An An Assessment of the Efficacy of Chlorhexidine in Nebulizer Disinfectant to Prevent Contaminated Aerosol Administration
Main Article Content
Abstract
Nebulization therapy is an essential method of drug administration that enables effective delivery of medications
to the respiratory tract in aerosol form; however, contaminated nebulizer components may serve as a source of pathogenic
microorganisms associated with nosocomial pneumonia. This in vitro experimental study aimed to evaluate the effectiveness of
chlorhexidine as a nebulizer disinfectant in eliminating pathogenic bacteria. The study employed a post-test control group design
using six groups of nebulizer chambers, consisting of two control groups and four intervention groups. Two clinically relevant
bacteria, Pseudomonas aeruginosa and Acinetobacter baumannii, were inoculated into the nebulizer chambers. The intervention
groups were disinfected using chlorhexidine gluconate at concentrations of 2.5%, 4%, and 5% diluted in 70% alcohol, and 2.5%
chlorhexidine diluted in distilled water, while the control groups received sterile water and 70% alcohol, in accordance with
existing guidelines. After a standardized exposure period, bacterial growth was assessed using Colony Forming Unit (CFU) counts. Data were analyzed descriptively and comparatively to evaluate bacterial eradication across groups. The results demonstrated that 5% chlorhexidine diluted in 70% alcohol achieved complete bacterial elimination (0 CFU) for both bacterial strains, whereas lower concentrations showed residual growth. These findings indicate that chlorhexidine, particularly at higher concentrations, demonstrates strong disinfectant activity against common nosocomial pneumonia pathogens in nebulizer chambers. Nevertheless, the results are limited to in vitro conditions; therefore, further studies involving a wider range of microorganisms, standardized exposure times, and assessments of aerosol contamination during clinical nebulization are warranted to support its practical application.
Article Details
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
The authors retain the copyright and grant the journal the right of first publication simultaneously under the Creative Commons Attribution License. This license allows others to share the work with proper acknowledgment of authorship and initial publication in this journal. Authors are permitted and encouraged to deposit their articles in institutional repositories, on their personal websites, or in other online repositories after the article has been published in JSFK.
References
[1]. Chinese College of Emergency Physicians (CCEP). Expert consensus on nebulization therapy in pre-hospital and in-hospital emergency care. Ann Transl Med [Internet]. 2019 Sep;7(18):487–487. Available from: https://atm.amegroups.com/article/view/29746/25813
[2]. Le Brun PPH, de Boer AH, Frijlink HW, Heijerman HGM. A review of the technical aspects of drug nebulization. Pharmacy World and Science. 2000;22(3):75–81.
[3]. Longest W, Spence B, Hindle M. Devices for Improved Delivery of Nebulized Pharmaceutical Aerosols to the Lungs. J Aerosol Med Pulm Drug Deliv. 2019 Oct 1;32(5):317–39.
[4]. Talwar D, Ramanathan R, Lopez M, Hegde R, Gogtay J, Goregaonkar G. The emerging role of nebulization for maintenance treatment of chronic obstructive pulmonary disease at home. Lung India. 2021;38(2):168.
[5]. Mac Giolla Eain M, Cahill R, MacLoughlin R, Nolan K. Aerosol release, distribution, and prevention during aerosol therapy: a simulated model for infection control. Drug Deliv [Internet]. 2022 Dec 31;29(1):10–7. Available from: https://www.tandfonline.com/doi/full/10.1080/10717544.2021.2015482
[6]. Terry PD, Dhand R. Maintenance Therapy with Nebulizers in Patients with Stable COPD: Need for Reevaluation. Pulm Ther. 2020 Dec 20;6(2):177–92.
[7]. Bell J, Alexander L, Carson J, Crossan A, McCaughan J, Mills H, et al. Nebuliser hygiene in cystic fibrosis: evidence-based recommendations. Breathe. 2020 Jun;16(2):190328.
[8]. Vassal S, Taamma R, Marty N, Sardet A, d’Athis P, Brémont F, et al. Microbiologic contamination study of nebulizers after aerosol therapy in patients with cystic fibrosis. Am J Infect Control. 2000 Oct;28(5):347–51.
