Clinical evaluation of a chlorhexidine intravascular catheter gel dressing on short-term central venous catheters

Chlorhexidine gluconate-coated gel pad dressings for prevention of central venous catheter-related bloodstream infections in patients with hematologic diseases or autologous stem cell transplantation: A registry-based matched-pair analysis

OBJECTIVES

Chlorhexidine gluconate (CHG)-coated gel pad dressings for central venous catheter (CVC) may prevent CVC-related bloodstream infections (CRBSI). However, real-world data showing beneficial effects in patients with hematologic malignancies are scarce.

METHODS

In a matched-pair analysis with data from a multicenter CVC registry, non-tunneled jugular and subclavian vein CVC in adults with hematologic malignancies or germ cell tumors (including patients receiving autologous hematopoietic stem cell transplantation [ASCT]) with CHG were compared with non-CHG dressings. The primary endpoint was definite CRBSI rate within 14 days (dCRBSI14) of CVC insertion; secondary endpoints were combined rate of definite or probable CRBSI within 14 days (dpCRBSI14), overall (dpCRBSI), and CRBSI incidences of all estimates.

RESULTS

In total, 2070 CVCs were assessed. There was no statistically significant difference in dCRBSI14 (2.3% vs. 3.5%) between patients with and without CHG gel dressings. Likewise, with regards to dpCRBSI14 (6.2% vs. 6.3%) and the overall dpCRBSI rate (9.2% vs. 10.5%), no significant difference was detected. Furthermore, dCRBSI14 incidence (2.0 vs. 3.2/1000 CVC days), dpCRBSI14 incidence (5.4 vs. 5.6/1000 CVC days), and overall CRBSI incidence (5.5 vs. 6.0/1000 CVC days) showed no significant differences.

CONCLUSIONS

CRBSI rates were not reduced by the use of CHG gel dressings in patients with hematologic malignancies and/or ASCT.

Pharmaceutical Incompatibility of Lubricating Gel Formulation Reduces Antibacterial Activity of Chlorhexidine Gluconate: In Vitro Study in Northern Thailand

Chlorhexidine gluconate (CHG) is a cationic disinfectant. The positive charge of CHG molecules binds to phospholipid's negative charge in bacterial cell walls, causing membrane disruption. The in vitro kinetic physical, chemical and biological incompatibilities of nine lubricating gels with 1% w/v CHG were investigated. Five containing anionic thickener, two containing nonionic thickener, and two containing cationic thickener were collected from hospitals in northern Thailand. All the anionic and nonionic lubricating gels significantly reduced (p < 0.05) the CHG amount after 5 min of exposure time from 12.54% to 54.99%, respectively. In contrast, the amount of CHG exposed with cationic lubricating gels was maintained. Antibacterial activity was significantly reduced to a 1.17-4.33 log10 reduction for Staphylococcus aureus ATCC25923 and a 1.07-3.52 log10 reduction for Escherichia coli ATCC25922 after 5 min exposure to all anionic and nonionic lubricating gels. In contrast, the two cationic lubricating gels maintained the antibacterial activity of the CHG solution (5.69 ± 0.14 and 5.45 ± 0.17 log10 reduction). The results suggest that anionic and nonionic thickeners in lubricating gel formulations may neutralize the positive charge and reduce the antibacterial activity of CHG, reducing its effectiveness as a disinfectant.

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

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.

In vitro antimicrobial effects of chlorhexidine diacetate versus chlorhexidine free base dressings

OBJECTIVE

The aim of this study was to investigate the in vitro antimicrobial performance of a chlorhexidine diacetate dressing and a chlorhexidine free base dressing to determine if the free base form of chlorhexidine has the potential to be an effective alternative to the chlorhexidine salts used in conventional, chlorhexidine-based antimicrobial dressings.

METHOD

Dressing samples were inoculated with clinically relevant pathogenic microorganisms including Gram-positive and Gram-negative bacteria, yeasts and fungus, and subsequently evaluated for in vitro log₁₀ reduction at 1-, 3-, and 7-day time points. Chlorhexidine mole content was also calculated as a function of dressing surface area for both sample types to allow for formulation-independent comparison between the dressings.

