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


Therapeutics

Antiseptic catheters reduced catheter-related infections and were well tolerated

ACP J Club. 1998 Mar-April; 128:40. doi:10.7326/ACPJC-1998-128-2-040

Related Content in this Issue
• Companion Abstract and Commentary: A catheter coated with minocycline and rifampin reduced bloodstream infections


Source Citation

Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter. Ann Intern Med. 1997 Aug 15;127:257-66. [PubMed ID: 9265424]


Abstract

Objective

To determine the effectiveness of a chlorhexidine and silver sulfadiazine-impregnated catheter on central venous catheter-related colonization and infections, sources of catheter-related infections, and patient tolerance.

Design

Randomized, double-blind, controlled trial.

Setting

An intensive care unit of a university hospital in the United States.

Patients

158 patients (mean age 48 y) without allergies to chlorhexidine, silver, or sulfonamides who were scheduled to receive a central venous catheter.

Intervention

442 noncuffed, triple-lumen, polyurethane central venous catheters (227 catheters impregnated with chlorhexidine-silver sulfadiazine and 215 control catheters that were similar in appearance) were allocated to 158 patients. 72 patients received antiseptic catheters, and 86 received control catheters. After skin disinfection with povidone-iodine, catheters were inserted percutaneously using maximal barrier precautions and the Seldinger technique or exchanged over a guidewire into an existing site. The insertion site was disinfected every 48 hours and dressed with sterile gauze. Catheters that were removed within 8 hours or could not be cultured on removal (19 antiseptic and 20 control catheters) were excluded.

Main outcome measures

Catheter-tip colonization, catheter-related bacteremia, and origins of infections. Itching, pain, erythema, and tenderness at the insertion site were collectively evaluated using a composite inflammatory score.

Main results

Fewer antiseptic catheters (n = 28) than control catheters (n = 47) were colonized on removal (13.5% vs 24.1%, P = 0.005). Fewer antiseptic catheters (n = 2) than control catheters (n = 9) led to bacteremia (1% vs 5%, P = 0.03). Staphylococcus aureus, gram-negative bacilli, enterococci, or Candida species caused 8 of 11 cases of bacteremia. These organisms caused infections in 8 patients who received control catheters (4%) and in no patients who received antiseptic catheters (P = 0.003). The other 3 bloodstream infections were caused by coagulase-negative staphylococci. No difference was seen in the overall inflammatory scores between catheters.

Conclusion

Antiseptic catheters impregnated with chlorhexidine-silver sulfadiazine reduced catheter-associated infections and were well tolerated.

Source of funding: In part, Arrow International.

For article reprint: Dr. D.G. Maki, University of Wisconsin Hospital and Clinics-H4/574, Madison, WI 53794, USA. FAX 608-263-4464.


Table. Antiseptic vs control catherters*

Outcomes Antispetic catheters Control catheters RRR (95% CI) NNT (CI)
Catheter colonization 13% 24% 44 (15 to 63) 9 (5 to 33)
Bacteremia 1% 5% 79 (16 to 95) 27 (13 to 182)
Bloodstream infection with staphylococcus aureus, gram-negative bocilli, entero cocci, or Candida species 0% 4% 100% (56 to 100) 24 (13 to 48)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

The incidence of central venous catheter infection and associated bacteremia is high in patients who are critically ill, resulting in substantial morbidity and mortality. Aside from strict adherence to aseptic practices during catheter insertion (e.g., “maximal barrier precautions,” including gloves, gowns, and large sterile drapes) and during subsequent care, few interventions have been shown to effectively reduce infection rates. Innovative strategies to minimize the risk for infection that are being actively pursued include new biomaterials to improve the resistance of catheters to microbial colonization, as illustrated by these 2 trials of antiseptic-impregnated or antibiotic-coated catheters.

Maki and colleagues found a nearly 5-fold reduction of catheter-related bacteremia with antiseptic-impregnated catheters and a 2-fold reduction in the rate of catheter colonization. In this study, catheters, rather than patients, were used as the unit of analysis because patients were allocated to receive an antiseptic-impregnated catheter or a standard catheter on repeated insertion, either at a new site or with exchange over a guidewire. A trend was shown for fewer cases of bacteremia with antiseptic-impregnated catheters, whether it was a first catheter in a new site (1.4% vs 4.6%, P = 0.14) or a catheter inserted using guidewire exchange (2.0% vs 6.1%, P = 0.14). Although more local erythema was noted with impregnated catheters (54% vs 35%, P < 0.01), no patient experienced local or systemic hypersensitivity. Small amounts of chlorhexidine or silver sulfadiazine were detected in the blood of 1 of the 12 patients tested; however, 6 of the 12 patients had detectable serum levels of sulfadiazine (0.3 to 8.9 mg/L).

Raad and colleagues found a 3-fold reduction in the rate of catheter colonization with antibiotic-coated catheters and a markedly decreased rate of catheter-related bacteremia. As expected, these differences were entirely accounted for by a lower rate of colonization with gram-positive cocci (present in 31 uncoated vs 4 coated catheters, P < 0.001), whereas the rate of colonization with gram-negative bacilli or Candida was similar (6 uncoated vs 4 coated catheters). Staphylococci isolates recovered from catheters or skin insertion sites were not resistant to the antibiotics coating the catheters (minimal inhibitory concentration of 1 mg/L for minocycline and 2 mg/L for rifampin). However, it is not known whether the minimal inhibitory concentration of these strains differs from those of staphylococci isolated at the participating institutions and whether tetracycline resistance (endemic worldwide among staphylococci detected in hospitals) would affect the preventive efficacy of antibiotic-coated catheters. Concern remains about the selection of resistant strains with the use of antibiotic-coated catheters.

Both studies used molecular typing to compare isolates from blood and catheters and to confirm the origin of infection. The results of both trials are remarkably consistent in terms of the relatively high rates of infection in control catheters despite maximal barrier precautions used on insertion (about 25% colonization rate of catheters and an incidence of bacteremia of 7/1000 catheter-days or in 5% of catheters) and in the protective effect from coating catheters. Both trials studied triple-lumen central venous polyurethane catheters inserted for a relatively short period (mean of 6 d in both studies) in patients who were critically ill. It is unknown whether a similar benefit would result from using either antiseptic- or antibiotic-coated catheters in patients at lower risk for infection or different types of catheters (i.e., single- or double-lumen catheters). Moreover, it is unclear whether a similar benefit would allow longer-term catheterization because the antiseptics or antibiotics are gradually released and anti-microbial activities may persist for about 10 to 15 days.

For now, this new approach to prevention appears to be beneficial in high-risk patients who are critically ill and require relatively short-term central venous access (e.g., for 3 to 10 d). It may also decrease costs in institutions where the rates of infection remain high despite adequate infection control practices.

Christian Brun-Buisson, MD
Université Paris XIICréteil, France

Christian Brun-Buisson, MD
Université Paris XII
Créteil, France