Surgical site infections are stubborn adversaries. They extend hospital stays, push patients back into the operating room, and turn simple recoveries into arduous ones. Over the last fifteen years, one practice has proven consistently helpful in lowering these risks: chlorhexidine gluconate skin cleansing before surgery. It is mundane yet powerful, a habit as simple as a shower that changes outcomes downstream. When this step is done correctly, infection rates fall in a measurable way, especially for orthopedic implants, cardiac procedures, and other surgeries that rely on foreign materials.
I have watched fastidious preoperative routines tip the scales in the right direction. The difference between a clean, uneventful incision and a wound that brews bacteria often starts the night before the procedure. Chlorhexidine is not magic, but it is effective when you respect its strengths and limitations.
What chlorhexidine is and why it works
Chlorhexidine gluconate is an antiseptic that binds to skin proteins and continues working for hours after you rinse it off. Surgeons use it on the operating field, dentists rely on it for gum disease, and hospitals press it into service in catheter care. Unlike alcohol, which evaporates quickly, chlorhexidine lingers on the stratum corneum, the top layer of skin, and suppresses a broad range of microbes, including Staphylococcus aureus and many gram negative organisms. That residual effect matters the morning of surgery when you travel from home to pre-op, touch doorknobs, and change into a gown. Your skin repopulates itself, but it does so more slowly after chlorhexidine.
Formulations vary, and that matters. For preoperative bathing, 4 percent chlorhexidine solution or 2 percent impregnated cloths are the usual choices. The higher concentration in bottle form must be lathered and rinsed, while cloths deposit a lower, measured dose that dries on the skin. Either works if you apply it deliberately and avoid common mistakes, such as diluting it with regular soap or failing to target high bacterial load areas like the underarms and groin.
Where the evidence is strongest
Research spanning thousands of patients shows a modest but real reduction in surgical site infections with preoperative chlorhexidine cleansing. The signal appears strongest in surgeries where a small contamination can cause major trouble, such as joint replacement, spinal instrumentation, vascular grafting, and cardiac surgery. Clean procedures without implants still benefit, but the absolute difference is smaller.
In orthopedic practice, we have seen superficial infection rates drop by 20 to 40 percent when we combined chlorhexidine showers with nasal decolonization for carriers of S. aureus. Those are relative numbers, so context matters. If the baseline risk is 2 percent, a 40 percent reduction means an infection rate closer to 1.2 percent. That may sound small, but for a joint replacement program performing 500 cases a year, that is several fewer infections, fewer readmissions, and a handful of patients spared long courses of antibiotics and revision surgery.
Cardiac teams report similar trends, particularly when chlorhexidine bathing is part of a broader bundle: timely antibiotics, proper hair removal, controlled blood glucose, and diligent temperature management. Chlorhexidine alone will not overcome sloppy technique or system gaps. It amplifies good practice.
The practical routine that works
The most reliable routines are boring by design. Simplicity makes adherence more likely, and adherence is the real lever here. In our program, we send patients home with a concise instruction sheet and either a bottle of 4 percent chlorhexidine or a pack of 2 percent cloths, depending on preference and skin sensitivity. We also review the plan by phone a day or two before surgery to catch late questions.
A chlorhexidine shower routine looks like this in plain language: shower the night before and again the morning of surgery. Wash your hair and body with regular shampoo first, rinse well, then turn off the water and apply chlorhexidine from the neck down with your hands or a clean washcloth, keeping it away from eyes, ears, and genital mucosa. Lather for three minutes, paying extra attention to underarms, groin folds, belly button, under the breasts, and any skin folds. Turn the water back on, rinse thoroughly, and do not apply lotions, deodorants, or powders afterward. Put on clean clothes and sleep on clean linens. If you are using cloths instead of a shower, wipe methodically and let the skin air dry, again avoiding the face and genital mucosa.
Why the fuss about clean clothes and bedding? Because chlorhexidine reduces skin flora, but reinoculation comes from anything that touches you. That includes pajamas, bed sheets, and the waistband of your favorite sweatpants. A fresh set leaves less to undo the work you just did.
When cloths are a better choice
Not everyone can shower safely. Patients with limited mobility, casts, fresh wounds, or a fall risk can use prepackaged 2 percent chlorhexidine cloths instead. They are simple, less messy, and require no rinsing. The trade-off, in my experience, is coverage. Cloths demand a methodical approach, one area at a time, to avoid missing high-risk zones. For larger body habitus, plan on extra time to reach skin folds.
Cloths also shine for the morning of surgery when time is tight. A nurse can assist with a quick once-over in pre-op if the home routine was incomplete. Hospitals that standardize this process often see better compliance, because the last opportunity to apply chlorhexidine is not left to chance.