RESULTS

The chlorhexidine free base dressing demonstrated >0.5 log₁₀ superior mean antimicrobial efficacy at 67% of the experimental time points and equivalent mean antimicrobial efficacy (≤0.5 log₁₀ different) at the remaining time points when compared with the chlorhexidine diacetate dressing. The chlorhexidine free base dressing was also found to contain 36% less chlorhexidine mole content than the chlorhexidine diacetate dressing.

CONCLUSION

Our results suggest that a dressing formulated with chlorhexidine free base can deliver in vitro antimicrobial performance at both a magnitude and rate that meets or exceeds that of a chlorhexidine diacetate-based dressing, while also allowing for a reduction in total chlorhexidine content per dressing. These findings could be of particular interest to researchers developing new antimicrobial technologies as well as to infection preventionists when evaluating antimicrobial products for use on clinical patients at elevated risk of infection.

Universal adhesive vascular access securement with Grip-Lok devices

The use of sutureless, adhesive securement devices in vascular access has become recommended as best practice, because they are a cost-effective, reliable solution. After a vascular access device has been inserted, catheter securement is one of the most important aspects of care and maintenance. The Grip-Lok® range offers secure, comfortable adhesive securement for all types of vascular access devices. The products use hypoallergenic medical adhesive, which reduces the risk of skin irritation and provides a reliable, adaptable alternative to suturing.

Preventing catheter-related infections in cancer patients: a review of current strategies

Introduction: Central line-associated bloodstream infections (CLABSI) are a frequent cause of healthcare-associated infections, increasing healthcare costs and decreasing the quality of life for critically and chronically ill patients such as those with cancer. These infections are largely preventable and have been significantly reduced throughout the United States. However, further reduction of CLABSI requires continued innovation in preventive strategies.Areas covered: We provide an overview of the recent medical literature on catheter-related infections among cancer patients, discussing epidemiology, risk factors, and pathogenesis of CLABSI with a focus on the newest and current preventive measures. The data discussed here were retrieved mainly from clinical trials, meta-analyses, and systematic reviews published in the English language using a MEDLINE database search from 1 January 1990 until the end of December 2019.Expert opinion: The growing impact of CLABSI on the healthcare setting and mortality and morbidity rates in cancer patients calls for novel technologies for preventing central line-related infections. Advances in antimicrobial lock therapy are not limited to salvage therapy but have also provided a novel and promising prophylactic approach to CLABSI. Also, the use of antimicrobial-coated catheters with chlorhexidine-impregnated dressings, along with the application of insertion and maintenance bundles, is an effective and cost-effective approach for preventing central line-related infections.

Multifunctional, Low Friction, Antimicrobial Approach for Biomaterial Surface Enhancement

Poly(vinyl chloride) (PVC) biomaterials perform a host of life-saving and life-enhancing roles when employed as medical devices within the body. High frictional forces between the device surface and interfacing tissue can, however, lead to a host of complications including tissue damage, inflammation, pain, and infection. We herein describe a versatile surface modification method using multifunctional hydrogel formulations to increase lubricity and prevent common device-related complications. In a clinically relevant model of the urinary tract, simulating the mechanical and biological environments encountered in vivo, coated candidate catheter surfaces demonstrated significantly lower frictional resistance than uncoated PVC, with reductions in coefficient of friction values of more than 300-fold due to hydration of the surface-localized polymer network. Furthermore, this significant lubrication capacity was retained following hydration periods of up to 28 days in artificial urine at pH 6 and pH 9, representing the pH of physiologically normal and infected urine, respectively, and during 200 repeated cycles of applied frictional force. Importantly, the modified surfaces also displayed excellent antibacterial activity, which could be facilely tuned to achieve reductions of 99.8% in adherence of common hospital-acquired pathogens, Staphylococcus aureus and Proteus mirabilis, relative to their uncoated counterparts through incorporation of chlorhexidine in the coating matrix as a model antiseptic. The remarkable, and pH-independent, tribological performance of these lubricious, antibacterial, and highly durable surfaces offers exciting promise for use of this PVC functionalization approach in facilitating smooth and atraumatic insertion and removal of a wide range of medical implants, ultimately maintaining user health and dignity.

Chlorhexidine gluconate transparent dressing does not decrease central line‐associated bloodstream infection in critically ill patients: A randomized controlled trial

Background

Central line‐associated blood stream infections are accompanied by increased mortality and health care costs. The application of different types of dressings in infection control has not been fully investigated to date.

