Hostname: page-component-84b7d79bbc-dwq4g Total loading time: 0 Render date: 2024-07-29T13:52:56.708Z Has data issue: false hasContentIssue false
  • English
  • Français

Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis

Published online by Cambridge University Press:  16 September 2020

Mireia Puig-Asensio Open the ORCID record for Mireia Puig-Asensio [Opens in a new window] ,
Alexandre R. Marra ,
Christopher A. Childs ,
Mary E. Kukla ,
Eli N. Perencevich  and
Marin L. Schweizer
Mireia Puig-Asensio*
Affiliation:
University of Iowa Carver College of Medicine, Iowa City, Iowa, United States Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
Alexandre R. Marra
Affiliation:
University of Iowa Carver College of Medicine, Iowa City, Iowa, United States Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
Christopher A. Childs
Affiliation:
Hardin Library for the Health Sciences, University of Iowa Libraries, Iowa City, Iowa, United States
Mary E. Kukla
Affiliation:
University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
Eli N. Perencevich
Affiliation:
University of Iowa Carver College of Medicine, Iowa City, Iowa, United States Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
Marin L. Schweizer
Affiliation:
University of Iowa Carver College of Medicine, Iowa City, Iowa, United States Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, United States
*
Author for correspondence: Mireia Puig-Asensio, E-mail: mireia-puigasensio@uiowa.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To evaluate the effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections (CRBSIs).

Design:

Systematic review and meta-analysis.

Methods:

We searched PubMed, CINAHL, EMBASE, and ClinicalTrials.gov for studies (randomized controlled and quasi-experimental trials) with the following criteria: patients with short- or long-term catheters; CHG dressings were used in the intervention group and nonantimicrobial dressings in the control group; CRBSI was an outcome. Random-effects models were used to obtain pooled risk ratios (pRRs). Heterogeneity was evaluated using the I2 test and the Cochran Q statistic.

Results:

In total, 20 studies (18 randomized controlled trials; 15,590 catheters) without evidence of publication bias and mainly performed in intensive care units (ICUs) were included. CHG dressings significantly reduced CRBSIs (pRR, 0.71; 95% CI, 0.58–0.87), independent of the CHG dressing type used. Benefits were limited to adults with short-term central venous catheters (CVCs), including onco-hematological patients. For long-term CVCs, CHG dressings decreased exit-site/tunnel infections (pRR, 0.37; 95% CI, 0.22–0.64). Contact dermatitis was associated with CHG dressing use (pRR, 5.16; 95% CI, 2.09–12.70); especially in neonates and pediatric populations in whom severe reactions occurred. Also, 2 studies evaluated and did not find CHG-acquired resistance.

Conclusions:

CHG dressings prevent CRBSIs in adults with short-term CVCs, including patients with an onco-hematological disease. CHG dressings might reduce exit-site and tunnel infections in long-term CVCs. In neonates and pediatric populations, proof of CHG dressing effectiveness is lacking and there is an increased risk of serious adverse events. Future studies should investigate CHG effectiveness in non-ICU settings and monitor for CHG resistance.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 12 , December 2020 , pp. 1388 - 1395
Check for updates
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

ADDITIONAL PRESENTATION: Results from this study were accepted to be presented at the following scientific meetings: SHEA/CDC Decennial 6th International Conference on Healthcare Associated Infections and the 30th European Congress of Clinical Microbiology and Infectious Diseases.

