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Efficacy of Chlorhexidine-Containing Cutaneous Antiseptics in Prevention of (Vascular) Catheter Related Infection.
Andrew Longmate on behalf of the SICS EBM group
Intensive Care Unit, Stirling Royal Infirmary, Livilands, Stirling FK8 2AU
Citation: EBM Reviews. Scottish Intensive Care Society EBM Group. Andrew Longmate. Efficacy of Chlorhexidine-Containing Cutaneous Antiseptics in Prevention of (Vascular) Catheter Related Infection. 2005
Background: (Vascular) Catheter related bloodstream infection is associated with an increased morbidity, mortality, length of hospitalization and medical costs. The pathophysiology of catheter related infection remains uncertain but three main possibilities have been identified. These include skin colonisation and invasion of the transcutaneous insertion tract by micro-organisms of the patient ‘s own flora, hub colonisation with contiguous intraluminal spread or infusate contamination. Heavy cutaneous colonisation is a risk factor for CVC related BSI and chlorhexidine is a potent germicide that has been used for many years for skin disinfection. Multimodal strategies are important in the prevention of intensive care associated infections including catheter related blood stream infections. However Chlorhexidine containing cutaneous antiseptics have been widely recommended for use prior to catheter insertion to prevent CrBSI.
Objectives: The objectives of this search was to assess published RCTs and meta-analyses that have attempted to address whether the use of chlorhexidine skin preparation may be beneficial in preventing catheter related bloodstream infection.
Search strategy: Medline(1) catheterisation (explode) (2) catheterisation/ or catheterization, Swan-Ganz/ or Heart Catheterization/ or ctaheterisation.mp or Catheterization, Central venous (3) 1 and 2 (4)infection or infection m.p. (5) 3 and 4 (6) limit 5 to English language and "all adult(19 plus years)" and meta analysis. (7) limit 5 to "all adult(19 plus years)" and randomised controlled trial (8) 6 or 7. This resulted in 21 publications. Additional hand searches of reference lists from these publications and review articles.
Selection criteria: RCTs or meta-analysis published in peer reviewed journals comparing rates of catheter colonization or infection between different antiseptic skin regimes prior to insertion of vascular catheter (arterial or central venous catheter).
Excluded tunnelled catheters, antimicrobial impregnated catheters, non adult patients and non ITU patients, insertion site infections and articles not published in English language. Studies presented at meetings or in abstract form were also excluded.
Definitions: Definitions used vary between different studies which can make comparisons confusing. For the purposes of this review the results have been limited to 2 main groups: catheter colonization and bacteraemic catheter related blood stream infection.
Search results: Produce 5 papers – Four RCTs1-4, one meta-analysis5.
Analysis of the Evidence:
* Apparently shows significant reduction. Not verified by authors.
One meta analysis was reviewed (5). The Meta analysis used the 4 studies noted above and an additional 5 other studies which are listed below and have not been assessed separately in this review. The meta-analysis included non ITU patients and all vascular catheters including peripheral venous lines.
There was significant reduction in colonisation rates associated with use of chlorhexidine but authors correctly stated that the study populations were too heterogenous to allow their results to be collated.
When applied to Catheter related bloodstream infections the study populations were homogenous enough to allow collation. They found that use of chlorhexidine gluconate can reduce the risk for catheter related bloodstream infection by approximately 50%.
· In ITU adult patients there is some evidence to support the preferential use of chlorhexidine over povidone iodine for skin antisepsis before catheter insertion to prevent catheter colonisation. Certainly chlorhexidine is no worse than povidone iodine. One trial has shown a benefit when using the combination of sequential chlorhexidine and povidone iodine4 over either agent alone.
· Different studies use different formulations (aqueous or alcoholic) and concentrations (0.5% to 2%). of chlorhexidine Different formulations of iodine and or alcohol were used as control groups.
· A chlorhexidine containing solution should be considered for use as skin asepsis prior to vascular catheter insertion (arterial catheter or CVC) with the aim of reducing catheter colonization.
· Consideration should be made to using sequential chlorhexidine and povidone iodine skin preparation to prevent catheter colonization.
Areas of further research: Further trials using combined sequential antisepsis would be useful to examine the effects on colonisation. Further trails assessing effects on catheter related bloodstream infection would be difficult because of the number of potential confounding variables and would require large numbers of patients.
Citations with links to CATs:
The meta analysis reviewed the papers above (1-4) and the 5 studies below.
•Sheehan et al Chlorhexidine versus povidone iodine as cutaneous antisepsis for prevention of vascular catheter infections. Abstract 1993 Interscience Conference on Antimicrobial Agents and Chemotherapy. American Society for Microbiology
•Meffre et al Is peripheral venous catheter colonisation related to the antiseptic used for disinfection of the insertion site ? Povidone iodine vs alcoholic chlkorhexidine: a multicentre randomised prospective study. Abstract 1995. Catheter Study Group. Hygienes
•Legras et al. Etude prospectitive randomisee pour la prevntion des infections liees aux catheters: chlorhexidine alcoolique contre povidone iodee. 1997 Reanimation et Urgences
•LeBlanc and Cobett. IV site infection: a prospective randomised clinical trial comparing the efficacy of three methods of asepsis. 1999 Canadian Intravenous Nurses Association Journal.
•Knasinski and Maki. A prospective randomised controlled trial of 1% chlorhexidine 75% alcohol vs 10% povidone iodine for cutaneous disinfection and follow up site care with central venous and arterial catheters. 2000. Presented paper. National Association of Vascular Access Network Conference.
Reviewed & Edited DS, CC, BC, MD
© SICS EBM Group 2005