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Aaron M Milstone - One of the best experts on this subject based on the ideXlab platform.
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absorption and tolerability of aqueous chlorhexidine gluconate used for skin Antisepsis prior to catheter insertion in preterm neonates
Journal of Perinatology, 2013Co-Authors: Alison K Chapman, Susan W Aucott, Maureen M Gilmore, Sonali Advani, William Clarke, Aaron M MilstoneAbstract:Absorption and tolerability of aqueous chlorhexidine gluconate used for skin Antisepsis prior to catheter insertion in preterm neonates
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absorption and tolerability of aqueous chlorhexidine gluconate used for skin Antisepsis prior to catheter insertion in preterm neonates
Journal of Perinatology, 2013Co-Authors: Alison K Chapman, Susan W Aucott, Maureen M Gilmore, William Clarke, Aaron M Milstone, Sonali D AdvaniAbstract:To assess chlorhexidine absorption and skin tolerability in premature infants, following skin Antisepsis with 2% aqueous chlorhexidine gluconate (CHG) prior to peripherally inserted central catheter (PICC) placement. Neonates less than 32 weeks gestation had skin cleansed with CHG prior to PICC placement. CHG concentrations were measured on serial blood samples. Skin integrity was evaluated for 2 weeks after CHG exposure. Twenty infants were enrolled; median gestational age was 28 2/7 weeks (range 24 3/7 to 31 4/7). Ten infants had detectable serum chlorhexidine concentrations (range 1.6 to 206 ng ml−1). Seven of these infants had their highest serum concentration 2 to 3 days following exposure. No CHG-related skin irritation occurred in any infant. CHG was detected in the blood of preterm infants receiving CHG skin Antisepsis for PICC insertion. Highest serum concentrations occurred 2 to 3 days after exposure. Further investigation is needed to determine the clinical relevance of CHG absorption in preterm infants.
Edwin Chan - One of the best experts on this subject based on the ideXlab platform.
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pitfalls in evidence assessment the case of chlorhexidine and alcohol in skin Antisepsis
Journal of Antimicrobial Chemotherapy, 2014Co-Authors: Matthias Maiwald, Edwin ChanAbstract:Chlorhexidine has attracted increasing attention for its role in skin Antisepsis in recent years. It was tested in several prominent clinical trials and subsequently recommended in important guidelines for blood culture collection, vascular catheter insertion and surgical skin preparation. We noticed and subsequently reported a widespread misinterpretation of evidence surrounding chlorhexidine and its role in skin Antisepsis. Multiple clinical trial reports and systematic reviews that had assessed the clinical efficacy of chlorhexidine/alcohol combinations for skin Antisepsis had attributed efficacy solely to the chlorhexidine component. This misinterpretation was carried over into the tertiary literature, including evidence-based guidelines. Here we discuss some of the scientific, ethical, patient safety and infection control implications of this misinterpretation, as well as broader implications for evidence-based medicine.
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the forgotten role of alcohol a systematic review and meta analysis of the clinical efficacy and perceived role of chlorhexidine in skin Antisepsis
PLOS ONE, 2012Co-Authors: Matthias Maiwald, Edwin ChanAbstract:Background Skin Antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin Antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin Antisepsis and the extent of a possible misinterpretation of evidence. Methods We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution. Results In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines. Conclusions Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.
Didier Pittet - One of the best experts on this subject based on the ideXlab platform.