Aim

To assess the effects of two different dressing types on central line‐associated bloodstream infections.

Methods

A randomized, nonblinded, controlled trial was conducted. Central lines were randomly allocated to intervention (chlorhexidine gluconate transparent dressing, n = 259) and control groups (standard dressing, n = 215). The central line‐associated bloodstream infection rate was assessed.

Results

A statistically nonsignificant difference was noted in the overall central line‐associated bloodstream infection rates between the two groups. The frequency of dressing changes in the patients with the chlorhexidine gluconate transparent dressing was significantly lower than that in the patients with a standard dressing. The predominant type of infectious microorganisms isolated from the central line‐associated bloodstream infection episodes was Gram‐negative bacteria (57.2%). Gram‐positive bacteria and fungi were noted at lower percentages (28.5% and 14.3%, respectively).

Conclusion

The use of a chlorhexidine gluconate transparent dressing does not decrease the central line‐associated bloodstream infection rate, although it decreases the frequency of dressing changes so may save nursing time.

What is already known about this topic?

The use of a chlorhexidine gluconate transparent dressing has been reported to significantly reduce central line‐associated bloodstream infections or maintain low central line‐associated bloodstream infections in Western countries, but few studies have been carried out in Asian countries.

The chlorhexidine dressing does not decrease central line‐associated bloodstream infections due to the presence of Gram‐negative bacteria.

It has been reported that nurses prefer the chlorhexidine gluconate transparent dressing over the standard dressing.

What this paper adds?

Compared with the standard dressing, the chlorhexidine gluconate transparent dressing does not significantly decrease the central line‐associated bloodstream infection rate.

The predominant infectious microorganisms isolated from central line-associated bloodstream infections episodes were Gram-negative bacteria.

The cost of the chlorhexidine gluconate transparent dressing was significantly higher than that of the standard dressing, although the former could save nursing time due to the decreased frequency of dressing changes.

The implications of this paper are as follows:

The use of chlorhexidine gluconate transparent dressing does not offer any additional benefit in controlling infection.

Further studies are required to identify ways to control the colonization or infection of Gram‐negative bacteria in patients because Gram‐negative bacteria are the predominant infectious microorganisms that cause central line‐associated bloodstream infection.

The use of a chlorhexidine gluconate transparent dressing is proposed as an alternative choice that can reduce ICU nursing time in hospital settings and therefore should be considered by nursing managers for human resource cost control.

A clinical evaluation of two central venous catheter stabilization systems

BACKGROUND

Central venous catheters (CVCs) are commonly secured with sutures which are associated with microbial colonization and infection. We report a comparison of a suture-free system with standard sutures for securing short-term CVC in an international multicentre, prospective, randomized, non-blinded, observational feasibility study. Consented critical care patients who had a CVC inserted as part of their clinical management were randomized to receive either sutures or the suture-free system to secure their CVC. The main outcome measures were CVC migration (daily measurement of catheter movement) and unplanned catheter removals.

RESULTS

The per cent of unplanned CVC removal in the two study groups was 2% (suture group 2 out of 86 patients) and 6% (suture-free group 5 out of 85 patients). Both securement methods were well tolerated in terms of skin irritation. The time and ease of application and removal of either securement systems were not rated significantly different. There was also no significant difference in CVC migration between the two securement systems in exploratory univariate and multivariate analyses. Overall, 42% (36 out of 86) of the CVC secured with sutures and 56% (48 out of 85) of the CVC secured with the suture-free securement system had CVC migration of ≥ 2 mm.

CONCLUSIONS

The two securement systems performed similarly in terms of CVC migration and unplanned removal of CVC; however, the feasibility study was not powered to detect statistically significant differences in these two parameters.

TRIAL REGISTRATION

ISRCTN, ISRCTN13939744. Registered 9 July 2015, http://www.isrctn.com/ISRCTN13939744 .

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

BACKGROUND

In patients with short-term percutaneous central venous catheter (CVC), it is recommended that a dressing be applied to the catheter insertion site to prevent catheter-related infections.

OBJECTIVES

The objective of this study was to assess the feasibility of a randomised controlled trial to compare the efficacy of chlorhexidine-impregnated dressing with that of polyurethane dressing in the prevention of catheter-related infections in critically ill adult patients with short-term percutaneous CVC.