What to avoid and why it matters
Chlorhexidine is safe, but it is not gentle on every surface. Keep it away from eyes, inside the ears, and genital mucosa. Do not use it on open wounds unless your surgeon specifically instructs you to, because irritation can complicate wound assessment. Avoid mixing it with your usual soaps or body washes, as detergents can inactivate the antiseptic properties or leave a film that limits binding to the skin. The bottle looks like any other soap, but it plays by different rules.
Allergic reactions are rare but real. Watch for itching, redness, hives, or swelling. If you have a history of sensitivity to chlorhexidine or related products, tell your surgical team early. They can pivot to alternatives such as povidone iodine for skin prep. Hospitals track chlorhexidine allergies more carefully now because the compound appears in different places, from catheter dressings to mouthwashes.
Skin types, hair, and the question of shaving
People often ask whether to shave before surgery. The short answer is no. Shaving can create microabrasions that harbor bacteria, raising your risk of infection, especially in the groin and underarms. If hair removal is necessary for your surgery, your team will clip the area immediately before the operation with single-use clippers. If you cannot resist tidying up, trim with scissors at most and keep the skin intact.
For sensitive skin or eczema, test chlorhexidine on a small area two days before your first full wash. Some patients tolerate cloths better than the 4 percent solution, and vice versa. Moisturizers are usually off-limits on the night before and morning of surgery, because they act like a film barrier. If your skin is prone to dryness or cracking and you require daily ointments, coordinate with your surgeon. Sometimes we split the difference, allowing moisturizers up until 24 hours before surgery, then switching to chlorhexidine without emollients for the final two cleanses.
How chlorhexidine fits into the bigger infection-prevention bundle
No single step carries the day. Surgeons reduce infection risk with layered defenses, and chlorhexidine is one layer. Timely perioperative antibiotics, typically a cephalosporin within 60 minutes of incision, add another. For patients allergic to beta lactams, alternatives such as clindamycin or vancomycin are chosen thoughtfully, with attention to local resistance patterns. A nasal swab to detect S. aureus carriage can guide prophylactic mupirocin ointment and additional measures when needed.
Glucose management deserves a spotlight. Poorly controlled diabetes raises infection risk even if the surgery is minor. If you use Metformin, Glipizide, Sitagliptin, or combinations like Sitagliptin Metformin, discuss preoperative dosing with your team. Injectable therapies such as Insulin Glargine, Insulin Detemir, Insulin Aspart, Insulin Lispro, Insulin Regular, and basal analogs like Lantus require a plan for the night before and the morning of surgery. GLP-1 receptor agonists, including Dulaglutide, Liraglutide, and Semaglutide, affect gastric emptying and perioperative fasting. Clinicians increasingly adjust dosing schedules before anesthesia to lower aspiration risk. SGLT2 inhibitors like Dapagliflozin and Empagliflozin are often held several days before surgery to reduce ketoacidosis risk. These adjustments belong in a coordinated conversation among the surgeon, anesthesiologist, and prescribing clinician.
Anticoagulants and antiplatelet agents carry their own calculus. Warfarin, Apixaban, Rivaroxaban, and Clopidogrel demand a timeline for holding and resuming, balanced against stroke or stent thrombosis risk. The chlorhexidine routine does not alter this plan, but the same disciplined approach applies: clear instructions, written dates, and a backup number to call if confusion arises.
Steroids and immunomodulators affect wound healing and infection risk. Prednisone and Prednisolone suppress immune function at moderate to high doses. Agents like Methotrexate, Hydroxychloroquine, Adalimumab, and Etanercept require thoughtful timing around surgery, weighing flare risk against infection. Rheumatology guidelines often allow continuation of some disease-modifying drugs, holding biologics for a dosing interval. The surgical team should align with your specialist rather than making assumptions at the last minute.
Respiratory conditions shape risk as well. Asthma and COPD patients using Albuterol, Ipratropium Albuterol, Fluticasone, or Budesonide inhalers should bring them to the hospital. Optimized lungs mean fewer perioperative complications, better oxygenation, and lower overall infectious risk. If your wheeze is flaring, proceed with caution rather than pushing forward and hoping for the best.
Medication interactions with chlorhexidine body washes
Chlorhexidine acts on the skin surface and does not meaningfully interact with most systemic drugs, which is one reason it is so widely useful. Still, medications can affect your skin and alter how you tolerate the wash. Isotretinoin dries the skin. Topical retinoids, ketoconazole shampoos, and medicated acne regimens can make the skin more irritable. If you are on chronic steroids, skin thinning may make you more prone to abrasion.
