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Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults

  1. Nai Ming Lai1,*,
  2. Nathorn Chaiyakunapruk2,3,
  3. Nai An Lai4,
  4. Elizabeth O'Riordan5,
  5. Wilson Shu Cheng Pau6,
  6. Sanjay Saint7

Editorial Group: Cochrane Anaesthesia Group

Published Online: 6 JUN 2013

Assessed as up-to-date: 15 MAR 2012

DOI: 10.1002/14651858.CD007878.pub2


How to Cite

Lai NM, Chaiyakunapruk N, Lai NA, O'Riordan E, Pau WSC, Saint S. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007878. DOI: 10.1002/14651858.CD007878.pub2.

Author Information

  1. 1

    University of Malaya Medical Center, Department of Paediatrics, Paediatric and Child Health Research Group, Kuala Lumpur, Malaysia

  2. 2

    Monash University Sunway Campus, Discipline of Pharmacy, Selangor, Malaysia

  3. 3

    Faculty of Pharmaceutical Sciences, Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Phitsanulok, Thailand

  4. 4

    Queen Elizabeth II Jubilee Hospital, Intensive Care Unit, Coopers Plains, Queensland, Australia

  5. 5

    The University of Sydney and The Children's Hospital at Westmead, Faculty of Nursing and Midwifery, Sydney, New South Wales, Australia

  6. 6

    Hospital Tuanku Jaafar, Department of Paediatrics, Seremban, Negeri Sembilan Darul Khusus, Malaysia

  7. 7

    Ann Arbor VA Medical Center and the University of Michigan Health System, Department of Internal Medicine, Ann Arbor, Michigan, USA

*Nai Ming Lai, Department of Paediatrics, Paediatric and Child Health Research Group, University of Malaya Medical Center, Kuala Lumpur, 50603, Malaysia. lainm@doctors.org.uk. lainm123@yahoo.co.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 6 JUN 2013

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

The central venous catheter (CVC) is a commonly used device in managing acutely ill patients in the hospital. Bloodstream infections are major complications in patients who require a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is CVC impregnated with various forms of antimicrobials (either with an antiseptic or with antibiotics).

Objectives

We aimed to assess the effects of antimicrobial CVCs in reducing clinically diagnosed sepsis, established catheter-related bloodstream infection (CRBSI) and mortality.

Search methods

We used the standard search strategy of the Cochrane Anaesthesia Review Group (CARG). We searched MEDLINE (OVID SP) (1950 to March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2012), EMBASE (1980 to March 2012), CINAHL (1982 to March 2012) and other Internet resources using a combination of keywords and MeSH headings.

Selection criteria

We included randomized controlled trials that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another impregnation. We excluded cross-over studies.

Data collection and analysis

We extracted data using the standard methods of the CARG. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data where appropriate with their 95% confidence intervals (CIs).

Main results

We included 56 studies with 16,512 catheters and 11 types of antimicrobial impregnations. The total number of participants enrolled was unclear as some studies did not provide this information. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to different appearances between the catheters assessed. Overall, catheter impregnation significantly reduced CRBSI, with an ARR of 2% (95% CI 3% to 1%), RR of 0.61 (95% CI 0.51 to 0.73) and NNTB of 50. Catheter impregnation also reduced catheter colonization, with an ARR of 10% (95% CI 13% to 7%), RR of 0.66 (95% CI 0.58 to 0.75) and NNTB of 10. However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0 (95% CI 0.88 to 1.13)) and all-cause mortality (RR 0.88 (95% CI 0.75 to 1.05)).

In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied in studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in intensive care units (ICUs) (RR 0.68 (95% CI 0.59 to 0.78)) but not in studies conducted in haematological and oncological units (RR 0.75 (95% CI 0.51 to 1.11)) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (TPN)(RR 0.99 (95% CI 0.74 to 1.34)). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.

There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site.

Authors' conclusions

This review confirms the effectiveness of antimicrobial CVCs in improving such outcomes as CRBSI and catheter colonization. However, the magnitude of benefits in catheter colonization varied according to the setting, with significant benefits only in studies conducted in ICUs. Limited evidence suggests that antimicrobial CVCs do not appear to significantly reduce clinically diagnosed sepsis or mortality. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Central venous catheter coating with antiseptics or antibiotics in reducing catheter-related infections in adult patients.

Central venous catheters (CVCs) are essential devices for giving fluids, medications, intravenous nutrition and cancer treatment. Compared to peripheral catheters, CVCs are much longer and reach far deeper into the major veins of the body, providing a more secured and durable intravenous access. However, infections, especially of the bloodstream, are common in patients with CVCs. Sometimes these infections are fatal. Several measures have been developed to reduce such infections, including catheter impregnation, namely, coating the CVC with antiseptics or antibiotics, which was introduced in the 1980s. Many established guidelines recommend the use of impregnated CVCs, although studies from different settings and participant groups reveal conflicting results. In this systematic review, we synthesize evidence on the benefits and harms of these modified catheters for adults, focusing on the outcomes of bloodstream infections and death.

We included 56 studies with 16,512 catheters and 11 types of impregnations evaluated. The total number of participants was unclear as some studies did not provide this information. The amount of information that we have gathered contributed to an overall moderate-to-high quality of evidence. Compared to those given non-impregnated catheters, participants who had impregnated catheters had lower rates of bloodstream infections that are established as catheter-related (CRBSI) (average absolute reduction in CRBSI: 2%). There was also a lower chance of finding bacteria on these impregnated catheters (catheter colonization) when they were removed from the participants (average absolute reduction in catheter colonization: 10%). However, the benefits of these impregnated catheters in reducing catheter colonization varied according to the study setting, with significant benefits observed only in studies conducted in the intensive care units (ICUs). Further, there were no statistically significant differences in the overall rates of bloodstream infections and in death, although these outcomes were less often assessed than CRBSI and catheter colonization. Impregnated catheters appeared no more likely than non-impregnated catheters to cause adverse effects such as bleeding, clots, pain or redness at the insertion site.

Based on our findings, we conclude that while impregnated catheters are effective in reducing CRBSI and catheter colonization, they may not be effective across all settings. There are uncertainties on the extent of their benefits if all bloodstream infections and death are considered. We advise caution in the use of such impregnated catheters across all settings and circumstances. We suggest that future research should include overall bloodstream infections and death as the key outcomes.