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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.4 São Paulo Aug. 2011
Infection control related to central venous catheter impregnated with antiseptics: an integrative review*
Control de infección relacionada con catéter venoso central impregnado con antisépticos: revisión integradora
Maria Verônica Ferrareze FerreiraI; Denise de AndradeII; Adriano Menis FerreiraIII
Master in Fundamental Nursing by Ribeirão Preto College of Nursing -
University of São Paulo. Ribeirão Preto, SP, Brazil. firstname.lastname@example.org
IIFull Professor of the Depaertment of General and Specialized Nursing at Ribeirão Preto College of Nursing - University of São Paulo. Ribeirão Preto, SP, Brazil. email@example.com
IIINurse. Ph.D. by Ribeirão Preto College of Nursing - University of São Paulo. Professor of the Department of Nursing at Federal University of Mato Grosso do Sul. Três Lagoas, MT, Brazil. firstname.lastname@example.org
The use of central venous catheter is pointed out as a risk factor to blood stream infection. The objective of this study was to reach scientific evidence on infection control related to central venous catheter impregnated with antiseptics, used in hospitalized adult patients. Studies were selected from the LILACS, CINAHL and MEDLINE databases. Nine articles were selected by means of integrative literature review. The publications on the use of catheters impregnated with antiseptics showed statistically significant differences regarding the reduction of microbial colonization; however, only one study showed reduction in the occurrence of infection. The analysis of the studies revealed there is a need for further research in different patient populations in order to obtain general conclusions.
Descriptors: Cross infection; Infection control; Catheterization, central venous; Bacteremia; Evidence-based medicine
El uso de catéter venoso central es señalado como uno de los principales factores de infección de la corriente sanguínea. El estudio objetiva buscar evidencias científicas sobre control de infección relacionada con catéter venoso central impregnado con antisépticos utilizado en pacientes adultos hospitalizados. Para seleccionar estudios se utilizaron las bases de datos LILACS, CINAHL y MEDLINE. Se totalizaron 9 artículos mediante revisión integradora de literatura. Las publicaciones referidas a utilización de catéteres impregnados con antisépticos mostraron diferencias estadísticamente significantes en lo referente a reducción de colonización microbiana, mientras apenas un estudio demostró reducción de ocurrencia de infección. Ante el análisis de los estudios, existe necesidad de investigaciones adicionales en diferentes poblaciones de pacientes con la finalidad de efectuar generalizaciones.
Descriptores: Infección hospitalaria; Control de infecciones; Cateterismo venoso central; Bacteriemia; Medicina basada en evidencia
Infections associated to health care are a serious problem posing a global challenge, especially considering the variability of diagnoses and therapeutic procedures.
More specifically, vascular catheter (VC)-related infections are worrisome due to the severity and lethality involved(1-2). VC etiology is complex and multifactorial. Studies have highlighted that aspects calling for greater attention include: the clinical conditions of the patients, catheter type, composition, insertion technique, location, the frequency of handling the system, and the duration.
The use of antiseptics has been investigated as one of the possibilities of changing properties of the surface of the device and reducing catheter microbe colonization. Acknowledging this possibility has, over the last decades, implemented the use of antiseptic-impregnated catheters(1-3).
This study was performed using evidence based practice (EBP), as its approach allows for a systematic use of the best available evidence to evaluate options and make decisions when providing comprehensive patient care(4).
In this sense, the main objective established for this study was to search evidence on the association between the use of antiseptic-impregnated central venous catheter (CVC) and the reduction of bloodstream infection (BSI).
This is an integrative literature review that permits to summarize previous studies and establish conclusions based on a thorough analysis of the methodological outline and results regarding the investigated theme(5-6).
The following question was used to guide this study: What evidence is available in the literature on infection control related to central venous catheter without cuff, non-tunneled, of short permanence, antiseptic-impregnated, used in hospitalized adult patients?
Searches were performed on the Latin-America and Caribbean Health Sciences Literature (LILACS), Medical Literature Analysis and Retrieval System on-line (MEDLINE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, using the following keywords: infection control and central venous catheter.
The inclusion criteria were: articles available in full; use of central venous catheter without cuff, not tunneled, short permanence, antiseptic-impregnated in hospitalized adult patients; indexed in the abovementioned databases; published in English, Spanish, or Portuguese, between 1996 and 2006, with evidence levels I and II, according to Ganong(5) and with Stetler classification(6).
RESULTS AND DISCUSSION
Nine articles on antiseptic-impregnated CVC were found, seven (77.8%) of which corresponded to randomized controlled trials (evidence level II), and two (22.2%) to meta-analyses (evidence level I). All articles were in English. Chart 1 shows a summary of the main aspects analyzed in the articles.
The researchers of the randomized clinical trials evaluated the effectiveness of using CVC impregnated on the external surface with chlorhexidine and silver sulfadiazine as to the reduction in catheter-related infections(7-12).
The studies demonstrated that most patients were under a high risk of catheter-related infection. As to the number of lumens, most corresponded to double- and triple-lumen. In this context, a meta-analysis demonstrated that those with multiple lumens were most prone to infection compared to those with single lumen(13).
