acinetobacter baumannii clinical isolates after implementation of advanced source control.Infect Control Hosp Epidemiol. 2014; 35: 98-99
- Homologs of the Acinetobacter baumannii AceI transporter represent a new family of bacterial multidrug efflux systems.mBio. 2015; 6: e01982-14
- Outbreak of infection by extended-spectrum beta-lactamase SHV-5-producing Serratia marcescens in a Mexican hospital.J Chemother. 2008; 20: 586-592
- Drug resistance studies with topical antiseptics.J Pharm Sci. 1978; 67: 1629-1631
- Decreased susceptibility of Serratia marcescens to chlorhexidine related to the inner membrane.J Antimicrob Chemother. 1985; 15: 559-565
- Mutational upregulation of a resistance–nodulation–cell division-type multidrug efflux pump, SdeAB, upon exposure to a biocide, cetylpyridinium chloride, and antibiotic resistance in Serratia marcescens.Antimicrob Agents Chemother. 2009; 53: 5230-5235
- Studies on resistant mechanisms in the resistant bacteria to chlorhexidine. II. Chemical components of the cell membrane and the electron microscopical observation of cell surface structure of chlorhexidine-resistant bacteria.Yakugaku Zasshi. 1990; 110: 414-425
- Reduced susceptibility of methicillin-resistant Staphylococcus aureus to cetylpyridinium chloride and chlorhexidine.Chemotherapy. 1996; 42: 248-252
- Susceptibility of community associated methicillin resistant Staphylococcus aureus isolated from faeces to antiseptics.J Infect Dev Ctries. 2012; 6: 317-323
- Antiseptic resistance in methicillin sensitive and methicillin resistant Staphylococcus aureus isolates from some major hospitals, Iran.Recent Pat Antiinfect Drug Discov. 2015; 10: 105-112
- Chlorhexidine resistance in methicillin-resistant Staphylococcus aureus or just an elevated MIC? An in vitro and in vivo assessment.Antimicrob Agents Chemother. 1991; 35: 1997-2002
- Emergence of community-associated methicillin-resistant Staphylococcus aureus strains in the neonatal intensive care unit: an infection prevention and patient safety challenge.Clin Microbiol Infect. 2016; 645: e1-e8
- Relationship between the resistance genes to quaternary ammonium compounds and antibiotic resistance in staphylococci isolated from surgical site infections.Med Sci Monit. 2014; 20: 544-550
- Analysis of the adaptation capacity of Staphylococcus aureus to commonly used antiseptics by microplate laser nephelometry.Skin Pharmacol Physiol. 2012; 25: 288-297
- Role of EfrAB efflux pump in biocide tolerance and antibiotic resistance of Enterococcus faecalis and Enterococcus faecium isolated from traditional fermented foods and the effect of EDTA as EfrAB inhibitor.Food Microbiol. 2014; 44: 249-257
- Review and phylogenetic analysis of qac genes that reduce susceptibility to quaternary ammonium compounds in Staphylococcus species.Eur J Microbiol Immunol. 2015; 5: 44-61
- The association between biocide tolerance and the presence or absence of qac genes among hospital-acquired and community-acquired MRSA isolates.J Antimicrob Chemother. 2008; 61: 78-84
- Distribution of disinfectant resistance genes qacA/B in clinical isolates of meticillin-resistant and -susceptible Staphylococcus aureus in one Belgrade hospital.J Hosp Infect. 2010; 76: 266-267
- Widespread distribution of qacA/B gene among coagulase-negative Staphylococcus spp. in Rio de Janeiro, Brazil.J Hosp Infect. 2010; 75: 333-334
- Multidrug resistance proteins QacA and QacB from Staphylococcus aureus: membrane topology and identification of residues involved in substrate specificity.Proc Natl Acad Sci USA. 1996; 93: 3630-3635
- Sensitivities to biocides and distribution of biocide resistance genes in quaternary ammonium compound tolerant Staphylococcus aureus isolated in a teaching hospital.Scand J Infect Dis. 2009; 41: 403-409
- Frequency of biocide-resistant genes and susceptibility to chlorhexidine in high-level mupirocin-resistant, methicillin-resistant Staphylococcus aureus (MuH MRSA).Diagn Microbiol Infect Dis. 2015; 82: 278-283
- Impact of combined low-level mupirocin and genotypic chlorhexidine resistance on persistent methicillin-resistant Staphylococcus aureus carriage after decolonization therapy: a case–control study.Clin Infect Dis. 2011; 52: 1422-1430