METHODS

One hundred fifteen patients with a CVC were randomised to chlorhexidine-impregnated gel dressing (chlorhexidine gel group) or transparent polyurethane dressing (polyurethane group) between April and December 2014. Feasibility outcomes included data on eligibility, recruitment, missing data, and protocol violation. The primary outcome measure of efficacy was the presence of colonisation with the same microorganism in both the skin swab around catheter insertion site and the catheter tip.

RESULTS

Of 526 patients assessed for eligibility, 411 (78%) did not meet inclusion criteria, and 115 (22%) were randomised. Among participants of both groups, there were 14 missing primary outcomes of which 10 were due to failure to collect the catheter tip (a protocol violation). The final sample had 47 and 54 individuals in the chlorhexidine and polyurethane groups, respectively. Skin and catheter tip were colonised by the same microorganism for 13% of the participants in the chlorhexidine group and 8% in the polyurethane group, although the difference was not statistically significant (p = 0.51). There were no differences between the two groups for catheter tip colonisation, skin site colonisation, catheter insertion site infection, catheter-related bloodstream infection, skin irritation, and the number of unplanned dressing changes.

CONCLUSIONS

Our preliminary results found that a large randomised controlled trial would be feasible. This study provides valuable information that can be used to design more robust studies to prevent infection among patients with short-term percutaneous CVC when using either chlorhexidine or polyurethane dressing.

A Randomized Controlled Study to Evaluate the Effectiveness of 2 Treatment Methods in Reducing Incidence of Short Peripheral Catheter-Related Phlebitis

Short peripheral catheter (SPC)-related phlebitis can lead to bloodstream infections and affect patients' quality of life. A randomized trial was carried out to evaluate the effectiveness of 2 treatment methods in reducing the incidence of SPC-related phlebitis. The 2 treatment methods differed in terms of the cleansing solution used before insertion and dressing material used after removal. The results demonstrated that the type of cleansing solution and postremoval dressing material did not make a difference in the incidence of phlebitis. Strict adherence to aseptic techniques and prompt removal of the SPC remained the cornerstone in the prevention of phlebitis.

One percent chlorhexidine-alcohol for preventing central venous catheter-related infection during intensive chemotherapy for patients with haematologic malignancies

A central venous catheter (CVC) is a catheter placed into a large vein, and is used for chemotherapy administration. However, there is little confirmatory data on which antiseptic-such as chlorhexidine or povidone-iodine (PI) -is more protective against CVC-related infectious complications in patients receiving intensive chemotherapy. We aimed to compare the effectiveness of 1% chlorhexidine gluconate in 70% alcohol (CH) vs. PI for skin disinfection before CVC insertion in patients receiving intensive chemotherapy. Methods We used either CH or 10% PI as skin antiseptics before CVC insertion, and assessed which agent was more protective against CVC-related infection. The participants were 112 patients with haematologic malignancies who underwent chemotherapy; a total of 292 CVCs were inserted over this period. Blood cultures were obtained when febrile neutropenia occurred. The CVC was removed and the catheter-tip qualitatively cultured when catheter-related infection was suspected. The cumulative incidence of febrile neutropenia, microbial growth from blood or catheter-tip culture, and catheter-related blood stream infection (CRBSI) was evaluated retrospectively. A univariate Cox proportional hazards model showed that CH significantly alleviated infectious complications. Notably, no case of CRBSI occurred in the CH group. Multivariate analysis, adjusted for prolonged neutropenia (>15 days) and older age (>52 years), also showed significant reduction in the cumulative incidence of microbial growth from catheter-tips in the CH group (hazard ratio = 0.146, 95% confidence interval: 0.023-0.502, p = 0.0008). Disinfection using CH, compared with PI, can potentially decrease catheter-related infection without causing adverse skin reactions in patients with haematologic malignancies.

Evaluation of Compatibility of a Gum Mastic Liquid Adhesive and Liquid Adhesive Remover With an Alcoholic Chlorhexidine Gluconate Skin Preparation

The compatibility of a 2% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) skin preparation with a gum mastic liquid adhesive (GMLA) and liquid adhesive remover (LAR) was assessed in healthy volunteers. Twenty subjects completed test material combination with microbial sampling at 3- and 7-day time points. Mean log10 reductions from baseline for normal flora were assessed. There was no significant difference in reduction of normal flora on skin prepped with CHG/IPA versus skin prepped with CHG/IPA followed by GMLA or LAR. The conclusion of the study was that the use of GMLA or LAR with CHG/IPA does not affect the antiseptic effectiveness of CHG/IPA.

