The Importance of Chlorohexidine in Catheter Placement and Maintenance

Abstract

Clinical problem: Central venous catheters (CVC) are used in patients who require a steady supply of medicines, nutrients, or direct blood supply to the heart, and can be left in place for much longer than intravenous catheters. Central Line-Associated Bloodstream Infections (CLABSI) occur over the course of a CVC placement due to a host of reasons. CLABSI represents a significant threat to the health and well-being of patients who require long-term supplies of medicines, nutrients, or direct blood supply to the heart.

Objective: To distinguish the most effective evidence-based practices for implementation within non-ICU, general population patients who require CVC. A specific objective is to distinguish the most effective method of decreasing CLABSI within non-ICU patients through the regular utilization of chlorohexidine impregnated dressings.

Data sources: Published results of three randomized control trials were obtained using PubMed. In order to focus the search parameters, the key words used included: chlorohexidine, CLABSI, non-ICU, central catheter, and patient cleansing. A clinical guideline for the reduction of CLABSI was obtained from the Centers for Disease Control and Prevention.

Results: Chlorohexidine impregnated catheters showed a significant decrease in the incidence of CLABSI for all patient populations. Interventions such as evidence-based practices and training programs for healthcare professionals implicated in CVC placement showed a significant decrease in the prevalence of CLABSI.

Conclusion: Chlorohexidine is an important factor in reducing CLABSI across all patient populations, and while the guidelines are challenging for ICU conditions they can be implemented in general patient populations when necessary.

The Importance of Chlorohexidine in Catheter Placement and Maintenance

With the advent of new evidence-based practices coupled to the technological gains of the medical industry, health care professionals are able to apply lifesaving therapies with a broader reach. Central venous catheters (CVC) are important tools in the care for patients requiring long term supplies of medicines, nutrients, or direct blood supply to the heart. Such catheters are beginning to be used more and more outside of intensive care units (ICU), and within general patient populations.

While the use of a CVC may be indicated in non-ICU patients, the prevalence of central line-associate bloodstream infections (CLABSI) presents just as large of a risk. While such patients may not be affected as severely by CLABSI as ICU patients, such infection presents a significant risk. O’Grady et al. (2011) has laid out a set of important pathogenic determinants when considering the use of CVC in non-ICU patients including a consideration of the material the catheter is made from, the incidence of protein adhesions around catheters which can lead to a more potent infection, the intrinsic virulence factors of organisms that could possibly infect the patient in question, and the capacity for nursing care to maintain the CVC insertion site (O’Grady et al., 2011). Daily cleansing of patients with a CVC is one of the most important preventative measure that keep a general population patient from contracting CLABSI. In order to determine proper evidence-based practices the following research question is proposed: In general, medical patients (non-ICU) with central lines, would daily bathing with chlorohexidine-impregnated wipes compared with non-antimicrobial cloths decrease the incidence of CLABSI within one months?

Literature Search

A computerized search of the PUBMED databases for publications in any language was conducted using the key words chlorohexidine, CLABSI, non-ICU, central catheter, and patient cleansing. The listed references from each case study were reviewed for additional studies, and review articles focused on chlorohexidine, CLABSI, non-ICU CVC, and patient cleansing in patients with CVC were summarized to gain insights into randomized, clinical trials relating to the subject matter.

Literature Review

Three randomized, controlled trials were evaluated for evidence-based practices that could answer the PICOT question: In general, medical patients (non-ICU) with central lines, would daily bathing with chlorohexidine-impregnated wipes compared with non-antimicrobial cloths decrease the incidence of CLABSI within one months?

The first study by Maki, Stolz, Wheele, and Mermel (1997) was used as a baseline to determine the efficacy of chlorohexidine in CVC placement and maintenance. As the study took place in the early stages of chlorohexidine use for CVC utilization, it was determined to be relevant to the utilization of a novel chlorohexidine therapy. The study by Maki et al. (1997), centered at the University of Wisconsin-Madison, was an important randomized, controlled trial when CVC-related infections began to rise, and chlorohexidine was implicated in decrease CLABSI. The purpose of the study was to determine how effective a novel antiseptic catheter was at decreasing CLABSI, to distinguish certain sources of CLABSI, and to determine how well patients would respond to a new antiseptic catheter (Table 1). The study was conducted in a medical-surgical unit of a 450-bed university hospital and included 158 adults who were previously set to receive a CVC for some measure of treatment (Maki et al., 1997). A total of 403 catheters were implicated in the study, and they were later analyzed for sources of infection. Upon removal of the CVC, catheters were analyzed for colonization with local and systemic effects implicated in infected catheters. Patients who experienced CABSI provided skin samples which were cultured along with catheter segments, hubs, and infusate. Restriction-fragment DNA subtyping was used to confirm colonization results. The study concluded, from the results, that chlorohexidine catheters were well tolerated, reduced the incidence of CVC-related infection, increased the amount of time CVC’s could be left in place, and could even allow for significant cost savings in long term health care incidences (Maki et al., 1997).

The second study by Tennenberg et al. (1997) focused on the efficacy of antibiotic-CVC versus antiseptic-CVC in order to determine new measures for CVC-related infections. As the study took place in the early stages of chlorohexidine use for CVC utilization, it was determined to be relevant to the utilization of a novel chlorohexidine therapy. This prospective, randomized, controlled trial in a tertiary care medical center looked at fresh stick double and triple lumen catheters in 282 patients who required CVC placement as part of their treatment regimen, but were not ICU patients (Table 1). Patients were prospectively randomized to receive either the standard CVC or the antiseptic silver sulfadiazine and chlorohexidine coated CVC (Tennenberg et al., 1997). While the antiseptic CVC showed a significant decrease in catheter site colonization and in local catheter-related infection rates, there was not a significant reduction in the incidence of CVC septicemia. Tennenberg et al. (1997) concluded that this was likely due to an increased pathogenic dependence on contamination of the catheter hub, instead of catheter site colonization at time of CVC introduction.

