CATETERI VENOSI CENTRALI
TRATTATI CON ANTISETTICI O
ANTITROMBOTICI: QUALI
EVIDENZE
FULVIO PINELLI
CENTRO ACCESSI VASCOLARI
DIPARTIMENTO DI ANESTESIA E RIANIMAZIONE
AZIENDA OSPEDALIERO-UNIVERSITARIA CAREGGI
FIRENZE
Impossibile trovare nel file la parteimmagine con ID relazione rId3.
ANTIMICROBIAL
COATED CVCs
Impossibile trovare nel file la parte immagine con ID relazione rId3. Impossibile trovare nel file la parte immagine con ID relazione rId3.
Impossibile trovare nel file la parte immagine con ID relazione rId3.
Impossibile trovare nel file la parte immagine con ID relazione rId3.
ANTISEPTIC and
ANTITHROMBO
TIC COATED
CVCs
ANTIMICROBIAL CENTRAL VENOUS
CATHETERS IN ADULTS: A SYSTEMATIC
REVIEW AND METANALYSIS
Casey A. Lancet Infect Disease 2008
Cateteri all’argento
CATETERI
ALL’ARGENTO
I cateteri all’argento (impregnati, ricoperti o
trattati con la iontoforesi)
NON SONO
EFFICACI
nel ridurre la
colonizzazione
né le
CRBSI
FAVOURS ANTIMICROBIAL CVC
FAVOURS STANDARD CVC
www.thelancet.com/infection Vol 8 December 2008
769
Review
Silver alloy coated
Bach et al (1999)
457/33
9/34
1·33 (0·44–4·05)
Dunser et al (2005)
5219/160
27/160
1·50 (0·80–2·80)
Goldschmidt et al (1995)
5450/113
54/120
1·03 (0·62–1·73)
Total (FEM)
76/306 90/314
1·21 (0·84–1·77)
Test for heterogeneity: Q=0·85 (2 df), p=0·65; I
2=0%
Silver iontophoretic
Moretti et al (2005)
6664/262
61/252
0·99 (0·66–1·48)
Corral et al (2003)
5041/103
29/103
0·60 (0·34–1·06)
Total (FEM)
105/365 90/355
0·84 (0·60–1·16)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2=0%
Silver impregnated
Stoiser et al (2002)
7414/47
10/50
0·59 (0·24–1·49)
Kalfon et al (2007)
6136/397
47/320
1·25 (0·78–1·98)
Total (FEM)
50/344 57/370
1·07 (0·71–1·62)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2=0%
First-generation CSS
Tennenberg et al (1997)
7532/145
8/137
0·26 (0·14–0·52)
Maki et al (1997)
6447/195
22/208
0·50 (0·30–0·82)
Marik et al (1999)
6511/39
7/36
0·62 (0·22–1·79)
van Heerden et al (1996)
7610/26
4/28
0·29 (0·09–0·97)
Hannan et al (1999)
5671/177
47/174
0·56 (0·36–0·87)
Bach et al (1996)
4436/117
21/116
0·51 (0·28–0·92)
Collin et al (1999)
4925/139
2/98
0·21 (0·09–0·47)
Sheng et al (2000)
7325/122
9/113
0·36 (0·18–0·75)
Heard et al (1998)
5881/157
60/151
0·62 (0·40–0·97)
Dunser et al (2005)
5219/160
12/165
0·59 (0·28–1·23)
Osma et al (2006)
6714/69
14/64
1·10 (0·48–2·52)
Ciresi et al (1996)
4712/127
10/124
0·84 (0·35–2·02)
Jaeger et al (2005)
609/55
5/51
0·57 (0·19–1·74)
Total (FEM)
392/1528 227/1465
0·51 (0·42–0·61)
Test for heterogeneity: Q=15·82 (12 df), p=1·00; I
2=30·5%
Second-generation CSS
Rupp et al (2005)
7259/393
32/384
0·52 (0·34–0·81)
Ostendorf et al (2005)
6831/94
11/90
0·31 (0·16–0·62)
Brun-Buisson et al (2004)
4623/175
7/188
0·29 (0·14–0·61)
Total (REM)
113/662 50/662
0·39 (0·25–0·60)
Test for heterogeneity: Q=2·69 (2 df), p=0·26; I
2=62·8%
Benzalkonium chloride
Jaeger et al (2001)
594/25
4/25
1·00 (0·22–4·47)
Minocycline–rifampicin
Raad et al (1997)
7036/136
11/130
0·29 (0·16–0·56)
Marik et al (1999)
6511/39
4/38
0·33 (0·11–1·01)
Chatzinikolaou et al (2003)
4816/64
13/66
0·74 (0·32–1·68)
Leon et al (2004)
6245/180
20/187
0·38 (0·22–0·64)
Total (REM)
108/419 48/421
0·39 (0·27–0·55)
Test for heterogeneity: Q=3·24 (3 df), p=0·36; I
2=38·3%
Rifampicin–miconazole
Yucei et al (2004)
7738/105
6/118
0·14 (0·07–0·27)
Total antimicrobial CVCs (REM) 886/3754 572/3730
0·54 (0·43–0·67)
Test for heterogeneity: Q=84·19 (28 df), p=1·00; I
2=67·9%
Standard Comparator
CVCs (n/N)
OR
OR (95% CI)
0·01
0·1
1·0
10
100
Favours antimicrobial CVC
Favours standard CVC
Figure 2: CVC colonisation in
trials comparing
antimicrobial CVCs with
standard CVCs
CATETERI CON CLOREXIDINA-
SULFADIAZINA (CSS)
FAVOURS ANTIMICROBIAL CVC
FAVOURS STANDARD CVC
www.thelancet.com/infection Vol 8 December 2008
769
Review
Silver alloy coated
Bach et al (1999)
457/33
9/34
1·33 (0·44–4·05)
Dunser et al (2005)
5219/160
27/160
1·50 (0·80–2·80)
Goldschmidt et al (1995)
5450/113
54/120
1·03 (0·62–1·73)
Total (FEM)
76/306
90/314
1·21 (0·84–1·77)
Test for heterogeneity: Q=0·85 (2 df), p=0·65; I
2=0%
Silver iontophoretic
Moretti et al (2005)
6664/262
61/252
0·99 (0·66–1·48)
Corral et al (2003)
5041/103
29/103
0·60 (0·34–1·06)
Total (FEM)
105/365
90/355
0·84 (0·60–1·16)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2=0%
Silver impregnated
Stoiser et al (2002)
7414/47
10/50
0·59 (0·24–1·49)
Kalfon et al (2007)
6136/397
47/320
1·25 (0·78–1·98)
Total (FEM)
50/344
57/370
1·07 (0·71–1·62)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2=0%
First-generation CSS
Tennenberg et al (1997)
7532/145
8/137
0·26 (0·14–0·52)
Maki et al (1997)
6447/195
22/208
0·50 (0·30–0·82)
Marik et al (1999)
6511/39
7/36
0·62 (0·22–1·79)
