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S Saint, Ann Arbor VAMC and University of Michigan; N Chaiyakunapruk, University of Washington; DL Veenstra, University of Washington; BA Lipsky, Seattle VAMC and University of Washington

Objectives: Vascular catheters, commonly used in caring for hospitalized patients, are associated with significant infectious complications. Catheter-related bloodstream infection occurs in over 250,000 patients per year in the United States and is associated with increased morbidity, mortality, and costs. One important method for preventing catheter-related infection is adequately disinfecting the skin overlying the site of catheter insertion. Though povidone-iodine is the most commonly used antiseptic solution for catheter site care, another solution may in fact be better. Several recent trials have compared the efficacy of povidine-iodine with chlorhexidine gluconate in reducing catheter colonization and bloodstream infection with mixed results. We, therefore, performed a meta-analysis to answer the following question: "Compared with povidone-iodine, is chlorhexidine gluconate solution less likely to lead to catheter colonization and bloodstream infection when used for vascular catheter site care?"

Methods: A computerized search of the MEDLINE database from July 1966 to September 2000 was performed to identify any language studies using a randomized design comparing povidone-iodine and chlorhexidine gluconate for catheter site care. The reference lists of all retrieved articles were scanned, and experts and product manufacturers were contacted to identify additional published and unpublished reports. The primary outcomes assessed were the incidence of catheter colonization and bloodstream infection. Statistical pooling was performed using Mantel-Haenszel methods under a fixed-effects model.

Results: Seven trials satisfied inclusion criteria. These studies included data on 3705 vascular catheters (1534 central venous, 1117 peripheral venous, 1001 peripheral arterial, and 53 hemodialysis). The summary relative risk of catheter colonization for all catheters was 0.48 (95% CI: 0.30-0.76), indicating a significant decrease in colonization in patients whose catheter sites were disinfected with chlorhexidine gluconate. The summary relative risk of bloodstream infection for all vascular catheters was 0.44 (95% CI: 0.25-0.78), indicating a significant benefit in patients using chlorhexidine gluconate. Among central venous catheter users, chlorhexidine gluconate reduced the risk of colonization by 47% (RR = 0.53; 95% CI: 0.31-0.91) and reduced the risk of bloodstream infection by 49% (RR = 0.51; 95% CI: 0.27-0.98).

Conclusions: Our meta-analysis indicates that chlorhexidine gluconate significantly reduces the incidence of both vascular catheter colonization and bloodstream infection by approximately 50% compared to provide-iodine when used as the site disinfectant. We estimate that for every 1000 catheter sites disinfected with chlorhexidine gluconate rather than povidone-iodine, 71 episodes of catheter colonization and 16 episodes of bloodstream infection might be prevented.

Impact: The use of chlorhexidine gluconate in patients requiring vascular catheters is likely to enhance patient safety by reducing bloodstream infection. Thus, its use for catheter site care should be considered as part of a comprehensive infection control program, at least in those at high-risk for catheter-related infection (e.g., critically ill or immunocompromised patients). However, given that the cost of chlorhexidine gluconate is currently 6-fold greater than the cost of povidone-iodine (30 cents vs 5 cents per 5 cc of solution), a formal economic evaluation will be required to determine the economic consequences of using chlorhexidine gluconate routinely for catheter site care.