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Alcohol-impregnated caps for the prevention of central line-associated infections: a systematic review and meta-analysis

Presented at the Neonatal Society 2016 Summer Meeting.

Johnson MJ1, Vijayakumaran V2, Hall M1

1 Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
2 Department of Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK

Background: Central Line Associated Bloodstream infections (CLABSIs) are a significant healthcare problem, with patients in intensive care, particularly neonates and children, at highest risk. Many care packages aimed at reducing CLABSIs rely on decontaminating central line access ports using cleaning wipes, and this is often subject to variable and suboptimal practice, with variable adherence. Alcohol impregnated caps (AIC) for central line access ports offer a method of decontamination which removes this element of variable adherence. As part of a project aimed at improving CLABSI rates in our neonatal unit, we performed a systematic review to determine if AICs reduce CLABSIs compared to standard methods.

Methods: The databases MEDLINE, EMBASE, CINAHL and ‘Web of Science’ were searched between 1947 and May 2016. Studies were eligible if they were RCTs or observational studies comparing AIC to standard care in hospitalised patients with central venous catheters in situ, and reported any significant central line infections or positive blood cultures. Whilst we originally planned to focus on neonatal and paediatric studies, the search was extended to include all patient groups in view of a paucity of literature on preliminary searches. The review was registered prospectively with PROSPERO. Meta-analysis was conducted using Review Manager v5.3.5.

Results: Twenty-eight studies (10 published articles and 18 conference abstracts) were identified. All were observational studies; 20 reported CLABSI rates per 1000 central line days and were included in the meta-analysis. Meta-analysis of the nine published studies demonstrated a rate ratio of 0.39 in favour of AICs (95% Confidence Interval, CI, 0.18-0.82, p=0.01), with a similar finding in the 11 conference abstracts (rate ratio 0.41, 95% CI 0.23-0.76, p=0.004). The overall meta-analysis gave a rate ratio of 0.40 (95% CI 0.25-0.65, p<0.001), suggesting that AICs reduce the risk of CLABSI by 60%. There was no heterogeneity. Five studies (3 published articles and 2 conference abstracts) also reported blood culture contamination (BCC) rates. Meta-analysis of the published studies revealed a rate ratio of 0.41 in favour of AICs (95% CI 0.17-1.00, p=0.05), with a non-significant effect on BCC rates in the conference abstracts (rate ratio 0.38, 95% CI 0.06-2.47, p=0.31). Only one neonatal study was identified, which showed a reduction in standardised infection ratios from 1.723 to 0.722 after the introduction of AICs (p=0.04).

Conclusion: AICs seem to significantly reduce the risk of CLABSIs in hospitalised patients with a central venous line in situ. They also seem to offer promise for reducing CLABSI rates in neonatal patients. However, to date there have been few published trials and all have been observational. These findings warrant testing in a formal RCT in high risk patients.

Corresponding author: m.johnson@soton.ac.uk

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