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Three Part Question

In [a patient in whom a central venous catheter is required] are [antimicrobial or antibiotic coated central venous catheters preferable to conventional central venous catheters] at [improving patient outcomes] ?

Clinical Scenario

A patient is brought into the emergency department acutely unwell with circulatory collapse. It is deemed necessary to obtain central venous access in order to monitor central venous pressure and administer inotropic support if required. You wonder if insertion of an antimicrobial or antibiotic coated central venous catheter will confer any advantage to the patient over a conventional central line.

Search Strategy

Medline 1966 - 05/04 using the OVID interface.
Central venous catheter.mp AND (antimicrobial.mp OR antibiotic.mp OR antiseptic.mp) LIMIT to human and English.

Search Outcome

Altogether 198 papers were found, of which 13 presented the best evidence to answer the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Thornton J. 1996 UK	Plain central venous catheter (85) v tridodecylmethylammonium treated and bonded with vancomycin (91) ITU study	Prospective randomised controlled	Catheter colonisation	20% controls: no growth, 38% of vancomycin bonded catheters: no growth (significant difference p=0.01)	Catheter related sepsis not discussed Unblinded
Pemberton L.B. et al 1996 USA	Plain central venous catheter (40) v Silver sulphadiazine and chlorhexidine coated central venous catheter (32) All lines used for administration of TPN	Prospective randomised controlled	Catheter tip culture, catheter related sepsis	Catheter sepsis: 6 in antiseptic group, 7 in control group (no statistical difference)	No tip culture statistics TPN administration only
Tennenburg et al 1997 USA	Control central venous catheters (137) v Silver sulphadiazine and chlorhexidine coated catheters (145)	Prospective randomised controlled	Inflammation/colonisation at catheter site; culture of catheter segment	Reduced rate of catheter site colonisation in antiseptic group (28% v 49% p<0.001).	Not blinded Commerical sponsor 20% of enrolled patients excluded from analysis
			Catheter related sepsis	No significant difference in rates of catheter related sepsis (3.8% in antiseptic group v 6.4% in control group)
Raad I. et al 1997 USA	Control central venous catheters (136) v Tidodecylmethylammonium chloride plus minocyline and rifampicin coated (130)	Prospective double-blinded randomised controlled	Catheter colonisation	Colonisation: Controls 36, Coated 11 (relative risk 3.13 CI 1.66-5.88) p<0.001.	32 catheters not cultured
			Catheter related septicaemia	Sepsis: Controls 7 Coated 0 p<0.01
Logghe C. et al 1997 Belgium	Control central venous catheters (342) v Chlorhexidine/silver sulphadiazine coated central venous catheters (338) All patients undergoing chemotherapy	Prospective randomised controlled	Central venous catheter bacteraemia	Central venous catheter bacteraemia: Control 15 (4.4%), coated 17 (5%) No siginificant difference	Central line not removed No Blinding Select patient group
Maki D. G. et al 1997 USA	Control central venous catheters (195) v Chlorhexidine/ silver sulphadiazine coated catheters (208)	Prospective randomised controlled	Catheter colonisation	Colonisation: Controls 24.1% v antiseptic 13.5% RR 0.56 p=0.005	Not blinded 34 excluded from analysis
			Catheter related infection	Infection: Controls 4.6% v antiseptic coated 1% RR 0.21 p=0.03
Heard S. O. et al 1998 USA	Control central venous catheters (157) v Chlorhexidine/ silver sulphadiazine coated catheters (151)	Prospective randomised controlled	Catheter colonisation	Colonisation: Control 52%, coated 40% Significant difference p<0.05	19% of catheters not included in analysis
			Catheter related bacteraemia	Bacteraemia: Control 3.8%, Coated 3.3% p=0.13
Marik P.E. et al 1999 USA	Control central venous catheters (39) v chlorhexidine-silver sulphadiazine coated (36) v minocycline-rifampicin coated (38)	Prospective randomised controlled	Catheter colonisation	Colonisation: Control v Chlorhexidine: No siginificant difference. Chlorhexidine coated colonisation rate 19% v Antibiotic coated colonisation rate 11% (p<0.05 CI 5%-35%)	Not blinded
			Catheter related sepsis	Catheter related sepsis: no significant difference
Moss H.A. et al 2000 UK	Control central venous catheters (98) v Benzalkonium-impregnated central venous catheters (106)	Prospective randomised controlled	Colonisation (distal/subcutaneous)	Distal colonisation: control 45, antiseptic 26 (p=0.0019). Subcutaneous: Control 38, antiseptic 21 (p=0.0016);	Not blinded Low overall infection rates (planned surgical admissions)
			Catheter related bacteraemia	Catheter related bacteraemia 2, antiseptic 0 (no significant difference)
Sheng W-H et al 2000 Taiwan	Control central venous catheters (122) v Chlorhexidine and silver sulphadiazine impregnated central venous catheters (113)	Prospective blinded randomised controlled	Central venous catheter culture	Colonisation: Control 25, antiseptic 9 RR 0.34 (CI 0.15-0.74 p<0.01)	Randomisation and blinding methods not explicit
			Catheter related blood stream infections	Infection: control 2, antiseptic 1 - no significant difference
Jaeger K.et al 2001 Germany	Control central venous catheters (25) v Benzalkonium impregnated central venous catheters (25)	Prospective randomised controlled	Catheter colonisation	Colonisation: Control 4, antiseptic 4 -no difference	Small numbers Cancer patients - for chemotherapy Not blinded
			Catheter related bacteraemia	Bacteraemia; Control 1, antiseptic1 - no difference
Richards B. et al 2003 Australia	Control central venous catheters (223) v chlorhexidine-silver sulphadiazine coated central venous catheters (237)	Prospective non-randomised controlled	Colonisation	Colonisation: control 30, antiseptic 14 (p<0.01)	Not blinded Block allocation to treatment group
			Catheter related bacteraemia	Bacteraemia: Control 6, antiseptic 2 (p=0.16)
Chatzinikolaou I. et al 2003 USA	Control central venous catheter (64) v minocycline/rifampicin coated central venous catheters (66) Hospitalised adult cancer patients requiring haemodialysis	Prospective randomised controlled	Catheter related blood stream infections	7 catheter related infections, all in control group (p=0.006)	Blinding to patient only

