Chlorhexidine Gluconate (CHG) in CLABSI Prevention: Evidence and Clinical Application

Evidence-based guide to chlorhexidine gluconate (CHG) in CLABSI prevention: skin antisepsis (2% CHG vs povidone-iodine), CHG-impregnated dressings, daily CHG bathing, application technique, dry time requirements, and CHG safety considerations.

guide•Feb 2026•CLABSI Prevention

Chlorhexidine Gluconate (CHG) in CLABSI Prevention: Evidence and Clinical Application

Chlorhexidine gluconate (CHG) is the cornerstone antiseptic agent in vascular access infection prevention. It appears in three distinct CLABSI prevention applications: pre-insertion skin antisepsis (2% CHG/IPA solution), CHG-impregnated catheter dressings, and daily CHG patient bathing. Understanding the evidence, mechanism, application requirements, and safety considerations for each application enables consistent, effective CHG use across the CLABSI prevention bundle.

Parent guide: CLABSI Prevention: Complete Clinical Reference

Why CHG Is the Preferred Antiseptic

CHG has several pharmacologic properties that make it uniquely suited for vascular access antisepsis:

Broad-spectrum activity: Effective against gram-positive bacteria (including MRSA and CoNS — the most common CLABSI pathogens), gram-negative bacteria, fungi (Candida spp.), and enveloped viruses.

Residual activity: Unlike alcohol (which has rapid but no residual effect) or povidone-iodine (which is inactivated by blood and organic matter), CHG binds covalently to skin proteins. This binding creates a depot that continues releasing bactericidal CHG for hours after application — the “substantivity” of CHG.

Alcohol synergy: CHG-alcohol combinations leverage alcohol’s immediate rapid kill combined with CHG’s sustained residual effect. The combination is significantly more effective than either agent alone.

Resistance: Despite decades of use, clinically relevant resistance to CHG in the context of CLABSI prevention remains uncommon. CHG operates via multiple membrane disruption mechanisms that are difficult for organisms to overcome simultaneously.

Application 1: Pre-Insertion Skin Antisepsis

The Formulation

Preferred: 2% CHG in 70% isopropyl alcohol (IPA) solution (e.g., ChloraPrep, Frepp applicators).

Alternative: Aqueous CHG solutions (2% in water) — less preferred due to slower kill time and reduced residual activity.

Do not use: Povidone-iodine as first-line skin antiseptic for CVC/PICC insertion (unless CHG is contraindicated). Multiple meta-analyses demonstrate significantly higher CLABSI rates with povidone-iodine vs. CHG-IPA.

Evidence

Chaiyakunapruk et al. (2002, Ann Intern Med) meta-analysis: CHG-based antisepsis was significantly superior to povidone-iodine (relative risk 0.49; NNT = 44 to prevent one CLABSI). This study formed the basis for the CDC and INS CHG recommendations.

Subsequent meta-analyses (Mimoz et al., Lancet, 2015) confirmed CHG-IPA superiority over povidone-iodine-IPA as well — confirming that CHG (not just the alcohol component) provides the additive benefit.

Application Technique

  1. Apply CHG-IPA to the insertion site and a broad surrounding area (minimum 8–10 cm for CVC; 6 cm for PICC)
  2. Use the friction scrub technique (back-and-forth motion, not circular) for 30 seconds
  3. Allow complete dry time — do not blot, wipe, or fan to accelerate drying
  4. Standard dry time: 30 seconds minimum; 60 seconds for hairy or moist skin
  5. Insert needle only after the preparation site is visibly dry and no longer tacky

The Dry Time Imperative

CHG dry time is one of the most commonly skipped bundle elements and one of the most consequential. Inadequate dry time:

  • Reduces antiseptic efficacy (alcohol must evaporate for CHG to bind to skin proteins)
  • May transport antiseptic into the bloodstream with the insertion needle
  • Results in a suboptimal antiseptic film on the skin surface

During audit of insertion bundle compliance, dry time verification is frequently suboptimal. Standardized timing with a verbal or procedural prompt (“we will now wait 45 seconds for the prep to dry”) improves compliance.

Application 2: CHG-Impregnated Catheter Dressings

Products

  • CHG gel pad (Biopatch equivalent): A polyurethane foam disc impregnated with CHG (chlorhexidine gluconate + silver sulfadiazine in some formulations, or CHG alone). Placed directly over the insertion site under a TSM dressing. The blue/CHG-impregnated side faces the skin.
  • CHG-impregnated TSM dressings: Integrated TSM dressings with CHG incorporated into the dressing material (e.g., Tegaderm CHG, Kendall 3000). Single-product alternative to the gel pad + TSM combination.

Evidence

Timsit et al. (2009, Lancet): RCT of 1,636 patients — CHG-impregnated dressings reduced catheter colonization (HR 0.41) and CLABSI (incidence rate ratio 0.39). These results were replicated in subsequent trials and meta-analyses.

