Chlorhexidine Antisepsis 1

Does implementation of chlorhexidine vs. povidone-iodine during central line site

care reduce the incidence of catheter related blood stream infections?

Michael J Thorn Jr.

Husson University

February 23rd, 2010

 Chlorhexidine Antisepsis 2

Introduction:

A central venous catheter, also known as a CVC, is a catheter that is placed

into large venous vessel away from the peripheral. It is a significant tool that allows

nurses and physicians to help treat and manage care of patients who are severely ill.

They allow us as healthcare providers to administer blood products, intravenous

fluids, vasoactive medications, total parental nutrition, and give us access to

monitor hemodynamics of the patient (Earsing, Hobson, & White, 2005). About

half of US ICU patients have a central venous catheter, which accounts for 15

million catheter days per year in the ICU (Earsing, Hobson, & White, 2005). Even

though these CVC’s had a tremendous they also can have a detrimental effect on

the patient’s condition when they become infected.

Because CVC’s provide venous access to patients, they disrupt skin integrity

making infection from bacteria and fungi possible…this infection can spread to the

bloodstream causing sepsis, changes in hemodynamics, and ultimately death. With

any sort of infection or diminished health status of a patient comes a financial

burden as well (Earsing, Hobson, & White, 2005). According to the Institute for

Healthcare Improvement (IHI), as of 2007, cost per infection was an estimated

$34,000 to $56,000 per incident, with an average CR-BSI extending hospital length

of stay by 7 days (Harnage, 2009).

Over the past few years studies have been conducted to illustrate whether

chlorohexidine or povidine-iodine helps reduce the incidence of catheter related

bloodstream infections. With the adoption of chlorohexidine into the IHI central
 Chlorhexidine Antisepsis 3

line bundle framework, it has obviously been shown that chlorohexidine is a better

solution to use to prevent CRBSI’s.

We as nurses, it is our duty to look out for the health and wellbeing of our

patients and the overall viability of our healthcare system. A CRBSI leads to many

negative outcomes that potentially result in systemic infection, increase mortality,

and financial burden that can be prevented by adhering to EBP interventions such as

site prep and site care with chlorhexidine. Experts report 15 million CVC days in

the United States occur in the ICU each year; the rate of infection is estimated to be

5.3 cases per 1,000 catheter days, resulting in approximately 80,000 CR-BSI’s each

year. Researchers reported a CR-BSI associated mortality rate of 0% to 35%, with

as many as 28,000 patients dying annually in U.S. ICU’s (Buttes, Lattus, Stout, &

Thomas, 2006).

Safety is one of the outlined competencies from the Quality and Safety

Education for Nurses (QSEN) that I feel has a strong relationship with the nurses’

role in preventing CR-BSI’s. According to Cronenwett et al, the definition of safety

is to “minimize risk of harm to patients and providers through both system

effectiveness and individual performance. Safety relates to the discussion about CR-

BSI’s because patients whom acquire infections are not in a safe situation and are at

risk of further declination of health status. We as nurses must obtain knowledge that

is evidenced based practice so we ensure that the care we are giving is safe. In order

to do so we must adhere to standards and protocols those have been proven to be

safe and effective.

 Chlorhexidine Antisepsis 4

The three pillars (knowledge, skills, and attitudes) of the safety competency

have continuously been intertwined and embedded into the nursing practice to

prevent CR-BSI. “Examining human factors and other basic safety design principles

as well as commonly used unsafe practices are a key concept that nurses to discuss

(Cronenwett et al., 2007).” Being able to have open forum and allow others to instill

knowledge that can help fellow nurses understand that unsafe practice has negative

consequences that affect the patient, the institution, and the nurse’s practice can

give them insight to implement new practice or to change to a practice that is

evidenced based.

“Use national patient safety resources for own professional development and

to focus attention on safety in care settings (Cronenwett et al., 2007).” This has

already become evident in the practice to prevent CR-BSI’s. The Institute on

Healthcare Improvement has already set forth guidelines and “care bundles” that are

to be used to prevent CR-BSI’s. With information like this already being made

readily available it is now important for nurses and administrative personnel to aid

in the implementation for these guidelines to help establish a safe environment for

patients.