The long list of common medications prescribed to surgical patients usually plays well with chlorhexidine, including Atorvastatin, Rosuvastatin, Simvastatin, Pravastatin, and other statins, antihypertensives like Lisinopril, Losartan, Olmesartan, Valsartan, Amlodipine, Metoprolol, Carvedilol, and diuretics such as Hydrochlorothiazide, Spironolactone, and Furosemide. Acid suppressants such as Omeprazole and Pantoprazole, mood agents like Sertraline, Escitalopram, Fluoxetine, Duloxetine, Bupropion, Venlafaxine, sleep aids such as Zolpidem, pain medicines including Tramadol, Oxycodone, Morphine, and combinations like Hydrocodone Acetaminophen, and seizure medications like Lamotrigine, Levetiracetam, and Topiramate do Homepage not change chlorhexidine’s effectiveness on skin. If anything seems amiss after a wash, such as unusual flushing or dermatitis, report it. Occasionally, the combination of dry winter air, a long hot shower, and chlorhexidine tips sensitive skin into irritation, and a simple change in technique fixes it.
Special scenarios: pediatrics, OB, and high-risk skin
Chlorhexidine can be used in children and in pregnancy with attention to concentration and application. Pediatric teams often prefer cloths for convenience and to avoid eye exposure. Obstetric surgery, like cesarean delivery, relies on careful skin prep in the operating room as the mainstay. Preoperative bathing can still help, but keep the solution away from the breasts if you plan to breastfeed, and choose a mild formulation.
For patients with chronic skin conditions like psoriasis or atopic dermatitis, the decision is nuanced. Flares around the incision can complicate recovery. We coordinate with dermatology when possible. Sometimes we limit chlorhexidine to areas away from compromised skin and rely on the operating room prep for the surgical field, while maintaining the rest of the infection-prevention bundle.
The right expectations: what chlorhexidine can and cannot do
Chlorhexidine reduces the microbial burden on the skin. It does not sterilize you, and it does not replace antibiotics. If you are colonized with resistant organisms, it helps but does not eliminate the risk entirely. A patient with diabetes, chronic kidney disease, and obesity carries a higher baseline risk than a healthy twenty-five-year-old, even with perfect pre-op hygiene. That does not mean the routine is less worthwhile for high-risk patients. It means the payoff is larger in the aggregate, because each percentage point matters.
On the flip side, do not expect chlorhexidine to correct problems unrelated to infection risk, such as poor wound perfusion due to nicotine or uncontrolled blood sugar. I have seen patients take meticulous showers while still smoking up to the day of surgery. The best antiseptic in the world cannot outmuscle carbon monoxide and vasoconstriction in a healing incision.
A brief anecdote from the trenches
Years ago, our arthroplasty unit wrestled with a cluster of superficial infections after clean joint replacements. We found no smoking gun in the operating rooms. The same surgeons, the same drapes, the same antibiotic timing. We tightened protocols and added point-of-care reminders, yet the rate budged only slightly. The breakthrough came from a nurse who noted inconsistent pre-op cleansing during chart audits. Some patients had never picked up their chlorhexidine bottles, and others used it once, not twice. We standardized the routine, switched to chlorhexidine cloths for the morning of surgery, and added a quick phone call the day before. Over six months, the superficial infection rate dropped by about a third. It was not glamorous work, but it was measurable, and it stuck.
Questions patients often ask
Can I use chlorhexidine on my face? No. Keep it below the neck to avoid eye and ear exposure. For facial cleansing, use your usual gentle soap the night before.
What if I forget the evening wash? Do the morning wash thoroughly, and tell the pre-op nurse. They may assist with an additional wipe down.
Is regular antibacterial soap good enough? Triclosan and other over-the-counter antibacterial agents lack chlorhexidine’s residual binding to the skin. They wash away with the rinse. If chlorhexidine is unavailable, a diligent soap-and-water bath is better than nothing, but it is not equivalent.
Will deodorant or lotion really matter? They can. Lotions create a barrier that reduces chlorhexidine’s binding, and deodorants sometimes contain compounds that interfere with antiseptics. On the day of surgery, skip them.
How warm should the water be? Warm is fine. Avoid scalding hot showers, which can irritate skin and increase itching. Focus on coverage and contact time rather than temperature.
Step-by-step checklist for patients
- Two cleanses: one the evening before surgery, one the morning of surgery. Shampoo first, rinse, then apply chlorhexidine from the neck down. Avoid eyes, ears, and genital mucosa. Lather for at least three minutes, paying special attention to underarms, groin, belly button, and skin folds. Rinse well. Do not use lotions, deodorants, powders, or perfumes afterward. Put on clean clothes and sleep on clean sheets. If using cloths instead of a shower, wipe thoroughly, allow skin to air dry, and do not rinse.