- Clinical and molecular features of decreased chlorhexidine susceptibility among nosocomial Staphylococcus aureus isolates at Texas Children’s Hospital.Antimicrob Agents Chemother. 2016; 60: 1121-1128
- Introduction of biocides into clinical practice and the impact on antibiotic-resistant bacteria.Symp Ser Soc Appl Microbiol. 2002; 31: 121S-135S
- High prevalence of qacA/B carriage among clinical isolates of meticillin-resistant Staphylococcus aureus in Malaysia.J Hosp Infect. 2012; 81: 206-208
- The presence of qacA/B gene in Brazilian methicillin-resistant Staphylococcus aureus.Memorias do Instituto Oswaldo Cruz. 2007; 102: 539-540
- Prevalence of antiseptic resistance genes qacA/B and specific sequence types of methicillin-resistant Staphylococcus aureus in the era of hand hygiene.J Antimicrob Chemother. 2012; 67: 1549-1550
- Methicillin-susceptible and -resistant Staphylococcus aureus with high-level antiseptic and low-level mupirocin resistance in Malaysia.Microb Drug Resist. 2014; 20: 472-477
- Coexistence of mupirocin and antiseptic resistance in methicillin-resistant Staphylococcus aureus isolates from Korea.Diagn Microbiol Infect Dis. 2013; 75: 308-312
- Distribution of the antiseptic resistance genes qacA, qacB and qacC in 497 methicillin-resistant and -susceptible European isolates of Staphylococcus aureus.J Antimicrob Chemother. 2001; 47: 896-897
- Distribution of antiseptic-resistance genes qacA/B in clinical isolates of meticillin-resistant Staphylococcus aureus in China.J Hosp Infect. 2008; 69: 393-394
- Susceptibilities to antiseptic agents and distribution of antiseptic-resistance genes qacA/B and smr of methicillin-resistant Staphylococcus aureus isolated in Asia during 1998 and 1999.J Med Microbiol. 2005; 54: 557-565
- The effect of targeted decolonization on methicillin-resistant Staphylococcus aureus colonization or infection in a surgical intensive care unit.Am J Infect Control. 2016; 44: 533-538
- Antimicrobial agent of susceptibilities and antiseptic resistance gene distribution among methicillin-resistant Staphylococcus aureus isolates from patients with impetigo and staphylococcal scalded skin syndrome.J Clin Microbiol. 2006; 44: 2119-2125
- Analysis on distribution and genomic diversity of high-level antiseptic resistance genes qacA and qacB in human clinical isolates of Staphylococcus aureus.Microb Drug Resist. 2003; 9: 109-121
- Identification of active efflux system gene qacA/B in methicillin-resistant Staphylococcus aureus and its significance.Zhong nan da xue xue bao Yi xue ban. 2009; 34: 537-542
- Staphylococcus aureus infections in pediatric oncology patients: high rates of antimicrobial resistance, antiseptic tolerance and complications.Pediatr Infect Dis J. 2013; 32: 124-128
- Current status of Staphylococcus aureus infection in a central teaching hospital in Shanghai, China.BMC Microbiol. 2013; 13: 153
- Investigation of the presence of disinfectant resistance genes qaca/b in nosocomial methicillin-resistant Staphylococcus aureus isolates and evaluation of their in vitro disinfectant susceptibilities.Mikrobiyoloji bulteni. 2013; 47: 1-10
- Frequency of biocide resistance genes, antibiotic resistance and the effect of chlorhexidine exposure on clinical methicillin-resistant Staphylococcus aureus isolates.J Antimicrob Chemother. 2008; 61: 524-532
- Characteristics of qacA/B-positive Staphylococcus aureus isolated from patients and a hospital environment in China.J Antimicrob Chemother. 2015; 70: 653-657
- Current molecular epidemiology of methicillin-resistant Staphylococcus aureus in elderly French people: troublesome clones on the horizon.Front Microbiol. 2016; 7: 31
- Prevalence of qacA/B genes and mupirocin resistance among methicillin-resistant Staphylococcus aureus (MRSA) isolates in the setting of chlorhexidine bathing without mupirocin.Infect Control Hosp Epidemiol. 2016; 37: 590-597
- Distribution of antiseptic resistance genes qacA, qacB, and smr in methicillin-resistant Staphylococcus aureus isolated in Toronto, Canada, from 2005 to 2009.Antimicrob Agents Chemother. 2011; 55: 2999-3001
