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Meta-Analysis
. 2016 Jul 13;7(7):CD010140.
doi: 10.1002/14651858.CD010140.pub2.

Skin antisepsis for reducing central venous catheter-related infections

Nai Ming Lai  1 , Nai An Lai, Elizabeth O'Riordan, Nathorn Chaiyakunapruk, Jacqueline E Taylor, Kenneth Tan
Affiliations
Meta-Analysis

Skin antisepsis for reducing central venous catheter-related infections

Nai Ming Lai et al. Cochrane Database Syst Rev. .

Abstract

Background: The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs.

Objectives: To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities.

Search methods: In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place.

Data collection and analysis: Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs).

Main results: Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events.

Authors' conclusions: It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

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Conflict of interest statement

Nai Ming Lai: none known.

Nai An Lai: none known.

Elizabeth O’Riordan: none known.

Nathorn Chaiyakunapruk: none known.

Jacqueline Taylor: none known.

Kenneth Tan: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Chlorhexidine versus povidone‐iodine, outcome: 1.1 Catheter‐related BSI.
5
5
Forest plot of comparison: 1 Chlorhexidine versus povidone‐iodine, outcome: 1.3 All‐cause mortality.
6
6
Forest plot of comparison: 1 Chlorhexidine versus povidone‐iodine, outcome: 1.4 Catheter colonisation.
1.1
1.1. Analysis
Comparison 1 Povidone‐iodine (in aqueous solution) versus no skin antisepsis, Outcome 1 Catheter‐related BSI.
1.2
1.2. Analysis
Comparison 1 Povidone‐iodine (in aqueous solution) versus no skin antisepsis, Outcome 2 Catheter colonisation.
2.1
2.1. Analysis
Comparison 2 Chlorhexidine (in aqueous solution) versus no skin antisepsis, Outcome 1 Septicaemia.
2.2
2.2. Analysis
Comparison 2 Chlorhexidine (in aqueous solution) versus no skin antisepsis, Outcome 2 Catheter colonisation.
2.3
2.3. Analysis
Comparison 2 Chlorhexidine (in aqueous solution) versus no skin antisepsis, Outcome 3 Number of patients who required antibiotics during in‐dwelling period of catheter.
3.1
3.1. Analysis
Comparison 3 Alcohol versus no skin antisepsis, Outcome 1 Catheter colonisation.
4.1
4.1. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 1 Catheter‐related BSI.
4.2
4.2. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 2 Catheter‐related BSI per 1000 catheter‐days.
4.3
4.3. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 3 All‐cause mortality.
4.4
4.4. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 4 Catheter colonisation.
4.5
4.5. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 5 Catheter colonisation per 1000 catheter‐days.
4.6
4.6. Analysis
Comparison 4 Chlorhexidine versus povidone‐iodine, Outcome 6 Insertion site infection.
5.1
5.1. Analysis
Comparison 5 Chlorhexidine (in aqueous solution) versus alcohol, Outcome 1 Catheter‐related BSI.
5.2
5.2. Analysis
Comparison 5 Chlorhexidine (in aqueous solution) versus alcohol, Outcome 2 Catheter colonisation.
6.1
6.1. Analysis
Comparison 6 Povidone‐iodine (in aqueous solution) versus alcohol, Outcome 1 Catheter‐related BSI.
6.2
6.2. Analysis
Comparison 6 Povidone‐iodine (in aqueous solution) versus alcohol, Outcome 2 Catheter colonisation.
7.1
7.1. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 1 Catheter‐related BSI.
7.2
7.2. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 2 Catheter‐related BSI per 1000 catheter‐days.
7.3
7.3. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 3 Catheter colonisation.
7.4
7.4. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 4 Catheter colonisation per 1000 catheter‐days.
7.5
7.5. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 5 Skin colonisation.
7.6
7.6. Analysis
Comparison 7 Alcohol versus octenidine in alcohol, Outcome 6 Adverse effects.
8.1
8.1. Analysis
Comparison 8 Chlorhexidine (in alcohol) plus povidone‐iodine (in aqueous solution) versus chlorhexidine (in alcohol), Outcome 1 Catheter colonisation.
8.2
8.2. Analysis
Comparison 8 Chlorhexidine (in alcohol) plus povidone‐iodine (in aqueous solution) versus chlorhexidine (in alcohol), Outcome 2 Catheter colonisation per 1000 catheter‐days.
9.1
9.1. Analysis
Comparison 9 Chlorhexidine (in alcohol) plus povidone‐iodine (in aqueous solution) versus povidone‐iodine (in aqueous solution), Outcome 1 Catheter colonisation.
9.2
9.2. Analysis
Comparison 9 Chlorhexidine (in alcohol) plus povidone‐iodine (in aqueous solution) versus povidone‐iodine (in aqueous solution), Outcome 2 Catheter colonisation per 1000 catheter‐days.
10.1
10.1. Analysis
Comparison 10 Sanosil (hydrogen peroxide and silver) versus water as adjunct to chlorhexidine 2% aqueous bath plus povidone‐iodine aqueous 10% scrub, Outcome 1 Catheter colonisation.
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Levy 2005 {published data only}
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Madeo 1998 {published data only}
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McCann 2016 {published data only}
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Montecalvo 2012 {published data only}
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Munoz‐Price 2009 {published data only}
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Munoz‐Price 2012 {published data only}
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Nikoletti 1999 {published data only}
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Noto 2014 {published data only}
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Parienti 2004 {published data only}
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Raad 1994 {published data only}
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Render 2006 {published data only}
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Richardson 2006 {published data only}
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Spiegler 2010 {published data only}
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Tietz 2005 {published data only}
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References to studies awaiting assessment

Atahan 2012 {published data only}
    1. Atahan K, Cokmez A, Bekoglu M, Durak E, Tavusbay C, Tarcan E. The effect of antiseptic solution in central venous catheter care. Bratislavske Lekarske Listy 2012;113(9):548‐51. - PubMed
BIlir 2013 {published data only}
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Knasinski 2000 {unpublished data only}
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Mimoz 2015 {published data only}
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References to ongoing studies

Goudet 2013 {published data only}
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References to other published versions of this review

Lai 2012
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