Review
Antimicrobial central venous catheters in adults: a systematic review and meta-analysis

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Summary

Several antimicrobial central venous catheters (CVCs) are available. We did a meta-analysis to assess their efficacy in reducing microbial colonisation and preventing catheter-related bloodstream infection (CRBSI). An extensive literature search of articles in any language was undertaken. We assessed randomised clinical trials in which available antimicrobial CVCs were compared with either a standard CVC or another antimicrobial CVC. Outcomes assessed were microbial colonisation of CVCs and CRBSI. The first-generation chlorhexidine–silver sulfadiazine (CSS) CVCs reduce colonisation (odds ratio [OR] 0·51 [95% CI 0·42–0·61]) and CRBSI (OR 0·68 [0·47–0·98]), as do the minocycline–rifampicin CVCs (OR 0·39 [0·27–0·55] and OR 0·29 [0·16–0·52], respectively). The minocycline–rifampicin CVCs outperformed the first-generation CSS CVCs in reducing colonisation (OR 0·34 [0·23–0·49]) and CRBSI (OR 0·18 [0·07–0·51]). Many shortcomings in methodological quality limit our interpretation of the study results. However, the available evidence suggests that use of CSS and minocycline–rifampicin CVCs are useful if the incidence of CRBSI is above institutional goals despite full implementation of infection prevention interventions.

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

These are described in detail in the Methods section.

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