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Impact of 4.0% Chlorhexidine Cord Cleansing on the Bacteriologic Profile of the Newborn Umbilical Stump in Rural Sylhet District, Bangladesh: A Community-Based, Cluster-Randomized Trial

Mullany, Luke C. PhD*; Saha, Samir K. PhD†,‡; Shah, Rasheduzzaman MB BS*; Islam, Mohammad Shahidul MSc†,‡; Rahman, Mostafiz BA§; Islam, Maksuda BA†,‡; Talukder, Radwanur Rahman MPH; Arifeen, Shams El MB BS, DrPH; Darmstadt, Gary L. MD*; Baqui, Abdullah H. MB BS, DrPH*,¶

The Pediatric Infectious Disease Journal: May 2012 - Volume 31 - Issue 5 - p 444–450
doi: 10.1097/INF.0b013e3182468ff0
Original Studies

Background: Randomized trials from South Asia indicate umbilical cord chlorhexidine cleansing reduces mortality and omphalitis. No community-based data are available on bacteriological profile of the cord, early neonatal colonization dynamics, or impact of cord cleansing on colonizing organisms. Such data could clarify the design of scaled chlorhexidine interventions.

Methods: Umbilical swabs were collected at home (days 1, 3, 6) after birth from infants participating in a trial of 3 cord-care regimens (no chlorhexidine, single cleansing, multiple cleansing) in Sylhet, Bangladesh. Overall and organism-specific positivity rates were estimated by cord-care regimen and by day of collection.

Results: Between September 2008 and October 2009, 1923 infants contributed 5234 umbilical swabs. Positivity rate was high (4057 of 5234, 77.5%) and varied substantially across groups. Immediate (day 1) reductions in cord colonization were observed in single- (prevalence rate ratio = 0.75, 95% confidence interval: 0.70–0.81) and multiple- (prevalence rate ratio = 0.71, 95% confidence interval: 0.66–0.77) cleansing groups. Reductions persisted and increased in magnitude through day 6 only if babies received multiple applications. On days 1, 3, and 6, respectively, multiple cleansing consistently reduced invasive organisms such as Escherichia coli (49%, 64%, and 42% lower), Klebsiella pneumoniae (46%, 53%, and 33% lower), and Staphylococcus aureus (34%, 84%, and 85% lower).

Conclusions: Cord cleansing with 4.0% chlorhexidine immediately after birth reduces overall and organism-specific colonization of the stump. Reductions are greater and sustained longer with daily cleansing through the first week of life, suggesting that programs promoting chlorhexidine cleansing should favor multiple over single applications.

Supplemental Digital Content is available in the text.

*Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Child Health Research Foundation, Dhaka, Bangladesh

Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh

§Shimantik (a Bangladeshi NGO), Sylhet, Bangladesh

International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh

Accepted for publication December 13, 2011.

Gary L. Darmstadt is currently at Bill and Melinda Gates Foundation, Seattle, WA.

Supported by a grant from the Thrasher Research Fund (#02875–5). The larger chlorhexidine trial was supported by the United States Agency for International Development (USAID), through cooperative agreements (GHS-A-00–03–00019–00, GHS-A-00–09–00004–00) with the Johns Hopkins Bloomberg School of Public Health and by the Saving Newborn Lives program of Save the Children-US through a grant (131) from the Bill and Melinda Gates Foundation. The authors have no conflict of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Address for correspondence: Luke C. Mullany, PhD, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Room W5009, Baltimore, MD 21205. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.