Table 4

Appendix - Updated Recommendations on the Use of Chlorhexidine-Impregnated Dressings for Prevention of Intravascular Catheter-Related Infections (2017)
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Appendix: Table 4.
Strength of Evidence for Using C-I Gel Dressings or C-I Sponge under Standard Dressings vs. Using Highly Adhesive Dressing or Standard Dressing Alone among Patients Aged ≥ 18 Years with Short-term, Non-tunneled Central Venous Catheters A

Outcome type, findings, quantity and type of evidence for patients 18 or over.
Outcome Findings Quantity and Type of Evidence
(Sample Size)		 GRADE of Evidence for Outcome
(Limitations of the Evidence)
CRBSI B
  • 3 RCTs found that C-I dressings decreased rates of CRBSI.
    • 1 multicenter RCT1 (N=1,879) of ICU patients with CVCs, arterial catheters, or both compared transparent C-I gel dressing with either highly adhesive transparent dressing alone or standard, breathable, hypoallergenic dressing alone; HR for CVCs and arterial catheters combined: 0.40 (CI: 0.19–0.87); p=0.02; HR for CVC only: 0.30 (CI: 0.10–0.92); p=0.04. The study found no difference in CRBSI rates by dressing type among patients with arterial catheters: HR: 0.51 (CI: 0.15–1.74); p=0.28. Patients in these 3 analyses may have concurrently used multiple CVCs, multiple arterial catheters, or both.
    • 1 multicenter RCT2 (N=1,636) of ICU patients with CVCs, arterial catheters, or both, compared C-I sponge under semipermeable, transparent dressing with semipermeable, transparent dressing alone; HR: 0.24 (CI: 0.09–0.65); p<0.01. This study did not stratify results by catheter type.
    • 1 single-center RCT3 (N=601) of hematology-oncology unit patients with chlorhexidine and silver sulfadiazine-impregnated CVC compared C-I sponge under standard, sterile, transparent wound dressing with standard, sterile, transparent wound dressing alone; RR: 0.54 (CI: 0.31–0.94); p=0.02.
  • 1 multicenter RCT4 (N=306) of ICU patients with CVCs compared C-I sponge under transparent, semipermeable, polyurethane, occlusive dressing with transparent, semipermeable, polyurethane, occlusive dressing alone; found no difference in CRBSI rates by dressing type: HR: 1.65 (CI: 0.27–10.01); p=0.59.
 4 RCTs1-4

(N=4,422)

 High
(None)
CRIB
  • 2 large multicenter RCTs in ICUs found that use of C-I dressings decreased rates of CRI.
    • 1 multicenter RCT1 (N=1,879) of ICU patients with CVCs, arterial catheters, or both compared transparent C-I gel dressing with highly adhesive transparent dressing alone or standard, breathable, hypoallergenic dressing alone; HR (arterial catheters and CVCs): 0.33 (CI: 0.17–0.62); p< 0.01; HR (for CVCs): 0.27 (CI: 0.11–0.66); p=<0.01. The study found no difference in CRI rates by dressing type among patients with arterial catheters: HR: 0.39 (CI: 0.15–1.03); p=0.06. Patients in these 3 analyses may have concurrently used multiple CVCs, multiple arterial catheters, or both.
    • 1 multicenter RCT2 (N=1,636) of ICU patients with CVCs, arterial catheters, or both, compared C-I sponge under semipermeable, transparent dressing with semipermeable, transparent dressing alone; HR: 0.39 (0.16–0.93); p=0.03. This study did not stratify results by catheter type.
    • 2 smaller RCTs found no difference in CRI rates by dressing type.
  • 1 multicenter RCT4 (N=306) of ICU patients with CVCs compared C-I sponge under transparent, semipermeable, polyurethane, occlusive dressing with transparent, semipermeable, polyurethane, occlusive dressing alone; HR: 0.65 (CI: 0.23–1.85); p=0.42.
  • 1 single-center RCT5 (N=32) of ICU patients with CVCs compared C-I sponge under occlusive dressing with occlusive dressing alone; incidence (per catheter): 1/17 vs. 0/16; p=NS.
 4 RCTs1,2,4,5

