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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 59-62

Clinical experience of using chlorhexidine gluconate-impregnated dressings in reducing the central line-associated bloodstream infection rate at a Level 1 trauma centre


1 Department of Lab Medicine, JPNATC, AIIMS, New Delhi, India
2 Department of Anaesthesia, JPNATC, AIIMS, New Delhi, India
3 Department of Neurosurgery, JPNATC, AIIMS, New Delhi, India
4 Department of Neuroanaesthesia, JPNATC, AIIMS, New Delhi, India
5 Department of Critical and Intensive Care, JPNATC, AIIMS, New Delhi, India
6 Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Purva Mathur
Room No 211, Second Floor, Department of Laboratory Medicine, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_15_18

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  Abstract 


Introduction: Central venous catheters are vital in critical care which can be associated with infectious and non-infectious adverse events.
Materials and Methods: This case–control study was conducted over 1 year in trauma centre of India. All patients admitted in intensive care units (ICUs) having central line inserted during the study period (November 2013–October 2014) were included as cases. Historical controls with non-antibiotic-impregnated dressings were used as controls (November 2012–October 2013). Standard central line insertion and maintenance checklist was followed.
Results: A total of 2034 patients were admitted in ICUs during study period, and the central line-associated bloodstream infection (CLABSI) rate was 2.89/1000 catheter days. During the year 2012–2013, 2100 patients were admitted and CLABSI rate was 3.04/1000 catheter days. The mean central line insertion bundle compliance rate was 76.8% in 2012–2013 and 78.37% in 2013–2014. The compliance with scrubbing the access port was minimum 34% while that with change in dressing was the maximum 79%.
Discussion: Since CLABSI rate reduction was not statistically significant, the use of biopatch in our setting could not be justified and its use was not found to be cost-effective. In maintenance bundle, compliance with scrubbing the hub was least only 35%. Thus, the use of effective maintenance bundle parameters could easily reduce CLABSI rate.

Keywords: Biopatch, central line-associated bloodstream infections, insertion bundle, maintenance bundle


How to cite this article:
Batra P, Thomas S, Gunjyal J, Mathur P, Gupta B, Swahnney C, Agarwal D, Bindra A, Goyal K, Aggarwal R, Soni K, Malhotra R. Clinical experience of using chlorhexidine gluconate-impregnated dressings in reducing the central line-associated bloodstream infection rate at a Level 1 trauma centre. J Patient Saf Infect Control 2018;6:59-62

How to cite this URL:
Batra P, Thomas S, Gunjyal J, Mathur P, Gupta B, Swahnney C, Agarwal D, Bindra A, Goyal K, Aggarwal R, Soni K, Malhotra R. Clinical experience of using chlorhexidine gluconate-impregnated dressings in reducing the central line-associated bloodstream infection rate at a Level 1 trauma centre. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Apr 23];6:59-62. Available from: http://www.jpsiconline.com/text.asp?2018/6/2/59/249844




  Introduction Top


Central venous catheters (CVCs) are vital in the care of critically ill-hospitalised patients as they are often used by clinicians as a portal for the delivery of medications, parenteral nutrition, collection of blood samples and monitoring of haemodynamic variables. In the USA, >5 million patients require central venous access each year. Unfortunately, central venous access can be associated with infectious and non-infectious adverse events that are hazardous to patients and expensive to treat. Bloodstream infections due to CVCs, also known as central line-associated bloodstream infections (CLABSIs) or catheter-related bloodstream infections (CRBSIs), are one of the common nosocomial infections in critically ill patients.[1]

CLABSI is a major contributing factor to in-hospital mortality and morbidity accounting for nearly 12%–25% of the healthcare-associated infection-associated mortality rate.[2] A recent analysis estimated that each CLABSI episode independently increases length of hospitalisation from 7 to 21 days and adds an attributable cost of about 37,000 USD per patient.[2] The annual national cost of caring for patients who develop CLABSI is estimated to range from $0.67 to $2.68 billion.[2],[3],[4]

CLABSIs are potentially preventable through the use of evidence-based practices.[5] The original 'Making Health Care Safer' report examined the prevalence, strategies and costs associated with CLABSI prevention and found that certain practices (e.g., the use of maximal sterile precautions) were associated with both a decrease in CLABSI risk and reduced cost, whereas others (e.g., intravenous antimicrobial prophylaxis) added expense without clear benefit.[6],[7]

Healthcare Infection Control Practices Advisory Committee recently updated their evidence-based guidelines associated with reduction in CLABSI rate, as given in [Table 1].[5] According to these guidelines, the use of chlorhexidine gluconate (CHG)-impregnated dressings is recommended in category IB as the use of antibiotic-impregnated dressings allows 360° contact with the skin and has a continuous release of CHG around the catheter insertion site.
Table 1: Healthcare Infection Control Practices Advisory Committee guidelines for central line-associated bloodstream infection prevention

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We conducted a small pilot study in our centre to evaluate the role of CHG-impregnated sponge dressings in reducing the CLABSI rate. All the data obtained were analysed using the SPSS software version 21, (IBM, Armonk, NY, United States of America).


  Materials and Methods Top


A small case–control study was conducted over 1 year in a 160-bedded Level 1 trauma centre of India. All patients admitted in the intensive care units (ICUs) (surgical and neurosurgical) having central line inserted during the 1-year study period (November 2013–October 2014) were included as cases in the study. Historical controls with non-antibiotic-impregnated dressings were used as the control group (November 2012–October 2013). Standard central line insertion checklist [Table 1] was followed. The form was filled by the ICU and Operation theatre (OT) staff performing/assisting the procedure.