- Prevalence of chlorhexidine-resistant methicillin-resistant Staphylococcus aureus following prolonged exposure.Antimicrob Agents Chemother. 2014; 58: 4404-4410
- Rapid and simultaneous detection of the chlorhexidine and mupirocin resistance genes qacA/B and mupA in clinical isolates of methicillin-resistant Staphylococcus aureus.Diagn Microbiol Infect Dis. 2013; 77: 270-272
- Determining the resistance of carbapenem-resistant Klebsiella pneumoniae to common disinfectants and elucidating the underlying resistance mechanisms.Pathog Glob Health. 2015; 109: 184-192
- Extremely high prevalence of antiseptic resistant Quaternary Ammonium Compound E gene among clinical isolates of multiple drug resistant Acinetobacter baumannii in Malaysia.Ann Clin Microbiol Antimicrob. 2015; 14: 11
- Prevalence of antiseptic-resistance genes in staphylococci isolated from orthokeratology lens and spectacle wearers in Hong Kong.Invest Ophthalmol Vis Sci. 2015; 56: 3069-3074
- Decreased susceptibilities to retapamulin, mupirocin, and chlorhexidine among Staphylococcus aureus isolates causing skin and soft tissue infections in otherwise healthy children.Antimicrob Agents Chemother. 2014; 58: 2878-2883
- Do biocides select for antibiotic resistance?.J Pharm Pharmacol. 2000; 52: 227-233
- Possible link between bacterial resistance and use of antibiotics and biocides.Antimicrob Agents Chemother. 1998; 42: 2151
- Significant differences characterise the correlation coefficients between biocide and antibiotic susceptibility profiles in Staphylococcus aureus.Curr Pharm Des. 2015; 21: 2054-2057
- Comparative analysis of antibiotic and antimicrobial biocide susceptibility data in clinical isolates of methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa between 1989 and 2000.J Appl Microbiol. 2004; 97: 699-711
- Biocide susceptibility of the Burkholderia cepacia complex.J Antimicrob Chemother. 2009; 63: 502-510
- Characterization of Salmonella enterica isolates from turkeys in commercial processing plants for resistance to antibiotics, disinfectants, and a growth promoter.Foodborne Pathog Dis. 2011; 8: 593-600
- Resistance of 700 gram-negative bacterial strains to antiseptics and antibiotics.Annales de recherches veterinaires. 1991; 22: 11-23
- Reduced susceptibility to biocides in Acinetobacter baumannii: association with resistance to antimicrobials, epidemiological behaviour, biological cost and effect on the expression of genes encoding porins and efflux pumps.J Antimicrob Chemother. 2015; 70: 3222-3229
- Role of novel multidrug efflux pump involved in drug resistance in Klebsiella pneumoniae.PLoS One. 2014; 9: e96288
- KpnEF, a new member of the Klebsiella pneumoniae cell envelope stress response regulon, is an SMR-type efflux pump involved in broad-spectrum antimicrobial resistance.Antimicrob Agents Chemother. 2013; 57: 4449-4462
- Multidrug-resistant Pseudomonas aeruginosa strain that caused an outbreak in a neurosurgery ward and its aac(6′)-Iae gene cassette encoding a novel aminoglycoside acetyltransferase.Antimicrob Agents Chemother. 2005; 49: 3734-3742
- Chlorhexidine resistance in Escherichia coli isolated from clinical lesions.Zentralbl Bakteriol Hyg, I Abt Orig B. 1981; 251: 177-184
- The effect of cationic microbicide exposure against Burkholderia cepacia complex (Bcc); the use of Burkholderia lata strain 383 as a model bacterium.J Appl Microbiol. 2013; 115: 1117-1126
- Antimicrobial resistance patterns of colonizing flora on nurses’ hands in the neonatal intensive care unit.Am J Infect Control. 2007; 35: 231-236
- Chlorhexidine induces VanA-type vancomycin resistance genes in enterococci.Antimicrob Agents Chemother. 2016; 60: 2209-2221
- Characterization of pre-antibiotic era Klebsiella pneumoniae isolates with respect to antibiotic/disinfectant susceptibility and virulence in Galleria mellonella.Antimicrob Agents Chemother. 2015; 59: 3966-3972
- What antimicrobial resistance has taught us about horizontal gene transfer.Methods Mol Biol. 2009; 532: 397-411
- Multidrug resistance to antiseptics and disinfectants in coagulase-negative staphylococci.J Med Microbiol. 1994; 40: 214-220
