Review
Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis

https://doi.org/10.1016/j.ijnurstu.2017.01.007Get rights and content

Abstract

Background

Microorganisms can intraluminally access a central venous catheter via the catheter hub. The catheter hub should be appropriately disinfected to prevent central line-associated bloodstream infections (CLABSIs). However, compliance with the time-consuming manual disinfection process is low. An alternative is the use of an antiseptic barrier cap, which cleans the catheter hub by continuous passive disinfection.

Objective

To compare the effects of antiseptic barrier cap use and manual disinfection on the incidence of CLABSIs.

Design

Systematic review and meta-analysis.

Methods

We systematically searched Embase, Medline Ovid, Web-of-science, CINAHL EBSCO, Cochrane Library, PubMed Publisher and Google Scholar until May 10, 2016. The primary outcome, reduction in CLABSIs per 1000 catheter-days, expressed as an incidence rate ratio (IRR), was analyzed with a random effects meta-analysis. Studies were included if 1) conducted in a hospital setting, 2) used antiseptic barrier caps on hubs of central lines with access to the bloodstream and 3) reported the number of CLABSIs per 1000 catheter-days when using the barrier cap and when using manual disinfection.

Results

A total of 1537 articles were identified as potentially relevant and after exclusion of duplicates, 953 articles were screened based on title and abstract; 18 articles were read full text. Eventually, nine studies were included in the systematic review, and seven of these nine in the random effects meta-analysis. The pooled IRR showed that use of the antiseptic barrier cap was effective in reducing CLABSIs (IRR = 0.59, 95% CI = 0.45–0.77, P < 0.001).

Conclusions

Use of an antiseptic barrier cap is associated with a lower incidence CLABSIs and is an intervention worth adding to central-line maintenance bundles.

Introduction

Microorganisms can access central venous catheters (CVCs) via an intraluminal or an extraluminal route. An important route is intraluminally via the catheter hub (Salzman et al., 1993a). Microorganisms may be a source of central line-associated bloodstream infections (CLABSIs), especially in patients with impaired immunity (e.g. patients who are on chemotherapy) and in patients admitted to the Intensive Care Unit (ICU) (Ziegler et al., 2015). Research has shown that a combination of interventions, known as central line insertion and maintenance bundles, is effective in preventing CLABSIs in ICU settings and is cost saving (Blot et al., 2014, Ista et al., 2016 Ista et al., 2016). To prevent intraluminal contamination, important aspects of the bundles are ensuring a maximum sterile barrier during catheter insertion and adequate disinfection of the hub prior to intravenous medication administration (Salzman et al., 1993b). Adequate disinfection means rubbing the hub for 10 s with chlorhexidine, povidone iodine, an iodophor, or 70% alcohol followed by 30 s drying time, which is a time consuming procedure O’Grady et al., 2011, Hong et al., 2013). However, the optimal duration of rubbing and drying is still unclear and is therefore not present in guidelines. A recently published meta-analysis showed that maximum compliance with maintenance bundles is hard to reach (Ista et al., 2016). Also, a study by Helder et al. showed that nurses’ compliance with the 30 s drying time after hub disinfection was only 35% before and only 45% after a feedback intervention (Helder et al., 2016).

To protect the hub from contamination an antiseptic barrier cap was developed (Menyhay and Maki, 2006, Menyhay and Maki, 2008). Through continuous contact with the disinfectant, this device optimizes needleless connector disinfection through cleaning of the catheter hub without active scrubbing (Menyhay and Maki, 2006, Menyhay and Maki, 2008). The antiseptic barrier cap is placed onto an intravenous (IV) needleless connector and bathes the connector in 70% isopropyl alcohol. The single-use antiseptic barrier cap remains in place until the next catheter access. This design allows for direct safe access to the hub when the barrier cap is removed. In vitro studies suggest that an antiseptic barrier cap placed over an IV needleless connector reduces colonization of microorganisms on the connectors and thereby lowers the risk of CLABSIs (Menyhay and Maki, 2006, Menyhay and Maki, 2008). With this systematic review and meta-analysis we aimed to answer the question: what is the effect of antiseptic barrier caps compared to manual disinfection on the incidence of CLABSIs?

Section snippets

Search strategy

This systematic review and meta-analysis followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement (S1 file) (Moher et al., 2009). The study protocol was registered in the PROSPERO international register (registration number: CRD42016032303). A librarian devised and executed the search strategy. This included the terms CLABSIs, catheter and infusion, in combination with disinfectant, in combination with a cap or hub. The full

Description of included studies

A total of 1536 articles were identified as potentially relevant (Fig. 1, S2 file). Additionally, we selected one article from the reference lists of 14 reviews about preventing CLABSIs in patients (Fig. 1). Screening of the titles and abstracts yielded 18 articles that met the eligibility criteria described in the Methods section when. After reading these 18 articles full-text, we eventually included nine articles (Ramirez et al., 2012, Sweet et al., 2012, Wright et al., 2013, Devries et al.,

Summary of evidence

We found evidence that the antiseptic barrier cap compared to manual disinfection is associated with a risk reduction of the incidence of CLABSIs, also when excluding the two studies with possible conflicts of interest and low methodological quality. Further, both brands of barrier cap, the Curos and the SwabCap, are effective in reducing CLABSIs. While use of the latter was more frequent, the Curos was associated with a lower IRR. However, confidence intervals were large and close to one as

Ethical approval

No.

Conflict of interest

Onno K. Helder PhD is a board member of the European Foundation for the Care of Newborn Infants (EFCNI). He has obtained lecture and consultancy fees from 3M. All other authors report no conflict of interest relevant to this article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

We thank Wichor M. Bramer, BSc, biomedical information specialist, Medical Library, Erasmus MC University Medical Center. The authors also thank Ko Hagoort for carefully editing the manuscript.

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