Timsit, J.F., Schwebel, C., Bouadma, L., Geffroy, A., Garrouste-Orgeas, M., Pease, S., . . . Dressing Study Group. (2009). Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. JAMA, 301, 1231–1241. 

To assess chlorhexidine-impregnated sponge dressings for prevention of catheter-related infections

Patients were randomly assigned to one of four treatment groups. Groups were (a) standard dressing every three days, (b) chlorhexidine sponge dressing every three days, (c) standard dressing every seven days, and (d) chlorhexidine dressing every seven days. Insertion sites were the radial artery or subclavian vein whenever possible. Insertions were done with maximal barriers and antisepsis techniques. Semitransparent dressings were used for all. Povidone-idodine was used for skin antisepsis with each dressing change. Patients were followed for 48 hours after discharge from the ICU. A noninferiority analysis was planned with the identification of a 3% difference in catheter-related infection (CRI) rate as the comparison value. Only cultured catheters were considered to compare three- versus seven-day dressing intervals.

• N = 1,636 in intent to treat analysis, 28,931 catheter days   
• MEDIAN AGE = 62 years
• AGE RANGE = 50–74 years
• MALES: 64.3%, FEMALES: 35.7%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: 64 patients (3.9%) had metastatic cancer and 52 (3.2%) had hematologic cancer
• OTHER KEY SAMPLE CHARACTERISTICS: 45% were arterial catheters and, of these, 41% were femoral; 54.3% were venous catheters and, of these, 40% were subclavian; the rest were jugular or femoral catheters.

• SITE: Multi-site   
• SETTING TYPE: Inpatient    
• LOCATION: France

• Four-group, single-blind randomized, controlled trial

• CRI defined as either catheter-related sepsis without bloodstream infection or catheter-related bloodstream infection. 
• Catheter colonization was the major outcome for comparison of three- versus seven-day dressing intervals
• Catheter colonization: At least 1,000 colony forming units/ml
• CRI defined as combination of (a) body temperature ≥ 38.5 C or hypothermia, (b) catheter tip culture with at least 10³ CFUs/ml, (c) pus at insertion site or resolution of clinical sepsis with catheter removal, and (d) absence of any other foci for infection.

Use of chlorhexidine dressings overall were associated with a 0.6 CRI rate compared to 1.4 in the control groups per 1,000 catheter days (hazard ratio [HR] = 0.39, p = 0.03). Of those assigned to seven-day dressings, 50.6% had more frequent unplanned dressing changes. There was no significant difference in colonization rate between those having three- and seven-day dressing intervals. There was a slight but insignificant increase in skin colonization in the seven-day group at the time of catheter removal. Overall, the rate of central line–associated bloodstream infection (CLABSI) was lower (p = 0.005) with sponge dressings. 

Use of chlorhexidine sponge dressing reduced the incidence of catheter-related bloodstream infections. Analysis by dressing change interval did not show any significant difference in outcomes.

• There was no analysis of each separate group to determine which combination of dressing frequency and dressing type was most effective.  
• Low volume of patients with cancer
• No subgroup analysis by catheter insertion site. A rather large proportion were femoral and jugular sites.

Findings showed lower CLABSI rate and risk with use of chlorhexidine-impregnated sponge dressings. Findings also suggest no difference in infection outcomes related to catheters according to the frequency of dressing changes, although more than half of patients assigned to dressing changes every seven days needed changes more frequently for soiling or separation. Chlorhexidine-impregnated dressings can reduce CLABSI rate, and less frequent catheter dressing changes can be done with no apparent increase in infections.