[9]. Shebl E, Gulick PG. Nosocomial Pneumonia. StatPearls [Internet]. 2022 Jul 18 [cited 2023 Feb 8]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK535441/
[10]. Jain V, Vashisht R, Yilmaz G, Bhardwaj A. Pneumonia Pathology. StatPearls [Internet]. 2022 Aug 1 [cited 2023 Feb 9]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK526116/
[11]. Lim WS. Pneumonia—Overview. Encyclopedia of Respiratory Medicine [Internet]. 2022 Jan 1 [cited 2023 Feb 8];4:185. Available from: /pmc/articles/PMC7241411/
[12]. Morrow LE, Kollef MH. Hospital-Acquired Pneumonia. In: Netter’s Infectious Diseases [Internet]. Elsevier; 2012. p. 137–45. Available from: https://linkinghub.elsevier.com/retrieve/pii/B9781437701265000276
[13]. O’Malley CA. Device cleaning and infection control in aerosol therapy. Respir Care. 2015;60(6):917–30.
[14]. Yegit CY, Ergenekon P, Duman N, Mursaloglu H, Cenk M, Uzunoglu BS, et al. Microbial Contamination of Nebulizers in Patients With Cystic Fibrosis. Turkish Archives of Pediatrics. 2025 Jan 2;60(1):22–8.
[15]. Biney IN, Ari A, Barjaktarevic IZ, Carlin B, Christiani DC, Cochran L, et al. Guidance on Mitigating the Risk of Transmitting Respiratory Infections During Nebulization by the COPD Foundation Nebulizer Consortium. Chest. 2024 Mar;165(3):653–68.
[16]. Riquena B, Monte L de FV, Lopes AJ, Silva-Filho LVRF da, Damaceno N, Aquino E da S, et al. Microbiological contamination of nebulizers used by cystic fibrosis patients: an underestimated problem. Jornal Brasileiro de Pneumologia. 2019;45(3).
[17]. Knobloch MJ, Musuuza JS, McKinley L, Zimbric ML, Baubie K, Hundt AS, et al. Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project. Am J Infect Control [Internet]. 2021;49(6):775–83. Available from: https://www.sciencedirect.com/science/article/pii/S0196655320310658
[18]. Hutauruk SM, Hermani B, Monasari P. Role of chlorhexidine on tracheostomy cannula decontamination in relation to the growth of Biofilm-Forming Bacteria Colony- a randomized controlled trial study. Annals of Medicine and Surgery [Internet]. 2021;67(June):102491. Available from: https://doi.org/10.1016/j.amsu.2021.102491
[19]. Shen K, Hong J, El Beleidy A, Furman E, Liu H, Yin Y, et al. International expert opinion on the use of nebulization for pediatric asthma therapy during the COVID-19 pandemic. J Thorac Dis. 2021 Jul;13(7):3934–47.
[20]. Swarnakar R, Gupta NM, Halder I, Khilnani GC. Guidance for nebulization during the COVID-19 pandemic. Lung India. 2021 Mar;38(Suppl 1):S86–91.
[21]. Hohenwarter K, Prammer W, Aichinger W, Reychler G. An evaluation of different steam disinfection protocols for cystic fibrosis nebulizers. Journal of Cystic Fibrosis [Internet]. 2016;15(1):78–84. Available from: https://dx.doi.org/10.1016/j.jcf.2015.07.005
[22]. Towle D, Baker V, Schramm C, O’Brien M, Collins MS, Feinn R, et al. Ozone disinfection of home nebulizers effectively kills common cystic fibrosis bacterial pathogens. Pediatr Pulmonol. 2018;53(5):599–604.
[23]. Towle D, Callan DA, Lamprea C, Murray TS. Baby bottle steam sterilizers for disinfecting home nebulizers inoculated with non-tuberculous mycobacteria. Journal of Hospital Infection [Internet]. 2016;92(3):222–5. Available from: https://dx.doi.org/10.1016/j.jhin.2015.08.030
[24]. Nitin K, Santlal Hassani U. Microbial Colonization Profile of Respiratory Devices. 2016 Apr;165–7.
