These are described in detail in the Methods section.
ReviewAntimicrobial central venous catheters in adults: a systematic review and meta-analysis
Introduction
Central venous catheters (CVCs) are used primarily to administer drugs, fluids, and to monitor haemodynamic status. Their use is associated with infections, either localised at the site of insertion or systemic with bloodstream infection and metastatic seeding of distant anatomic sites. Indeed, CVCs are also responsible for the highest proportion of hospital-acquired bacteraemias.1 Not surprisingly, catheter-related infections are the most common cause of nosocomial endocarditis,2, 3 and have also been reported to increase medical costs and extend hospital stay independently of other confounding variables.4, 5, 6, 7, 8 Many predisposing risk factors have been reported to be independently associated with the development of catheter-related bloodstream infections (CRBSIs), such as the duration of catheterisation, anatomical location of CVC placement, and the receipt of total parenteral nutrition via the CVC.9, 10, 11, 12
Preventive strategies to reduce the risk of CRBSI include the use of a maximum sterile barrier technique during CVC insertion,13 chlorhexidine-containing cutaneous antiseptics,14 educational programmes for health-care workers,15 comprehensive prevention programmes,16, 17 novel technologies such as chlorhexidine gluconate dressings,18 catheter hubs containing iodinated alcohol,19 and the modification of catheter materials.20, 21, 22
The surfaces of intravascular catheters are ideal for microbial colonisation. After insertion, the catheter surface is conditioned by a film that may include fibrin, fibronectin, fibrinogen, collagen, elastin, thrombospondin, laminin, vitronectin, and von Willibrand's factor.23 The proteins facilitate the adherence of microorganisms (ie, staphylococcal species) in the biofilm. This biofilm, combined with exopolysaccharide material produced by colonising microorganisms, protects them from chemotherapeutic agents and opsonophagocytosis.24 Fragments of biofilm may detach and seed the blood with microorganisms.25
Antimicrobial agents, such as antiseptics or antibiotics coated onto or incorporated into the catheter polymer, have more recently been used in an attempt to prevent colonisation and the development of CRBSI. Several antimicrobial CVCs are currently commercially available within the UK and USA (table 1). 238 500 CVCs were issued in England by UK National Health Service Logistics during the 2004–05 financial year. Of these, 10 077 (4·2%) were antimicrobial, 3452 (34%) of which were silver-impregnated CVCs and the remaining 6625 (66%) were coated with chlorhexidine–silver sulfadiazine (CSS). Thus, current use of antimicrobial CVCs in the UK is relatively low. Data on use in the USA are currently unavailable.
The purpose of this meta-analysis was to determine the efficacy of antimicrobial CVCs on the basis of the available data. All adult populations were included in the analysis and potential reductions in CRBSI were determined. As CVC colonisation can be a precursor to CRBSI,26, 27, 28 this endpoint was also considered.
Section snippets
Methods
The QUORUM (quality of reporting of meta-analyses) statement and Cochrane Collaboration handbook were used as guidance for the completion of this meta-analysis.29, 30
Results
603 potentially relevant references were initially identified by our search (figure 1). Most of these references were excluded because they did not report on RCTs that assessed colonisation or CRBSI rates associated with the use of any available antimicrobial CVC in adults. Of 42 RCTs identified, eight were excluded from the analysis,36, 37, 38, 39, 40, 41, 42, 43 leaving 34 studies eligible for inclusion (table 2).44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63,
Discussion
The pooled results from all trials that assessed the effect of antimicrobial CVCs versus standard CVCs showed a reduction in colonisation and CRBSI. However, results varied between different antimicrobial CVCs. The meta-analysis indicated that silver-alloy-coated CVCs did not reduce colonisation nor CRBSI. Additionally, no reduction in colonisation or CRBSI was shown with either silver-impregnated or silver-iontophoretic CVCs. Silver-alloy-coated and iontophoretic CVCs were also inferior to
Search strategy and selection criteria
References (101)
- et al.
Device related sources of bacteraemia in English hospitals: opportunities for the prevention of hospital-acquired bacteraemia
J Hosp Infect
(2003) - et al.
Rate, risk factors and outcomes of catheter-related bloodstream infection in a paediatric intensive care unit in Saudi Arabia
J Hosp Infect
(2006) - et al.
