Antiseptic-Impregnated Triple-Lumen Catheters
January 1, 1998 4 minutes read
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Antiseptic-Impregnated Triple-Lumen Catheters
an indication for a larger endotracheal tube.ABSTRACT & COMMENTARY
Synopsis: The use of antiseptic-impregnated triple-lumen central venous catheters in a medical-surgical intensive care unit resulted in significantly lower rates of catheter colonization and bloodstream infection compared with control central venous catheters.
Source: Maki DG, et al. Ann Intern Med 1997;127: 257-266.
This study was a randomized, controlled, blinded study carried out in a medical-surgical intensive care unit. Patients requiring central venous access were randomized to receive either a triple-lumen 16-G polyurethane central venous catheter (CVC) or a triple-lumen test catheter impregnated with chlorhexidine gluconate and silver sulfadiazine. The catheters were indistinguishable from each other. Four hundred three CVCs were placed in 158 adult patients by house officers. Following catheter removal, the hub, infusate, and catheter were cultured. Microorganisms isolated from blood cultures were evaluated by DNA fingerprinting (restriction endonuclease digestion and pulsed-field gel electrophoresis) to determine if the microorganism came from the patient’s CVC.
No patients developed hypersensitivity reactions to the antiseptic impregnated catheters. On removal, 24% of the control CVCs were colonized with more than 15 colony forming units, as compared with 13.5% of the antiseptic CVCs. Coagulase-negative staphylococci, gram-negative bacilli, and Candida species were the most frequent colonizers. Nine catheter-related bloodstream infections occurred in the control group (4.6 infections per 100 catheters; 7.6 infections per 1000 catheter-days) as compared with two cases in the antiseptic catheter group (1.0 infection per 100 catheters; 1.6 infections per 1000 catheter-days). The relative risk of bloodstream infection with antiseptic catheters was 0.21 (CI, 0.03-0.95; P = 0.03).
A second study (Raad I, et al. Ann Intern Med 1997;127:267-274) evaluated a minocycline- and rifampin-coated triple-lumen CVC. This study was also randomized, controlled, and double-blinded and evaluated 298 CVCs in 281 patients in five university-based medical centers. Pulsed-field gel electrophoresis was also used to type microorganisms. Raad and colleagues report colonization of 26% of control catheters as compared with 8% of coated catheters. Catheter-related bloodstream infection occurred in seven patients with control catheters (5%) and no patients with coated catheters (P < 0.05).
COMMENT BY MARK T. GLADWIN, MD
Most catheter-related infections appear to result from the migration of microorganisms from the insertion site into the tunneled catheter tract, potentially leading to catheter tip colonization and blood stream infection (Pearson ML, et al. Am J Infect Control 1996;24:262-293). Previous studies have demonstrated that silver-chelated cuffs attached to CVCs reduce the rate of catheter colonization and bloodstream infection (Flowers RH III, et al. JAMA 1989;261:878-883; Maki DG, et al. Am J Med 1988;85:307-314), further suggesting that prevention of tunnel colonization and infection will prevent catheter-related bacteremia.
The two studies described above demonstrate the efficacy of depositing antiseptic or antibiotic agents in this cutaneous tunnel between the colonized skin surface and the sterile bloodstream. The studies are adequately blinded, reflect a sick ICU patient population, and meticulously document the origin of bloodstream infection with molecular biologic techniques. Both studies demonstrate a reduced catheter colonization rate with antiseptic or antibiotic impregnated catheters and a smaller but significant reduction in bloodstream infection.
While the actual number of reported bloodstream infections is low, the cost of the antiseptic-impregnated catheter is only $25 more than the standard triple-lumen CVC. Maki and associates performed a simple cost-benefit evaluation and concluded that antiseptic-impregnated catheters would save money by reducing bloodstream infections (estimated cost of $29,000 per bloodstream infection by prolonging hospitalization 7-14 days). It would have been interesting to see an actual summary of hospital expenses for both groups. If the number of febrile episodes is reduced with antiseptic-impregnated catheters, there would be further cost savings by reductions in blood cultures and other diagnostic tests.
The use of these newer catheters must not replace vigilant care of central venous catheters. Guidelines for the prevention of CVC-related infections include preparation of the skin prior to CVC insertion with 10% povidone-iodine or 2% aqueous chlorhexidine (shown to be superior to povidone-iodine and 70% alcohol), the use of barrier precautions, daily inspection and palpation of the catheter insertion site, rigorous handwashing, use of sterile gauze or transparent dressing to cover catheter site, and prompt removal of catheters if there is clinical indication of tunnel infection or bacteremia (Pearson ML, et al. Am J Infect Control 1996;24:262-293).
The following devices have been demonstrated to reduce central venous catheter-related infections:
a. Antiseptic-impregnated catheters
b. Minocycline and rifampin coated catheters
c. Preparation of the skin prior to catheter insertion with 2% chlorhexidine
d. Silver chelated cuffs
e. All of the above
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