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

Medical Device-Associated Biofilm Infections and Multidrug-Resistant Pathogens

Medical devices such as venous catheters (VCs) and urinary catheters (UCs) are widely used in the hospital setting. However, the implantation of these devices is often accompanied by complications. About 60 to 70% of nosocomial infections (NIs) are linked to biofilms. The main complication is the ability of microorganisms to adhere to surfaces and form biofilms which protect them and help them to persist in the host. Indeed, by crossing the skin barrier, the insertion of VC inevitably allows skin flora or accidental environmental contaminants to access the underlying tissues and cause fatal complications like bloodstream infections (BSIs). In fact, 80,000 central venous catheters-BSIs (CVC-BSIs)-mainly occur in intensive care units (ICUs) with a death rate of 12 to 25%. Similarly, catheter-associated urinary tract infections (CA-UTIs) are the most commonlyhospital-acquired infections (HAIs) worldwide.These infections represent up to 40% of NIs.In this review, we present a summary of biofilm formation steps. We provide an overview of two main and important infections in clinical settings linked to medical devices, namely the catheter-asociated bloodstream infections (CA-BSIs) and catheter-associated urinary tract infections (CA-UTIs), and highlight also the most multidrug resistant bacteria implicated in these infections. Furthermore, we draw attention toseveral useful prevention strategies, and advanced antimicrobial and antifouling approaches developed to reduce bacterial colonization on catheter surfaces and the incidence of the catheter-related infections.

Central venous access device terminologies, complications, and reason for removal in oncology: a scoping review

BACKGROUND

Lack of agreed terminology and definitions in healthcare compromises communication, patient safety, optimal management of adverse events, and research progress. The purpose of this scoping review was to understand the terminologies used to describe central venous access devices (CVADs), associated complications and reasons for premature removal in people undergoing cancer treatment. It also sought to identify the definitional sources for complications and premature removal reasons. The objective was to map language and descriptions used and to explore opportunities for standardisation.

METHODS

A systematic search of MedLine, PubMed, Cochrane, CINAHL Complete and Embase databases was performed. Eligibility criteria included, but were not limited to, adult patients with cancer, and studies published between 2017 and 2022. Articles were screened and data extracted in Covidence. Data charting included study characteristics and detailed information on CVADs including terminologies and definitional sources for complications and premature removal reasons. Descriptive statistics, tables and bar graphs were used to summarise charted data.

RESULTS

From a total of 2363 potentially eligible studies, 292 were included in the review. Most were observational studies (n = 174/60%). A total of 213 unique descriptors were used to refer to CVADs, with all reasons for premature CVAD removal defined in 84 (44%) of the 193 studies only, and complications defined in 56 (57%) of the 292 studies. Where available, definitions were author-derived and/or from national resources and/or other published studies.

CONCLUSION

Substantial variation in CVAD terminology and a lack of standard definitions for associated complications and premature removal reasons was identified. This scoping review demonstrates the need to standardise CVAD nomenclature to enhance communication between healthcare professionals as patients undergoing cancer treatment transition between acute and long-term care, to enhance patient safety and rigor of research protocols, and improve the capacity for data sharing.

Evaluation of the prevention effect of high-quality nursing quality control in disinfection supply center on nosocomial infection

To explore the application effect of high-quality nursing quality control in disinfection supply center. The control group consisted of 1850 medical devices managed using the conventional quality control mode from January 2021 to December 2021, while the observation group consisted of 1900 medical devices managed using the high-quality nursing quality control mode from January 2022 to December 2022. The qualified rates of equipment cleaning, sterilization, and packaging were analyzed in both the observation and control groups. The occurrence of nosocomial infections in 2021 and 2022 were compared, and the changes in the Beck-Srivaatava stress scale index (BSSI) and Symptom Checklist-90 scores of the staff before and after implementing the high-quality nursing quality control mode were analyzed. The qualified rate of equipment cleaning, sterilization, and packaging in the observation group were 99.08%, 99.73%, and 99.78%, respectively, which were significantly higher than those in the control group (P < .05). The incidence of nosocomial infections in interventional and surgical cases in 2022 was 0.79%, which was significantly lower than that in 2021 (P < .05). The BSSI score of female staff was (68.76 ± 7.81) points, which was higher than that of male staff (P < .05). After the implementation of the high-quality nursing quality control mode, the BSSI score of the staff was (47.76 ± 9.12) points, which was significantly lower than that before implementation (P < .05). After the implementation of the high-quality nursing quality control mode, the staff's Symptom Checklist-90 scores for somatization, compulsion, interpersonal sensitivity, depression, hostility, and paranoia were (1.28 ± 0.29), (1.53 ± 0.24), (1.50 ± 0.21), (1.46 ± 0.32), (1.44 ± 0.26), and (1.38 ± 0.30) points, respectively, showing a decrease compared to before implementation (P < .05). The high-quality nursing quality control mode has great application value in the disinfection supply center. It can effectively improve the qualified rates of equipment cleaning, sterilization, and packaging, prevent nosocomial infections and improve the working pressure and psychological health of staff.

