For critically ill patients in intensive care units, use of a sponge containing the antimicrobial agent chlorhexidine gluconate as part of the dressing for catheters reduced the risk of major catheter-related infections, according to a study in the March 25 issue of JAMA. The researchers also found that reducing the frequency of changing unsoiled dressings from every three days to seven days appears to be safe.
Patients admitted to the intensive care unit (ICU) usually require insertion of central venous catheters (CVCs). In the United States, approximately 80,000 CVC-related bloodstream infections are estimated to occur each year in ICU patients. The rate of death from CVC-related bloodstream infections ranges from 0 percent to 11.5 percent, and the additional ICU length of stay resulting from these infections is estimated at 9 to 12 days. "Consequently, efforts are required to decrease the incidence of these infections," the authors write.
Most organisms responsible for CVC-related bloodstream infections originate from the insertion sites of short-term CVCs. Use of a chlorhexidine gluconate–impregnated sponge (CHGIS) as part of the dressing over the skin at the site of insertion of the intravascular catheter may reduce catheter-related infections (CRIs). It is also not certain whether changing catheter dressings every 3 days may be more frequent than necessary, according to background information in the article.
Jean-François Timsit, M.D., Ph.D., of University Joseph Fourier, Albert Bonniot Institute, Grenoble, France, and colleagues evaluated the effects of using CHGIS dressings and increasing the time between dressing changes in adult ICU patients. The randomized controlled trial included 1,636 patients from seven intensive care units in three university and two general hospitals in France, who were expected to require an arterial catheter, central-vein catheter, or both, inserted for 48 hours or longer. The median (midpoint) duration of catheter insertion was 6 days. A chlorhexidine gluconate–impregnated sponge or standard dressing (control) was used for the patients. The scheduled change of unsoiled adherent dressings was every 3 or 7 days, with immediate change of any soiled or leaking dressings.
Use of CHGIS dressings decreased the rates of major CRIs (catheter-related clinical sepsis without bloodstream infection or catheter-related bloodstream infection) by 61 percent (10/1,953 [0.5 percent] vs. 19/1,825 [1.1 percent]). Use of CHGIS dressings was estimated to prevent 1 major CRI for every 117 catheters left in place for an average duration of 10 days.
Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1,000 catheters).
The rate of catheter colonization (the presence of bacteria on the catheter at the time of removal) was 7.8 percent in the 3-day group and 8.6 percent in the 7-day group, an average absolute difference of 0.8 percent. The median number of dressing changes per catheter was 4 in the 3-day group and 3 in the 7-day group.
"… the interval between dressing changes can be safely extended to more than 3 days but not exceeding 7 days, provided the dressings are closely monitored and changed immediately should separation or soiling be detected," the authors write.
(JAMA. 2009;301:1231-1241. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Preventing Catheter-Related Bloodstream Infections - Thinking Outside the Checklist
In an accompanying editorial, Eli N. Perencevich, M.D., M.S., of the University of Maryland Medical Center and School of Medicine and VA Maryland Health Care System, Baltimore, and Didier Pittet, M.D., M.S., of the University of Geneva Hospitals and Faculty of Medicine and World Health Organization, Geneva, Switzerland, comment on the findings of Timsit and colleagues.
"Achieving the lowest possible rates of health care–associated infection is the ultimate goal, whether through mandate or individual hospital initiative. Even though the rates of catheter-related bloodstream infections have clearly declined during the past decade, efforts beyond the checklist are needed. Current guidelines suggest that the low rates achievable through optimized insertion practices and adherence to checklists might be sufficient. The study by Timsit et al has the potential to change the current clinical approach, given that rates of catheter-related bloodstream infection were driven even lower through the relatively simple use of a CHGIS dressing. Future advances in infection prevention will require similar investments in government-sponsored, high-quality randomized controlled trials."
(JAMA. 2009;301:1285-1287. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
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