Dressing Disruption Is a Major Risk Factor for Catheter-Related Infection
Timsit JF, Bouadma L, Ruckly S, et al
Crit Care Med. 2012;40:1707-1714
Dressing Disruption and Catheter-Related Infection
Central line insertion sites are a potential route of catheter-related infection, and disruption of catheter insertion-site dressings might be a factor in the risk for infection.
Timsit and colleagues performed a secondary analysis of a multicenter randomized controlled trial in intensive care units in France that assessed the effect of 2 dressing-change interventions in a 2-way factorial design: standard vs chlorhexidine-impregnated sponge at the insertion site, and routine dressing changes at 3 days vs 7 days. This study used French recommendations for catheter insertion and care that are similar to the Centers for Disease Control and Prevention (CDC) guidelines. No antibiotic- or antiseptic-coated central venous catheters were used. Both venous and arterial catheters were included in the analysis.
Dressing disruption was defined as soiling or leakage (nonadherence) and required immediate dressing change. Cultures of the insertion site and the catheter tip were obtained at the time of catheter removal. Catheter-related bloodstream infection (CR-BSI) was defined as at least 1 peripheral blood culture with either catheter-tip colonization with the same organism (≥ 1000 colony-forming units/mL) or differential time to positivity of 2 or more hours between blood and catheter-tip cultures; for coagulase-negative staphylococci, the strains from catheter and blood had to be the same pulsotype. Catheter sepsis without BSI was defined as fever or hypothermia in the setting of either catheter colonization, pus at the insertion site, or clinical resolution after catheter removal without any other source of infection. Data were analyzed to determine risk factors for disruption and risk for infection from disruption.
Of 1636 available patients, 1419 with at least 1 dressing change were included, representing more than 11,000 dressings, 3000 catheters, and 24,000 catheter-days. Remarkably, two thirds of all dressing changes were performed earlier than the planned date because of soiling or disruption. The median intervals between first and second dressing changes were 35 and 71 hours, respectively. A total of 296 insertion site colonization events, 23 CR-BSIs, and 29 major catheter-related infections (CR-BSI or catheter sepsis without BSI) occurred. The final dressing was disrupted in about three fourths of patients with CR-BSI or major catheter-related infection.
An interesting finding was that the disruption rate varied from 25% to more than 75%, and it was correlated with the cost of a dressing in that intensive care unit, most of which was associated with staff labor rather than supplies. In the multivariate analysis, higher cost, male sex, metastatic cancer, and coma were associated with reduced dressing disruption, whereas a higher Sequential Organ Failure Assessment (SOFA) score, use of a non-subclavian insertion site, and catheter dwell time of more than 4 days were all associated with increased dressing disruption. The investigators concluded that dressing disruptions were associated with CR-BSI and should be addressed by using postinsertion bundles.
Viewpoint
A major limitation of this study is its observational design as a secondary analysis of a randomized controlled trial. These findings need to be confirmed with further research.
The current central line bundle comprises 4 elements related to insertion, and only 1 element dealing with ongoing maintenance. This bundle, therefore, does not provide guidance for the ongoing care of a catheter that is needed for patient care, including many processes that many institutions use, such as clear adherent dressings, hand hygiene, and cleaning the hub before accessing it. Dressings for vascular access devices are thought to prevent CR-BSI by preventing the introduction of bacteria through the extraluminal pathway. These data suggest that after conquering the insertion bundle, attention to the maintenance of essential catheters, including dressings, may be the next frontier in prevention of CR-BSI.
Although the above-mentioned potential maintenance bundle elements are practical and self-evident, they need to be validated individually and rigorously. The study findings of increased dressing disruptions with increasing SOFA score, use of non-subclavian insertion sites, and increased catheter dwell time all make intuitive sense, but the protective effects of male sex and metastatic cancer are not well explained, suggesting the need for further study.