Randomized controlled trial on healthy volunteers of pharmacokinetic and antimicrobial activity of a novel hydrogel-containing chlorhexidine dressing to prevent catheter-related bloodstream infection

Introduction

Catheter-related blood stream infection (CRBSI) is one of the most relevant complications associated to the use of intravascular catheters. In this context, chlorhexidine gluconate (CHG) releasing dressings have been developed to reduce the catheter colonization rate and the risk of infection. The aim of this study is to analyze the release rate of CHG and the antimicrobial activity of a novel CHG-releasing dressing, Oper film® protect CHG, and to compare these parameters to those of the dressing Tegaderm™ CHG in healthy volunteers.

Methods

The study was performed in a cohort of 25 healthy volunteers. Two commercially available chlorhexidine-containing dressings were evaluated and compared in this study, Oper film® protect CHG and Tegaderm™ CHG. The release of CHG and the antimicrobial capacity was determined for one week.

Results

HPLC analysis revealed that both dressings have an equivalent CHG release to the skin 2 days (Oper film® protect CHG, 321 μg/cm2; Tegaderm™ CHG, 279 μg/cm2) and 7 days (Oper film® protect CHG, 456 μg/cm2; Tegaderm™ CHG, 381 μg/cm2) after the placement of the products in the non-disinfected back of the subjects. On the other hand, Oper film® protect CHG and Tegaderm™ CHG similarly reduced colony forming units (CFU) in cultures obtained from the skin under the CHG-containing hydrogel compared to control cultures at both 2 days (control, 3.34 log10 cfu/cm2; Oper film® protect CHG, 0.64 log10 cfu/cm2; Tegaderm™ CHG, 0.7 log10 cfu/cm2) and 7 days (control, 3.95 log10 cfu/cm2; Oper film® protect CHG, 0.11 log10 cfu/cm2; Tegaderm™ CHG, 1 log10 cfu/cm2).

Discussion

Data confirm that the recent commercially available dressing Oper film® protect CHG maintains the release of CHG and the antimicrobial activity during at least 7 days, and possesses equivalent drug release and antimicrobial action to Tegaderm™ CHG.

The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: A systematic review and meta-analysis

BACKGROUND

Central venous catheters are commonly used in healthcare, but they come with a range of potential complications. Over the last 15 years, an influx of securement and dressing products has been released, with unknown overall effectiveness to prevent these complications.

OBJECTIVE

To compare the effects of dressings and securement devices for central venous catheters on a range of common complications including catheter-related bloodstream infection, catheter tip colonisation, entry/exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing durability and mortality.

DESIGN

Systematic review with meta-analysis.

METHODS

Following standard Cochrane methods, a systematic search of Cochrane Wounds Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, EBSCO CINAHL, and multiple clinical trial registries was completed in November 2022. Randomised controlled trials evaluating the effectiveness of dressing and securement devices for all CVC types were included. A random-effects model was used during the meta-analysis. Results were expressed using risk ratio (RR), rate ratio, or mean difference (MD), with 95 % confidence intervals (CIs). Methodological quality and bias were assessed.

