• Screening & Prevention
• Infectious Disease Clinical Trials
• Bacterial Infections Laboratory Techniques

The Center for Disease Control guidelines recommend that clean skin be prepared with >0.5% chlorhexidine in 70% isopropyl alcohol (CHX-OH) before invasive procedures. Similar preparation is recommended by the American Society of Anesthesiologists in preparation for a central venous catheter. However, to date there has been insufficient data to evaluate CHX-OH compared with povidone iodine in alcohol (PVI-OH).

Jean-Jacques Parienti, MD, PhD, Centre Hospitalier Universitaire de Caen, Caen, France, presented results from a late-breaking clinical trial suggesting that the use of 1-step 2% CHX-OH without scrubbing was more effective than 4-step PVI-OH with scrubbing for preventing central venous catheter (CVC) colonization.

The source for these data was the first 215 consecutive patients from a single center who were participating in an ongoing randomized controlled trial [NCT01478153] comparing mechanical, infectious, and thrombotic complications between 3 venous access sites (subclavian, internal jugular, and femoral veins) for CVCs in patients admitted in the intensive care unit. The subjects in the analysis presented by Dr. Parienti received surgical site preparation with 10% PVI scrub, rinse, and dry followed by 5% PVI-OH (4-step) during August 2011 to January 2012 or CHX-OH without scrubbing (1-step) during January 2012 to August 2012. The endpoints were catheter-tip colonization (≥1000 CFU/mL) and central line-associated bloodstream infection (CLABSI; based on systematic peripheral blood cultures at CVC removal). Baseline characteristics were similar between the 2 periods except for a trend toward more successful first insertion attempts with CHX-OH (60%) versus PVI-OH (49%), mostly due to higher use of ultrasound guided insertions during the period with CHX-OH use.

Colonization on catheter removal was significantly lower with 1-step CHX-OH compared with 4-step PVI-OH on both univariate analysis (HR, 0.12; 95% CI, 0.04 to 0.43; p≤0.0001) and after controlling for body mass index, site, and antibiotic treatment (adjusted HR, 0.17; 95% CI, 0.05 to 0.57; p<0.005). Eleven of the 24 colonizations with PVI-OH (24/106) were Gram-positive (Staphylococcus epidermidis and Staphylococcus aureus); 13 were Gram-negative (Pseudomonas aeruginosa, Escherichia coli, Enterobacter spp). Of the 4 colonizations with CHX-OH, 3 were Gram-positive (all S. epidermidis) and 1 was fungal. The study was not powered to detect a significant difference in CLABSI, but the incidence was low in both groups (2 with PVI-OH and none with CHX-OH).

The colonization rate with PVI-OH in this study (24/106; 22.6%) was similar to that reported previously [Mimoz O et al. Arch Intern Med 2007; Parienti JJ et al. JAMA 2008] and when data from an earlier study [Parienti JJ et al. Crit Care Med 2004] were added to the current data, the use of CHX-OH remained independently associated with a lower risk of CVC colonization (HR, 0.19; 95% CI, 0.06 to 0.54).

Although Dr. Parienti cautioned the current study is limited in that it represents a small number of patients from a single center, observational study, he believes that 1-step 2% CHX-OH is unlikely to be inferior to 4-step PVI-OH, but it is simpler and is safe without scrubbing for skin antisepsis in ICU patients. A large randomized clinical trial is needed and will be started in France.

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