Attitudes that we as nurses need to instill in our nursing practice is to “value

vigilance and monitoring by patients, families, and other members of the healthcare

team (Cronenwett et al., 2007).” This is important because we as humans are not

perfect and are not able to pick up on everything that is not safe. Instilling these

values into our practice insure that we are taking the patients safety into

consideration at all times and that we are doing everything in our power to ensure
 Chlorhexidine Antisepsis 5

that no-harm is done. Working collaboratively with other members in the healthcare

team help us increase our awareness of the patient and allow more than one nurse

helping to empower a safe and healing environment.

Review of Literature:

In 2002, Chaiyakunapruk et al submitted an article to the Annuls of Internal

Medicine. In the meta-analysis it evaluated the effectiveness of skin antisepsis with

Chlorhexidine versus Povidone-iodine in preventing CRBSI’s. There was analysis

of eight studies involving a total of 4143 central venous catheters that varied in

type. “Among patients with a central vascular catheter, chlorhexidine reduced the

risk for catheter-related bloodstream infection by 49% (Chaiyakunapruk, Veenstra,

Lipsky, & Saint, 2002).”

In 2007, Mimoz et al. conducted a study that was published in the Archives

of Internal Medicine. There study was to determine whether chlorhexidine was a

better antiseptic to use then povidone-iodine in the site care of a CVC. “Catheters

assigned to the chlorhexidine group (11.1%) were less frequently colonized than

those assigned to the povidone-iodine group (22.2%). The incidence of catheter

colonization was 9.7 versus 18.3 per catheter days.” There was also a trend toward

lower rates of catheter-related blood stream infections; Chlorhexidine=1.7% vs.

Povidone-Iodine=4.2% (Mimoz et al., 2007).

In the Journal of Infection Control, a meta analysis and cost effectiveness

analysis of randomized controlled trials comparing Chlorhexidine with Povidone-

iodine solutions for venous catheter site care found that the use of Chlorhexidine
 Chlorhexidine Antisepsis 6

significantly reduced the risk of CRBSI’s and that is was cost-effective. Of the 312

subjects, 120 received Chlorhexidine solution and 192 received Povidone-iodine.

The results of the study showed that the CVC subjects that received Chlorhexidine

had a lower incidence of CRBSI than subjects who received Povidone-iodine, with

3.2 versus 5.6 episodes per 1000 CVC days (Balamongkhon & Thamlikitkul, 2007).

A study conducted that can be found in the Lancet journal. It was conducted

to assess the efficacy of cutaneous antisepsis for disinfection of patients’ central

venous catheter insertion sites in a SICU. 668 patients were included and

randomized to Povidone-iodine, Chlorhexidine, and alcohol. Chlorhexidine was

associated with the lowest incidence of CR-infection; 2.3/100 (Chlorhexidine) vs.

9.3/100 (Povidone-iodine) (Maki, Ringer, & Alvarado, 1991).

In the Journal of Pediatric Nephrology a retrospective study was aimed to

investigate if the application of Chlorhexidine-based solutions to the insertion site

could prevent catheter related bactremia and prolonged catheter survival rate when

compared with Povidone-iodine solutions. There were 20,784 catheter days

observed. The use of Chlorhexidine significantly decreased the incidence of CRB

(1.0 vs. 2.2/1000 catheter days) and the hospitalization due to CRB (1.8 vs. 4.1

days/1,000 catheter days) (Under et al., 2009).

Case Exemplar:

The summer of 2009 I participated in the Mayo Clinic summer III program.

That summer I was able to work on the cardiothoracic ICU, Oncology, and the

ENT/Plastics surgical unit; all of whom had numerous patients with central venous
 Chlorhexidine Antisepsis 7

access devices. While at the Mayo Clinic, I was able to be involved in the care of

many patients who had some sort of central line placement. It was either being used

for vasopressors, chemotherapy, total parenteral nutrition, or vancomycin. Many

measures were taken during insertion and during site care to ensure that the lowest

possible risk of infection was taken. To allow for a safe and harm-free environment

during insertion and maintenance site care a set of evidenced based protocols were

embedded into the nursing practice.

Education becomes a very important function of practice and should always

be included to ensure that we have the best possible outcomes for our patients. As a

student intern at the hospital, I had to go through clinical simulation to allow for

improvement and learning of the proper technique to safely do CVC site care. As an

intern I also had to review the written protocols and guidelines set in place as well

as have the nurse and clinical nurse specialist exemplify how it was completed by

illustrating several times on a patient first.