RESULTS

We included 46 studies involving 10,054 participants. All studies had either an unclear or high-performance bias. The blinding of outcome assessment was unclear in most studies. Chlorhexidine gluconate-impregnated dressings, compared with standard polyurethane dressings, may reduce the incidence (7 studies; N = 5816; RR 0.60, 95 % CI 0.44-0.83; low certainty evidence) and rate (4 studies; N = 4447; RR 0.51, 95 % CI 0.32-0.79; moderate certainty evidence) of catheter-related bloodstream infection and catheter tip colonisation (8 studies; N = 4788; RR 0.70, 95 % CI 0.52-0.95; very low certainty evidence). Medication-impregnated dressings may reduce the incidence of catheter-related bloodstream infection (6 studies; N = 5687; RR 0.60, 95 % CI 0.39-0.93; low certainty evidence) and catheter-tip colonisation (7 studies; N = 4769; RR 0.60, 95 % CI 0.47-0.76; low certainty evidence) relative to non-impregnated dressing types. Tissue adhesive may increase the risk of skin irritation or damage compared with integrated securement dressings (3 studies; N = 166; RR 1.88, 95 % CI 1.09-3.24; low certainty evidence) or sutureless securement devices (4 studies; N = 241; RR 1.64, 95 % CI 1.10-2.44; moderate certainty evidence). Tissue adhesive increased dressing durability compared with integrated securement dressings (MD 43.03 h, 95 % CI 4.88-81.18; moderate certainty evidence) and sutureless securement devices (MD 42.90 h, 4.64-81.16; moderate certainty evidence). Tissue adhesive increased failed catheter securement rate compared with suture (2 studies; N = 103; RR 9.33, 95 % CI 1.10-79.21; moderate certainty evidence).

CONCLUSIONS

The findings of the review provide insights and guidance for clinicians in selecting the appropriate dressings and securements for catheters. Findings should be interpreted with caution due to heterogeneity in catheters and patient types.

REGISTRATION

#CD010367.

TWEETABLE ABSTRACT

Time to implement chlorhexidine gluconate-impregnated dressings to prevent catheter-related bloodstream infections; a meta-analysis by @GraceNP and team.

Chlorhexidine-based versus non-chlorhexidine dressings to prevent catheter-related bloodstream infections: An evidence-based review

In patients with central venous catheters (CVCs) in situ, the development of catheter-related bloodstream infections (CRBSIs) is often linked with increased morbidity and mortality. Sterile gauze or transparent polyurethane dressings are conventionally used as extraluminal barriers; however, antimicrobial chlorhexidine CVC dressings could potentially reduce infection risk. This short evidence-based review examined the literature comparing the effectiveness of chlorhexidine-based CVC dressings against non-chlorhexidine dressings in reducing CRBSI occurrence. Four systematic reviews with meta-analysis were reviewed, all of which reported a statistically significant reduction in CRBSI occurrence on using chlorhexidine-based dressings. Further research is needed to determine the cost-effectiveness of chlorhexidine-based CVC dressings and their effectiveness in reducing CRBSIs in different catheter types and entry sites because infection risk is not uniform.

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.

Risk factors for catheter-related bloodstream infections in patients with intestinal failure undergoing home parenteral nutrition: a single-center study

PURPOSE

The incidence and risk factors of catheter-related bloodstream infections (CRBSI) in patients with intestinal failure (IF) have not been established, partly because catheter management methods vary from different facilities. This study aimed to identify the risk factors and incidence rate of CRBSIs in patients with IF who were given prophylactic treatment.

METHODS

Sixteen patients with IF who required home parenteral nutrition were enrolled in this study. Prophylactic management of CRBSI included monthly ethanol lock therapy and standardized infection prevention education. The outcomes included the incidence and risk factors of CRBSI.

RESULTS

The median incidence rate of CRBSI was 1.2 per 1000 catheter days. Univariate analysis showed that the risk of developing CRBSI was significantly associated with short bowel syndrome (< 30 cm) (p = 0.016). Other relevant findings included a significant negative correlation between serum albumin and CRBSI rate (r = - 0.505, p = 0.046), and past history of mixed bacterial infections was significantly associated with increased CRBSI rate (p = 0.013).

CONCLUSION

CRBSIs can still develop despite undergoing prophylactic management. Risk factors for CRBSI include the residual intestinal length, nutritional status, and susceptibility to certain microorganisms.

Decreasing the incidence of central line-associated bloodstream infection in a medical intensive care unit: a best practice implementation project

INTRODUCTION AND OBJECTIVES

Bloodstream infections are common in critically ill patients using central venous access devices (CVAD) in intensive care units (ICU). This project aimed to decrease the incidence of central line-associated bloodstream infections (CLABSI) by using evidence-based strategies.

