Anti-infective-treated central venous catheters for total parenteral nutrition or chemotherapy: a systematic review.

This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in patients who received a CVC for total parenteral nutrition (TPN) or chemotherapy. Randomised controlled trials were retrieved from Medline and the Cochrane Library up to 14 October 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model, and subgroup meta-analysis was carried out where applicable. The impact of the risk for CRBSI in the control group on the effect of anti-infective CVCs was studied by using meta-regression based on the bivariate meta-analysis model. Nine trials were included in the review. One trial showed that antibiotic-treated CVCs reduced the risk for CRBSI in outpatients with chemotherapy and a CVC in-situ during a period of about nine weeks. Eight trials did not find an overall significant benefit in favour of antiseptic-treated CVCs in patients who had a CVC during a mean of about two weeks. No relationship could be established between the effect of anti-infective-treated CVCs and the underlying risk for CRBSI, although nearly all trials had serious methodological shortcomings. Thus, available scientific evidence to prevent CRBSI by the use of anti-infective-treated CVCs in patients receiving chemotherapy or TPN is not sufficient as a basis to recommend their use. The recommendation of the Centers for Disease Control and Prevention to use antibiotic- or antiseptic-impregnated CVCs, when the risk for CRBSI remains high despite good hygienic practice, should therefore be limited to patients in the intensive care/perioperative setting.

Anti-infective-treated central venous catheters: a systematic review of randomized controlled trials.

OBJECTIVE: This systematic review assesses the effect of anti-infective-treated central venous catheters (CVCs) on catheter-related bloodstream infection (CRBSI) in the acute care setting. METHODS: Randomized controlled trials were retrieved from Medline and the Cochrane Library up to 15 January 2007. Two reviewers independently assessed trial quality and extracted data. Data for CRBSI were combined where appropriate, using a random effects model. The impact of the risk for CRBSI in the control group (baseline risk) on the benefit of anti-infective CVCs was studied by using meta-regression based on the binomial normal bivariate meta-analysis model. RESULTS: Twenty-one trials were included in the review. Mainly intensive care (IC) patients were studied. Eighteen trials showed that anti-infective CVCs reduced the risk of CRBSI. The number needed to treat (NNT) varied from 182 to 12, with baseline risks ranging from 1% to 10%. Nearly all trials had serious methodological shortcomings. Three trials comparing minocycline-rifampicin-treated catheters with antiseptic-treated catheters showed inconsistent results. One trial suggested that there is not any difference in CRBSI between heparin- and antiseptic-treated CVCs. CONCLUSION: Because the NNT is large when the baseline risk is low, the use of anti-infective-treated CVCs in the acute care setting should only be considered in situations in which background rates of CRBSI are high. The magnitude of benefit as calculated in this review should be interpreted with caution because of strong arguments in favor of a systematic overestimation of the effect. Which type of anti-infective catheter is most effective could not be established from the available data.

Policies for endotracheal suctioning of patients receiving mechanical ventilation: a systematic review of randomized controlled trials.

OBJECTIVE: The Dutch Working Party on Infection Prevention (Werkgroep Infectiepreventie [WIP]) aimed to determine whether certain policies on endotracheal suctioning are better than others in terms of prevention of ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation in the intensive care unit. METHODS: Publications were retrieved by a systematic search of Medline and the Cochrane Library for literature published before February 2006. Additionally, the reference lists of all identified trials were examined. All randomized trials, quasi-randomized trials, and systematic reviews or meta-analyses of randomized or quasi-randomized trials that compared different policies on endotracheal suctioning for patients receiving mechanical ventilation in the intensive care unit were selected. Two reviewers independently assessed trial quality and extracted data. Disagreements were resolved by discussion with a third reviewer. Data from the original publications were used to calculate the relative risk of VAP. Data for VAP were combined in the analysis where appropriate, by use of a random-effects model. RESULTS: Ten trials were included in the review. The quality of the trials and the way they were reported were generally unsatisfactory. Eight low-quality trials indicate that use of closed instead of open suction systems has no effect on the incidence of VAP. Two moderate-quality trials indicate that changing in-line suction catheters less frequently than every 24 hours does not increase the incidence of VAP. CONCLUSION: The WIP recommends that there be no preferential use of either open or closed endotracheal suction systems to reduce the rate of VAP, but it elucidates that the quality of the evidence is low. Considerations other than prevention of VAP should determine the choice of the suction system. When closed systems are used, the WIP recommends changing the in-line suction catheters every 48 hours. In case of mechanical failure or soiling of the suction system, they may be changed more frequently.