Prevention of Vascular Catheter-Related Bloodstream Infections

Catheter-related bloodstream infections (CRBSI) are responsible for significant morbidity, mortality, and excess health care costs. It is increasingly evident that many CRBSI can be prevented with current knowledge and techniques. Preventive measures can be broadly grouped into clinical practice-based interventions and technologic innovations. Clinical practice-based interventions require changes in human behavior and can be subdivided into interventions before and at the time of insertion and postinsertion. Despite recent successes with prevention of CRBSI, pertinent questions regarding pathogenesis and prevention remain unanswered and work on improved surveillance, devices less prone to infection, and more effective prevention techniques are needed.

Chlorhexidine-impregnated transparent dressings decrease catheter-related infections in hemodialysis patients: a quality improvement project

PURPOSE

Central venous catheters (CVC) are associated with increased infection rates, morbidity and mortality compared to other hemodialysis vascular access. Chlorhexidine-impregnated transparent (CHG-transparent) dressings allow for continuous antimicrobial exposure and easy visibility of the CVC insertion site. We conducted a quality improvement project to compare catheter-related infection (CRI) rates in two dressing regimens - CHG-transparent dressings and adhesive dry gauze dressing in hemodialysis patients with tunneled CVCs.

METHODS

The study was conducted in two phases. In phase 1, CHG-transparent dressing was introduced to EDC hemodialysis unit, while EDG and EDN hemodialysis units, served as the control sites and maintained adhesive dry gauze dressing. Phase 2 of the study involved replacing the adhesive dry gauze dressing with CHG-transparent dressing at EDG and EDN and maintaining CHG-transparent dressing at EDC. CRI rates at each hemodialysis unit during the 12-month intervention were compared to CRI rates for the 12-month pre-intervention period for each study phase. CRI rates were also compared between all three hemodialysis units.

RESULTS

In phase 1, CRI rates (per 1000 days) in EDC (intervention site) decreased by 52% (1.69 vs. 0.82, p<0.05) and increased by 12% (1.80 vs. 2.02, p = 0.75) at EDG, and 35% (0.91 vs. 1.23, p = 0.40) at EDN. In phase 2, CRI rates at EDG and EDN (intervention sites) decreased by 86% (1.86 vs. 0.26 p<0.05), and 53% (1.89 vs. 0.88, p<0.05), respectively, and decreased by 20% at EDC (0.73 vs. 0.58, p = 0.65).

CONCLUSIONS

Replacing adhesive dry gauze dressing with CHG-transparent dressing for hemodialysis patients with tunneled CVC was associated with decreased CRI rates.

Incorporation of biguanide compounds into poly(GL)-b-poly(GL-co-TMC-co-CL)-b-poly(GL) monofilament surgical sutures

A new biodegradable coating was developed for bioabsorbable monofilament sutures. Specifically, a random copolymer having 35wt-% and 65wt-% of lactide and trimethylene carbonate units showed appropriate flexibility, stickiness and degradation rate, as well as capability to produce a complete and uniform coating. Monofilament sutures of polyglycolide-b-poly(glycolide-co-trimethylene carbonate-co-ε-caprolactone)-b-polyglycolide were loaded with chlorhexidine (CHX) and poly(hexamethylene biguanide) (PHMB) to explore the possibility to achieve antimicrobial activity without adverse cytotoxic effects. To this end, two processes based on single drug adsorption onto the suture surface and incorporation into the coating copolymer were used and subsequently evaluated. Although the second process could be considered more complex, clear benefits were observed in terms of drug loading efficiency, antimicrobial effect and even lack of cytotoxicity. In general, drugs could be loaded in an amount leading to a clear bacteriostatic effect for both Gram-negative and Gram-positive bacteria without causing significant cytotoxicity. Release profiles of PHMB and CHX were clearly different. Specifically, adsorption of the drug onto the fiber surface which prevented complete release was detected for PHMB. This polymer had advantages derived from its high molecular size, which hindered penetration into cells, thus resulting in lower cytotoxicity. Furthermore, bacterial growth kinetics measurements and bacterial adhesion assays showed greater effectiveness of this polymer.