Evidence Based Practice in Nursing: Chlorhexidine Gluconate Impregnated Dressings

Evidence Based Practice in Nursing: Chlorhexidine Gluconate Impregnated Dressings

Introduction

The use of antimicrobial dressings at central vascular catheter (CVC) insertion sites is highly important to help decrease the risk of catheter related nosocomial bloodstream infections. It is important for the nurse to know when and how to use the dressing at appropriate times to prevent clinical infection. There are several types of antimicrobial dressings to choose from based on assessing a wound properly and knowing which dressing would be appropriate.

The use of chlorhexidine gluconate-impregnated dressings in individuals who have a CVC may help prevent catheter related infections. Chlorhexidine gluconate (CHG) is an antimicrobial solution used to disinfect skin surfaces (Ho & Litton, 2006). It is typically used to sterilize the catheter insertion site before catheterization. This paper will be discussing whether chlorhexidine gluconate-impregnated dressings at CVC insertion sites will decrease the risk of catheter-related nosocomial bloodstream infections compared to the implementation of a standard non-antimicrobial dressing.

Insertion of CVCs is one of the most common procedures performed today. They allow for intravenous administration of drugs, antibiotics, blood products, fluids, and nutrition over a long period of time without having to frequently replace an IV. Access for easy blood draw samples also eliminates many venipunctures, heightening patients' level of comfort and quality of life. Though obtaining a device used for vascular access is generally a safe procedure, it is not without complications, some of which can be life threatening because it is a potential source of infection.

Central vascular catheters (CVCs) are the most frequent source of nosocomial bloodstream infections (Ho & Litton, 2006). Bloodstream infections are associated with an increased risk of death and with increases in morbidity, length of stay, health care costs, and increased complications (Krien et al., 2007). According to Harbarth, Sax, & Gastmeier's work (as cited in Krien et al., 2007) at least 20% of health care-associated infections and more than 50% of vascular catheter-related infections can be preventable. With mortality rates as high as 12% to 15% for each catheter-related blood stream infection (CDC 2002), preventative strategies are necessary in reducing catheter-related bloodstream infections. Given the importance of prevention, Centers for Disease Control and Prevention (CDC) has published evidence-based recommendations for preventing intravascular catheter-related blood stream infections. Among the listed recommendations great emphasis has been highlighted on the use of chlorhexidine-impregnated dressings at catheter insertion sites. What first started out as circular foam discs impregnated with chlorhexidine gluconate (CHG), over time has evolved into transparent chlorhexidine gluconate (CHG) gel dressings shown to be well tolerated and performed in a manner that equaled or well exceeded the original antimicrobial dressing application (Heilman et al., 2008). In either form, chlorhexidine-impregnated dressings has shown significant antimicrobial effects against antibiotic-resistant Staphylococcus, Enterococcus species and Candida species as stated in Bhende and Spangler's work (as cited in Ho & Litton, 2006).

The use of chlorhexidine-impregnated dressings is not a standard practice to prevent vascular catheter colonization and infection in many institutions (Ho & Litton, 2006). Catheter insertion sites are portals for pathogens to enter the bloodstream and cause infection. Chlorhexidine gluconate (CHG) used for site preparation during insertion has demonstrated to prevent CVC-related infections based on research implemented by Maki, Ringer, and Alvarado's randomized trial of providone-iodine, alcohol, and chlorhexidine for prevention of infections associated with central venous and arterial catheters (as cited in Heiner et al., 2008). Meticulous sterile techniques should not only be emphasized during the insertion process but also during the maintenance period. Therefore, the use of this anti-microbial dressing that continuously releases chlorhexidine gluconate (CHG) at the insertion site should be an additional tactic used with all central vascular catheters to prevent infection.

Clinical Question in PICO Format

This paper will discuss whether the use of chlorhexidine-impregnated dressings at central vascular catheter site insertions will reduce the incidence of a catheter-related nosocomial bloodstream infections compared to standard non-antimicrobial dressings.

Population: Patients with central vascular lines who have a chlorhexidine-impregnated dressing at catheter site insertion and patients with central venous lines with a standard non-antiseptic-impregnated dressing at catheter site insertion.

Intervention of interest: Use of a chlorhexidine-impregnated dressing at catheter site insertion.

Comparison of interest: Use of a standard non-antimicrobial impregnated dressing at catheter site insertion.

Outcome of interest: Reduction in catheter-related bloodstream infections.

Literature Review & Analysis

The potential risk of CVC's to cause catheter-related bloodstream infections has been studied in several researches. According to a report from National Nosocomial Infections Surveillance (NNIS, 2004) System (Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services) it is estimated that 250,000 to 500,000 catheter-related bloodstream infections occur annually in the United States. Based on these staggering numbers, great emphasis needs to be addressed on preventing catheter-related infections. Among the many recommendations encouraged by Centers for Disease Control (CDC) in the prevention of intravascular catheter-related infections, the use of chlorhexidine-impregnated dressings at CVC insertion sites has notoriously been overlooked. For instance, Krein et al. (2007) conducted a study examining the use of CVC-related bloodstream infection prevention practices among nonfederal hospitals and Department of Veterans Affairs medical centers. Only 25% of nonfederal hospitals with an intensive care unit with more than 50 hospital beds (n=600) and 29% of VA hospitals (n=119) reported regular use of chlorhexidine dressing at central catheter