References

Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732.CrossRefGoogle ScholarPubMed
Ista, E, van der Hoven, B, Kornelisse, RF, et al. Effectiveness of insertion and maintenance bundles to prevent central-line–associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:724–734.Google ScholarPubMed
Magill, SS, Edwards, JR, Bamberg, W, et al. Multistate point-prevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198–1208.CrossRefGoogle Scholar
Annual Epidemiological Report for 2017. Healthcare-associated infections acquired in intensive care units. European Centre for Disease Prevention and Control website. https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2017-HAI.pdf. Published 2019. Accessed October 31, 2019.Google Scholar
Ziegler, MJ, Pellegrini, DC, Safdar, N. Attributable mortality of central-line–associated bloodstream infection: systematic review and meta-analysis. Infection 2015;43:29–36.Google ScholarPubMed
Karpanen, TJ, Casey, AL, Conway, BR, Lambert, PA, Elliott, TS. Antimicrobial activity of a chlorhexidine intravascular catheter site gel dressing. J Antimicrob Chemother 2011;66:1777–1784.CrossRefGoogle ScholarPubMed
Karpanen, TJ, Casey, AL, Whitehouse, T, Nightingale, P, Das, I, Elliott, TS. Clinical evaluation of a chlorhexidine intravascular catheter gel dressing on short-term central venous catheters. Am J Infect Control 2016;44:54–60.Google ScholarPubMed
Ullman, AJ, Cooke, ML, Mitchell, M, et al. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev 2015:CD010367.Google Scholar
Safdar, N, O’Horo, JC, Ghufran, A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med 2014;42:1703–1713.CrossRefGoogle ScholarPubMed
Wei, L, Li, Y, Li, X, Bian, L, Wen, Z, Li, M. Chlorhexidine-impregnated dressing for the prophylaxis of central venous catheter-related complications: a systematic review and meta-analysis. BMC Infect Dis 2019;19:429.CrossRefGoogle ScholarPubMed
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, Group, P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336–341.CrossRefGoogle ScholarPubMed
Elbourne, DR, Altman, DG, Higgins, JP, Curtin, F, Worthington, HV, Vail, A. Meta-analyses involving cross-over trials: methodological issues. Int J Epidemiol 2002;31:140–149.Google ScholarPubMed
Higgins, JPT, Green, S (editors). Measures of relative effect: the risk ratio and odds ratio. In: Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0. Cochrane Training website. https://handbook-5-1.cochrane.org/chapter_9/9_2_2_2_measures_of_relative_effect_the_risk_ratio_and_odds.htm. Updated March 2011. Accessed August 7, 2019.Google Scholar
Higgins, JPT, Green, S (editors). How to include multiple groups from one study. In: Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0. Cochrane Training website. https://handbook-5-1.cochrane.org/chapter_16/16_5_4_how_to_include_multiple_groups_from_one_study.htm. Updated March 2011. Accessed December 7, 2019Google Scholar
Higgins, JPT, Thomas, J, Chandler, J, et al (editors). Cochrane Handbook for Systematic Reviews of Interventions, version 6.0. Cochrane Training website. www.training.cochrane.org/handbook. Updated July 2019. Accessed July 24, 2019.Google Scholar
Sterne, JA, Hernan, MA, Reeves, BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919.Google ScholarPubMed
DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–188.CrossRefGoogle ScholarPubMed
Chaiyakunapruk, N, Veenstra, DL, Lipsky, BA, Saint, S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002;136:792–801.Google ScholarPubMed
Garland, JS, Alex, CP, Mueller, CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001;107:1431–1436.Google ScholarPubMed
Maki, DG, Mermel, LA, Kluger, D, Narans, L, Knasinski, V, Parenteau, S, Covington, P. The efficacy of a chlorhexidine-impregnated sponge (Biopatch) for the prevention of intravascular catheter-related infection: A prospective, randomized, controlled, multicenter study. 40th Interscience Conference on Antimicrobial Agents and Chemotherapy. Toronto; 2000.Google Scholar
Arvaniti, K, Lathyris, D, Clouva-Molyvdas, P, et al. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: a multicenter, randomized, controlled study. Crit Care Med 2012;40:420–429.CrossRefGoogle ScholarPubMed
Timsit, JF, Schwebel, C, Bouadma, L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231–1241.Google ScholarPubMed
Timsit, JF, Mimoz, O, Mourvillier, B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012;186:1272–1278.CrossRefGoogle ScholarPubMed
Margatho, AS, Ciol, MA, Hoffman, JM, et al. Chlorhexidine-impregnated gel dressing compared with transparent polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients: a pilot randomised controlled trial. Aust Crit Care 2018;32:471–478.CrossRefGoogle ScholarPubMed
Pivkina, AI, Gusarov, VG, Blot, SI, Zhivotneva, IV, Pasko, NV, Zamyatin, MN. Effect of an acrylic terpolymer barrier film beneath transparent catheter dressings on skin integrity, risk of dressing disruption, catheter colonisation and infection. Intensive Crit Care Nurs 2018;46:17–23.Google ScholarPubMed
Duzkaya, DS, Sahiner, NC, Uysal, G, Yakut, T, Citak, A. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. Crit Care Nurse 2016;36:e1–e7.Google Scholar
Biehl, LM, Huth, A, Panse, J, et al. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Ann Oncol 2016;27:1916–1922.Google ScholarPubMed
Chan, RJ, Northfield, S, Larsen, E, et al. Central venous access device securement and dressing effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial. Trials 2017;18:458.CrossRefGoogle ScholarPubMed