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shortening the application time of alcohol based hand rubs to 15 seconds may improve the frequency of hand Antisepsis actions in a neonatal intensive care unit
Infection Control and Hospital Epidemiology, 2017Co-Authors: Axel Kramer, Didier Pittet, Romana Klasinc, Stefan Krebs, Torsten Koburger, Christoph Fusch, Ojan AssadianAbstract:BACKGROUND For alcohol-based hand rubs, the currently recommended application time of 30 seconds is longer than the actual time spent in clinical practice. We investigated whether a shorter application time of 15 seconds is microbiologically safe in neonatal intensive care and may positively influence compliance with the frequency of hand Antisepsis actions. METHODS We conducted in vitro experiments to determine the antimicrobial efficacy of hand rubs within 15 seconds, followed by clinical observations to assess the effect of a shortened hand Antisepsis procedure under clinical conditions in a neonatal intensive care unit (NICU). An independent observer monitored the frequency of hand Antisepsis actions during shifts. RESULTS All tested hand rubs fulfilled the requirement of equal or even significantly higher efficacy within 15 seconds when compared to a reference alcohol propan-2-ol 60% (v/v) within 30 seconds. Microbiologically, reducing the application time to 15 seconds had a similar effect when compared to 30-second hand rubbing, but it resulted in significantly increased frequency of hand Antisepsis actions (7.9±4.3 per hour vs 5.8±2.9 per hour; P=.05). CONCLUSION Time pressure and workload are recognized barriers to compliance. Therefore, reducing the recommended time for hand Antisepsis actions, using tested and well-evaluated hand rub formulations, may improve hand hygiene compliance in clinical practice. Infect Control Hosp Epidemiol 2017;38:1430-1434.
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testing of the world health organization recommended formulations for surgical hand preparation and proposals for increased efficacy
Journal of Hospital Infection, 2011Co-Authors: Miranda Suchomel, Didier Pittet, Michael Kundi, Benedetta Allegranzi, M RotterAbstract:The 2009 World Health Organization (WHO) Guidelines on hand hygiene in health care recommend alcohol-based hand rubs for both hygienic and pre-surgical hand treatment. Two formulations based on ethanol 80% v/v and 2-propanol 75% v/v are proposed for local preparation in healthcare settings where commercial products are not available or too expensive. Both formulations and our suggested modifications (using mass rather than volume percent concentrations) were evaluated for their conformity with the efficacy requirements of the forthcoming amendment of the European Norm (EN) 12791, i.e. non-inferiority of a product when compared with a reference procedure (1-propanol 60% v/v for 3 min) immediately and 3 h after Antisepsis. In this study, the WHO-recommended formulations were tested for 3 min and 5 min. Neither formulation met the efficacy requirements of EN 12791 with 3 min application. Increasing the respective concentrations to 80 w/w (85% v/v) and 75 w/w (80% v/v), together with a prolonged application of 5 min, rendered the immediate effect of both formulations non-inferior to the reference Antisepsis procedure. This was not the case with the 3h effect, which remained significantly inferior to the reference. Although the original formulations do not meet the efficacy requirements of EN 12791, the clinical significance of this finding deserves further clinical trials. To comply with the requirement of EN 12791, an amendment to the formulations is possible by increasing the alcohol concentrations through changing volume into mass percent and prolonging the duration of application from 3 min to 5 min.
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Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force
American Journal of Infection Control, 2002Co-Authors: John M Boyce, Didier PittetAbstract:The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand Antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS, CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand Antisepsis in health care settings. Am J Infect Control 1995:23;251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.
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bacterial contamination of the hands of hospital staff during routine patient care
JAMA Internal Medicine, 1999Co-Authors: Didier Pittet, Sylvie Touveneau, V Sauvan, Sasi Dharan, Thomas V. PernegerAbstract:Background Cross-transmission of microorganisms by the hands of health care workers is considered the main route of spread of nosocomial infections. Objective To study the process of bacterial contamination of health care workers' hands during routine patient care in a large teaching hospital. Methods Structured observations of 417 episodes of care were conducted by trained external observers (S.T. and V.S.). Each observation period started after a hand-cleansing procedure and ended when the health care worker proceeded to clean his or her hands or at the end of a coherent episode of care. At the end of each period of observation, an imprint of the 5 fingertips of the dominant hand was taken and bacterial colony counts were quantified. Regression methods were used to model the intensity of bacterial contamination as a function of method of hand cleansing, use of gloves during patient care, duration and type of care, and hospital ward. Results Bacterial contamination increased linearly with time on ungloved hands during patient care (average, 16 colony-forming units [CFUs] per minute; 95% confidence interval, 11-21 CFUs per minute). Patient care activities independently (P Conclusions The duration and type of patient care affect hand contamination. Furthermore, because hand Antisepsis was superior to hand washing, intervention trials should explore the role of systematic hand Antisepsis as a cornerstone of infection control to reduce cross-transmission in hospitals.