(N=3,853)

 Moderate
(Imprecise C)
Product-related adverse events
  • 2 RCTs1,2 of ICU patients with CVCs, arterial catheters, or both, found no systemic adverse reactions to chlorhexidine.
  • 1 multicenter RCT1 (N=1,879) of ICU patients with CVCs, arterial catheters, or both, compared transparent C-I gel dressing with highly adhesive transparent dressing or standard, breathable, hypoallergenic dressing; incidence (per patient) of severe contact dermatitis: 22/938 (2.3%) vs. 5/941 (0.5%); p<0.01. Rate of abnormal ICDRG score: 2.3% vs. 1%; p<0.01
  • 1 multicenter RCT2 (N=1,525) of ICU patients with CVCs, arterial catheters, or both compared C-I sponge under semipermeable, transparent dressing with semipermeable, transparent dressing alone. Severe contact dermatitis occurred in 8 patients (10.4/patient or 5.3/1000 catheters) that required permanent removal of the C-I dressing. (Severe contact dermatitis in patients with standard dressings not reported.) Rate of abnormal ICDRG score (events/catheter): 100/6,720 (1.49%) vs. 63/5,875 (1.02%); p=0.02
  • 1 multicenter RCT4 (N=306) of ICU patients with CVCs compared C-I sponge under transparent, semipermeable, polyurethane, occlusive dressing with transparent, semipermeable, polyurethane, occlusive dressing alone; suggested all patients tolerated C-I sponge well; none were excluded due to allergy to C-I sponge.
  • 1 single-center RCT3 (N=601) of hematology-oncology unit patients with chlorhexidine and silver sulfadiazine-impregnated triple-lumen CVC compared C-I sponge under standard, sterile, transparent wound dressing with the standard, sterile, transparent wound dressing alone; found no product-related adverse events associated with either dressing type.
 4 RCTs1-4

(N=4,311)

 Moderate
(Imprecise D)
Chlorhexidine resistance
  • 1 multicenter RCT2 (N=1,525) of ICU patients with CVCs, arterial catheters, or both compared C-I sponge under semipermeable, transparent dressing with semipermeable, transparent dressing alone; found no difference by dressing type in median minimum bactericidal concentration (MBC): 4 (IQR 4–16) vs. 4 (IQR 4–8).
  • 1 single-center RCT3 (N=601) of hematology-oncology unit patients in which all patients received chlorhexidine and silver sulfadiazine impregnated CVCs compared C-I sponge under standard, sterile, transparent wound dressing with standard, sterile, transparent wound dressing alone; suggested no differences in bacterial resistance by dressing type.
 2 RCTs2,3

(N=2,126)

 Low
(Imprecise E)

Footnotes

  1. The overall strength of evidence for this comparison is Moderate. The overall strength of evidence for a comparison is determined by the lowest GRADE of Evidence for a Critical Outcome in that comparison.
  2. A critical outcome
  3. Inconsistent results and inconsistent outcome definitions.
  4. Low number of events.
  5. Low number of events; no difference between study group

References

  1. Timsit JF, Mimoz O, Mourvillier B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med. 2012;186(12):1272-1278.
  2. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. 2009;301(12):1231-1241.
  3. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol. 2009;88(3):267-272.
  4. Arvaniti K, Lathyris D, Clouva-Molyvdas P, et al. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: a multicenter, randomized, controlled study. Crit Care Med. 2012;40(2):420-429.
  5. Roberts B, Cheung D. Biopatch–a new concept in antimicrobial dressings for invasive devices. Aust Crit Care. 1998;11(1):16-19.
Page last reviewed: December 14, 2017
Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP)