Interventions for preventing infectious complications in haemodialysis patients with central venous catheters.
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.


OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
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).


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.


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.
McCann
Margaret
M
School of Nursing & Midwifery, Trinity College Dublin, 24 D'Olier St, Dublin, Ireland.
Moore
Zena Eh
ZE
D056705:Apitherapy / Q000379:methods; D001414:Bacitracin / Q000627:therapeutic use; D016470:Bacteremia / Q000517:prevention & control*; D055499:Catheter-Related Infections / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D004338:Drug Combinations; D006096:Gramicidin / Q000627:therapeutic use; D006801:Humans; D016712:Mupirocin / Q000627:therapeutic use; D011112:Polymyxin B / Q000627:therapeutic use; D011206:Povidone-Iodine / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis / Q000295:instrumentation*; D013203:Staphylococcal Infections / Q000517:prevention & control
D004338:Drug Combinations; C420142:polysporin ointment; D001414:Bacitracin; D006096:Gramicidin; D011206:Povidone-Iodine; D016712:Mupirocin; D011112:Polymyxin B