van Heerden et al (1996)
7610/26
4/28
0·29 (0·09–0·97)
Hannan et al (1999)
5671/177
47/174
0·56 (0·36–0·87)
Bach et al (1996)
4436/117
21/116
0·51 (0·28–0·92)
Collin et al (1999)
4925/139
2/98
0·21 (0·09–0·47)
Sheng et al (2000)
7325/122
9/113
0·36 (0·18–0·75)
Heard et al (1998)
5881/157
60/151
0·62 (0·40–0·97)
Dunser et al (2005)
5219/160
12/165
0·59 (0·28–1·23)
Osma et al (2006)
6714/69
14/64
1·10 (0·48–2·52)
Ciresi et al (1996)
4712/127
10/124
0·84 (0·35–2·02)
Jaeger et al (2005)
609/55
5/51
0·57 (0·19–1·74)
Total (FEM)
392/1528
227/1465
0·51 (0·42–0·61)
Test for heterogeneity: Q=15·82 (12 df), p=1·00; I
2=30·5%
Second-generation CSS
Rupp et al (2005)
7259/393
32/384
0·52 (0·34–0·81)
Ostendorf et al (2005)
6831/94
11/90
0·31 (0·16–0·62)
Brun-Buisson et al (2004)
4623/175
7/188
0·29 (0·14–0·61)
Total (REM)
113/662
50/662
0·39 (0·25–0·60)
Test for heterogeneity: Q=2·69 (2 df), p=0·26; I
2=62·8%
Benzalkonium chloride
Jaeger et al (2001)
594/25
4/25
1·00 (0·22–4·47)
Minocycline–rifampicin
Raad et al (1997)
7036/136
11/130
0·29 (0·16–0·56)
Marik et al (1999)
6511/39
4/38
0·33 (0·11–1·01)
Chatzinikolaou et al (2003)
4816/64
13/66
0·74 (0·32–1·68)
Leon et al (2004)
6245/180
20/187
0·38 (0·22–0·64)
Total (REM)
108/419
48/421
0·39 (0·27–0·55)
Test for heterogeneity: Q=3·24 (3 df), p=0·36; I
2=38·3%
Rifampicin–miconazole
Yucei et al (2004)
7738/105
6/118
0·14 (0·07–0·27)
Total antimicrobial CVCs (REM) 886/3754
572/3730
0·54 (0·43–0·67)
Test for heterogeneity: Q=84·19 (28 df), p=1·00; I
2=67·9%
Standard
Comparator
CVCs (n/N)
OR
OR (95% CI)
0·01
0·1
1·0
10
100
Favours antimicrobial CVC
Favours standard CVC
Figure 2: CVC colonisation in
trials comparing
antimicrobial CVCs with
standard CVCs
CATETERI CON CLOREXIDINA-
SULFADIAZINA (CSS)
Ø
I cateteri CSS di
prima e seconda generazione
SONO EFFICACI
nella
riduzione della colonizzazione
Ø
I cateteri CSS di
prima generazione
sono efficaci nella
riduzione
delle CRBSI
Ø
I cateteri CSS di
seconda generazione
sono efficaci nella riduzione
delle
CRBSI
, ma
in maniera meno significativa
, probabilmente
perché gli studi su di essi sono stati condotti in anni più recenti, in cui
l’incidenza di CRBSI era comunque diminuita
per l’implementazione
Limitazioni dei cateteri CSS
Ø
Resistenze in vitro
a Acinetobacter baumanii,
Stenotrophomoas maltophilia, Enterobacter cloacae
Ø
Resistenze in vivo
, però,
mai segnalate
CATETERI con
MINOCICLINA-RIFAMPICINA (MR)
www.thelancet.com/infection Vol 8 December 2008
769
Review
Silver alloy coated
Bach et al (1999)
45
7/33
9/34
1·33 (0·44–4·05)
Dunser et al (2005)
52
19/160 27/160
1·50 (0·80–2·80)
Goldschmidt et al (1995)
54
50/113 54/120
1·03 (0·62–1·73)
Total (FEM)
76/306 90/314
1·21 (0·84–1·77)
Test for heterogeneity: Q=0·85 (2 df), p=0·65; I
2
=0%
Silver iontophoretic
Moretti et al (2005)
66
64/262 61/252
0·99 (0·66–1·48)
Corral et al (2003)
50
41/103 29/103
0·60 (0·34–1·06)
Total (FEM)
105/365 90/355
0·84 (0·60–1·16)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2
=0%
Silver impregnated
Stoiser et al (2002)
74
14/47
10/50
0·59 (0·24–1·49)
Kalfon et al (2007)
61
36/397 47/320
1·25 (0·78–1·98)
Total (FEM)
50/344 57/370
1·07 (0·71–1·62)
Test for heterogeneity: Q=1·99 (1 df), p=0·16; I
2
=0%
First-generation CSS
Tennenberg et al (1997)
75
32/145
8/137
0·26 (0·14–0·52)
Maki et al (1997)
64
47/195 22/208
0·50 (0·30–0·82)
Marik et al (1999)
65
11/39
7/36
0·62 (0·22–1·79)
van Heerden et al (1996)
76
10/26
4/28
0·29 (0·09–0·97)
Hannan et al (1999)
56
71/177 47/174
0·56 (0·36–0·87)
Bach et al (1996)
44
36/117 21/116
0·51 (0·28–0·92)
Collin et al (1999)
49
25/139
2/98
0·21 (0·09–0·47)
Sheng et al (2000)
73
25/122
9/113
0·36 (0·18–0·75)
Heard et al (1998)
58
81/157 60/151
0·62 (0·40–0·97)
Dunser et al (2005)
52
19/160 12/165
0·59 (0·28–1·23)
Osma et al (2006)
67
14/69
14/64
1·10 (0·48–2·52)
Ciresi et al (1996)
47
12/127 10/124
0·84 (0·35–2·02)
Jaeger et al (2005)
60
9/55
5/51
0·57 (0·19–1·74)
Total (FEM)
392/1528 227/1465
0·51 (0·42–0·61)
Test for heterogeneity: Q=15·82 (12 df), p=1·00; I
2
=30·5%
Second-generation CSS
Rupp et al (2005)
72
59/393 32/384
0·52 (0·34–0·81)
Ostendorf et al (2005)
68
31/94
11/90
0·31 (0·16–0·62)
Brun-Buisson et al (2004)
46
23/175
7/188
0·29 (0·14–0·61)
Total (REM)
113/662 50/662
0·39 (0·25–0·60)
Test for heterogeneity: Q=2·69 (2 df), p=0·26; I
2
=62·8%
Benzalkonium chloride
Jaeger et al (2001)
59
4/25
4/25
1·00 (0·22–4·47)
Minocycline–rifampicin
Raad et al (1997)
70
36/136 11/130
0·29 (0·16–0·56)
Marik et al (1999)
65
11/39
4/38
0·33 (0·11–1·01)
Chatzinikolaou et al (2003)
48
16/64
13/66
0·74 (0·32–1·68)
Leon et al (2004)
62
45/180 20/187
0·38 (0·22–0·64)
Total (REM)
108/419 48/421
0·39 (0·27–0·55)
Test for heterogeneity: Q=3·24 (3 df), p=0·36; I
