Adding a chlorhexidine dressing to an already ongoing catheter bundle still reduces all catheter-associated bloodstream infections
Care bundles have demonstrated the interest in reducing catheter associated bloodstream infections (CABSI), although their efficacy seems to plateau around 1.0 episodes/1000-catheter-days. The study proposed by Philippe Eggimann concerns a long-term, real-world study, evaluating the impact of a progressive introduction of CHG dressings to an ongoing catheter bundle, and compares two different types of CHG dressings (CHG sponge + transparent dressing versus CHG gel all-in-one dressing).
The study was performed between January 2006 and December 2014 in a mixed 35-bed ICU comprising 5 distinct units, and included 18,286 patients (91,292 ICU-days and 155,242 catheter days).
The standard of care for the first period, January 2006 – October 2007, included up-dated general infection control measures and guidelines for catheter insertion, handling and maintenance. CHG sponges and CHG gel dressings were then progressively introduced in each of the 5-7 bed sections of the ICU, until the post-study period, from January 2014 to December 2018, when all the units used CHG gel dressings. Both a designated physician and a designated nurse were in charge of the project, giving periodic feedback and face-to-face training.
Findings confirmed a six-fold reduction in the CABSI rate compared to the first period (95% CI 13.6-19.3), representing 16 avoided episodes every year for this 35 bed-ICU. Results were further confirmed by a four-year post-study data analysis. CHG gel dressings seemed to be more effective than sponges, but the difference was not significative.
STUDY STRENGTHS & LIMITATIONS
This is largest real-world data study on catheter infection in ICU, for such a long period (9 years) and in a mixed intensive unit, without discriminating medical patients from surgical patients. Despite increased workload and patient severity, the post-study data, until 2018, confirmed the infection reduction achieved at the end on the fifth period, once all units and catheters used CHG gel dressings.
Nevertheless, the before-after design of this monocentric study limits the external validity of the study, and does not determine the effect of the different interventions of the ongoing bundle and the actual contribution of CHG dressings. Besides, the lack of systematic culture of catheters, the tips could have underestimated the final rate of CABSI.
TAKE HOME MESSAGE
CHG gel dressings for all catheters in severely ill patients within a catheter infection control bundle is associated with a sustained and probably cost-effective reduction of all catheter-associated bloodstream infections, despite evolutions through time, with more severely ill patients, an increased catheter use and a higher nursing workload.
This article review was prepared and submitted by Silvia Calvino Gunther from the N&AHP section, on behalf of Journal Review Club.
1) Sustained reduction of catheter-associated bloodstream infections with enhancement of catheter bundle by chlorhexidine dressings over 11 years, Intensive Care Medicine , Volume 45, Issue 6, pp 823–833.