Humidification policies for mechanically ventilated intensive care patients and prevention of ventilator-associated pneumonia: a systematic review of randomized controlled trials.

The Dutch Working Party on Infection Prevention (WIP) aimed to determine whether certain humidification policies are better than others in terms of prevention of ventilator-associated pneumonia (VAP) in mechanically ventilated intensive care unit (ICU) patients. Publications were retrieved by a systematic search of Medline and the Cochrane Library up to February 2006. All (quasi-) randomized trials and systematic reviews/meta-analyses comparing humidification methods in ventilated ICU patients were selected. Two reviewers independently assessed trial quality and extracted data. If the data was incomplete, clarification was sought from original authors and used to calculate the relative risk of VAP. Data for VAP were combined in the analysis, where appropriate, using a random-effects model. Ten trials were included in the review. In general, the quality of the trials and the way they were reported were unsatisfactory. The results did not show any benefit from specific humidification techniques in terms of reducing VAP. WIP do not recommend either passive or active humidifiers to prevent VAP, nor the type of passive humidifiers to be used. Regarding active humidification, WIP recommends using heated wire circuits. This is due to the theoretical consideration that less condensate reduces colonization and subsequent risk of spread throughout an ICU when condensate is removed.

Is there evidence for recommending needleless closed catheter access systems in guidelines? A systematic review of randomized controlled trials.

A systematic review was conducted to determine whether certain vascular access policies are better than others in terms of prevention of catheter-related infections. Publications were retrieved by a search of Medline, the Cochrane Library and Embase up to May 2005. All randomized trials and systematic reviews/meta-analyses of randomized trials evaluating the effect of vascular access policies (i.e. needleless closed systems, conventional closed systems or conventional open systems) on catheter-related infection in hospitalized patients with intravascular catheters in situ were selected. Two reviewers independently assessed trial quality and extracted data. Data from the original publications were used to calculate the relative risk or the incidence-density relative rate of catheter-related infection. Data for similar outcomes were combined in the analysis where appropriate using a random-effects model. Of the six studies reviewed, one was excluded. Five randomized controlled trials were included in the review. The quality of the trials and the way they were reported were generally unsatisfactory. Four trials compared needleless closed systems with conventional open systems. There was a trend for an advantage of the needleless closed devices in terms of less catheter-associated bloodstream infection, less catheter tip colonization and less hub inlet colonization. There were no possibilities for combining data because of clinical heterogeneity. One trial compared needleless closed systems with conventional closed systems and the evidence was inconclusive. From the point of view of infection prevention, there are no objections to use these new systems. However, there is insufficient evidence at this stage to recommend the needleless closed vascular devices.

Urinary catheter policies for short-term bladder drainage in adults.