2
=38·3%
Rifampicin–miconazole
Yucei et al (2004)
77
38/105
6/118
0·14 (0·07–0·27)
Total antimicrobial CVCs (REM) 886/3754 572/3730
0·54 (0·43–0·67)
Test for heterogeneity: Q=84·19 (28 df), p=1·00; I
2
=67·9%
Standard Comparator
CVCs (n/N)
OR
OR (95% CI)
0·01
0·1
1·0
10
100
Favours antimicrobial CVC
Favours standard CVC
Figure 2: CVC colonisation in
trials comparing
antimicrobial CVCs with
standard CVCs
Within each subgroup, the
studies are ordered by
increasing mean catheter
indwell duration. The vertical
line represents the null
hypothesis of no diff erence
between test and control
groups. Odds ratios (ORs) and
95% CIs are shown. Black
diamonds indicate the pooled
ORs (95% CIs). Results of the
Peto fi xed-eff ects model
(FEM) are quoted unless
substantial heterogeneity is
present, in which case results
of the DerSimonian-Laird
random-eff ects model (REM)
are stated.
CATETERI con
MINOCICLINA-RIFAMPICINA (MR)
ü
I cateteri MR
SONO EFFICACI
nella riduzione della
colonizzazione e delle CRBSI
ü
Superiorità
in
un trial
di confronto
rispetto a CSS
di prima generazione
(necessità, però,di un
Pur con i limiti indicati, i cateteri
medicati tipo
MR
e
CSS
sono provatamente efficaci nella
riduzione
della colonizzazione e delle CRBSI
ANTIMICROBIAL CENTRAL VENOUS CATHETERS IN ADULTS:
A SYSTEMATIC REVIEW AND METANALYSIS
Cochrane
Database of Systematic Reviews
Catheter impregnation, coating or bonding for reducing
central venous catheter-related infections in adults (Review)
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S.
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults.
Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD007878.
DOI: 10.1002/14651858.CD007878.pub3.
www.cochranelibrary.com
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults (Review)
Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CochraneDatabase of Systematic Reviews
Catheter impregnation, coating or bonding for reducing
central venous catheter-related infections in adults (Review)
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S.
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD007878.
DOI: 10.1002/14651858.CD007878.pub3.
www.cochranelibrary.com
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
•
Impregnated catheter
(MR and CCS) DID REDUCE
the rate of
CRBSI
and
colonization
•
Significant benefits
only
in studies conducted for patients
ICUs
•
No effects on sepsis and mortality
Cochrane
Database of Systematic Reviews
Catheter impregnation, coating or bonding for reducing
central venous catheter-related infections in adults (Review)
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S.
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults.
Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD007878.
DOI: 10.1002/14651858.CD007878.pub3.
www.cochranelibrary.com
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults (Review)
Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CochraneDatabase of Systematic Reviews
Catheter impregnation, coating or bonding for reducing
central venous catheter-related infections in adults (Review)
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S
Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WSC, Saint S.
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD007878.
DOI: 10.1002/14651858.CD007878.pub3.
www.cochranelibrary.com
Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Lai NM et al.
2015
“should be great caution in recommending the use of
antimicrobial-impregnated CVCs
across all settings
without incorporating the current uncertainties on their
o 1485
children in ICU
o
Minocicline/rifampicine
reduced the
risk of bloodstream infection by 57%
compared with standard central venous catheters
o No effects on mortality
Articles
www.thelancet.com Published online March 3, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00340-8 1
Impregnated central venous catheters for prevention of
bloodstream infection in children (the CATCH trial):
a
randomised controlled trial
Ruth E Gilbert, Quen Mok, Kerry Dwan, Katie Harron, Tracy Moitt, Mike Millar, Padmanabhan Ramnarayan, Shane M Tibby, Dyfrig Hughes,
Carrol Gamble, for the CATCH trial investigators*
Summary
Background
Impregnated central venous catheters are recommended for adults to reduce bloodstream infections but
not for children because there is not enough evidence to prove they are eff ective. We aimed to assess the eff ectiveness
of any type of impregnation (antibiotic or heparin) compared with standard central venous catheters to prevent
bloodstream infections in children needing intensive care.
Methods
We did a randomised controlled trial of children admitted to 14 English paediatric intensive care units.