CDC 2011 guidelines: Category IB recommendation for CHG-impregnated sponge dressings for CVADs in adults. INS 2021: recommended for all CVAD patients (Standard 40).

Application

  • Place gel pad centered on insertion site (blue side toward skin for Biopatch)
  • Cover with TSM dressing
  • Change every 5–7 days or when dressing is wet, soiled, or non-intact
  • Inspect for skin reactions at each dressing change; MARSI from CHG-containing adhesive products is possible

Safety Considerations for CHG Dressings

Adults: Well tolerated; contact dermatitis (CHG allergy) is rare but can occur. If a patient develops erythema or vesiculation under the CHG dressing disproportionate to mechanical skin trauma, consider CHG contact allergy; switch to standard TSM dressing.

Premature neonates: CHG-impregnated dressings are not recommended for infants <7 days old or <26 weeks gestation — percutaneous CHG absorption can cause chemical skin burns and systemic CHG toxicity in very preterm neonates.

General neonates: Use with caution in neonates <2 months; institutional NICU protocols vary.

Application 3: Daily CHG Patient Bathing

Evidence

Daily CHG bathing of ICU patients reduces CLABSI rates by reducing the overall skin bioburden — the reservoir of organisms that could migrate to the catheter insertion site or infect via hematogenous seeding.

Key trials:

  • Bleasdale et al. (2007): ICU crossover trial, daily CHG bathing reduced CLABSI by 46%
  • Climo et al. (2013, NEJM): Multi-center RCT, 28% reduction in CLABSI, 37% reduction in MRSA/VRE acquisition
  • Noto et al. (2015, JAMA): 5-ICU cluster RCT, no significant CLABSI reduction at low-CLABSI-rate institutions — suggesting CHG bathing is most beneficial when baseline CLABSI rates are elevated

Technique

Products: Pre-moistened 2% CHG-impregnated washcloths (Sage 2% CHG cloths, Cardinal Health equivalents). Available in various sizes and warmable for patient comfort.

Procedure:

  1. Warm cloths if available
  2. Apply to all body surfaces except: face (eyes, ears, mouth), mucous membranes, genitalia, any open wounds
  3. Do not rinse CHG off — allow to air dry on skin
  4. Apply daily, ideally in the morning or evening as part of standard bathing routine
  5. Change CHG cloths if contaminated; do not reuse

Does not replace: Full soap-and-water bathing for patients with soiling or significant hygiene needs — CHG bathing supplements standard care.

Patient Populations

Most evidence in: Adult ICU patients with CVADs (greatest CLABSI risk, most studied).

Pediatric: CHG bathing for children >2 months is supported by extrapolation from adult data; pediatric-specific evidence is emerging. For children 2–12 months: use with caution; diluted formulations or alternative products may be considered per institutional pediatric protocol.

Neonates: Avoid CHG bathing in neonates <2 months due to immature skin barrier and percutaneous absorption risk.

CHG Safety and Adverse Events

Systemic Toxicity

Systemic CHG absorption is negligible through intact adult skin. Significant systemic absorption is documented only in:

  • Very premature neonates (immature epidermal barrier)
  • Patients with extensive burns or widespread skin breakdown

Anaphylaxis

CHG anaphylaxis is rare but can be severe. Risk factors: prior allergic reaction to CHG, repeated CHG exposure (healthcare workers), latex allergy (cross-reactivity not established but concurrent allergies are common). Pre-procedure allergy screening should include CHG.

Management: Treat per standard anaphylaxis protocol; do not use CHG products in confirmed CHG-allergic patients.

Contact Dermatitis

Irritant or allergic contact dermatitis at CHG application sites is more common than anaphylaxis. Presents as localized erythema, vesiculation, or pruritus at the dressing site. If suspected:

  • Remove CHG-containing dressing
  • Apply standard TSM dressing without CHG
  • Consider allergy consultation for formal testing

CHG Resistance

True microbiological CHG resistance is uncommon but has been reported in:

  • Some CoNS strains with elevated CHG minimum inhibitory concentrations (MICs)
  • Serratia marcescens and some gram-negative organisms in water-associated contamination

Clinical significance: Current evidence does not suggest that routine clinical use of CHG for CLABSI prevention is selecting for clinically relevant resistance. Surveillance for CHG tolerance is a research and public health priority, not a reason to avoid CHG use.

Related guides:

Related policies:

References

  1. Chaiyakunapruk N, et al. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter site care. Ann Intern Med, 136(11):792–801.
  2. Timsit JF, et al. (2009). CHG-impregnated sponge and risk of CVC infection. Lancet, 373(9677):1709–1718.
  3. Climo MW, et al. (2013). Effect of daily CHG bathing on hospital-acquired infection. N Engl J Med, 368(6):533–542.
  4. Mimoz O, et al. (2015). Skin antisepsis with CHG–alcohol versus povidone iodine–alcohol. Lancet, 386(10008):2069–2077.
  5. O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).