This experience I had this summer exemplifies that safety of the patient is

the primary concern. Using an evidenced based intervention, such as the central line

bundle checklist, ensures that proven research is utilized in practice. The measures

taken to ensure that patient safety was the priority in the CVC site care and multiple

measures were taken to ensure that no harm was done to the patient.

Nursing Implications:

Practice:
 Chlorhexidine Antisepsis 8

After the countless number of articles I found on the prevention of CRBSI’s,

Chlorhexidine is the key antiseptic in the prevention of CRBSI’s on a wide array of

multitudes including cost effectiveness and the toxicity and the high percentage of

the population being allergic to iodine. Evidence has shown that the benefits of

chlorhexidine outweigh iodine.

The cost of care is also an issue when it comes to managing the care of our

patients. We as healthcare providers need to remember the key concept that our

financial institutions keep embedded in our institutions and that is to provide the

best possible care at the lower cost possible which comes into perspective with the

use of chlorhexidine versus povidone-iodine. The costs of treating a patient in an

intensive care setting are very high. When you add the cost of a nosocomial

infection such as a bloodstream infection the average costs are astronomical.

With this being said the extra cost of using an evidenced based product of

chlorhexidine surely outweighs the use of a cheaper product such as povidone-

iodine. “The extra attributable costs of a nosocomial bloodstream infection are

$40,000 per survivor and the mortality is 35%. Although chlorhexidine ($0.92) is

more expensive than povidone-iodine ($0.41), the difference seems far less than the

costs of treating bloodstream infections (Chaiyakunapruk, Veenstra, Lipsky, &

Saint, 2002).”

Evidence also shines light upon the persistent efficacy of chlorhexidine over

povidone-iodine. In Nursing 2009 it states that: “chlorhexidine demonstrated

significant residual antimicrobial effect over 72 hours and was more effective than

povidone-iodine alone (Moureau, 2009).” This illustrates that with duration of

 Chlorhexidine Antisepsis 9

effectiveness of this solution that it allows for a decreased need of changing central

venous catheter dressings. This allows for less need of exposing the line insertion

site to air and allows for a closed seal so that there is less exposure to open air that

is potentially contaminated.

More evidence that further clarifies that the use of chlorhexidine has great

benefit is a cost-benefit analysis conducted by Crawford and his colleagues. The

results of the analysis were that the estimated potential annually U.S. net benefits

from the use of chlorhexidine impregnated dressings use ranged from $275 million

to approximately $1.97 billion due to the decrease in catheter related bloodstream

infections. Preventable mortality analyses showed potential decreases of between

339 and 3,906 U.S. deaths annually as a result of nationwide use of chlorhexidine

(Crawford, Fur, & Rao, 2004).

Education:

The need for further education is imperative to ensure that nurses are

confident and competent in the skills to reduce BSI. Continuing education and the

implementation of courses to allow nurses to be competent in central line bundle

care is imperative to our practice as a nurse. Being able to follow updated

guidelines and protocol and learn about different way to prevent CVC infection

makes us grow as a nurse.

A case of how nursing practice is taking the role of maintaining EBP

standards and monitoring takes place in Liverpool, Australia. Two advanced

practice nurses formulated a service call Central Venous Access Service. These
 Chlorhexidine Antisepsis 10

nurses did not have the role of inserting CVC’s but actively engaged in the setting

and monitoring of clinical practice standards. “The CVAS plays an important

education and training role through performing sessions and educational programs

for nursing and medical staff on CVC management and handling. The CVAS is an

example of how a nurse coordinated model of care using EBP can improve patient

outcomes through reducing infection ("CEC | Programs: Central Line Associated

Bactremia in Intensive Care Units," n.d.).”

In a nonteaching hospital a group of physicians’ objective of their study was

to evaluate the effectiveness of an EB approach to prevent CR-BSI through the

means of education. They provided a self-study packet as well as provided

classroom teaching through the means of posters and lectures. What the study

concluded was that there was a 57% reduction of CR-BSI by implementing a

teaching program for ICU nurses (Warren, Zack, Cox, Cohen, & Fraser, 2003).

There is also a study present in literature that also supports the use of

integrating an innovative teaching program among nurses in a teaching hospital as

well. The educational program used self-study packets, hands-on simulation, as well

as verbal in-service at staff meetings. What the study concluded was that there was

a 66% decrease in CR-BSI over the course of 18 months (Coopersmith, Rebmann,

Zack, Ward, & Corcoran, 2002).

