An antiseptic combination of chlorhexidine-alcohol may be superior to povidone iodine-alcohol in reducing infection in patients with catheters, according to a study published recently in The Lancet

Olivier Mimoz, MD, PhD, and colleagues at the University Hospital of Poitiers in France noted that the use of 2% chlorhexidine–70% isopropyl alcohol (chlorhexidine–alcohol) is superior to 5% povidone iodine–69% ethanol (povidone iodine–alcohol) in skin disinfection after enrolling 2,349 adults over the age of 18 in an open label, randomly assigned controlled trial. Participants were in 11 French ICUs at one general hospital and five university hospitals. 

Researchers examined data on 1,181 patients needing a total of 2,547 catheters. Of this group, 594 patients were first scrubbed with detergent, and 587 were not. Another group of 1,168 patients, 580 of whom were scrubbed, were given povidone iodine–alcohol.

The researchers reported that there were no statistically significant differences in infection in patients who were scrubbed versus those who were not.


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While there was a greater chance of severe skin reactions to chlorhexidine-alcohol (3% of patients) over povidone-iodine–alcohol (1%), Dr Mimoz and colleagues noted that there were no systemic adverse effects. Severe skin reactions to chlorhexidine-alcohol caused discontinuation in two study participants.

“Incidence of catheter-related infection in patients assigned to chlorhexidine–alcohol was 0.28 per 1000 catheter-days (6 infections) compared with 1.77 per 1000 catheter-days (39 infections) in those assigned to povidone iodine–alcohol (HR 0.15, 95% CI 0.05–0.41; p=0.0002),”1 said Dr Mimoz.

The study concludes that, “for skin antisepsis, chlorhexidine–alcohol provides greater protection against short-term catheter-related infections than does povidone iodine–alcohol and should be included in all bundles for prevention of intravascular catheter-related infections.”

Vineet Chopra, MD, an Assistant Professor of Medicine and Research Scientist at The Patient Safety Enhancement Program and Center for Clinical Management Research at the Ann Arbor VA Medical Center whose research interests include catheter infection prevention, was not involved with the study but commented on the findings. In an interview he told Infectious Disease Advisor, “This study is important not only because it shows that chlorhexidine-alcohol is better than povidone-iodine in preventing catheter-related infections, but also because it suggests that this difference is quite large and substantial.”

“But what we still don’t know is whether the ‘active ingredient’ is the chlorhexidine, the alcohol or the combination of the two,” Dr Chopra added. “This isn’t just a matter for academic debate, but is relevant because some patients experience skin-reactions from chlorhexidine that limit its utility. Understanding whether a therapeutic dose or combination limits these adverse effects but is still efficacious is thus relevant to clinical care.”

Dr Chopra noted that, “a number of catheter-infections can be prevented by making the switch to chlorhexidine-containing alcohol solutions during insertion. What we must still address is how best to prevent infections after the insertion.”

The study highlights how a highly effective antiseptic can reduce infection rates in catheter patients.

Antiseptic use is not the only method for reducing infection, according to Dr Chopra.

“These findings should not take away from basic infection prevention practices during maintenance of the device — hand hygiene before catheter use, hubs decontamination before access and removal of devices that are clinically no longer needed. Clinicians must now focus beyond insertion — as these remain important moments for infection to occur.”

References

  1. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015; 386: 2069-2077. DOI: 10.1016/S0140-6736(15)00244-5.
  2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32. DOI: 10.1056/NEJMoa061115.