Pedrolo, E, Danski, MT, Vayego, SA. Chlorhexidine and gauze and tape dressings for central venous catheters: a randomized clinical trial. Rev Lat Am Enfermagem 2014;22:764–771.Google ScholarPubMed
Gerceker, GO, Yardimci, F, Aydinok, Y. Randomized controlled trial of care bundles with chlorhexidine dressing and advanced dressings to prevent catheter-related bloodstream infections in pediatric hematology-oncology patients. Eur J Oncol Nurs 2017;28:14–20.CrossRefGoogle ScholarPubMed
Chambers, ST, Sanders, J, Patton, WN, et al. Reduction of exit-site infections of tunnelled intravascular catheters among neutropenic patients by sustained-release chlorhexidine dressings: results from a prospective randomized controlled trial. J Hosp Infect 2005;61:53–61.Google ScholarPubMed
Levy, I, Katz, J, Solter, E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J 2005;24:676–679.CrossRefGoogle ScholarPubMed
Ruschulte, H, Franke, M, Gastmeier, P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88:267–272.Google ScholarPubMed
Roberts, B, Cheung, D. Biopatch—a new concept in antimicrobial dressings for invasive devices. Aust Crit Care 1998;11:16–19.CrossRefGoogle ScholarPubMed
Yu, K, Lu, M, Meng, Y, Zhao, Y, Li, Z. Chlorhexidine gluconate transparent dressing does not decrease central-line–associated bloodstream infection in critically ill patients: a randomized controlled trial. Int J Nurs Pract 2019:e12776.Google Scholar
Arpa, Y, Aygün, H, YalçInbaş Y, San D, Ulukol A. Comparison of catheter related infection rates in pediatric cardiovascular surgery patients with use of transparent cover and transparent cover saturated with chlorhexidin gluconate in central catheter care. Turkish J Res Dev Nurs 2013;15:57–67.Google Scholar
Ergul, AB, Gokcek, I, Ozcan, A, Cetin, S, Gultekin, N, Torun, YA. Use of a chlorhexidine-impregnated dressing reduced catheter-related bloodstream infections caused by gram-positive microorganisms. Pak J Med Sci 2018;34:347–351.CrossRefGoogle ScholarPubMed
O’Horo, SK, Corson, D, Baum, RA. Efficacy of biopatch in reducing catheter related infections in cuffed, tunneled central venous catheters. J Vasc Interv Radiol 2013;24:S127.CrossRefGoogle Scholar
O’Grady, NP, Alexander, M, Burns, LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011;52:e162–e193.CrossRefGoogle ScholarPubMed
Talbot, TR, Stone, EC, Irwin, K, Overholt, AD, Dasti, M, Kallen, A, for the Healthcare Infection Control Practices Advisory Committeee. 2017 Updated recommendations on the use of chlorhexidine-impregnated dressings for prevention of intravascular-related infections. Center for Disease Control and Prevention website. https://www.cdc.gov/infectioncontrol/pdf/guidelines/c-i-dressings-H.pdf. Published 2017. Accessed November 11, 2019.Google Scholar
Mermel, LA. What is the predominant source of intravascular catheter infections? Clin Infect Dis 2011;52:211–212.CrossRefGoogle ScholarPubMed
Pfaff, B, Heithaus, T, Emanuelsen, M. Use of a 1-piece chlorhexidine gluconate transparent dressing on critically ill patients. Crit Care Nurse 2012;32:35–40.CrossRefGoogle ScholarPubMed
Banton, J, Banning, V. Impact on catheter-related bloodstream infections with the use of the BIOPATCH dressing. JVAD 2002;7:27–32.Google Scholar
Eggimann, P, Pagani, JL, Dupuis-Lozeron, E, et al. Sustained reduction of catheter-associated bloodstream infections with enhancement of catheter bundle by chlorhexidine dressings over 11 years. Intensive Care Med 2019;45:823–833.CrossRefGoogle ScholarPubMed
Edmond, MB. Getting to zero: is it safe? Infect Control Hosp Epidemiol 2009;30:74–76.Google Scholar
Wall, JB, Divito, SJ, Talbot, SG. Chlorhexidine gluconate-impregnated central-line dressings and necrosis in complicated skin disorder patients. J Crit Care 2014;29:1130 e1–e4.Google Scholar
Kampf, G. Adaptive bacterial response to low level chlorhexidine exposure and its implications for hand hygiene. Microb Cell 2019;6:307–320.Google ScholarPubMed
Kampf, G. Acquired resistance to chlorhexidine—is it time to establish an ‘antiseptic stewardship’ initiative? J Hosp Infect 2016;94:213–227.CrossRefGoogle ScholarPubMed
Heimann, SM, Biehl, LM, Vehreschild, JJ, Franke, B, Cornely, OA, Vehreschild, M. Chlorhexidine-containing dressings in the prevention of central venous catheter-related bloodstream infections: a cost and resource utilization analysis. Am J Infect Control 2018;46:992–997.CrossRefGoogle ScholarPubMed
Maunoury, F, Motrunich, A, Palka-Santini, M, Bernatchez, SF, Ruckly, S, Timsit, JF. Cost-effectiveness analysis of a transparent antimicrobial dressing for managing central venous and arterial catheters in intensive care units. PLoS One 2015;10:e0130439.Google ScholarPubMed
Ye, X, Rupnow, M, Bastide, P, Lafuma, A, Ovington, L, Jarvis, WR. Economic impact of use of chlorhexidine-impregnated sponge dressing for prevention of central-line–associated infections in the United States. Am J Infect Control 2011;39:647–654.Google ScholarPubMed
Pedrolo, E, Danski, MTR, Wiens, A, Boostel, R. Cost effectiveness of dressing in the prevention of catheter-related infection in critically ill patients. J Infect Dev Ctries 2018;12:871–877.CrossRefGoogle ScholarPubMed
Supplementary material: File

Puig-Asensio et al. supplementary material

Puig-Asensio et al. supplementary material 1

Download Puig-Asensio et al. supplementary material(File)
File 32.8 KB
Supplementary material: File

Puig-Asensio et al. supplementary material

Puig-Asensio et al. supplementary material 2

Download Puig-Asensio et al. supplementary material(File)
File 63.2 KB
Supplementary material: File

Puig-Asensio et al. supplementary material

Puig-Asensio et al. supplementary material 3

Download Puig-Asensio et al. supplementary material(File)
File 28 KB