Comment(s)

The studies summarised in the table are those in which antiseptic and/or antibiotic coated central venous catheters have been compared with a non-coated catheter. Most of the studies were not blinded and have been carried out in a variety of clinical settings from intensive care and acute medical and surical wards to planned surgical and oncology admissions. In the majority a statisically significant benefit of antiseptic and antibiotic coated catheters has been demonstrated in terms of reducing the frequency of catheter colonisation by organisms. Most studies also reveal a trend towards a benefit in terms of a reduction of catheter related infection, but few were large enough for this to reach statistical significance. It is reasonable to extrapolate these results to emergency department patients, who would be likely to benefit more as they have a higher rate of sepsis on presentation.

Clinical Bottom Line

Antiseptic or antibiotic coated central venous catheters should be used in preference to uncoated catheters if central venous access is required

References

1. Thornton J. Todd NJ. Webster NR. Central venous line sepsis in the intensive care unit. A study comparing antibiotic coated catheters with plain catheters. Anaesthesia 1996;51(11):1018-20 1996.
2. Pemberton LB. Ross V. Cuddy P. Kremer H. Fessler T. McGurk E. No difference in catheter related sepsis between standard and antiseptic central venous catheters Archives of Surgery 1996;131(9):986-989.
3. Tennenberg S. Lieser M. McCurdy B. Boomer G. Howington E. Newman C. Wolf I. A prospective randomised trial of an antibiotic and antiseptic coated central venous catheter in the prevention of catheter related infections. Archives of Surgery 1997;132(12):1348-51.
4. Raad I. Darouiche R. Dupuis J et al. Central venous catheters coated with minocycline and rifampicin for the prevention of catheter related colonization and blood stream infections. Annals of Internal Medicine 1997;127(4):267-274.
5. Logghe C. Van Ossel C. D'Hoore W. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: a randomized controlled trial. Journal of Hospital Infection 1997;37(2):145-156.
6. Maki DG. Stolz SM. Wheeler S. Mermel LA. Prevention of central venous catheter-related blood stream infection by use of an antiseptic-impregnated catheter: a randomised controlled trial. Annal of Internal Medicine 1997;127(4):257-266.
7. Heard SO. Wagle M. Vijayakumar E et al. Influence of central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteraemia. Archives of Internal Medicine 1998;158(1):81-87.
8. Marik PE. Abraham G. Careau P. Varon J. Fromm RE Jr. The ex vivo antimicrobial activity and colonisation rate of two antimicrobial bonded central venous catheters. Critical Care Medicine 1999;27(6):1128 1131.
9. Moss HA. Tebbs SE. Faroqui MH. Herbst T. Isaac JL. Brown J. Elliott TS. A central venous catheter coated with benzalkonium chloride for the prevention of catheter related microbial colonisation. European Journal Of Anaethesia 2000;17(11):680-687.
10. Sheng WH. Ko WJ. Wang JT. Chang SC. Hsueh PR. Luh KT. Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter related infection in intensive care patients. Diagnostic Microbiology and Infectious Disease 2000;38(1):1-5.
11. Jaeger K. Osthaus A. Heine J. Ruschulte H. Kuhlmann C. Weissbrodt H. Ganser A. Karthaus M. Efficicacy of a benzalkonium chloride-impregnated central venous catheter to prevent catheter associated infection in cancer patients. Chemotherapy 2001;47(1):50-55.
12. Richards B. Chaboyer W. Bladen T. Schluter PJ. Effect of central venous catheter type on infections: a prospective clinical trial. Journal of Hospital Medicine 2003;54(1):10-17.
13. Chatzinikolaou I. Finkel K. Hanna H. Boktour M. Foringer J. Ho T. Raad I. Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter related infections: a prospective, randomized study. American Journal of Medicine 2003;115(5):352-357.