Antimicrobial-impregnated central venous catheters

Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults

BACKGROUND

The central venous catheter (CVC) is essential in managing acutely ill patients in hospitals. Bloodstream infection is a major complication in patients with a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is impregnation of CVCs with various forms of antimicrobials (either with an antiseptic or with antibiotics). This review was originally published in June 2013 and updated in 2016.

OBJECTIVES

Our main objective was to assess the effectiveness of antimicrobial impregnation, coating or bonding on CVCs in reducing clinically-diagnosed sepsis, catheter-related blood stream infection (CRBSI), all-cause mortality, catheter colonization and other catheter-related infections in adult participants who required central venous catheterization, along with their safety and cost effectiveness where data were available. We undertook the following comparisons: 1) catheters with antimicrobial modifications in the form of antimicrobial impregnation, coating or bonding, against catheters without antimicrobial modifications and 2) catheters with one type of antimicrobial impregnation against catheters with another type of antimicrobial impregnation. We planned to analyse the comparison of catheters with any type of antimicrobial impregnation against catheters with other antimicrobial modifications, e.g. antiseptic dressings, hubs, tunnelling, needleless connectors or antiseptic lock solutions, but did not find any relevant studies. Additionally, we planned to conduct subgroup analyses based on the length of catheter use, settings or levels of care (e.g. intensive care unit, standard ward and oncology unit), baseline risks, definition of sepsis, presence or absence of co-interventions and cost-effectiveness in different currencies.

SEARCH METHODS

We used the standard search strategy of the Cochrane Anaesthesia, Critical and Emergency Care Review Group (ACE). In the updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE (OVID SP; 1950 to March 2015), EMBASE (1980 to March 2015), CINAHL (1982 to March 2015), and other Internet resources using a combination of keywords and MeSH headings. The original search was run in March 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another type of impregnation in adult patients cared for in the hospital setting who required CVCs. We planned to include quasi-RCT and cluster-RCTs, but we identified none. We excluded cross-over studies.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methodological procedures expected by Cochrane. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data, where appropriate, with their 95% confidence intervals (CIs).

MAIN RESULTS

We included one new study (338 participants/catheters) in this update, which brought the total included to 57 studies with 16,784 catheters and 11 types of impregnations. The total number of participants enrolled was unclear, as some studies did not provide this information. Most studies enrolled participants from the age of 18, including patients in intensive care units (ICU), oncology units and patients receiving long-term total parenteral nutrition. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to the catheters that were being assessed having different appearances. Overall, catheter impregnation significantly reduced catheter-related blood stream infection (CRBSI), with an ARR of 2% (95% CI 3% to 1%), RR of 0.62 (95% CI 0.52 to 0.74) and NNTB of 50 (high-quality evidence). Catheter impregnation also reduced catheter colonization, with an ARR of 9% (95% CI 12% to 7%), RR of 0.67 (95% CI 0.59 to 0.76) and NNTB of 11 (moderate-quality evidence, downgraded due to substantial heterogeneity). However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0, 95% CI 0.88 to 1.13; moderate-quality evidence, downgraded due to a suspicion of publication bias), all-cause mortality (RR 0.92, 95% CI 0.80 to 1.07; high-quality evidence) and catheter-related local infections (RR 0.84, 95% CI 0.66 to 1.07; 2688 catheters, moderate quality evidence, downgraded due to wide 95% CI).In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied between studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in ICUs (RR 0.70;95% CI 0.61 to 0.80) but not in studies conducted in haematological and oncological units (RR 0.75; 95% CI 0.51 to 1.11) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (RR 0.99; 95% CI 0.74 to 1.34). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site.

AUTHORS' CONCLUSIONS

This review confirms the effectiveness of antimicrobial CVCs in reducing rates of CRBSI and catheter colonization. However, the magnitude of benefits regarding catheter colonization varied according to setting, with significant benefits only in studies conducted in ICUs. A comparatively smaller body of evidence suggests that antimicrobial CVCs do not appear to reduce clinically diagnosed sepsis or mortality significantly. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults

BACKGROUND

The central venous catheter (CVC) is a commonly used device in managing acutely ill patients in the hospital. Bloodstream infections are major complications in patients who require a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is CVC impregnated with various forms of antimicrobials (either with an antiseptic or with antibiotics).

OBJECTIVES

We aimed to assess the effects of antimicrobial CVCs in reducing clinically diagnosed sepsis, established catheter-related bloodstream infection (CRBSI) and mortality.

SEARCH METHODS

We used the standard search strategy of the Cochrane Anaesthesia Review Group (CARG). We searched MEDLINE (OVID SP) (1950 to March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2012), EMBASE (1980 to March 2012), CINAHL (1982 to March 2012) and other Internet resources using a combination of keywords and MeSH headings.

SELECTION CRITERIA

We included randomized controlled trials that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another impregnation. We excluded cross-over studies.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the CARG. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data where appropriate with their 95% confidence intervals (CIs).

MAIN RESULTS

We included 56 studies with 16,512 catheters and 11 types of antimicrobial impregnations. The total number of participants enrolled was unclear as some studies did not provide this information. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to different appearances between the catheters assessed. Overall, catheter impregnation significantly reduced CRBSI, with an ARR of 2% (95% CI 3% to 1%), RR of 0.61 (95% CI 0.51 to 0.73) and NNTB of 50. Catheter impregnation also reduced catheter colonization, with an ARR of 10% (95% CI 13% to 7%), RR of 0.66 (95% CI 0.58 to 0.75) and NNTB of 10. However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0 (95% CI 0.88 to 1.13)) and all-cause mortality (RR 0.88 (95% CI 0.75 to 1.05)).In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied in studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in intensive care units (ICUs) (RR 0.68 (95% CI 0.59 to 0.78)) but not in studies conducted in haematological and oncological units (RR 0.75 (95% CI 0.51 to 1.11)) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (TPN)(RR 0.99 (95% CI 0.74 to 1.34)). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site.

AUTHORS' CONCLUSIONS

This review confirms the effectiveness of antimicrobial CVCs in improving such outcomes as CRBSI and catheter colonization. However, the magnitude of benefits in catheter colonization varied according to the setting, with significant benefits only in studies conducted in ICUs. Limited evidence suggests that antimicrobial CVCs do not appear to significantly reduce clinically diagnosed sepsis or mortality. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

Central venous catheter techniques in infants and children

PURPOSE OF REVIEW

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors.

RECENT FINDINGS

Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists.

SUMMARY

Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.