Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Chlorhexidine gluconate solution prevented catheter colonization and infection

ACP J Club. 1997 May-Jun;126:76. doi:10.7326/ACPJC-1997-126-3-076


Source Citation

Mimoz O, Pieroni L, Lawrence C, et al. Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Crit Care Med. 1996 Nov;24:1818-23.


Abstract

Objective

To compare an antiseptic solution containing chlorhexidine gluconate with povidone-iodine for the prevention of catheter colonization and infection in critically ill patients.

Design

Randomized controlled trial.

Setting

Surgical intensive care unit (ICU) in Paris, France.

Patients

162 patients who were ≥ 18 years of age (mean age 53 y) and were scheduled to receive a nontunneled central venous catheter or arterial catheter. Exclusion criteria were catheter insertion for long-term total parenteral nutrition or chemotherapy, insertion before admission to the ICU, or placement of the catheter at an existing site over a guidewire.

Intervention

Patients were allocated to an antiseptic solution consisting of 0.25% chlorhexidine gluconate, 0.025% benzalkonium chloride, and 4% benzyl alcohol { n = 88}*, or to an antiseptic solution of 10% povidone-iodine { n = 74}*.

Main outcome measures

Rates of catheter colonization (≥ 103 colony-forming units/mL by quantitative culture) and catheter-related sepsis.

Main results

During a 16-month period, 315 catheters were inserted (158 central venous and 157 arterial). The rate of catheter colonization was lower in patients who received the chlorhexidine solution than in those who received the povidone-iodine solution (12 vs 31 catheter colonizations/1000 catheter-days; relative risk [RR] 0.4, 95% CI 0.1 to 0.9; P < 0.01). The rate of catheter-related sepsis was marginally lower in patients who received chlorhexidine solution (6 vs 16 cases of catheter-related sepsis/1000 catheter-days; RR 0.4, CI 0.1 to 1; P = 0.05). {This means that 1 additional patient would need to be treated for 100 catheter-days to avoid 1 case of sepsis.}† Rates of central venous catheter colonization and sepsis were lower with chlorhexidine (8 vs 31 colonizations/1000 catheter-days, RR 0.3, CI 0.1 to 1, P = 0.03; and 5 vs 19 cases of sepsis/1000 catheter-days, RR 0.3, CI 0.1 to 1, P = 0.02, respectively). The rate of arterial catheter colonization was marginally lower with chlorhexidine (15 vs 32 colonizations/1000 catheter-days, RR 0.5, CI 0.1 to 1, P = 0.05).

Conclusion

An antiseptic solution containing 0.25% chlorhexidine gluconate was more effective than 10% povidone-iodine in preventing catheter colonization and catheter-related sepsis in critically ill patients.

Source of funding: In part, Les Laboratoires Nicholas.

For article reprint: Dr. O. Mimoz, Service d'Anesthésie-Réanimation, Hôpital Bicêtre, 94275 Le Kremlin Bicêtre, France. FAX 33-1-45-21-2875.

*Information supplied by author.

†Numbers calculated from data in article.


Commentary

It has been estimated that every year about 50 000 patients in the United States develop nosocomial infections related to indwelling vascular catheters, primarily central venous and arterial catheters (1). These infections are an important problem in terms of both morbidity and health care costs.

Povidone-iodine is a potent antiseptic agent that is widely used for skin preparation during vascular catheter insertion and dressing changes. Mimoz and colleagues convincingly show that, compared with povidone-iodine, a chlorhexidine-based antiseptic solution decreased the rate of catheter colonization and catheter-related infection. Their results reveal that the overall decrease in colonization and infection in patients in the chlorhexidine group was caused by a reduction in the number of gram-positive organisms. However, among patients with gram-negative isolates, more instances of colonization and infection occurred in the chlorhexidine group than in the povidone-iodine group. Although the latter finding was not statistically significant, the small number of gram-negative cultures limits interpretation. Nevertheless, the predominant culprits in catheter-related infections are gram-positive organisms, and reducing the overall incidence of catheter-related infections is probably advantageous even if the proportion of gram-negative infections might be somewhat increased.

Steadfast adherence to careful aseptic technique during catheter insertion, maintenance, and manipulation can reduce, but not completely eliminate, the ever-present threat of catheter-related infection. New developments, such as the use of silver-impregnated subcutaneous cuffs; antibiotic-coated or antiseptic-impregnated catheters; and, as shown by this study, improved antiseptic preparation solutions may help further reduce this risk (2).

James A. Kruse, MD
Wayne State UniversityDetroit, Michigan, USA

James A. Kruse, MD
Wayne State University
Detroit, Michigan, USA


References

1. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338:339-43.

2. Kruse JA, Shah NJ. Detection and prevention of central venous catheter-related infections. Nutr Clin Pract. 1993;8:163-70.