As to the mean catheter permanence time, the period ranged between 7.8 to 8.4 days and 14.3 to 16.6 days. In this reference, some authors reported these catheters were effective only if used for approximately 10 days; and that, after this period, infection is mostly intraluminal. Furthermore, the bactericide effect of the devices was limited to the surface of catheters, not extending to the lumens(14-15).
Only one study made reference to using a guidewire to change catheters in the same insertion site. It should be highlighted that some researchers do not recommend changing the CVC periodically with the purpose of reducing infection, and accepted using the guidewire only in cases of bad functioning if there is there no evidence of infection(16-17).
Four studied recommended using the aseptic technique for CVC insertion, whereas two articles did not specify using individual protection equipment, but reported the rigor of asepsis when inserting the device. The preparation for CVC insertion (using overalls, gloves and sterile fields, caps and masks) is well documented in the study and supported by experts(18-21).
As to the type of antiseptic solution used, it was observed there was a variability of products and their indication, i.e., iodine solutions at 10% with 1% free iodine, alcohol at 70% or 75%, and aqueous chlorhexidine at 2%. In this respect, researchers evaluated the use of chlorhexidine gluconate at 2% for CVC insertion compared to the iodine solution at 10%, and confirmed a reduction in CRBSI from 11.3 per 1000 CVC/day to 3.7 per 1000 CVC/day. There is vast literature addressing the evaluation of antimicrobial activity of antiseptics; and, has demonstrated the effectiveness of using chlorhexidine gluconate at 2% compared to iodine solutions at 10% or alcohol at 70%(20-23).
As to the CVC insertion site, it was observed that the most common site are the subclavian veins, and the least common are the jugular and femoral veins. Catheters inserted in the internal jugular veins have a higher risk for infection compared to insertions in the subclavian vein, considering its proximity to oropharyngeal secretions. In addition, it also implies greater difficulty to immobilize the catheter. Insertions in the femoral vein should be avoided, considering the high risk of complications such as deep venous thrombosis and infection, especially in incontinent adults(24-25).
Regarding the type of dressings, two studies point at the use of transparent coverings in CVC maintenance, and two dressings, sterile gaze and adhesive tape. It is important to stress that aspects related to dressings are complex and controversial. Furthermore, in cases that include drainage (blood or body fluids) and patients with sudoresis, the gaze dressing is the one preferred(26-27).
As for the adverse events stated in the studies, it was observed that most did not include an evaluation. Although catheter use is an advance in medicine, some factors such as hypersensitivity or anaphylactic reactions, as well as the induction to bacterial resistance and costs, have limited their effective applicability(28-29).
Most studies evinced statistically significant differences regarding the reduction in colonization rates in antiseptic-impregnated catheters; however, only one study found statistically significant differences for CRBSI rates. According to the authors of the meta-analysis(30), catheters impregnated with chlorhexidine and silver sulfadiazine are effective in reducing colonization and CRBSI compared to devices without antiseptics, in groups of patients with a high risk for these infections, submitted to short permanence catheterization. Researchers, however, have stressed that the decision of using these devices should take into consideration the potential reduction in morbidity and mortality, lower costs and the risk of adverse effects.
The other meta-analysis(31) did not find any significant odds ratio in the individual evaluation; however, nine of the evaluated studies had a tendency for lower catheter-related infection rates in the experimental group. They explained that the fact of being impregnated with antiseptic only on the external surface, and having been used for a short period of time could justify the results. Hence, they recommend the elaboration of additional studies to evaluate appropriate culture techniques, which are not influenceable by the action of antiseptics. And, although there were no ideal laboratory methods to diagnose catheter-related infection, there is a need for extra caution in overestimating the results, as well as in explaining the variables, and allocating and masking those involved.
It should be emphasized that in 2002 the CDC recommended using antimicrobial-impregnated CVC in adult patients that required catheterization for more than five days, or in institutions with high rates of infection complications(25).
Furthermore, other authors have discussed on the potential effects of antiseptic substances used to prepared these catheters, roll plate or sonication techniques; stressing the possibility of inhibiting microbial growth, and recommending the use of neutralizing agents when performing the microbiological analysis, so as to avoid false results(32).
By analyzing the studies, it was concluded that using antiseptic-impregnated central venous catheters reduced microbial colonization in six of the nine evaluated studies. Nevertheless, further studies are called for to investigate the effectiveness of using these catheters in other patient populations and compared to other types of catheters, considering that most of the studies analyzed in the present integrative review did not show statistically significant differences regarding CRBSI rates.
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Received: 16/12/2008 *
Taken from the dissertation "Revisão Integrativa do controle de infecção
relacionada a cateter venoso central: bases para a prática baseada em
evidências", Ribeirão Preto College of Nursing, University of São
* Taken from the dissertation "Revisão Integrativa do controle de infecção relacionada a cateter venoso central: bases para a prática baseada em evidências", Ribeirão Preto College of Nursing, University of São Paulo, 2007.