The third prospective, randomized, controlled trial by Freixas et al. (2013) focused on introducing multimodal interventions within non-ICU wards to address the prevalence of CLABSI in hospitals in Spain. Freixas et al. (2013) used four different measures to run their study including evidence-based bundles of practices relating to catheter insertion, training programs for those involved, tracking forms to follow the status of catheters with a four-point prevalence survey, and feedback reports from healthcare workers (Table 1). Their study took place in 11 hospitals within non-ICU wards in Catalonia, Spain, and their results showed that the incidence of CLABSI from CVC decreased from 0.14 to 0.10 after randomized multimodal interventions, and a statistically significant improvement in the adequate maintenance of CVC in non-ICU wards (Freixas et al., 2013).

O’Grady et al. (2011) has stated recommendations for the utilization of CVC’s, and special care should be made to follow these recommendations when dealing with CVC administration in non-ICU patients. While many recommendations may be out of the hands of nursing staff, such as careful consideration of whether or not to administer a central line when considering the risk of infection, the use of a 2% chlorohexidine wash for daily skin cleansing, regular education on catheter maintenance, time charting of catheter presence in non-ICU patients, and the use of maximal sterile barrier precautions are important measures (O’Grady et al., 2011). By following these evidence-based practices, non-ICU nursing staff can decrease the prevalence of CLABSI in patients who require central venous catheterization.

Synthesis

In order to determine the efficacy of chlorohexidine dressings and regular patient cleansing in the prevention of CLABSI in non-ICU patients, a literature search was conducted for randomized, controlled trials dealing with such situations. The use of CVC’s in non-ICU patients is increasing, along with the incidence of CLABSI in such patients, however there isn’t a large amount of randomized, controlled studies covering this topic. In order to determine evidence-based practices despite the lack of peer-reviewed literature, three randomized, controlled trials were used to aggregate specific measures of the PICOT question: In general medical patients (non-ICU) with central lines, would daily bathing with CHG impregnated wipes compared with non-antimicrobial cloths decrease the incidence of CLABSI within 3 months?

The two studies completed by Maki et al. (1997) and Tennenberg et al. (1997) focused on the utilization of chlorohexidine in the CVC insertion process. Both of these studies have widely been implicated in the use of CVC’s in non-ICU patients. Maki et al. (1997) showed that the utilization of chlorohexidine during the use of CVC’s allowed for a decrease in CABSI as well as a longer-term utilization of the original CVC. Tennenberg et al. (1997) showed that while the patients in their study did not have a significant response to chlorohexidine coated CVC’s, the focus of infection susceptibility was on the hub of the catheter. Finally, Freixas et al. (2013) showed that there was a significant decrease in CLABSI cases when interventions such as regular patient cleansing and prevalence surveys tracking the status of catheters in non-ICU patients were implemented. These three conclusions can be summated to show that chlorohexidine is important in the reduction of CLABSI, primary sites of infection can be reduced by regular patient cleansing, and non-ICU patients can benefit from the use of CVC interventions as long as evidence-based patient care practices related to catheter care are implemented.

Clinical Recommendations

While it is evident that good patient care techniques like regular cleansing and medication tracking are required for treatment measures to take place, healthcare professionals must focus on these regular tasks when new strategies are used on new patient populations. While the utilization of CVC’s in non-ICU patients is nothing new, the use of CVC’s in non-ICU patients is certainly on the rise. Concurrent with this rise is the prevalence of CLABSI in non-ICU patients. An important evidence-based clinical practice that healthcare professionals can implement is the use of a chlorohexidine impregnated dressing and washcloth when doing regularly scheduled cleansing of patients who have, or are set to have, central venous catheterization. This is supported by the findings of Tennenberg et al. (1997) when they showed that while chlorohexidine coated CVC’s can show a decrease in the incidence of CLABSI, it is usually the hub of the catheter that is implicated in colonization of organisms leading to CLABSI. This is also supported by the findings of Freixas et al. (2013) and their conclusions that CVC’s can be a very effective way to provide long-term medication and nutrition regimens, but the incidence of CLABSI will only decrease if the utilization of a CVC is coupled to proper patient cleansing, tracking surveys, and regular feedback.

(Table 1 omitted for preview. Available via download)

References

Maki, D. G., Stolz, S. M., Wheele, S., & Mermel, L. A. (1997). Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter. Annals of Internal Medicine, 127(4), 257.

Freixas, N., Bella, F., Limón, E., Pujol, M., Almirante, B., & Gudiol, F. (2013). Impact of a multimodal intervention to reduce bloodstream infections related to vascular catheters in non-ICU wards: A multicentre study. Clinical Microbiology and Infection, 19(9), 838-844.

O'Grady, N. P., Rupp, M. E., Dellinger, E. P., Burns, L. A., Alexander, M., Heard, S.O.,…, Saint, S. (2011). Guidelines for the prevention of intravascular catheter-related infections. American Journal of Infection Control, 39(4), S1-S34.

Tennenberg, S., Lieser, M., Mccurdy, B., Boomer, G., Howington, E., Newman, C., & Wolf, I. (1997). A prospective randomized trial of an antibiotic-and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Archives of Surgery, 132(12), 1348-1351.