Chlorhexidine Skin Prep

STUDY PURPOSE: To evaluate skin antisepsis in reducing catheter-related bloodstream infections (BSIs), catheter colonization, morbidities, and mortality

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 12 studies included in meta-analysis 
• TOTAL PATIENTS INCLUDED IN REVIEW: 2,011
• SAMPLE RANGE ACROSS STUDIES: 50–420
• KEY SAMPLE CHARACTERISTICS: Included studies in pediatric patients. Most studies included patients in intensive care units.

PHASE OF CARE: Not specified or not applicable

Analysis of chlorhexidine versus povidone iodine showed a relative risk of 0.064 (p = 0.05) in favor of chlorhexidine for the outcome of BSI. No significant difference existed between these two methods for all-cause mortality. Chlorhexidine was associated with less catheter colonization (RR = –0.08, p = 0.0003). Few studies compared the use of alcohol, octenidine, hydrogen peroxide, and silver.

The findings suggest that skin antisepsis with chlorhexidine is most effective in reducing BSI; however, the overall quality of the evidence is very low to moderate.

Mostly low quality/high risk of bias studies

Chlorhexidine is generally more effective than povidone iodine or alcohol for skin antisepsis as part of catheter care for reducing catheter-related BSIs and catheter colonization.

STUDY PURPOSE: To develop an evidence-based guideline on central venous catheter (CVC) care for patients with cancer

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE (PubMed) and the Cochrane Collaboration Library

KEYWORDS: Authors did not state which keywords were utilized.

INCLUSION CRITERIA: As long as the randomized clinical trials included a majority of patients with cancer, they were included for this review. Most recent trials were included as opposed to older trials. Authors searched from 1980–July 2012 in databases that were published in English.

EXCLUSION CRITERIA: No specific exclusion criteria were mentioned by authors. Randomized controlled trials (RCTs) were excluded if patients with CVCs were compared to patients with permanent catheters.

TOTAL REFERENCES RETRIEVED = 133, plus an unspecified number of pre-existing guidelines that were discovered during the search

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: 108 RCTs of patients with cancer and 25 meta-analyses or systematic reviews were found in the search. Several pre-existing guidelines also were discovered during the literature search.

• FINAL NUMBER STUDIES INCLUDED = 133, plus an unspecified number of pre-existing guidelines that were discovered during the search, 108 RCTs, and 25 meta-analyses
• KEY SAMPLE CHARACTERISTICS: Patients with cancer; patients with cancer with CVC access

• PHASE OF CARE: Active antitumor treatment     
• APPLICATIONS: Pediatrics, elder care, palliative care

Not enough evidence was found to suggest only one type of CVC for patients or to suggest only one insertion site or approach for tunneled lines. A CVC bundle should be used for line insertion and maintenance. 

Evidence is insufficient to recommend one type of CVC for patients with cancer. The choice of catheter needs to be patient-specific, avoiding femoral lines because of increased risk of infection. Hand hygiene, barrier precautions during catheter insertion and utilization, and chlorhexidine skin antisepsis during insertion are recommended to prevent catheter-related infections. Cultures should be drawn prior to antibiotic administration when an infection is suspected.

• No major limitations identified in meta-analysis

Hand hygiene and maximum barrier protection should be used during any type of catheter manipulation to avoid infection. Routine flushing with normal saline is recommended for patency. Blood cultures should be collected from CVCs prior to antibiotic administration. Tissue plasminogen activator should be used for catheters with patency issues. Routine prophylaxis with anticoagulants is not recommended for catheter-associated thrombus.

To compare the effectiveness of different skin antiseptics in the prevention of catheter-related infection (CRI)

The type of antiseptic used for skin disinfection for catheter care was chosen by the intensive care units of participating hospitals. Maximal sterile precautions for catheter insertion according to guidelines were used. All catheters were nontunneled, and none were used for routine blood sampling. Decisions to remove catheters were at the physicians' discretion and, after removal, catheter tip and peripheral blood cultures were conducted. A one-step procedure of skin cleansing was conducted with 2% chlorhexidine, and a four-step protocol of scrub, rinse, dry, and disinfect was used with other antiseptics. A propensity score was calculated from analysis of covariance to determine the propensity for CRI and was controlled in analysis techniques. In four ICUs, staff switched from a povidone iodine antisepsis to chlorhexidine, and separate analysis of differences in outcomes were analyzed individually (1,368 patients). All suspected cases of CRI were reviewed and determined by a blinded committee.

• N = 3,027
• MEAN AGE = 62.3 years
• MALES: 50.3%, FEMALES: 49.7%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Patient with multiple diseases, including cancer. All were in intensive care units. Over half were on antibiotics, 78% were on ventilators, 10%–14% had an immunodeficiency, and, overall, less than 1%  had neutropenia.

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

• Prospective cohort comparison

CRI defined as catheter-related bloodstream infection (CRBSI) or the combination of a catheter tip colonization and clinical signs of sepsis with no other cause identified.

