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Comment on ‘epic3: revised recommendation for intravenous catheter and catheter site care’
Journal of Hospital Infection 94 (2016) 106e112 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Letters to the Editor
Comment on ‘epic3: revised recommendation for intravenous catheter and catheter site care’
Conflict of interest statement None declared. Funding sources None.
References We read with interest the early version of the article published online by Loveday et al. and write to point out several omissions and errors of fact in the discussion of evidence related to the effectiveness of chlorhexidine gluconate (CHG)impregnated sponge dressings.1 With respect to evidence for the CHG sponge dressing, this guideline addendum cites a particular meta-analysis of eight randomized controlled trials (RCTs) which ‘found a reduction in exit site colonization but no significant reduction in CR-BSI’ (catheter-related bloodstream infection). The cited reference is incorrectly attributed to Hoffmann but actually comes from a 2006 meta-analysis by Ho and Litton.2,3 Whereas they correctly quoted the conclusion of Ho and Litton’s 2006 meta-analysis, Loveday et al. missed an update to this meta-analysis in 2010 which incorporated an additional two large RCTs of a CHGimpregnated sponge dressing for vascular catheters in oncology and intensive care patients.4e6 The updated analysis by Ho in 2010 concludes that the ‘chlorhexidine-impregnated dressing was strongly associated with a reduction in risk of CRBSI (random-effects model: OR [odds ratio] 0.55, 95% CI [confidence interval] 0.35e0.86, P ¼ 0.0008; I2 ¼ 24.5%).’ Additionally, Loveday et al. appear to have missed a more recent 2014 meta-analysis by Safdar which analysed nine RCTs and which concluded that use of chlorhexidine-impregnated dressing resulted in reduced prevalence of CRBSI (randomeffects relative risk: 0.60; 95% CI: 0.41e0.88; P ¼ 0.009) as well as catheter colonization (random-effects relative risk: 0.52; 95% CI: 0.43e0.64; P < 0.001).7 Of note, regardless of which meta-analysis, there is only one RCT of the CHG-impregnated gel dressing; the preponderance of the clinical data is based on the CHG-impregnated sponge dressing. Further, Loveday et al. refer to the CHG-impregnated sponge dressing as a ‘2% chlorhexidine-impregnated sponge dressings’ and we wish to clarify that the sponge dressing actually contains w25% CHG by weight. Finally, the RCT of 2% CHG-impregnated gel dressings compared with highly adhesive semipermeable dressings is referenced as Timsit et al. (2009) but should be Timsit et al. (2012).
1. Loveday HP, Wilson JA, Prieto J, Wilcox MH. epic3: revised recommendation for intravenous catheter and catheter site care. J Hosp Infect 2016;92:346e348. 2. Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA 1992;267:2072e2076. 3. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2006;58:281e287. 4. Ho KM. Comment on: Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2010;65:811e814. 5. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231e1241. 6. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88:267e272. 7. Safdar N, O’Horo JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med 2014;42:1703e1713.
L.G. Ovingtona,* R. Odehnalb a Ethicon, Inc., Medical Affairs, Somerville, NJ, USA b
Ethicon, Inc., Professional Education, Somerville, NJ, USA * Corresponding author. Address: Ethicon, Inc., Medical Affairs, Rt 22 West, Somerville, NJ 08876, USA. Tel.: þ1 9082182392. E-mail address: [email protected] (L.G. Ovington). Available online 7 June 2016
http://dx.doi.org/10.1016/j.jhin.2016.04.019 ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Letters to the Editor
Comment on ‘epic3: revised recommendation for intravenous catheter and catheter site care’
Conflict of interest statement None declared. Funding sources None.
References We read with interest the early version of the article published online by Loveday et al. and write to point out several omissions and errors of fact in the discussion of evidence related to the effectiveness of chlorhexidine gluconate (CHG)impregnated sponge dressings.1 With respect to evidence for the CHG sponge dressing, this guideline addendum cites a particular meta-analysis of eight randomized controlled trials (RCTs) which ‘found a reduction in exit site colonization but no significant reduction in CR-BSI’ (catheter-related bloodstream infection). The cited reference is incorrectly attributed to Hoffmann but actually comes from a 2006 meta-analysis by Ho and Litton.2,3 Whereas they correctly quoted the conclusion of Ho and Litton’s 2006 meta-analysis, Loveday et al. missed an update to this meta-analysis in 2010 which incorporated an additional two large RCTs of a CHGimpregnated sponge dressing for vascular catheters in oncology and intensive care patients.4e6 The updated analysis by Ho in 2010 concludes that the ‘chlorhexidine-impregnated dressing was strongly associated with a reduction in risk of CRBSI (random-effects model: OR [odds ratio] 0.55, 95% CI [confidence interval] 0.35e0.86, P ¼ 0.0008; I2 ¼ 24.5%).’ Additionally, Loveday et al. appear to have missed a more recent 2014 meta-analysis by Safdar which analysed nine RCTs and which concluded that use of chlorhexidine-impregnated dressing resulted in reduced prevalence of CRBSI (randomeffects relative risk: 0.60; 95% CI: 0.41e0.88; P ¼ 0.009) as well as catheter colonization (random-effects relative risk: 0.52; 95% CI: 0.43e0.64; P < 0.001).7 Of note, regardless of which meta-analysis, there is only one RCT of the CHG-impregnated gel dressing; the preponderance of the clinical data is based on the CHG-impregnated sponge dressing. Further, Loveday et al. refer to the CHG-impregnated sponge dressing as a ‘2% chlorhexidine-impregnated sponge dressings’ and we wish to clarify that the sponge dressing actually contains w25% CHG by weight. Finally, the RCT of 2% CHG-impregnated gel dressings compared with highly adhesive semipermeable dressings is referenced as Timsit et al. (2009) but should be Timsit et al. (2012).
1. Loveday HP, Wilson JA, Prieto J, Wilcox MH. epic3: revised recommendation for intravenous catheter and catheter site care. J Hosp Infect 2016;92:346e348. 2. Hoffmann KK, Weber DJ, Samsa GP, Rutala WA. Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks. JAMA 1992;267:2072e2076. 3. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2006;58:281e287. 4. Ho KM. Comment on: Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2010;65:811e814. 5. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:1231e1241. 6. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88:267e272. 7. Safdar N, O’Horo JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med 2014;42:1703e1713.
L.G. Ovingtona,* R. Odehnalb a Ethicon, Inc., Medical Affairs, Somerville, NJ, USA b
Ethicon, Inc., Professional Education, Somerville, NJ, USA * Corresponding author. Address: Ethicon, Inc., Medical Affairs, Rt 22 West, Somerville, NJ 08876, USA. Tel.: þ1 9082182392. E-mail address: [email protected] (L.G. Ovington). Available online 7 June 2016
http://dx.doi.org/10.1016/j.jhin.2016.04.019 ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.