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Published on: July 13, 2019
Interventions for preventing infectious complications in haemodialysis patients with central venous catheters
Margaret McCann1, Zena Eh Moore
1School of Nursing & Midwifery, Trinity College Dublin, 24 D'Olier St, Dublin, Ireland.
Insights
Mupirocin ointment effectively reduces catheter-related bacteraemia in haemodialysis patients. However, more research is needed on other topical agents and dressings to prevent infections and mortality.
Area of Science:
- Nephrology
- Infectious Diseases
- Clinical Trials
Background:
- Central venous catheters (CVC) are crucial for haemodialysis access, used by 46-70% of patients.
- CVC use is linked to significant risks including infections, hospitalizations, and mortality.
- Preventing CVC infections is a critical clinical challenge.
Purpose of the Study:
- To assess the efficacy and safety of topical antimicrobials, antiseptics, and dressings in preventing infectious complications in haemodialysis patients with CVC.
- To compare the benefits and harms of various prophylactic interventions.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs) and quasi-RCTs.
- Searched multiple databases including Cochrane, CENTRAL, MEDLINE, and EMBASE.
- Included studies focused on interventions preventing CVC infections, excluding antimicrobial-impregnated catheters or lock solutions.
Main Results:
- Mupirocin ointment significantly reduced catheter-related bacteraemia and Staphylococcus aureus infections.
- Polysporin and povidone-iodine ointments also decreased catheter-related bacteraemia risk.
- Polysporin showed a significant reduction in all-cause mortality, but other agents did not.
Conclusions:
- Mupirocin ointment is effective in reducing catheter-related bacteraemia.
- Further high-quality RCTs are warranted for povidone-iodine, polysporin, and topical honey due to limited data.
- Evidence is insufficient to recommend specific dressing types (transparent polyurethane vs. dry gauze) for infection prevention.
Background:
Central venous catheters (CVC) continue to play a prominent role in haemodialysis vascular access with 46% to 70% of patients commencing haemodialysis via a CVC. CVC access is associated with catheter-related infections, increased patient hospitalisations and death due to infection. A variety of interventions are used to prevent CVC infection.
Objectives:
To evaluate the benefits and harms of prophylactic topical antimicrobials, topical antiseptics, medicated and non-medicated dressings on infectious complications among haemodialysis patients with CVC.
Search Strategy:
We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and reference lists of articles without language restriction.
Selection Criteria:
We included randomised controlled trials (RCTs) and quasi-RCTs investigating any intervention that prevented infectious complications among haemodialysis patients with CVC. We excluded antimicrobial impregnated CVC or CVC using locking solutions with antimicrobial properties.
Data Collection And Analysis:
Two authors assessed study quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous outcomes as mean differences (MD).
Main Results:
Ten studies (786 patients) were included. Mupirocin ointment reduced the risk of catheter-related bacteraemia (RR 0.17, 95%CI 0.07 to 0.43) and had a significant effect on catheter-related infections caused by S. aureus. The risk of catheter-related bacteraemia was reduced by polysporin (RR 0.40, 95%CI 0.19 to 0.86) and povidone-iodine ointment (RR 0.10, 95%CI 0.01 to 0.72). Subgroup analysis suggested mupirocin (RR 0.12, 95%CI 0.01 to 2.13) and povidone-iodine ointment (RR 0.84, 95%CI 0.24 to 2.98) had no effect on all-cause mortality while polysporin ointment showed a significant reduction (RR 0.22, 95%CI 0.07 to 0.74). Mortality related to infection was not reduced by mupirocin, polysporin or povidone-iodine ointment. Topical honey did not reduce the risk of exit site infection (RR 0.45, 95%CI 0.10 to 2.11) or catheter-related bacteraemia (RR 0.80, 95%CI 0.37 to 1.73). Transparent polyurethane dressing compared to dry gauze dressing did not reduce the risk of CVC or exit site infection, or catheter-related bacteraemia.
Authors' Conclusions:
Mupirocin ointment appears effective in reducing the risk of catheter-related bacteraemia. Insufficient reporting on mupirocin resistance was noted and needs to be considered in future studies. A lack of high quality data on the routine use of povidone-iodine ointment, polysporin ointment and topical honey warrant larger RCTs. Insufficient data were available to determine which dressing type (transparent polyurethane or dry gauze dressing) has the lowest risk of catheter-related infections.
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