BACKGROUND: Indwelling urinary catheters are often used for bladder drainage during hospital care. Urinary tract infection is a common complication. Other issues that should be considered when choosing an approach to catheterisation are patients' comfort, other complications/adverse effects, and costs. OBJECTIVES: To determine the advantages and disadvantages of alternative approaches to catheterisation for short-term bladder drainage in adults. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 20 December 2004). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing catheter route of insertion for adults catheterised for up to 14 days. DATA COLLECTION AND ANALYSIS: Data were extracted by both reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If the data in trials had not been fully reported, clarification was sought directly from the authors. MAIN RESULTS: Seventeen parallel-group randomised controlled trials met the inclusion criteria. Fourteen trials compared indwelling urethral catheterisation with suprapubic catheterisation. Groups managed with an indwelling catheter had more cases of bacteriuria (RR 2.60; 95%CI 2.12 to 3.18), more frequent recatheterisation (RR 4.12; 95%CI 2.94 to 7.56), and more people with discomfort (RR 2.98; 95%CI 2.31 to 3.85). There were no reports of complications during insertion, although not all trials stated this explicitly. Three trials compared indwelling urethral catheterisation with intermittent catheterisation. In the two trials with data, there were fewer cases of bacteriuria in the intermittent catheterisation group (RR 2.90; 95%CI 1.44 to 5.84). Costs analyses reported in two trials favoured the indwelling group. AUTHORS' CONCLUSIONS: There was evidence that suprapubic catheters have advantages over indwelling catheters in respect of bacteriuria, recatheterisation and discomfort. The clinical significance of bacteriuria was uncertain, however, and there was no information about possible complications or adverse effects during catheter insertion. There was more limited evidence that the use of intermittent catheterisation was also associated with a lower risk of bacteriuria than indwelling urethral catheterisation, but might be more costly. Using intermittent catheterisation postoperatively limits catheterisation to those people who definitely need it.

Antibiotic policies for short-term catheter bladder drainage in adults.

BACKGROUND: Urinary tract infections account for about 40% of hospital-acquired (nosocomial) infections, and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters. OBJECTIVES: To determine if certain antibiotic policies are better than others in terms of prevention of urinary tract infections, complications, quality of life and cost-effectiveness in short-term catheterised adults. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Register (searched 20 December 2004). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing antibiotic policies for short-term (up to and including 14 days) catheterization in adults. DATA COLLECTION AND ANALYSIS: Data were extracted by both reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If data had not been fully reported, clarification was sought directly from the authors of the trial. MAIN RESULTS: Six parallel-group randomised controlled trials met the inclusion criteria. In one trial comparing antibiotic prophylaxis with giving antibiotics when clinically indicated amongst female surgical patients who had a urethral catheter for more than 24 hours, symptomatic urinary tract infection was less common in the prophylaxis group (RR 0.20, 95% CI 0.06 to 0.66). Five trials compared antibiotic prophylaxis with giving antibiotics when microbiologically indicated, bacteriuria, pyuria and gram-negative isolates in patients' urine were less common in the prophylaxis group amongst surgical patients with bladder drainage for at least 24 hours postoperatively. Bacteriuria rates were also about five-fold lower in the prophylaxis group in trials involving urological surgery patients and non-surgical patients. No trial compared giving antibiotics when microbiologically indicated with giving antibiotics when clinically indicated. AUTHORS' CONCLUSIONS: There was weak evidence that antibiotic prophylaxis compared to giving antibiotics when clinically indicated reduced the rate of symptomatic urinary tract infection in female patients with abdominal surgery and a urethral catheter for 24 hours. The limited evidence indicated that receiving antibiotics during the first three postoperative days or from postoperative day two until catheter removal reduced the rate of bacteriuria and other signs of infection such as pyuria and gram-negative isolates in patients urine in surgical patients with bladder drainage for at least 24 hours postoperatively. There was also limited evidence that prophylactic antibiotics reduced bacteriuria in non-surgical patients.

Urinary catheter policies for long-term bladder drainage.