Children younger than 16 years were eligible if they were admitted or being prepared for admission to a participating
paediatric intensive care unit and were expected to need a central venous catheter for 3 or more days. Children were
randomly assigned (1:1:1) to receive a central venous catheter impregnated with antibiotics, a central venous catheter
impregnated with heparin, or a standard central venous catheter with computer generated randomisation in blocks of
three and six, stratifi ed by method of consent, site, and envelope storage location within the site. The clinician
responsible for inserting the central venous catheter was not masked to allocation, but allocation was concealed from
patients, their parents, and the paediatric intensive care unit personnel responsible for their care. The primary
outcome was time to fi rst bloodstream infection between 48 h after randomisation and 48 h after central venous
catheter removal with impregnated (antibiotic or heparin) versus standard central venous catheters, assessed in the
intention-to-treat population. Safety analyses compared central venous catheter-related adverse events in the subset of
children for whom central venous catheter insertion was attempted (per-protocol population). This trial is registered
with ISRCTN number, ISRCTN34884569.
Findings
Between Nov 25, 2010, and Nov 30, 2012,
1485 children were recruited to this study. We randomly assigned
502 children to receive standard central venous catheters, 486 to receive antibiotic-impregnated catheters, and 497 to
receive heparin-impregnated catheters. Bloodstream infection occurred in 18 (4%) of those in the standard catheters
group, 7 (1%) in the antibiotic-impregnated group, and 17 (3%) assigned to heparin-impregnated catheters. Primary
analyses showed no eff ect of impregnated (antibiotic or heparin) catheters compared with standard central venous
catheters (hazard ratio [HR] for time to fi rst bloodstream infection 0·71, 95% CI 0·37–1·34). Secondary analyses
showed that antibiotic central venous catheters were better than standard central venous catheters (HR 0·43,
0·20–0·96) and heparin central venous catheters (HR 0·42, 0·19–0·93), but heparin did not diff er from standard
central venous catheters (HR 1·04, 0·53–2·03). Clinically important and statistically signifi cant absolute risk
diff erences were identifi ed only for antibiotic-impregnated catheters versus standard catheters (–2·15%, 95% CI
–4·09 to –0·20; number needed to treat [NNT] 47, 95% CI 25–500) and antibiotic-impregnated catheters versus
heparin-impregnated catheters (–1·98%, –3·90 to –0·06, NNT 51, 26–1667). Nine children (2%) in the standard
central venous catheter group, 14 (3%) in the antibiotic-impregnated group, and 8 (2%) in the heparin-impregnated
group had catheter-related adverse events. 45 (8%) in the standard group, 35 (8%) antibiotic-impregnated group, and
29 (6%) in the heparin-impregnated group died during the study.
Interpretation
Antibiotic-impregnated central venous catheters signifi cantly reduced the risk of bloodstream
infections compared with standard and heparin central venous catheters. Widespread use of antibiotic-impregnated
central venous catheters could help prevent bloodstream infections in paediatric intensive care units.
Funding
National Institute for Health Research, UK.
Published Online March 3, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)00340-8 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(16)00566-3 *Members listed at end of paper
UCL Institute of Child Health, London, UK (Prof R E Gilbert MD,
K Harron PhD); Paediatric and
Neonatal Intensive Care Unit
(Q Mok MB)and Children’s Acute Transport Service
(P Ramnarayan MD), Great
Ormond Street Hospital for Children, London, UK; Department of Biostatistics
(K Dwan PhD, Prof C Gamble PhD) and
Medicines for Children Clinical Trials Unit University (T Moitt), University of Liverpool, Liverpool, UK; Department of Infection, Barts Health NHS Trust, London, UK
(M Millar PhD); Evelina
Children’s Hospital, St Thomas’s Hospital, London, UK (S M Tibby MB); and Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales (Prof D Hughes PhD)
Correspondence to:
Prof Ruth E Gilbert, UCL Institute of Child Health,
London WC1N 1EH, UK
r.gilbert@ucl.ac.uk
Introduction
Bloodstream infections are important causes of adverse
clinical outcomes and costs to health services. Paediatric
intensive care units have one of the highest reported
rates of hospital-acquired bloodstream infections of any
clinical specialty, with central venous catheters being a
frequent cause of bloodstream infections.
1,2US studies
3–5report the success of improved aseptic practices during
insertion and maintenance of central venous catheters
for reducing rates of catheter-related bloodstream
infections. The Department of Health in England
invested in similar infection reduction initiatives,
RESEARCH ARTICLE
Generalisability and Cost-Impact of
Antibiotic-Impregnated Central Venous
Catheters for Reducing Risk of Bloodstream
Infection in Paediatric Intensive Care Units in
England
Katie Harron1*, Quen Mok2, Dyfrig Hughes3, Berit Muller-Pebody4, Roger Parslow5,
Padmanabhan Ramnarayan6, Ruth Gilbert1
1 Institute of Child Health, University College London, 30 Guilford Street, London WC1 N 1EH, United Kingdom, 2 Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom, 3 Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, LL57 2PZ, United Kingdom, 4 Public Health England, 61 Colindale Avenue, London, NW9 5EQ, United Kingdom, 5 University of Leeds, Leeds, LS2 9JT, United Kingdom, 6 Children’s Acute Transport Service, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom
*k.harron@ucl.ac.uk
Abstract
Background
We determined the generalisability and cost-impact of adopting antibiotic-impregnated CVCs in all paediatric intensive care units (PICUs) in England, based on results from a large randomised controlled trial (the CATCH trial; ISRCTN34884569).
Methods
BSI rates using standard CVCs were estimated through linkage of national PICU audit data (PICANet) with laboratory surveillance data. We estimated the number of BSI averted if PICUs switched from standard to antibiotic-impregnated CVCs by applying the CATCH trial rate-ratio (0.40; 95% CI 0.17,0.97) to the BSI rate using standard CVCs. The value of healthcare resources made available by averting one BSI as estimated from the trial eco-nomic analysis was £10,975; 95% CI -£2,801,£24,751.