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bacterial contamination of the hands of hospital staff during routine patient care
JAMA Internal Medicine, 1999Co-Authors: Didier Pittet, Sylvie Touveneau, V Sauvan, Sasi Dharan, Thomas V. PernegerAbstract:BACKGROUND: Cross-transmission of microorganisms by the hands of health care workers is considered the main route of spread of nosocomial infections. OBJECTIVE: To study the process of bacterial contamination of health care workers' hands during routine patient care in a large teaching hospital. METHODS: Structured observations of 417 episodes of care were conducted by trained external observers (S.T. and V.S.). Each observation period started after a hand-cleansing procedure and ended when the health care worker proceeded to clean his or her hands or at the end of a coherent episode of care. At the end of each period of observation, an imprint of the 5 fingertips of the dominant hand was taken and bacterial colony counts were quantified. Regression methods were used to model the intensity of bacterial contamination as a function of method of hand cleansing, use of gloves during patient care, duration and type of care, and hospital ward. RESULTS: Bacterial contamination increased linearly with time on ungloved hands during patient care (average, 16 colony-forming units [CFUs] per minute; 95% confidence interval, 11-21 CFUs per minute). Patient care activities independently (P<.05 for all) associated with higher contamination levels were direct patient contact, respiratory care, handling of body fluid secretions, and rupture in the sequence of patient care. Contamination levels varied with hospital location; the medical rehabilitation ward had higher levels (49 CFUs; P=.03) than did other wards. Finally, simple hand washing before patient care, without hand Antisepsis, was also associated with higher colony counts (52 CFUs; P=.03). CONCLUSIONS: The duration and type of patient care affect hand contamination. Furthermore, because hand Antisepsis was superior to hand washing, intervention trials should explore the role of systematic hand Antisepsis as a cornerstone of infection control to reduce cross-transmission in hospitals.
Axel Kramer - One of the best experts on this subject based on the ideXlab platform.
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comparison of chlorhexidine isopropanol with isopropanol skin Antisepsis for prevention of surgical site infection after abdominal surgery
British Journal of Surgery, 2018Co-Authors: Julian C Harnoss, Axel Kramer, Ojan Assadian, Pascal Probst, C Mullerlantzsch, L Scheerer, Thomas Bruckner, Markus K Diener, M W Buchler, Alexis UlrichAbstract:Background Prevention of surgical-site infection (SSI) has received increasing attention. Clinical trials have focused on the role of skin Antisepsis in preventing SSI. The benefit of combining antiseptic chlorhexidine with alcohol has not been compared with alcohol-based skin preparation alone in a prospective controlled clinical trial. Methods Between August and October 2014, patients undergoing abdominal surgery received preoperative skin Antisepsis with 70 per cent isopropanol (PA). Those treated between November 2014 and January 2015 received 2 per cent chlorhexidine with 70 per cent isopropanol (CA). The primary endpoint was SSI on postoperative day (POD) 10, which was evaluated using univariable analysis, and a multivariable logistic regression model correcting for known independent risk factors for SSI. The study protocol was published in the German Registry of Clinical Studies (DRKS00011174). Results In total, 500 patients undergoing elective midline laparotomy were included (CA 221, PA 279). The incidence of superficial and deep SSIs was significantly different on POD 10: 14 of 212 (6·6 per cent) among those treated with CA and 32 of 260 (12·3 per cent) in those who received PA (P = 0·038). In the multivariable analysis, skin Antisepsis with CA was an independent factor for reduced incidence of SSI on POD 10 (P = 0·034). Conclusion This study showed a benefit of adding chlorhexidine to alcohol for skin Antisepsis in reducing early SSI compared with alcohol alone.