[25]. Edmiston CE, Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: Does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013 May;41(5):S49–55.
[26]. Hasegawa T, Tashiro S, Mihara T, Kon J, Sakurai K, Tanaka Y, et al. Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis. BJS Open. 2022 Sep 2;6(5).
[27]. Reynolds SS, Woltz P, Keating E, Neff J, Elliott J, Hatch D, et al. Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial. Implementation Science [Internet]. 2021 Dec 26;16(1):45. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-021-01112-4
[28]. Asmar S, Drancourt M. Chlorhexidine decontamination of sputum for culturing Mycobacterium tuberculosis. BMC Microbiol. 2015 Dec 5;15(1):155.
[29]. Wieland K, Chhatwal P, Vonberg RP. Nosocomial outbreaks caused by Acinetobacter baumannii and Pseudomonas aeruginosa: Results of a systematic review. Am J Infect Control. 2018 Jun;46(6):643–8.
[30]. Reynolds D, Kollef M. The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update. Drugs. 2021 Dec 7;81(18):2117–31.
[31]. Yang YS, Lee YT, Huang TW, Sun JR, Kuo SC, Yang CH, et al. Acinetobacter baumannii nosocomial pneumonia: is the outcome more favorable in non-ventilated than ventilated patients? BMC Infect Dis. 2013 Dec 19;13(1):142.
[32]. Lu Q, Eggimann P, Luyt CE, Wolff M, Tamm M, François B, et al. Pseudomonas aeruginosa serotypes in nosocomial pneumonia: prevalence and clinical outcomes. Crit Care. 2014;18(1):R17.
[33]. Wolska K, Kot B, Jakubczak A. Phenotypic and genotypic diversity of Pseudomonas aeruginosa strains isolated from hospitals in siedlce (Poland). Brazilian Journal of Microbiology. 2012 Mar;43(1):274–82.
[34]. Ben-Knaz Wakshlak R, Pedahzur R, Avnir D. Antibacterial Activity of Chlorhexidine-Killed Bacteria: The Zombie Cell Effect. ACS Omega. 2019 Dec 17;4(25):20868–72.
[35]. Huang Y, Zhou Q, Wang W, Huang Q, Liao J, Li J, et al. Acinetobacter baumannii Ventilator-Associated Pneumonia: Clinical Efficacy of Combined Antimicrobial Therapy and in vitro Drug Sensitivity Test Results. Front Pharmacol. 2019 Feb 13;10.
[36]. Lynch J, Zhanel G, Clark N. Infections Due to Acinetobacter baumannii in the ICU: Treatment Options. Semin Respir Crit Care Med. 2017 Jun 4;38(03):311–25.
[37]. Ibrahim S, Al-Saryi N, Al-Kadmy IMS, Aziz SN. Multidrug-resistant Acinetobacter baumannii as an emerging concern in hospitals. Mol Biol Rep. 2021 Oct 30;48(10):6987–98.
[38]. Martinez-Resendez MF, Cruz-López F, Gaona-Chávez N, Camacho-Ortiz A, Mercado-Longoria R, Flores-Treviño S, et al. The effect of chlorhexidine on Acinetobacter baumannii in intensive care units. Iran J Microbiol. 2022 Feb 21;
[39]. McDonnell G, Russell AD. Antiseptics and Disinfectants: Activity, Action, and Resistance. Clin Microbiol Rev. 1999 Jan;12(1):147–79.
[40]. Biswas D, Tiwari M, Tiwari V. Molecular mechanism of antimicrobial activity of chlorhexidine against carbapenem-resistant Acinetobacter baumannii. PLoS One. 2019 Oct 29;14(10):e0224107.
[41]. Chiewchalermsri C, Sompornrattanaphan M, Wongsa C, Thongngarm T. Chlorhexidine Allergy: Current Challenges and Future Prospects. J Asthma Allergy [Internet]. 2020 Mar;Volume 13:127–33. Available from: https://www.dovepress.com/chlorhexidine-allergy-current-challenges-and-future-prospects-peer-reviewed-article-JAA.