The use of chlorhexidine was associated with a decreased risk of CRI (2 per 1,000 catheter days, p = 0.037). The unadjusted incidence of CRI was higher in the povidone iodine group compared to the chlorhexidine group (2.8 versus 2 per 1,000 catheter days, p = 0.001). Overall, CRI risk in the units that switched from povidone iodine to chlorhexidine was lower with chlorhexidine use (hazard ratio [HR] = 0.31, p = 0.005). However, no significant differences in CRBSI existed between groups.

The use of a skin antisepsis with a 2% chlorhexidine alcohol preparation for catheter care may be associated with a lower incidence of CRI.

• Risk of bias (no random assignment) 
• Key sample group differences that could influence results
• No data or control regarding other aspects of catheter care and use existed, which can also affect the development of CRI.
• No information is provided regarding the frequency of dressing changes, etc.
• The various solutions used for skin antisepsis were unclear—both a 2% and 1% chlorhexidine and 5% and 10% povidone iodine solutions were mentioned, but the study does not indicate which patients got which solution, or which solution was associated with which reported result.
• Differentiation of CRI versus CRBSI were unclear, and the association of these with the skin antisepsis used differed.

The use of chlorhexidine skin antisepsis may be associated with a lower incidence of CRI. The evidence has several limitations; however, it is consistent with the body of evidence showing the efficacy of chlorhexidine skin preparation as part of central venous catheter care.

To evaluate the effectivness of 1% chlorhexidine-gluconate ethanol (CHG-EtOH) versus 10% povidone-iodine among patients with hematologic malignancies and central line catheters

• N = 94 patients (107 CVCs)
• MEAN AGE = 54.9 years (range = 17–86 years)
• MALES: 42%, FEMALES: 58%
• KEY DISEASE CHARACTERISTICS: Malignant lymphoma, acute myeloid leukemia, acute lymphoblastic leukemia, and multiple myeloma
• OTHER KEY SAMPLE CHARACTERISTICS: Sites of CVCs were jugular, subclavian, and inguinal

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Japan

• PHASE OF CARE: Transition phase after active treatment

Randomized, controlled trial 

• Exit site infections and ​central line-associated bloodstream infections (CLABSIs) were measured as defined by the Centers for Disease Control and Prevention.

CVC exit site colonization rates were 11.9% with chlorhexidine and 29.2% with povidone-iodine (p = 0.03). CLABSI rates were 3.4% with chlorhexidine and 14.6% with povidone-iodine (p = 0.08). The incidence per catheter days was higher in the povidone iodine group (RR = 0.23, p = 0.041).

This study suggests that the use of 1% CHG-EtOH while preparing patients for the insertion of a central line and while dealing with central lines on a daily basis decreases the CLABSI rate as compared to the use of 10% povidone-iodine. This affects the length of a patient's stay in the hospital and delays the discharge process.

• Small sample (< 100)
• Risk of bias(sample characteristics)
• Other limitations/explanation: About 30% of patients had CVCs in the inguinal area, which is known to be associated with higher infection rates, and the percent of patients with inguinal catheters was higher in the povidone-iodine group. There was high attrition in the povidone-iodine group.

Nurses always are on the front line giving care to patients, and it is their responsibility to prevent the transmission of infection and provide quality care. One of the most certain ways of giving an infection to a patient is through a central line. These findings suggest that the use of 1% CHG-EtOH while manipulating central lines helps decrease the chance of CVC site contamination and may be more effective than povidone-iodine. However, study limitations reduce the strength of this particular finding. Additional studies of the most effective methods for skin preparation would be helpful.

To provide evidence-based recommendations for the prevention of intravascular catheter-related infections for healthcare personnel who insert and care for intravascular catheters and for those responsible for surveillance and infection control in hospital, outpatient, and home health settings. Patients addressed in the guidelines were adult and pediatric patients with intravascular catheters.

The resource is comprised of evidence-based guidelines. For the development process, evidence was categorized as category 1A to category 2 based on strength of recommendation and support from clinical or epidemiological studies.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics. 

The results were not summarized.

The guidelines provided extensive recommendations regarding the education and training of staff; selection of catheters and sites, including avoidance of the femoral vein for central venous access and use of the central venous catheter with the minimum number of ports needed; hand hygiene; use of maximal sterile barrier precautions for insertion; skin preparation with alcohol, iodine, or chlorhexidine; use of standard catheter site dressing regimens; specific aspects of care for umbilical and dialysis catheters; and use of piggybacks, stopcocks, and catheter flushing. Guideline recommendations include a bundling of multiple recommendations: antimicrobial-impregnated catheters and cuffs are recommended in patients with long-term use if the organizational central line-associated blood stream infection (CLABSI) rate is not decreasing despite the implementation of comprehensive strategies for improvement. Lower-level (category II) recommendations include the use of prophylactic antimicrobial lock solutions in patients with long-term catheters who have a history of CLABSIs despite optimal aseptic technique as well as daily cleansing of patients in the intensive care unit with 2% chlorhexidine-impregnated washcloths. Recommends changing IV administration sets no more often than every 96 hours unless used for blood products. For needleless components, recommends changing according to administration set timing as above, and states no benefit to changing more than every 72 hours.

Provides extensive recommendations for management of all types of intravenous catheters and system components. Nurses should refer to the full set of guidelines for all specific aspects of care.