Results
The BSI rate using standard CVCs was 4.58 (95% CI 4.42,4.74) per 1000 CVC-days in 2012. Applying the rate-ratio gave 232 BSI averted using antibiotic CVCs. The additional cost of purchasing antibiotic-impregnated compared with standard CVCs was £36 for each child, corresponding to additional costs of £317,916 for an estimated 8831 CVCs required in PICUs in 2012. Based on 2012 BSI rates, management of BSI in PICUs cost £2.5 million annually (95% uncertainty interval: -£160,986, £5,603,005). The additional cost of antibiotic
PLOS ONE | DOI:10.1371/journal.pone.0151348 March 21, 2016 1 / 11 OPEN ACCESS
Citation: Harron K, Mok Q, Hughes D, Muller-Pebody B, Parslow R, Ramnarayan P, et al. (2016) Generalisability and Cost-Impact of Antibiotic-Impregnated Central Venous Catheters for Reducing Risk of Bloodstream Infection in Paediatric Intensive Care Units in England. PLoS ONE 11(3): e0151348. doi:10.1371/journal.pone.0151348
Editor: Ewout W Steyerberg, University Medical Center Rotterdam, NETHERLANDS Received: January 21, 2016 Accepted: January 28, 2016 Published: March 21, 2016
Copyright: © 2016 Harron et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability Statement: As the underlying data set contains patient-level data, we are not able to deposit the data set publicly. Access to the data will need to be approved via the Trial Management Group (TMG). Requests for data should be sent to the Chief Investigator for the CATCH trial and will be considered by members of the TMG. The TMG will consider the purpose of the request and consider research duplication and resource implications for its provision. The contact email for the CATCH trial TMG iscatch.trial@liv.ac.uk.
RESEARCH ARTICLE
Generalisability and Cost-Impact of
Antibiotic-Impregnated Central Venous
Catheters for Reducing Risk of Bloodstream
Infection in Paediatric Intensive Care Units in
England
Katie Harron1*, Quen Mok2, Dyfrig Hughes3, Berit Muller-Pebody4, Roger Parslow5,
Padmanabhan Ramnarayan6, Ruth Gilbert1
1 Institute of Child Health, University College London, 30 Guilford Street, London WC1 N 1EH, United Kingdom, 2 Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom, 3 Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, LL57 2PZ, United Kingdom, 4 Public Health England, 61 Colindale Avenue, London, NW9 5EQ, United Kingdom, 5 University of Leeds, Leeds, LS2 9JT, United Kingdom, 6 Children’s Acute Transport Service, Great Ormond Street Hospital, London, WC1N 3JH, United Kingdom
*k.harron@ucl.ac.uk
Abstract
Background
We determined the generalisability and cost-impact of adopting antibiotic-impregnated CVCs in all paediatric intensive care units (PICUs) in England, based on results from a large randomised controlled trial (the CATCH trial; ISRCTN34884569).
Methods
BSI rates using standard CVCs were estimated through linkage of national PICU audit data (PICANet) with laboratory surveillance data. We estimated the number of BSI averted if PICUs switched from standard to antibiotic-impregnated CVCs by applying the CATCH trial rate-ratio (0.40; 95% CI 0.17,0.97) to the BSI rate using standard CVCs. The value of healthcare resources made available by averting one BSI as estimated from the trial eco-nomic analysis was £10,975; 95% CI -£2,801,£24,751.
Results
The BSI rate using standard CVCs was 4.58 (95% CI 4.42,4.74) per 1000 CVC-days in 2012. Applying the rate-ratio gave 232 BSI averted using antibiotic CVCs. The additional cost of purchasing antibiotic-impregnated compared with standard CVCs was £36 for each child, corresponding to additional costs of £317,916 for an estimated 8831 CVCs required in PICUs in 2012. Based on 2012 BSI rates, management of BSI in PICUs cost £2.5 million annually (95% uncertainty interval: -£160,986, £5,603,005). The additional cost of antibiotic
PLOS ONE | DOI:10.1371/journal.pone.0151348 March 21, 2016 1 / 11 OPEN ACCESS
Citation: Harron K, Mok Q, Hughes D, Muller-Pebody B, Parslow R, Ramnarayan P, et al. (2016) Generalisability and Cost-Impact of Antibiotic-Impregnated Central Venous Catheters for Reducing Risk of Bloodstream Infection in Paediatric Intensive Care Units in England. PLoS ONE 11(3): e0151348. doi:10.1371/journal.pone.0151348 Editor: Ewout W Steyerberg, University Medical Center Rotterdam, NETHERLANDS Received: January 21, 2016 Accepted: January 28, 2016 Published: March 21, 2016 Copyright: © 2016 Harron et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability Statement: As the underlying data set contains patient-level data, we are not able to deposit the data set publicly. Access to the data will need to be approved via the Trial Management Group (TMG). Requests for data should be sent to the Chief Investigator for the CATCH trial and will be considered by members of the TMG. The TMG will consider the purpose of the request and consider research duplication and resource implications for its provision. The contact email for the CATCH trial TMG iscatch.trial@liv.ac.uk.
v
The additional cost of antibiotic-impregnated CVCs=
£36
for each child
v
Total additional costs of
£317,916
(8831 CVCs required in PICUs in 2012)
v
BSI rates >1.2 per 1000 CVC-days (2012)
•
60 STUDIES
•
17,255 Catheters
•
14 types of impregnation
Clinical Infectious Diseases
Clinical Infectious Diseases® 2017;64(S2):S131–40
Efficacy of Antimicrobial CVCs in Reducing Catheter-Related BSIs • CID 2017:64 (Suppl 2) • S131
Comparative Efficacy of Antimicrobial Central Venous
Catheters in Reducing Catheter-Related Bloodstream
Infections in Adults: Abridged Cochrane Systematic
Review and Network Meta-Analysis
Huey Yi Chong,1 Nai Ming Lai,1,2 Anucha Apisarnthanarak,3 and Nathorn Chaiyakunapruk1,4,5,6
1School of Pharmacy, Monash University Malaysia; 2School of Medicine, Taylor’s University Lakeside Campus, Malaysia; 3Division of Infectious Diseases, Faculty of Medicine, Thammasat
University Hospital, Pratumthani, Thailand; 4School of Population Health, University of Queensland, Brisbane, Australia; 5Center of Pharmaceutical Outcomes Research, Department of Pharmacy
Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; and 6School of Pharmacy, University of Wisconsin, Madison
Background. The efficacy of antimicrobial central venous catheters (CVCs) remains questionable. In this network meta-analysis,
we aimed to assess the comparative efficacy of antimicrobial CVC impregnations in reducing catheter-related infections in adults.