With evidence supporting that educational programs at both teaching and

non-teaching hospitals has been a positive means of implementing EBP into

educational programs to help nurses be more informed in their nursing care so we

 Chlorhexidine Antisepsis 11

can decrease the mortality, morbidity, length of stay, and increase patient

satisfaction in our plan of care.

Research:

Research continues to revolve around the issue of whether Chlorhexidine is

the superior to povidone-iodine as an antiseptic to help reduce CRBSI’s. Research

has also gone in the direction of using Chlorhexidine impregnated catheters,

dressings, and the coating material on the tips of the lumen. This research is

imperative because of the need to have decrease patient mortality, duration of

hospitalization days, and healthcare costs. Halting the existence of the continuation

of studies that can be used for EBP in the hospital setting would be ignorant and

would not allow the exploration and discovering of new and better interventions to

reduce nosocomial infections.

We as nurses need to take the role as researcher, implementers, and

advocates to help continue research that can be implemented to prevent these

nosocomial infections. We as healthcare providers need to empower fellow nursing

staff and physicians to explore innovative techniques that have been proven to

decrease bloodstream infections and implement them into healthcare practice.

 Chlorhexidine Antisepsis 12

References

Balamongkhon, B., & Thamlikitkul, V. (2007). Implementation of chlorhexidine

gluconate for central venous catheter site care at Siriraj Hospital, Bangkok,

Thailand. American Journal of Infection Control, 35(9), 585-588.

Buttes, P., Lattus, J., Stout, C., & Thomas, L. (2006, May). Drive down infection

rates: Use care bundles to tale a multiprofessional approach to decreasing

catheter-related bloodstream infections. Nursing 2006 Critical Care, 41-45.

CEC | Programs: Central Line Associated Bacteraemia in Intensive Care Units.

(n.d.). Retrieved February 24, 2010, from

http://www.cec.health.nsw.gov.au/programs/clab-icu.html

Chaiyakunapruk, N., Veenstra, D. L., Lipsky, B. A., & Saint, S. (2002).

Chlorhexidine Compared with Povidone-Iodine Solution for Vascular

Catheter-Site Care: A Meta-Analysis. Annals of Internal Medicine, 136,

792-801.

Coopersmith, C. M., Rebmann, T. L., Zack, J. E., Ward, M. R., & Corcoran, R. M.

(2002). Effect of an education program on decreasing catheter-related

bloodstream infections in the surgical intensive care unit. Critical Care

Medicine, 30(1), 59-64.

Crawford, A. G., Fuhr, J. P., & Rao, B. (2004). Cost-benefit analysis of

chlorhexidine gluconate dressing in the prevention of catheter-related

bloodstream infections. Infection Control and Hospital Epidemiology, 25(8),

668-674.
 Chlorhexidine Antisepsis 13

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., ...

Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook,

55(3), 122-131.

Earsing, K., Hobson, D., & White, K. (2005, October). Best-Practice Protocols:

Preventing central line infection. Nursing Management, 18-24.

Harnage, S. (2009, June). Zero CR-BSI rate? It's possible. Nursing Management, 8-

12.

Maki, D. G., Ringer, M., & Alvarado, C. J. (1991). Prospective randomised trial of

povidone-iodine, alcohol, and chlorhexidine for prevention of infection

associated with central venous catheters. Lancet, 338(8763), 339-343.

Mimoz, O., Villeminey, S., Ragot, S., Dahyot-Fizelier, C., Laksiri, L., Petitpas, F.,

& Debaene, B. (2007). Chlorhexidine-Based Antiseptic Solution vs.

Alcohol-Based Povidone-Iodine for Central Venous Catheter Care. Archives

Internal Medicine, 167(19), 2066-2072.

Moureau, N. (2009, July). I.V. Rounds: Reducing the cost of catheter related

bloodstream infections. Nursing 2009, 14-15.

Onder, A. M., Chandar, J., Billings, A., Diaz, R., Francoeur, D., Abitbol, C., &

Zilleruelo, G. (2009). Chlorhexidine-based antiseptic solutions effectively

reduce catheter-related bacteremia. Pediatric Nephrology, 24(9), 1741-1747.

Warren, D. K., Zack, J., Cox, M. J., Cohen, M. M., & Fraser, V. J. (2003). An

educational intervention to prevent catheter-associated bloodstream

infections in a nonteaching, community medical center. Critical Care

Medicine, 31(7), 1959-1963.