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shortening the application time of alcohol based hand rubs to 15 seconds may improve the frequency of hand Antisepsis actions in a neonatal intensive care unit
Infection Control and Hospital Epidemiology, 2017Co-Authors: Axel Kramer, Didier Pittet, Romana Klasinc, Stefan Krebs, Torsten Koburger, Christoph Fusch, Ojan AssadianAbstract:BACKGROUND For alcohol-based hand rubs, the currently recommended application time of 30 seconds is longer than the actual time spent in clinical practice. We investigated whether a shorter application time of 15 seconds is microbiologically safe in neonatal intensive care and may positively influence compliance with the frequency of hand Antisepsis actions. METHODS We conducted in vitro experiments to determine the antimicrobial efficacy of hand rubs within 15 seconds, followed by clinical observations to assess the effect of a shortened hand Antisepsis procedure under clinical conditions in a neonatal intensive care unit (NICU). An independent observer monitored the frequency of hand Antisepsis actions during shifts. RESULTS All tested hand rubs fulfilled the requirement of equal or even significantly higher efficacy within 15 seconds when compared to a reference alcohol propan-2-ol 60% (v/v) within 30 seconds. Microbiologically, reducing the application time to 15 seconds had a similar effect when compared to 30-second hand rubbing, but it resulted in significantly increased frequency of hand Antisepsis actions (7.9±4.3 per hour vs 5.8±2.9 per hour; P=.05). CONCLUSION Time pressure and workload are recognized barriers to compliance. Therefore, reducing the recommended time for hand Antisepsis actions, using tested and well-evaluated hand rub formulations, may improve hand hygiene compliance in clinical practice. Infect Control Hosp Epidemiol 2017;38:1430-1434.
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new strategies for preoperative skin Antisepsis
Skin Pharmacology and Physiology, 2014Co-Authors: M Ulmer, Axel Kramer, Alexa Patzelt, Torsten Koburger, Ojan Assadian, J Lademann, Fanny Knorr, Georg Daeschlein, Bernhard LangeasschenfeldtAbstract:During the past decades, encouraging progress has been made in the prevention of surgical site infections (SSI). However, as SSI still occur today, strategic prevention measures such as standardized skin Antisepsis must be implemented and rigorously promoted. Recent discoveries in skin physiology necessitate the development of novel antiseptic agents and procedures in order to ameliorate their efficacy. In particular, alternate target structures in the skin need to be taken into consideration for the development of the next generation of antiseptics. Recent investigations have shown that a high number of microorganisms are located within and in the close vicinity of the hair follicles. This suggests that these structures are an important reservoir of bacterial growth and activity in human skin. To date, it has not been fully elucidated to what extent conventional liquid antiseptics sufficiently target the hair follicle-related microbial population. Modern technologies such as tissue-tolerable plasma (TTP) have been tested for their potential antiseptic efficiency by reducing the bacterial load in the skin and in the hair follicles. First experiments using liposomes to deliver antiseptics into the hair follicles have been evaluated for their potential clinical application. The present review evaluates these two innovative methods for their efficacy and applicability in preoperative skin antiseptics.
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Antisepsis of the follicular reservoir by treatment with tissue-tolerable plasma (TTP)
Laser Physics Letters, 2011Co-Authors: Olaf Lademann, J. Roewert-Huber, Klaus-dieter Weltmann, Viktor Czaika, Axel Kramer, Martina C. Meinke, Alexa Patzelt, Bernd Hartmann, Heike Richter, Stefan KochAbstract:The application of tissue-tolerable electrical plasma (TTP) is highly efficient in skin Antisepsis. However, the germs are not only ocated on teh skin surface, but also in the hair follicles, from where they re-colonize the skin surface after Antisepsis, e.g. The objective of the present study was to show that plasma is able to reach the follicular reservoir for Antisepsis. For the purpose, a solution containing particulate chlorophyll dye had been applied onto porcine skin samples. Teh fluoresent propertis of the dye changed during teh plasma tissue interaction. The results demonstrate that TTP penetrates deep into the hair follicles, whereupon the hairs act as a conductor for the plasma. Therefore, it can be concluded that micro-organisms of the follicular reservoir are destroyed more efficiently by the plasma than by conventional liquid antispetics.