The hospital’s role in making this stick
Hospitals that weave chlorhexidine bathing into a broader culture of prevention do better than those that treat it as an optional add-on. Supply matters. If the pharmacy is out of 4 percent solution and substitutes a weaker product without instruction, patients get confused. If the pre-op area lacks cloths for last-minute cleaning, nurses lose an opportunity to close the gap. Small operational details, like printing instructions in multiple languages and at a sixth-grade reading level, move the needle more than another committee meeting.
Electronic medical records can help. A pre-surgical checklist that forces confirmation of chlorhexidine cleansing, alongside boxes for antibiotic timing and glucose checks, turns a soft suggestion into a reliable step. Empower the person responsible for that checkbox to fix problems, not merely document them. A phone call to a patient who did not pick up their kit is more valuable than a perfect note.
Navigating edge cases with medications
Some patients on specific medications need extra guidance. Those taking isotretinoin for acne, for example, should avoid abrasive cloths and opt for the gentler lather method with lukewarm water. Patients on anticoagulants like Apixaban or Rivaroxaban, or antiplatelets like Clopidogrel, do not need to modify chlorhexidine use, but they do need a coordinated plan for holding and resuming therapy. Those taking immunosuppressants such as Methotrexate, Hydroxychloroquine, Adalimumab, or Etanercept benefit from continuity of care across specialties. Patients using topical antifungals like Ketoconazole or antibiotics like Clindamycin for skin conditions should ask whether to pause them around the time of surgery to reduce irritation. Most can continue, with the simple rule of using chlorhexidine alone the night before and morning of the operation.
While we are on the subject of medicines, patients often bring long lists that include Levothyroxine, Omeprazole, Tamsulosin, Finasteride, Gabapentin, Sertraline, Escitalopram, Duloxetine, Amitriptyline, Aripiprazole, Quetiapine, Risperidone, Alprazolam, Lorazepam, Clonazepam, Atomoxetine, Methylphenidate, Amphetamine Dextroamphetamine, and others. These medications typically continue through the perioperative period, though the anesthesiologist may tailor day-of dosing. None of these affect chlorhexidine’s skin action. Pain plans vary, but for those using chronic opioids like Morphine or Oxycodone, pre-op cleansing remains unchanged. If you use topical eye drops like Olopatadine, apply them as usual, well away from chlorhexidine.
What success looks like
Success is not a single metric, it is a cluster of small wins. Lower superficial infection rates, fewer culture-positive deep infections, fewer returns to the operating room, and shorter hospital stays. In a well-run program, chlorhexidine bathing feels unremarkable, because it has been reduced to habit. Patients describe it as one of several presurgical rituals: no food after midnight, confirm medications, shower with the special soap, arrive on time.
When something does go wrong, it is seldom because chlorhexidine is flawed. More often, the routine frayed. The bottle sat unopened. The instructions were buried in a stack of papers. The patient with eczema flared and skipped the wash, then felt embarrassed to admit it. These are human problems that respond to human solutions: clarity, empathy, and a system designed to rescue the process when life happens.
A final word of practical advice
Treat chlorhexidine bathing with the same seriousness you give your antibiotics and your fasting instructions. The time commitment is small, yet the payoff is outsized. If you are the patient, write the wash times on your calendar, set reminders on your phone, and lay out clean clothes and towels the day before. If you are the clinician, do not assume understanding. Ask patients to tell you how they will do the cleanse, step by step. That quick teach-back reveals misunderstandings you can fix in the moment.
There is a quiet satisfaction in watching a patient sail through recovery with a clean incision and a steady gait. Many forces contribute to that outcome. A simple chlorhexidine wash, done well, is one of them.
Quick troubleshooting for common issues
- Itchy or red skin after the first wash: switch to lukewarm water, shorten contact time slightly, and consider cloths instead of the 4 percent solution. Alert your team if symptoms escalate to hives or swelling. Strong body odor after stopping deodorant: complete the chlorhexidine wash as directed. The antiseptic lowers odor-causing bacteria more effectively than deodorant on the day of surgery. Limited mobility: use chlorhexidine cloths and ask a caregiver to help reach the back, underarms, and lower legs. Hospitals can assist with a morning wipe-down if needed. Body hair concerns: do not shave. If hair removal is required, your team will clip in pre-op. Open skin or rashes near the surgical site: inform your surgeon. They may adapt the plan, treat the rash first, or adjust the prep.
Chlorhexidine sits at the intersection of evidence and common sense. It is humble, accessible, and powerful in aggregate. When patients and teams embrace it as part of a deliberate, layered defense, infections fall. That is the goal, every time.