In the Literature
Bottom line: Among patients who are treated with clopidogrel for ACS, PPIs should be reserved for patients with a clear indication for gastric acid reduction and who cannot use alternative therapies.
Citation: Ho PM, Maddox TM, Wang L, et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA. 2009;301(9):937-944.
Chlorhexidine-Impregnated Sponge Use Reduces Line Infections
Clinical question: Does dressing vascular catheters with chlorhexidine gluconate-impregnated sponges (CHGIS) reduce rates of catheter-related infections, and are dressing changes every seven days inferior to every three days?
Background: Process improvement strategies—including educating providers, strictly adhering to sterile technique, and promptly removing unnecessary catheters—greatly decrease catheter-related infections. It is unclear if CHGIS dressings offer additional benefit. Also uncertain is whether weekly dressing changes are as safe as changing dressings every three days.
Study design: A 2x2 factorial, assessor-blinded, randomized controlled trial.
Setting: ICUs in three university hospitals and two general hospitals in France.
Synopsis: 1,636 French adults expected to require arterial and central venous catheters for >48 hours were randomly assigned to one of four groups. Each group received either CHGIS dressings or standard dressings, and each group had dressing changes every three or seven days. Dressings were changed sooner if soiled or nonadherent. CHGIS dressings were associated with fewer catheter-related infections than standard dressings (0.6 vs. 1.4 infections per 1,000 catheter days; P=0.03). No significant difference in rates of catheter colonization existed between the three-day and seven-day dressing change strategies (10.4 vs. 11 events per 1,000 catheter days, P>0.05).
Although microbiology assessors were blinded to patients’ status, the ICU staff was not, potentially creating experimenter bias. Approximately 30% of the venous catheters and 40% of the arterial catheters were in a femoral site. Secondary analyses found higher rates of severe dermatitis among patients with CHGIS dressings but no difference in minimal bactericidal concentration (MBC) or colonizing organisms. Preliminary calculations suggested CHGIS dressings could be cost-effective.
Bottom line: Among critically ill adults, CHGIS catheter dressings may marginally reduce catheter-related infection rates, but further evaluation is needed before this technology can be adopted widely.
Citation: Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically-ill adults: a randomized controlled trial. JAMA. 2009;301(12):1231-1241.