METHODS

The project applied the JBI audit and feedback methods. Thirty-two nurses and five resident physicians from the medical ICU of a medical center participated in the project. Preintervention compliance was measured for the 11 key evidence-based criteria (six audit criteria of central venous catheter insertion and five audit criteria of dressing and catheter securement). Strategies were implemented to overcome the barriers identified in the baseline assessment. Impact evaluation and sustainability were conducted to change the CLABSI rate and the competence of healthcare professionals in providing CVAD care. The JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit tools were used for the data collection, analysis, and implementation planning.

RESULTS

Barriers included insufficient knowledge among nurses and physicians, poor compliance with the standard CVAD insertion procedure by physicians, inadequate cooperation among the CVAD care team members, and lack of CVAD-related equipment. The strategies included education and training in CVAD care, the establishment of a team resource management program, and the provision of appropriate equipment. Following project implementation, the CLABSI rate decreased from 8.38 to 3.9 BSIs/1000 CVAD-days.

CONCLUSIONS

The project successfully decreased the CLABSI rate and increased the competence of healthcare professionals. Implementation of best practices in clinical care should focus on leadership, team resource management, education, monitoring, and innovation.

Moving Beyond Central Line-Associated Bloodstream Infections: Enhancement of the Prevention Process

The provision of medications and other treatments via intravenous (IV) therapy has provided millions of health care patients with extended benefits. IV therapy, however, is also associated with complications, such as associated bloodstream infections. Understanding the mechanisms of development and the factors that have contributed to the recent increases in such health care-acquired infections assists in formulating new preventive strategies that include the implementation of hospital-onset bacteremia, an innovative model that requires surveillance and prevention of bloodstream infections associated with all types of vascular access devices, expansion of vascular access service teams (VAST), and use of advanced antimicrobial dressings designed to reduce bacterial proliferation over the currently recommended time periods for maintenance of IV catheters.

[Update of the recommendations of the Bacteraemia Zero Project]

El proyecto Bacteriemia Zero (BZ) fue el primero de los Proyectos Zero que se implementó en las Unidades de Cuidados Intensivos (UCI), consiguiendo una disminución de las tasas de infección relacionadas con catéter por debajo de las recomendadas por los estándares de calidad de las sociedades científicas. A raíz de la pandemia causada por el SARS-CoV-2 en las UCI, se ha observado un incremento importante de estas tasas de infección. El incremento de las tasas de infección y la necesidad de incorporar en la práctica clínica la mejor evidencia disponible, justifica la necesidad de actualizar las recomendaciones del proyecto BZ. Se constituyó un grupo de trabajo formado por miembros de las diferentes sociedades científicas que consideró que el paquete de medidas obligatorias del proyecto no debía modificarse debido a su eficacia demostrada y decidió incorporar, después de su revisión, las siguientes medidas opcionales: uso de catéteres impregnados con antimicrobianos, uso de apósitos impregnados con clorhexidina, uso de tapones con solución antiséptica en los conectores e higiene corporal diaria con clorhexidina.

Chlorhexidine dressings could reduce external ventricular drain infections: results from a systematic review and meta-analysis

BACKGROUND

The incidence of external ventricular drain (EVD) infections remains high. Chlorhexidine dressings have demonstrated efficacy in reducing infections associated with indwelling catheters at other body sites, although evidence for their use with EVDs is limited.

AIM

The aim of this systematic review and meta-analysis was to evaluate the efficacy of chlorhexidine dressings in reducing EVD associated cerebrospinal fluid infection (EVDAI).

METHODS

Systematic review and meta-analysis. MEDLINE, EMBASE and the Cochrane library were queried for articles from inception. The primary outcome was the incidence of EVDAI. Secondary outcomes included device safety, microbiological outcomes and shunt-dependency.

FINDINGS

From 896 unique records, 5 studies were included of which 4 presented suitable data for quantitative analysis including 3 case series and one underpowered randomised controlled trial. There was a high risk of bias in all studies. 880 patients were included with a mean age of 57.7 years (95% CI 57.4-58.0 years). In primary outcome analysis, the chlorhexidine dressing group had a significantly lower incidence of EVDAI (1.7% vs. 7.9%, RD = 0.07, 95% CI 0.00 - 0.13, p = 0.04).

CONCLUSION

Chlorhexidine dressings may reduce the incidence of EVDAI but require future study in randomised trials to definitively determine efficacy.