Methods. We searched 4 electronic databases (Medline, the Cochrane Central Register of Controlled Trials, Embase, CINAHL)
and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016. Studies
that assessed CVCs with antimicrobial impregnation with nonimpregnated catheters or catheters with another impregnation were
included. Primary outcomes were clinically diagnosed sepsis, catheter-related bloodstream infection (CRBSI), and all-cause
mortal-ity. We performed a network meta-analysis to estimate risk ratio (RR) with 95% confidence interval (CI).
Results. Sixty studies with 17 255 catheters were included. The effects of 14 impregnations were investigated. Both CRBSI and
catheter colonization were the most commonly evaluated outcomes. Silver-impregnated CVCs significantly reduced clinically
diag-nosed sepsis compared with silver-impregnated cuffs (RR, 0.54 [95% CI, .29–.99]). When compared to no impregnation, significant
CRBSI reduction was associated with minocycline-rifampicin (RR, 0.29 [95% CI, .16–.52]) and silver (RR, 0.57 [95% CI, .38–.86])
impregnations. No impregnations significantly reduced all-cause mortality. For catheter colonization, significant decreases were
shown by miconazole-rifampicin (RR, 0.14 [95% CI, .05–.36]), 5-fluorouracil (RR, 0.34 [95% CI, .14–.82]), and chlorhexidine-silver
sulfadiazine (RR, 0.60 [95% CI, .50–.72]) impregnations compared with no impregnation. None of the studies evaluated antibiotic/
antiseptic resistance as the outcome.
Conclusions. Current evidence suggests that the minocycline-rifampicin—impregnated CVC appears to be the most effective in
preventing CRBSI. However, its overall benefits in reducing clinical sepsis and mortality remain uncertain. Surveillance for antibiotic
resistance attributed to the routine use of antimicrobial-impregnated CVCs should be emphasized in future trials.
Key words. catheter-related bloodstream infection; catheter colonization; central venous catheter.
The central venous catheter (CVC) is an essential device for
intensive care, cancer patients, or patients who require
paren-teral nutrition. However, catheter-related bloodstream infection
(CRBSI) is a major complication of CVCs, with its associated
mortality, morbidities, and costs [
1–5
]. In the United States, the
annual cases of CRBSI were estimated at 11 000 in 2010 [
6
] and
at 14 400 in 4 European countries (France, Germany, Italy, and
the United Kingdom) with associated annual costs of between
€35.9 and €163.9 million [
4
]. CRBSI remains an important
patient safety problem in high-, middle-, and low-income
coun-tries [
5
,
7–11
].
Several measures are in use to prevent CRBSI, including
max-imal sterile barriers [
12
], CVC site disinfection, and avoidance
of the femoral site for catheter insertion [
1
,
13–15
]. Since 1980s,
catheter impregnation with antiseptic or antibiotics has been
developed [
2
]. Among them, chlorhexidine-silver sulfadiazine
(CSS) and minocycline-rifampicin (MNR) impregnations are
the most commonly studied to date [
16
,
17
]. Other compounds
such as silver (SIL), platinum, carbon, and heparin (HEP) have
also been evaluated as CVC-impregnation materials [
18–20
]. It
is proposed that antimicrobial impregnation of the CVCs
inhib-its the colonization of microorganisms on the catheter surface
and prevents their spread into the bloodstream [
2
]. In vitro
and animal studies revealed the efficacy of these impregnated
S U P P L E M E N T A R T I C L E
© The Author 2017. Published by Oxford University Press for the Infectious Diseases Soci-ety of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/cix019
Correspondence: N. Chaiyakunapruk, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor, Malaysia (nathorn.chaiyakunapruk@ monash.edu).
Clinical Infectious Diseases
Clinical Infectious Diseases® 2017;64(S2):S131–40
Efficacy of Antimicrobial CVCs in Reducing Catheter-Related BSIs • CID 2017:64 (Suppl 2) • S131
Comparative Efficacy of Antimicrobial Central Venous
Catheters in Reducing Catheter-Related Bloodstream
Infections in Adults: Abridged Cochrane Systematic
Review and Network Meta-Analysis
Huey Yi Chong,1 Nai Ming Lai,1,2 Anucha Apisarnthanarak,3 and Nathorn Chaiyakunapruk1,4,5,6
1School of Pharmacy, Monash University Malaysia; 2School of Medicine, Taylor’s University Lakeside Campus, Malaysia; 3Division of Infectious Diseases, Faculty of Medicine, Thammasat
University Hospital, Pratumthani, Thailand; 4School of Population Health, University of Queensland, Brisbane, Australia; 5Center of Pharmaceutical Outcomes Research, Department of Pharmacy
Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; and 6School of Pharmacy, University of Wisconsin, Madison
Background. The efficacy of antimicrobial central venous catheters (CVCs) remains questionable. In this network meta-analysis,
we aimed to assess the comparative efficacy of antimicrobial CVC impregnations in reducing catheter-related infections in adults.
Methods. We searched 4 electronic databases (Medline, the Cochrane Central Register of Controlled Trials, Embase, CINAHL)
and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016. Studies that assessed CVCs with antimicrobial impregnation with nonimpregnated catheters or catheters with another impregnation were included. Primary outcomes were clinically diagnosed sepsis, catheter-related bloodstream infection (CRBSI), and all-cause mortal-ity. We performed a network meta-analysis to estimate risk ratio (RR) with 95% confidence interval (CI).
Results. Sixty studies with 17 255 catheters were included. The effects of 14 impregnations were investigated. Both CRBSI and
catheter colonization were the most commonly evaluated outcomes. Silver-impregnated CVCs significantly reduced clinically diag-nosed sepsis compared with silver-impregnated cuffs (RR, 0.54 [95% CI, .29–.99]). When compared to no impregnation, significant CRBSI reduction was associated with minocycline-rifampicin (RR, 0.29 [95% CI, .16–.52]) and silver (RR, 0.57 [95% CI, .38–.86]) impregnations. No impregnations significantly reduced all-cause mortality. For catheter colonization, significant decreases were shown by miconazole-rifampicin (RR, 0.14 [95% CI, .05–.36]), 5-fluorouracil (RR, 0.34 [95% CI, .14–.82]), and chlorhexidine-silver sulfadiazine (RR, 0.60 [95% CI, .50–.72]) impregnations compared with no impregnation. None of the studies evaluated antibiotic/ antiseptic resistance as the outcome.