- Analysis of the pSK1 replicon, a prototype from the staphylococcal multiresistance plasmid family.Microbiology. 2008; 154: 3084-3094
- Transduction of the plasmid encoding antiseptic resistance gene qacB in Staphylococcus aureus.Biol Pharm Bull. 2007; 30: 1412-1415
- Cerebral ventriculitis associated with Achromobacter xylosoxidans.J Clin Pathol. 1978; 31: 156-161
- Serratia marcescens outbreak in a paediatric oncology unit traced to contaminated chlorhexidine.Scot Med J. 1989; 34: 525-528
- A hospital outbreak caused by a chlorhexidine and antibiotic-resistant Proteus mirabilis.J Hosp Infect. 1987; 10: 10-16
- Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit.Clin Infect Dis. 2010; 50: 210-217
- Decreased susceptibility to chlorhexidine and prevalence of disinfectant resistance genes among clinical isolates of Staphylococcus epidermidis.APMIS. 2014; 122: 961-967
- A three-year surveillance of nosocomial infections by methicillin-resistant Staphylococcus haemolyticus in newborns reveals the disinfectant as a possible reservoir.Pathologie-biologie. 2009; 57: e29-e35
- Association between intensity of chlorhexidine use and microorganisms of reduced susceptibility in a hospital environment.J Hosp Infect. 2002; 51: 201-206
- The antimicrobial activity in vitro of chlorhexidine, a mixture of isothiazolinones (‘Kathon’ CG) and cetyl trimethyl ammonium bromide (CTAB).J Hosp Infect. 1993; 23: 87-111
- Use of a predictive protocol to measure the antimicrobial resistance risks associated with biocidal product usage.Am J Infect Control. 2016; 44: 458-464
- Evolution of resistance to cationic biocides in Streptococcus mutans and Enterococcus faecalis.J Dent. 2016; 47: 18-22
- In vitro susceptibility of Streptococcus mutans to chlorhexidine and six other antimicrobial agents.Antimicrob Agents Chemother. 1993; 37: 1158-1159
- Susceptibility of Streptococcus mutans and Streptococcus sobrinus to antimicrobial agents after short-term oral chlorhexidine treatments.Eur J Oral Sci. 1995; 103: 32-35
- Hospital hand hygiene opportunities: where and when (HOW2)? The HOW2 Benchmark Study.Am J Infect Control. 2011; 39: 19-26
- WHO guidelines on hand hygiene in health care. First Global Patient Safety Challenge – Clean Care is Safer Care.WHO, Geneva2009
- Chlorhexidine body washing to control antimicrobial-resistant bacteria in intensive care units: a systematic review.Intens Care Med. 2012; 38: 931-939
- Effectiveness of a dental care intervention in the prevention of lower respiratory tract nosocomial infections among intensive care patients: a randomized clinical trial.Infect Control Hosp Epidemiol. 2014; 35: 1342-1348
- Ventilator-associated pneumonia and oral care: a successful quality improvement project.Am J Infect Control. 2009; 37: 590-597
- Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update.Infect Control Hosp Epidemiol. 2014; 35: S133-S155
- Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis.JAMA Intern Med. 2014; 174: 751-761
- Decolonization in prevention of health care-associated infections.Clin Microbiol Rev. 2016; 29: 201-222
- Adaptive resistance to biocides in Salmonella enterica and Escherichia coli O157 and cross-resistance to antimicrobial agents.J Clin Microbiol. 2004; 42: 73-78
- Measuring residual activity of topical antimicrobials: is the residual activity of chlorhexidine an artefact of laboratory methods?.J Hosp Infect. 2014; 88: 113-115
- Acquisition of high-level mupirocin resistance in CoNS following nasal decolonization with mupirocin.J Antimicrob Chemother. 2015; 70: 1182-1184
- Mupirocin resistance: clinical implications and potential alternatives for the eradication of MRSA.J Antimicrob Chemother. 2015; 70: 2681-2692
- Molecular epidemiology of plasmid-mediated high-level mupirocin resistance in methicillin-resistant Staphylococcus aureus in four Spanish health care settings.Int J Med Microbiol. 2013; 303: 201-204
Article info
Publication history
Published online: August 27, 2016
Accepted:
August 18,
2016
Received:
July 27,
2016
Identification
Copyright
© 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