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standardized comparison of antiseptic efficacy of triclosan pvp iodine octenidine dihydrochloride polyhexanide and chlorhexidine digluconate
Journal of Antimicrobial Chemotherapy, 2010Co-Authors: Torsten Koburger, J Siebert, Nilsolaf Hubner, M Braun, Axel KramerAbstract:Background This study presents a comparative investigation of the antimicrobial efficacy of the antiseptics PVP-iodine, triclosan, chlorhexidine, octenidine and polyhexanide used for pre-surgical Antisepsis and antiseptic treatment of skin, wounds and mucous membranes based on internationally accepted standards. Methods MICs and MBCs were determined in accordance with DIN 58940-7 and 58940-8 using Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus), Enterococcus faecalis (including vancomycin-resistant Enterococcus), Streptococcus pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Clostridium perfringens, Haemophilus influenzae and Candida albicans. The microbicidal efficacy was determined in accordance with DIN EN 1040 and 1275 using S. aureus, P. aeruginosa and C. albicans. Results For chlorhexidine, octenidine and polyhexanide, MIC(48) and MBC(24) ranged from 16 to 32 mg/L. Maximum values for triclosan ranged from 256 to 512 mg/L, with an efficacy gap against P. aeruginosa, while the maximum values of PVP-iodine were 1024 mg/L, with a gap against S. pneumoniae. Comparing the minimal effective concentrations, octenidine was most effective. After 1 min, only octenidine and PVP-iodine fulfil the requirements for antiseptics. Conclusions Tests under standardized and harmonized conditions help to choose the most efficacious agent. When a prolonged contact time is feasible, ranking of agents would be polyhexanide = octenidine > chlorhexidine > triclosan > PVP-iodine. This is consistent with the recommendations for Antisepsis of acute wounds. Polyhexanide seems to be preferable for chronic wounds due to its higher tolerability. If an immediate effect is required, ranking would be octenidine = PVP-iodine>> polyhexanide > chlorhexidine > triclosan.
Matthias Maiwald - One of the best experts on this subject based on the ideXlab platform.
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pitfalls in evidence assessment the case of chlorhexidine and alcohol in skin Antisepsis
Journal of Antimicrobial Chemotherapy, 2014Co-Authors: Matthias Maiwald, Edwin ChanAbstract:Chlorhexidine has attracted increasing attention for its role in skin Antisepsis in recent years. It was tested in several prominent clinical trials and subsequently recommended in important guidelines for blood culture collection, vascular catheter insertion and surgical skin preparation. We noticed and subsequently reported a widespread misinterpretation of evidence surrounding chlorhexidine and its role in skin Antisepsis. Multiple clinical trial reports and systematic reviews that had assessed the clinical efficacy of chlorhexidine/alcohol combinations for skin Antisepsis had attributed efficacy solely to the chlorhexidine component. This misinterpretation was carried over into the tertiary literature, including evidence-based guidelines. Here we discuss some of the scientific, ethical, patient safety and infection control implications of this misinterpretation, as well as broader implications for evidence-based medicine.
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the forgotten role of alcohol a systematic review and meta analysis of the clinical efficacy and perceived role of chlorhexidine in skin Antisepsis
PLOS ONE, 2012Co-Authors: Matthias Maiwald, Edwin ChanAbstract:Background Skin Antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin Antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin Antisepsis and the extent of a possible misinterpretation of evidence. Methods We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution. Results In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines. Conclusions Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.