Conclusions. Current evidence suggests that the minocycline-rifampicin—impregnated CVC appears to be the most effective in
preventing CRBSI. However, its overall benefits in reducing clinical sepsis and mortality remain uncertain. Surveillance for antibiotic resistance attributed to the routine use of antimicrobial-impregnated CVCs should be emphasized in future trials.
Key words. catheter-related bloodstream infection; catheter colonization; central venous catheter.
The central venous catheter (CVC) is an essential device for intensive care, cancer patients, or patients who require paren-teral nutrition. However, catheter-related bloodstream infection (CRBSI) is a major complication of CVCs, with its associated mortality, morbidities, and costs [1–5]. In the United States, the annual cases of CRBSI were estimated at 11 000 in 2010 [6] and at 14 400 in 4 European countries (France, Germany, Italy, and the United Kingdom) with associated annual costs of between
€35.9 and €163.9 million [4]. CRBSI remains an important patient safety problem in high-, middle-, and low-income coun-tries [5, 7–11].
Several measures are in use to prevent CRBSI, including max-imal sterile barriers [12], CVC site disinfection, and avoidance of the femoral site for catheter insertion [1, 13–15]. Since 1980s, catheter impregnation with antiseptic or antibiotics has been developed [2]. Among them, chlorhexidine-silver sulfadiazine (CSS) and minocycline-rifampicin (MNR) impregnations are the most commonly studied to date [16, 17]. Other compounds such as silver (SIL), platinum, carbon, and heparin (HEP) have also been evaluated as CVC-impregnation materials [18–20]. It is proposed that antimicrobial impregnation of the CVCs inhib-its the colonization of microorganisms on the catheter surface and prevents their spread into the bloodstream [2]. In vitro and animal studies revealed the efficacy of these impregnated
S U P P L E M E N T A R T I C L E
© The Author 2017. Published by Oxford University Press for the Infectious Diseases Soci-ety of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/cix019
Correspondence: N. Chaiyakunapruk, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor, Malaysia (nathorn.chaiyakunapruk@ monash.edu).
Clinical Infectious Diseases
Clinical Infectious Diseases® 2017;64(S2):S131–40
Efficacy of Antimicrobial CVCs in Reducing Catheter-Related BSIs • CID 2017:64 (Suppl 2) • S131
Comparative Efficacy of Antimicrobial Central Venous
Catheters in Reducing Catheter-Related Bloodstream
Infections in Adults: Abridged Cochrane Systematic
Review and Network Meta-Analysis
Huey Yi Chong,1 Nai Ming Lai,1,2 Anucha Apisarnthanarak,3 and Nathorn Chaiyakunapruk1,4,5,6
1School of Pharmacy, Monash University Malaysia; 2School of Medicine, Taylor’s University Lakeside Campus, Malaysia; 3Division of Infectious Diseases, Faculty of Medicine, Thammasat
University Hospital, Pratumthani, Thailand; 4School of Population Health, University of Queensland, Brisbane, Australia; 5Center of Pharmaceutical Outcomes Research, Department of Pharmacy
Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; and 6School of Pharmacy, University of Wisconsin, Madison
Background. The efficacy of antimicrobial central venous catheters (CVCs) remains questionable. In this network meta-analysis,
we aimed to assess the comparative efficacy of antimicrobial CVC impregnations in reducing catheter-related infections in adults.
Methods. We searched 4 electronic databases (Medline, the Cochrane Central Register of Controlled Trials, Embase, CINAHL)
and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016. Studies that assessed CVCs with antimicrobial impregnation with nonimpregnated catheters or catheters with another impregnation were included. Primary outcomes were clinically diagnosed sepsis, catheter-related bloodstream infection (CRBSI), and all-cause mortal-ity. We performed a network meta-analysis to estimate risk ratio (RR) with 95% confidence interval (CI).
Results. Sixty studies with 17 255 catheters were included. The effects of 14 impregnations were investigated. Both CRBSI and
catheter colonization were the most commonly evaluated outcomes. Silver-impregnated CVCs significantly reduced clinically diag-nosed sepsis compared with silver-impregnated cuffs (RR, 0.54 [95% CI, .29–.99]). When compared to no impregnation, significant CRBSI reduction was associated with minocycline-rifampicin (RR, 0.29 [95% CI, .16–.52]) and silver (RR, 0.57 [95% CI, .38–.86]) impregnations. No impregnations significantly reduced all-cause mortality. For catheter colonization, significant decreases were shown by miconazole-rifampicin (RR, 0.14 [95% CI, .05–.36]), 5-fluorouracil (RR, 0.34 [95% CI, .14–.82]), and chlorhexidine-silver sulfadiazine (RR, 0.60 [95% CI, .50–.72]) impregnations compared with no impregnation. None of the studies evaluated antibiotic/ antiseptic resistance as the outcome.
Conclusions. Current evidence suggests that the minocycline-rifampicin—impregnated CVC appears to be the most effective in
preventing CRBSI. However, its overall benefits in reducing clinical sepsis and mortality remain uncertain. Surveillance for antibiotic resistance attributed to the routine use of antimicrobial-impregnated CVCs should be emphasized in future trials.
Key words. catheter-related bloodstream infection; catheter colonization; central venous catheter.
The central venous catheter (CVC) is an essential device for intensive care, cancer patients, or patients who require paren-teral nutrition. However, catheter-related bloodstream infection (CRBSI) is a major complication of CVCs, with its associated mortality, morbidities, and costs [1–5]. In the United States, the annual cases of CRBSI were estimated at 11 000 in 2010 [6] and at 14 400 in 4 European countries (France, Germany, Italy, and the United Kingdom) with associated annual costs of between
€35.9 and €163.9 million [4]. CRBSI remains an important patient safety problem in high-, middle-, and low-income coun-tries [5, 7–11].
