Interventions for preventing infectious complications in haemodialysis patients with central venous lines

Patients whose kidneys no longer work need to have water, toxins and other chemicals removed from their blood using an artificial kidney. One method of achieving this is to use a central venous catheter (CVC) which is a small tube inserted via the skin into a blood vessel in the neck of the patient. This tube allows blood to go from the patient, pass through an artificial kidney and return back to the patient. This process is referred to as a dialysis session which takes four hours and is usually performed three times a week. As CVC have direct access to the blood system they can cause serious infections which can be life threatening to the patient. Several strategies can be used to prevent these infections occurring including the application of different types of ointments (mupirocin, povidone-iodine and polysporin) or medicinal honey to the catheter site, and the use of different dressings which cover the catheter site (transparent or gauze and tape). The review of 10 studies (786 patients) found that mupirocin ointment reduced the risk of patients developing catheter-related bacteraemia (bacteria in the blood). However, monitoring of mupirocin resistance needs to be considered in future studies. There was not enough evidence to determine which ointment (povidone-iodine and polysporin) or dressing was the best in preventing infection. There was also insufficient evidence to support the use of medicinal honey for the prevention of infection.

Authors' conclusions: 

Mupirocin ointment appears effective in reducing the risk of catheter-related bacteraemia. Insufficient reporting on mupirocin resistance was noted and needs to be considered in future studies. A lack of high quality data on the routine use of povidone-iodine ointment, polysporin ointment and topical honey warrant larger RCTs. Insufficient data were available to determine which dressing type (transparent polyurethane or dry gauze dressing) has the lowest risk of catheter-related infections.

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Background: 

Central venous catheters (CVC) continue to play a prominent role in haemodialysis vascular access with 46% to 70% of patients commencing haemodialysis via a CVC. CVC access is associated with catheter-related infections, increased patient hospitalisations and death due to infection. A variety of interventions are used to prevent CVC infection.

Objectives: 

To evaluate the benefits and harms of prophylactic topical antimicrobials, topical antiseptics, medicated and non-medicated dressings on infectious complications among haemodialysis patients with CVC.

Search strategy: 

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and reference lists of articles without language restriction.

Selection criteria: 

We included randomised controlled trials (RCTs) and quasi-RCTs investigating any intervention that prevented infectious complications among haemodialysis patients with CVC. We excluded antimicrobial impregnated CVC or CVC using locking solutions with antimicrobial properties.

Data collection and analysis: 

Two authors assessed study quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous outcomes as mean differences (MD).

Main results: 

Ten studies (786 patients) were included. Mupirocin ointment reduced the risk of catheter-related bacteraemia (RR 0.17, 95%CI 0.07 to 0.43) and had a significant effect on catheter-related infections caused by S. aureus. The risk of catheter-related bacteraemia was reduced by polysporin (RR 0.40, 95%CI 0.19 to 0.86) and povidone-iodine ointment (RR 0.10, 95%CI 0.01 to 0.72). Subgroup analysis suggested mupirocin (RR 0.12, 95%CI 0.01 to 2.13) and povidone-iodine ointment (RR 0.84, 95%CI 0.24 to 2.98) had no effect on all-cause mortality while polysporin ointment showed a significant reduction (RR 0.22, 95%CI 0.07 to 0.74). Mortality related to infection was not reduced by mupirocin, polysporin or povidone-iodine ointment. Topical honey did not reduce the risk of exit site infection (RR 0.45, 95%CI 0.10 to 2.11) or catheter-related bacteraemia (RR 0.80, 95%CI 0.37 to 1.73). Transparent polyurethane dressing compared to dry gauze dressing did not reduce the risk of CVC or exit site infection, or catheter-related bacteraemia

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