Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis

Abstract

Objective: To evaluate the effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections (CRBSIs). Design: Systematic review and meta-analysis. Methods: We searched PubMed, CINAHL, EMBASE, and ClinicalTrials.gov for studies (randomized controlled and quasi-experimental trials) with the following criteria: patients with short- or long-term catheters; CHG dressings were used in the intervention group and nonantimicrobial dressings in the control group; CRBSI was an outcome. Random-effects models were used to obtain pooled risk ratios (pRRs). Heterogeneity was evaluated using the I2 test and the Cochran Q statistic. Results: In total, 20 studies (18 randomized controlled trials; 15,590 catheters) without evidence of publication bias and mainly performed in intensive care units (ICUs) were included. CHG dressings significantly reduced CRBSIs (pRR, 0.71; 95% CI, 0.58–0.87), independent of the CHG dressing type used. Benefits were limited to adults with short-term central venous catheters (CVCs), including onco-hematological patients. For long-term CVCs, CHG dressings decreased exit-site/tunnel infections (pRR, 0.37; 95% CI, 0.22–0.64). Contact dermatitis was associated with CHG dressing use (pRR, 5.16; 95% CI, 2.09–12.70); especially in neonates and pediatric populations in whom severe reactions occurred. Also, 2 studies evaluated and did not find CHG-acquired resistance. Conclusions: CHG dressings prevent CRBSIs in adults with short-term CVCs, including patients with an onco-hematological disease. CHG dressings might reduce exit-site and tunnel infections in long-term CVCs. In neonates and pediatric populations, proof of CHG dressing effectiveness is lacking and there is an increased risk of serious adverse events. Future studies should investigate CHG effectiveness in non-ICU settings and monitor for CHG resistance.

Actualización de las recomendaciones del Proyecto Bacteriemia Zero

“…Estos resultados, deben tratarse con cautela debido al diseño de los estudios. Uso de apósitos impregnados con clorhexidina 12 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 . (Evidencia moderada/ recomendación fuerte) …”

“…Se han analizado cinco metaanálisis 61 , 62 , 63 , 64 , 65 y cuatro ECA controlados 66 , 67 , 68 , 69 , se revisaron las recomendaciones de siete sociedades científicas 12 , 70 , 71 , 72 , 73 y dos revisiones sistemáticas 74 , 75 .…”

“…La revisión sistemática llevada a cabo por Puig-Asensio et al 75 informa de dermatitis de contacto asociada al uso de apósitos con clorhexidina (RR = 5,16; IC del 95%: 2,09-12,70), especialmente en neonatos y poblaciones pediátricas en las que se produjeron reacciones graves. La evidencia sobre la utilidad de la ecografía durante la inserción del catéter como medida preventiva de infección es muy limitada.…”

Assessing the methodological quality of studies included in systematic reviews: Interpretation of scores

“…Possible approaches to classify the quality of included studies could be (1) to divide the assessed scores of included studies for each tool in thirds, (2) to divide the highest possible score for each tool in thirds, (3) to come up with your own scoring system, (4) to not interpret scores, or (5) to establish uniform thresholds that would be used by all authors. Choosing the first or third option will result in noncomparability of systematic review on the same or similar topics, especially if the quality assessment of the included studies is not publicly accessible.…”

“…The fourth option does not allow for selection or stratification of studies based on quality scores. In systematic reviews recently published in the journal Infection Control and Hospital Epidemiology, assessment of risk of bias was either not reported, 3,4 an interpretation was not given and scores were reported for each individual study, 5 and/or the threshold was chosen by the authors. 6,7 We feel that scores alone do not give enough guidance to properly estimate the quality of a study.…”