BACKGROUND: People requiring long-term bladder draining commonly experience catheter-associated urinary tract infection and other problems. OBJECTIVES: To determine if certain catheter policies are better than others in terms of effectiveness, complications, quality of life and cost-effectiveness in long-term catheterised adults and children. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised trials register (searched 9 June 2003). Additionally, we examined all reference lists of identified trials. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing catheter policies (route of insertion and use of antibiotics) for long-term (more than 14 days) catheterisation in adults and children. DATA COLLECTION AND ANALYSIS: Data were extracted by both reviewers independently and compared. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. If the data in trials have not been fully reported, clarification were sought from the authors. When necessary, the incidence-density rates (IDR) and/or the incidence-density differences (IDD) within a certain time period were calculated. MAIN RESULTS: Seven trials met the inclusion criteria involving 328 patients in four crossover and three parallel-group randomised controlled trials. Only two of the pre-stated six comparisons were addressed in these trials. Three trials compared antibiotic prophylaxis with antibiotics when clinically indicated. For patients using intermittent catheterisation, there were inconsistent findings about the effect of antibiotic prophylaxis on symptomatic urinary tract infection. For patients using indwelling urethral catheterisation, one small trial reported fewer episodes of symptomatic UTI in the prophylaxis group.Four trials compared antibiotic prophylaxis with giving antibiotics when microbiologically indicated. For patients using intermittent catheterisation, there was limited evidence that receiving antibiotics reduced the rate of bacteriuria (asymptomatic and symptomatic). There was weak evidence that prophylactic antibiotics were better in terms of fewer symptomatic bacteriuria. AUTHORS' CONCLUSIONS: No eligible trials were identified that compared alternative routes of catheter insertion. The data from seven trials comparing differing antibiotic policies were sparse, particularly when intermittent catheterisation was considered separately from in-dwelling catheterisation. Possible benefits of antibiotic prophylaxis must be balanced against possible adverse effects, such as development of antibiotic resistant bacteria; these cannot be reliably estimated from currently available trials.

Hair removal policies in clean surgery: systematic review of randomized, controlled trials.

OBJECTIVE: To determine whether certain hair removal policies are better than others to prevent surgical-site infections in patients undergoing clean surgery. METHODS: Publications were retrieved by a systematic search of Medline, the Cochrane Library, and EMBASE up to February 2005. Additionally, the reference lists of all identified trials were examined. All randomized trials, quasi-randomized trials, and systematic reviews or meta-analyses of randomized or quasi-randomized trials comparing hair removal policies in clean surgery were selected. Trials involving patients undergoing cranial neurosurgery were excluded. Two reviewers independently assessed trial quality and extracted data. Disagreements were resolved by discussion with a third reviewer. Data from the original publications were used to calculate the relative risk or risk difference of surgical-site infection. Data for similar outcomes were combined in the analysis, where appropriate, with the use of a random effects model. RESULTS: Four trials were included in the review. No eligible systematic review or meta-analysis of randomized or quasi-randomized trials was found. The quality of the trials and how they were reported were generally unsatisfactory. Evidence regarding whether preoperative hair removal has any effect was inconclusive. When hair removal was considered necessary, evidence about the best time for removal was inconclusive. There was some evidence that hair removal by clipper is superior to removal by razor. CONCLUSIONS: Because of insufficient evidence as a basis for recommendations, the practical consequences for ward management were essential when the Dutch Working Party on Infection Prevention formulated its recommendations for hair removal policies. Large randomized, controlled trials are needed to determine the optimal policy for preoperative hair removal.

Is there evidence for recommending silver-coated urinary catheters in guidelines?

We evaluated the available literature on effectiveness of silver-coated versus uncoated catheters for the prevention of urinary tract infections in catheterized patients stratified by sex, systemic antibiotic use, renal function and duration of catheterization. Controlled clinical trials, randomized clinical trials and systematic reviews/meta-analysis were identified by a search strategy in Medline (1966-August 2001) and in the Cochrane Controlled Trials Register. Keywords were urinary catheterization, silver and infection. Trials using silver-coated catheters in the treatment group and uncoated catheters in the control group, with bacteriuria as the outcome measure, were selected. The quality of the methods used of all selected publications was assessed by using a quality assessment scale for randomized clinical trials. In addition we looked critically at subject-specific aspects. Data from the original publications were used to calculate the overall relative risk of bacteriuria in patients with silver-coated versus uncoated catheters, as well as the effect in subgroups. Thirteen trials and one meta-analysis were identified. Seven reports satisfied the selection criteria with only one achieving a high-quality score. Confounding variables were not considered in any trial. Additional studies with a high standard of internal quality and careful specification of the clinical question with regard to subject-specific critical points are necessary to decide whether the use of silver-coated catheters can be recommended.