Several measures are in use to prevent CRBSI, including max-imal sterile barriers [12], CVC site disinfection, and avoidance of the femoral site for catheter insertion [1, 13–15]. Since 1980s, catheter impregnation with antiseptic or antibiotics has been developed [2]. Among them, chlorhexidine-silver sulfadiazine (CSS) and minocycline-rifampicin (MNR) impregnations are the most commonly studied to date [16, 17]. Other compounds such as silver (SIL), platinum, carbon, and heparin (HEP) have also been evaluated as CVC-impregnation materials [18–20]. It is proposed that antimicrobial impregnation of the CVCs inhib-its the colonization of microorganisms on the catheter surface and prevents their spread into the bloodstream [2]. In vitro and animal studies revealed the efficacy of these impregnated
S U P P L E M E N T A R T I C L E
© The Author 2017. Published by Oxford University Press for the Infectious Diseases Soci-ety of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/cix019
Major Article
Are antimicrobial peripherally inserted central catheters associated
with reduction in central line-associated bloodstream infection?
A systematic review and meta-analysis
Rachel D. Kramer BS
a,*
, Mary A.M. Rogers PhD
b,c, Marisa Conte MLIS
d, Jason Mann MSA
b,
Sanjay Saint MD, MPH
b,c, Vineet Chopra MD, MSc
b,caUniversity of Michigan School of Medicine, Ann Arbor, MI
bThe Patient Safety Enhancement Program and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI cDivision of General Internal Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
dTaubman Health Science Library, University of Michigan School of Medicine, Ann Arbor, MI
Key Words:
Antimicrobial-coated Central venous access Infection prevention
Background: Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central
line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction.
Methods: MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016;
conference proceedings were searched to identify additional studies. Study selection and data extrac-tion were performed independently by 2 authors.
Results: Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies
included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I2, 71.6%; T2 = 1.07) was resolved by publication
type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003).
Conclusions: Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in
high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
INTRODUCTION
Use of peripherally inserted central catheters (PICCs) in hospi-talized patients and patients requiring long-term venous access has
increased substantially during the past decade.1,2When it comes to
central venous access, PICCs represent an advancement because they are easier and safer to insert, durable, and cost-effective
com-pared with traditional central venous catheters (CVCs).3-5Like
traditional CVCs, however, PICCs are associated with central
line-associated bloodstream infection (CLABSI).6-10These infections are
problematic because they increase morbidity, cost, duration of hos-pital stay, and mortality.11
In an effort to reduce CLABSI, strategies such as a checklist of best practices during catheter insertion and alcohol-and-chlorhexidine skin preparation have been introduced.12The recognition that CLABSI
often occurs by migration of bacteria from the catheter entry site
* Address correspondence to Rachel D. Kramer BS, University of Michigan School of Medicine, Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI, 48109
E-mail address:rdkramer@med.umich.edu(R.D. Kramer).
VC is supported by a career development award from the Agency of Health-care Research and Quality (1-K08-HS022835-01). The funding source had no role in the design, writing, analysis, or decision to submit this article for publication.
Concept and design were provided by RK, MAMR, MC, JM, SS, and VC. First draft was developed by RK, SS, VC, MC, and JM. Literature search was conducted by RK, MC, JM, and VC. Statistical analysis was conducted by MAMR and VC. Editing of the first draft and final approval was provided by RK, MAMR, MC, JM, SS, and VC.
This work does not necessarily represent the views of the US Government or the Department of Veterans Affairs.
Systematic Review Protocol: CRD-42015016958 available athttp://www.crd .york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015016958.
Conflicts of interest: None to report.
ARTICLE IN PRESS
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.07.021
American Journal of Infection Control ■■ (2016) ■■-■■
Contents lists available atScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
American Journal of Infection Control
Major Article
Are antimicrobial peripherally inserted central catheters associated
with reduction in central line-associated bloodstream infection?
A systematic review and meta-analysis
Rachel D. Kramer BS
a,*
, Mary A.M. Rogers PhD
b,c, Marisa Conte MLIS
d, Jason Mann MSA
b,
Sanjay Saint MD, MPH
b,c, Vineet Chopra MD, MSc
b,caUniversity of Michigan School of Medicine, Ann Arbor, MI
bThe Patient Safety Enhancement Program and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI cDivision of General Internal Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI
dTaubman Health Science Library, University of Michigan School of Medicine, Ann Arbor, MI
Key Words:
Antimicrobial-coated Central venous access Infection prevention
Background: Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central
line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed
to evaluate whether antimicrobial PICCs are associated with CLABSI reduction.
Methods: MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016;
conference proceedings were searched to identify additional studies. Study selection and data
extrac-tion were performed independently by 2 authors.
Results: Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies
included adult and pediatric patients from intensive care, long-term care, and general ward settings. The
incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI],
0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with
noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk
[RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I
2, 71.6%; T2 = 1.07) was resolved by publication
type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74).
Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of
adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003).
Conclusions: Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in
high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.
INTRODUCTION
Use of peripherally inserted central catheters (PICCs) in
hospi-talized patients and patients requiring long-term venous access has
increased substantially during the past decade.
1,2When it comes to
central venous access, PICCs represent an advancement because they
are easier and safer to insert, durable, and cost-effective
com-pared with traditional central venous catheters (CVCs).
3-5Like
traditional CVCs, however, PICCs are associated with central
line-associated bloodstream infection (CLABSI).
6-10These infections are
problematic because they increase morbidity, cost, duration of
hos-pital stay, and mortality.
11In an effort to reduce CLABSI, strategies such as a checklist of best
practices during catheter insertion and alcohol-and-chlorhexidine
skin preparation have been introduced.
12The recognition that CLABSI
often occurs by migration of bacteria from the catheter entry site
* Address correspondence to Rachel D. Kramer BS, University of Michigan School of Medicine, Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI, 48109
E-mail address:rdkramer@med.umich.edu(R.D. Kramer).
VC is supported by a career development award from the Agency of Health-care Research and Quality (1-K08-HS022835-01). The funding source had no role in the design, writing, analysis, or decision to submit this article for publication.
Concept and design were provided by RK, MAMR, MC, JM, SS, and VC. First draft was developed by RK, SS, VC, MC, and JM. Literature search was conducted by RK, MC, JM, and VC. Statistical analysis was conducted by MAMR and VC. Editing of the first draft and final approval was provided by RK, MAMR, MC, JM, SS, and VC.
This work does not necessarily represent the views of the US Government or the Department of Veterans Affairs.
Systematic Review Protocol: CRD-42015016958 available athttp://www.crd .york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015016958.
Conflicts of interest: None to report.
ARTICLE IN PRESS
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.07.021
American Journal of Infection Control ■■ (2016) ■■-■■
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