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Evid Based Nurs 12:115 doi:10.1136/ebn.12.4.115
  • Treatment

Intravascular catheter dressings with chlorhexidine-impregnated sponges reduced infections in the ICU

Questions

Do intravascular catheter dressings with chlorhexidine gluconate–impregnated sponges (CHGISs) reduce catheter-related infections (CRIs) compared with standard dressings in intensive care unit (ICU) patients? Are dressing changes every 7 days non-inferior to changes every 3 days?

Methods

Design:

2 × 2 factorial randomised controlled trial. Clinicaltrials.gov NCT00417235.

Allocation:

{concealed}.*

Blinding:

blinded (microbiologists, outcome assessors, {data analysts, and safety committee}*).

Follow-up period:

48 hours after ICU discharge.

Setting:

7 ICUs in 3 university and 2 general hospitals in France.

Patients:

1653 patients >18 years of age (median age 62 y, 64% men, based on 1636 patients) requiring catheters for ⩾48 hours. Exclusion criteria were allergy to chlorhexidine or transparent dressings.

Interventions:

CHGIS dressings, 3-day change (n = 412); CHGIS dressings, 7-day change (n = 413); standard dressings, 3-day change (n = 416); or standard dressings, 7-day change (n = 412). In all groups, soiled or leaking dressings were changed immediately.

Outcomes:

included major CRIs (clinical sepsis with or without bloodstream infections [BSIs]), catheter-related BSIs, and catheter colonisation.

Patient follow-up:

92% (99% in intention-to-treat analysis).

Main results

CHGIS dressings reduced major CRIs and catheter-related BSIs compared with standard dressings (table). 3-day and 7-day dressing changes did not differ for catheter colonisation (table).

Chlorhexidine gluconate-impregnated sponges (CHGISs) v standard dressings (control) and 3-day v 7-day dressing changes in intensive care unit (ICU) patients*

Conclusions

Intravascular catheter dressings with chlorhexidine gluconate–impregnated sponges reduced catheter-related infections compared with standard dressings in intensive care unit patients. Dressing changes every 7 days were non-inferior to changes every 3 days for catheter colonisation.

*Information provided by author.

Abstracted from

Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231–41.

Clinical impact ratings: Critical care 6/7; Wound care 6/7

Footnotes

  • Sources of funding French Ministry of Health; Biopatch dressings donated by Ethicon Inc.

Commentary

The study by Timsit et al has potential to revolutionise management of central-vein catheters and arterial lines in ICUs. Decreasing CRIs can affect patient length of stay, overall well-being, and costs. This is the largest study to date on the efficacy of CHGISs in ICU patients. The study design and implementation are rigorous, with large, multisite sampling from university and non-university settings and a mix of surgical and medical ICUs. The protocols were clearly delineated and implemented without advanced training or education by healthcare providers.

Limitations of the study include the lack of double-blinding of persons changing dressings, but a blinded procedure was used for the cultures. About 6.5% of catheters were not cultured for various reasons, a significant attrition rate in the study. Additionally, alcohol-based povidone iodine was used for skin asepsis, whereas use of chlorhexidine might have further reduced the incidence of CRIs in the control group. However, the pragmatic design is a clear strength, and overall the findings are robust.

Timsit et al also challenged the traditional frequency of unsoiled adherent dressing changes from every 3 days to every 7 days. Although the extended time for dressing changes would seem to generate important cost savings, it led to only a 9% decrease in changes/day. This warrants further study because many catheters were removed before day 6 and dressings were changed with the slightest separation from the skin. As with any dressing, slight separation from the skin is a concern for healthcare providers and often invokes hypervigilance, which may result in a total dressing change. A 9% decrease may not have much statistical significance, but challenging traditional and unsubstantiated practice has its own merit.

The strong design, multisite and large sampling, along with clear protocols and state of the art testing make the findings compelling. Use of CHGISs decreased risk of major CRIs by 60%, which has powerful implications for patients, healthcare providers, and overall costs within the healthcare system.

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