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


Therapeutics

Review: Central venous catheters coated with chlorhexidine and silver sulfadiazine reduce bloodstream infections

ACP J Club. 1999 July-Aug;131:15. doi:10.7326/ACPJC-1999-131-1-015


Source Citation

Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection. A meta-analysis. JAMA. 1999 Jan 20;281:261-7.


Abstract

Question

How effective are catheters coated with chlorhexidine and silver sulfadiazine in preventing catheter-related bloodstream infections?

Data sources

Studies were identified with MEDLINE (1966 to January 1998) by using the terms chlorhexidine, antiseptic, and catheter. Bibliographies of relevant studies and review articles were scanned, and the manufacturer of coated catheters and authors were contacted.

Study selection

Randomized and pseudorandomized controlled trials were selected if central venous catheters coated with chlorhexidine and silver sulfadiazine were compared with nonimpregnated catheters and if outcomes of catheter-related bloodstream infection or catheter colonization were measured.

Data extraction

Data were extracted in duplicate on sample size, patient characteristics, type of catheters, catheterization site, guide-wire catheter exchange, concurrent interventions, outcomes, adverse effects, and study duration.

Main results

13 studies met the inclusion criteria; 11 had outcome data on catheter-related bloodstream infections, and 12 had outcome data on catheter colonization. Of the 2830 catheters evaluated, 2494 were triple lumen, 306 were double lumen, and 30 were single lumen. Impregnated catheters had a lower rate of catheter-related bloodstream infections (P = 0.005) and catheter colonization (P < 0.001) (Table) than did nonimpregnated catheters. Subgroup analyses of studies that required the outcome of bloodstream infections to be symptomatic or culture-proven showed that impregnated catheters modestly but still significantly reduced the rate of bloodstream infections. The summary odds ratio (OR) for all studies was 0.56 (95% CI 0.37 to 0.84) and the OR for studies with confirmed infections was 0.60 (CI 0.37 to 0.97, P = 0.03).

Conclusion

Central venous catheters impregnated with chlorhexidine and silver sulfadiazine reduce the rate of catheter-related bloodstream infections and catheter colonization.

Source of funding: No external funding.

For correspondence: Dr. D.L. Veenstra, University of Washington School of Pharmacy, P.O. Box 357630, Seattle, WA 98195-7630, USA. FAX 206-543-3835.


Table. Central venous catheters impregnated with chlorhexidine and silver sulfadiazine vs nonimpregnated catheters*

Outcomes at removal of catheter Weighted event rates RRR (95% CI) NNT (CI)
Impregnated Nonimpregnated
Bloodstream infections 2.1% 5.1% 42% (15 to 60) 50 (30 to 113)
Catheter colonization 15.5% 28.5% 45% (36 to 52) 8 (7 to 10)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article by using a fixed-effects model.


Commentary

Millions of central venous catheters are inserted annually worldwide. Because the most common serious complication of these catheters is bloodstream infection, several methods to minimize this risk have been investigated in randomized controlled trials. Aside from standard aseptic technique and precautions to minimize infusate contamination, methods have included the use of heparin-bonded catheters, subcutaneous antimicrobial catheter cuffs, tunneled insertion, cutaneous antimicrobial gels, various approaches to site dressings, and scheduled catheter replacement.

Systematic reviews of randomized trials of many of these techniques have recently been published. However, studies of antiseptic or antibiotic-impregnated catheters have emerged more recently because these catheters logically represent a potentially beneficial strategy for minimizing catheter-related infection. This meta-analysis by Veenstra and colleagues convincingly shows that catheters coated with chlorhexidine and silver sulfadiazine reduce catheter-related bloodstream infections. On the downside, these agents have the potential, albeit rarely, to cause serious hypersensitivity reactions.

A similar approach using catheters coated with minocycline and rifampin was evaluated in a randomized trial in which bloodstream infections developed in 7 of 136 patients with uncoated catheters but in none of the 130 patients with coated catheters (1). In another recent head-to-head trial, catheters coated with minocycline and rifampin were associated with a significantly lower rate of catheter-related bloodstream infections compared with catheters impregnated with chlorhexidine and silver sulfadiazine (1 of 356 vs 13 of 383, respectively) (2).

Although additional large-scale confirmatory studies are desirable, antimicrobial-impregnated catheters seem to substantially reduce catheter-related bloodstream infections.

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


References

1. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infection. A randomized, double-blind trial. Ann Intern Med. 1997;127:267-74.

2. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med. 1999;340:1-8.