Antibiotic resistance of bacteria in biofilms
Lancet
(2001) - et al.
Clinical significance of isolated Staphylococcus aureus central venous catheter tip cultures
Clin Microbiol Infect
(2006) - et al.
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUORUM statement
Lancet
(1999) - et al.
Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill
J Hosp Infect
(2002) - et al.
Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections: a prospective, randomized study
Am J Med
(2003) Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: a continuous quality improvement project
Chest
(1999)- et al.
A prospective, randomized study in critically ill patients using the Oligon Vantex catheter
J Hosp Infect
(2003) - et al.
Prevention of catheter-related infections by silver coated central venous catheters in oncological patients
Zentral Bakteriol
(1995)
Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: a randomized controlled trial
J Hosp Infect
Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia
J Hosp Infect
Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit
J Hosp Infect
Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients
Diagn Microbiol Infect Dis
Contamination of central venous catheters in immunocompromised patients: a comparison between two different types of central venous catheters
J Hosp Infect
Which antimicrobial impregnated central venous catheter should we use? Modeling the costs and outcomes of antimicrobial catheter use
Am J Infect Control
Pharmacokinetics of the antimicrobial agents rifampicin and miconazole released from a loaded central venous catheter
J Hosp Infect
Hospital acquired native valve endocarditis: analysis of 22 cases presenting over 11 years
Heart
Nosocomial endocarditis in the intensive care unit: an analysis of 22 cases
Crit Care Med
The cost of infections related to central venous catheters designed for long-term use
Br J Med Econ
Outcomes of primary and catheter-related bacteremia, a cohort and case-control study in critically ill patients
Am J Respir Crit Care Med
Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit
Arch Surg
Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital
Crit Care Med
Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections
Clin Infect Dis
Infections due to infusion therapy
Central venous catheter infections at a county hospital in Sweden: a prospective analysis of colonization, incidence of infection and risk factors
Acta Anaesthesiol Scand
Nonuniform risk of bloodstream infection with increasing central venous catheter-days
Infect Control Hosp Epidemiol
Use of maximal sterile barriers during central venous catheter insertion: clinical and economic outcomes
Clin Infect Dis
Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis
Ann Intern Med
An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center
Crit Care Med
Reduction in central line-associated bloodstream infections among patients in intensive care unit—Pennsylvania, April 2001–March 2005
MMWR Morb Mortal Wkly Rep
An intervention to decrease catheter-related bloodstream infections in the ICU
N Engl J Med
Cost-benefit analysis of chlorhexidine gluconate dressing in the prevention of catheter-related bloodstream infections
Infect Control Hosp Epidemiol
Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study
Crit Care Med
Surface antimicrobial activity of heparin-bonded and antiseptic-impregnated vascular catheters
J Infect Dis
Can antimicrobial central venous catheters prevent associated infection?
Br J Haematol
Prevention of bloodstream infection with central venous catheters treated with anti-infective agents depends on catheter type and insertion time: evidence from a meta-analysis
Infect Control Hosp Epidemiol
Host factors predisposing to and influencing therapy of foreign body infections
Bacterial biofilms: a common source of persistent infections
Science
Catheter-tip colonization as a surrogate end point in clinical studies on catheter-related bloodstream infection: how strong is the evidence?
Clin Infect Dis
Bacteremic complications of intravascular catheters colonised with Staphylococcus aureus
Clin Infect Dis
A semiquantitative culture method for identifying intravenous-catheter-related infection
N Engl J Med
Diagnosis of central venous catheter-related sepsis. Critical level of quantitative tip cultures
Arch Intern Med
Three-year experience with sonicated vascular catheter cultures in a clinical microbiology laboratory
J Clin Microbiol
Guidelines for the prevention of intravascular catheter-related infections
MMWR Recomm Rep
Meta-analysis in medical research
Comparison of antimicrobial impregnation with tunnelling of long-term central venous catheters: a randomized controlled trial
Ann Surg
A central venous catheter coated with benzalkonium chloride for the prevention of catheter-related microbial colonization
Eur J Anaesthesiol
Antiseptic-impregnated central venous catheters reduce the incidence of bacterial colonization and associated infection in immunocompromised transplant patients
Eur J Anaesthesiol
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