Central line maintenance checklist was also formulated and communicated to the ICU staff taking care of the patients with the central line inserted. Compliance of the ICU staff to the maintenance bundles was assessed by the Hospital Infection Control Nurses posted in the ICU. The Hospital Infection Control Nurses (HICNs) would assess the compliance by observing the healthcare workers. This would be done twice in a week for 1 h at random without informing the staff performing the procedure.


  Results Top


A total of 2034 patients were admitted in the ICU during the study period (2013–2014), and the CLABSI rate was 2.89/1000 catheter days. During the year 2012–2013, 2100 patients were admitted in the ICUs and the CLABSI rate was 3.04/1000 catheter days. The mean central line insertion bundle compliance rate was 76.8% in 2012–2013 and 78.37% in 2013–2014 while the overall hand hygiene rate was 64.7% and 63.7%, respectively. The quarterly and overall CLABSI rate, central line bundle compliance rate and hand hygiene rate are given in [Figure 1].
Figure 1: Central line-associated bloodstream infection rate, bundle compliance rate and hand hygiene rate 2013–2014

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The percentage adherence to the central line maintenance bundle parameters is depicted in [Figure 2]. The compliance with scrubbing the access port before each use was the minimum 34% while the compliance with change in dressing was the maximum 79%.
Figure 2: Percentage adherence with maintenance bundle

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  Discussion Top


The CLABSI rate in our hospital in the year 2012–2013 was only 3.04/1000 catheter days and in the year 2013–2014 was only 2.89/1000 catheter days. The reduction in the rate was not statistically significant. However, there have been studies[8],[9] which have demonstrated a significant reduction in the CLABSI rate with the use of a biopatch. These studies have demonstrated a reduction in CRBSI rate with the relative risk reduction being 45% for CRBSI and 48% for catheter colonisation.[9]

Since the CLABSI rate reduction was not statistically significant, the use of biopatch in our setting could not be justified. The average cost of a single biopatch is almost $6 (amounting to nearly Rs. 390) while the cost of the transparent non-antibiotic-impregnated dressing being used earlier was only Rs. 10. Thus, the use of biopatch in our setting was not found to be very cost-effective. Ye et al.[10] recently performed a study using computer models based on average effectiveness data and CRBSI rates. They found that consistent use of CHG dressing in a hypothetical 400-bedded hospital would be expected to prevent 35 CRBSI events and save a net of $895,000 annually.

In our study, we also evaluated the adherence to maintenance bundle parameters and found that compliance with scrubbing the hub before use was the least being only 35%. The compliance was maximum with changing the catheter dressing every 7 days or SOS. Studies conducted worldwide have demonstrated that consistent compliance with scrubbing the needless connectors was associated with continuous reduction in the CLABSI rate.[11]

A major limitation of our study is that the emergence of resistance to chlorhexidine among isolates recovered from blood or catheter segments was not assessed.In vitro studies of Pseudomonas stutzeri exposed to slowly increasing concentrations of chlorhexidine led to the emergence of resistance to CHG and several other antimicrobial agents.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Frasca D, Dahyot-Fizelier C, Mimoz O. Prevention of central venous catheter-related infection in the intensive care unit. Crit Care 2010;14:212.  Back to cited text no. 1
    
2.
Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005;33:501-9.  Back to cited text no. 2
    
3.
Scott R. The Direct Medical Costs of Healthcare-Assicated Infections in U.S. Hospitals and the Benefits of Prevention. Available from: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf. [Last accessed on 2012 Jan 30].  Back to cited text no. 3
    
4.
Roberts RR, Scott RD 2nd, Hota B, Kampe LM, Abbasi F, Schabowski S, et al. Costs attributable to healthcare-acquired infection in hospitalized adults and a comparison of economic methods. Med Care 2010;48:1026-35.  Back to cited text no. 4
    
5.
O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011;39:S1-34.  Back to cited text no. 5
    
6.
Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: A critical analysis of patient safety practices. Evid Rep Technol Assess (Summ) 2001;(43):i-x, 1-668.  Back to cited text no. 6
    
7.
Saint S. Prevention of Intravascular Catheter Associated Infections. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. AHRQ Publication No. 01-E058. Ch. 16. Rockville, MD: Agency for Healthcare Research and Quality; 2001. p. 163- 83. Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.118.6874&rep=rep1&type=pdf. [Last accessed on 2018 Dec 28].  Back to cited text no. 7
    
8.
Ruiz RR, Villasis Keever MA, Miranda Novales MG, Martínez DC, Muñoz NV, Barba GC, et al. Efficacy of a chlorhexidine-gluconate impregnated patch for prevention of catheter-related infections in pediatric patients: Systematic review and meta-analysis. Bol Med Hosp Infant Mex 2011;68:349-55.  Back to cited text no. 8
    
9.
Safdar N, O'Horo JC, Ghufran A, Bearden A, Didier ME, Chateau D, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: A meta-analysis. Crit Care Med 2014;42:1703-13.  Back to cited text no. 9
    
10.
Ye X, Rupnow M, Bastide P, Lafuma A, Ovington L, Jarvis WR, et al. Economic impact of use of chlorhexidine-impregnated sponge dressing for prevention of central line-associated infections in the United States. Am J Infect Control 2011;39:647-54.  Back to cited text no. 10
    
11.
Dumyati G, Concannon C, van Wijngaarden E, Love TM, Graman P, Pettis AM, et al. Sustained reduction of central line-associated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance. Am J Infect Control 2014;42:723-30.  Back to cited text no. 11
    
12.
Tattawasart U, Maillard JY, Furr JR, Russell AD. Development of resistance to chlorhexidine diacetate and cetylpyridinium chloride in Pseudomonas stutzeri and changes in antibiotic susceptibility. J Hosp Infect 1999;42:219-29.  Back to cited text no. 12
    


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