One possible explanation for the differences observed in the studies could be that the strengths of the chlorhexidine solution were different. It could also be that over time more effective techniques have been developed in the application of the solution, as the results do appear to improve over time.
There are limitations to the methodology of the study which are centered on the use of secondary data for analysis. The use of secondary data allows a wider range of data to be gathered from across the U.S. than would be practical from primary data collection which is the reason for the choice in this study. However this puts the control of several variables beyond the researcher. The results of the techniques may have been affected by the application of different individuals, departments and hospitals, all of whom may vary techniques and other factors influencing the success of these techniques. The analysis and interpretation of study results by different researchers in each study may also affect the overall outcome, as different researchers will choose to collect and interpret data in different ways, with the only the final versions being available for this study. Despite these limitations, the overall agreement between the different sources suggests that clear conclusions may be drawn from the study for synthesis.
Number of catheters
Mean catheter duration
Proportion of positive cultures with catheter colonization
Catheter related blood stream infection
Povidone Iodine group
Maki et al., 1991 ICU 214-227 5.3-5.3-5-2.3-21 9.2-1-0.4 Sheeham et al., 1993 ICU 169-177 n/a 3-1.8-12 6.8-1-0.6 Meffre et al., 1995 Across hospital 568-549 1.6-1.6-9-1.6-22 4-3-0.5 Mimoz et al., 1996 ICU 170-145 4.5-3.9-12 7.1-24-16.6-3-1.8 Legras et al., 1997 ICU 208-249 10-10-19 9.1-31-12.4-0-0 LeBlanc and Cobett, 1999 83-161 1.6-1.7-6-7.2-23-16.1 n/a Humar et al., 2000 Any hospital unit 116-116 5.3-6.3-36-31 27-23.3-4-2.1 Langartner et al., 2004 Any hospital unit 45-52-13.3-14.5-11-24.4-16-30.8
Table 1 - Results of the studies which were taken for the analysis of chlorhexidine vs. povidone Iodine in infection control when placing CVCs
In the time period since the introduction of chlorhexidine there have been advances made in alternative solutions. In the study by Langgartner et al. (2004) the effect of combining the two methods of disinfectant was combined in order to assess whether the effects of the disinfectants would combine to produce better results. The study found that only 4.7% of patients were found to have colonization of catheters after receiving both methods of disinfection prior to placement of the catheter. Although this figure is higher than many of the other studies have revealed by either method alone, the figure is much lower than the cases observed in Langgartner et al.'s study for either method alone. Therefore it could be suggested that the combination of skin disinfection with chlorhexidine followed by disinfection with povidone Iodine would be the most effective form of antiseptic treatment before placing an IV catheter. However as there is only one study which shows these results at the present time it would be suggested that further studies would be necessary in order to ascertain whether this is true. The main limitation in the study by Langgartner et al. was that there was no measure of the number of infections which arose as a result of the catheter placement. This means that even though there was a clear reduction in the number of catheters displaying colonization this would not necessarily result in a lower number of infections. It is only if the infections could be lowered through performing both techniques that it would be beneficial as otherwise it would simply increase healthcare costs and prolong the procedure for the patient without visibly better results.
Recent research has primarily dealt with new advances in intravenous catheter technology whereby the impregnation of the needle with antiseptic is an additional measure to prevention of infections. Some studies have been published to examine the effects of introducing chlorhexidine impregnated CVCs in reducing CRBSIs and these have shown promising results (Schuerer et al., 2007). There are now moves to standardize this across the whole U.S. As an additional measure to antiseptic swabbing techniques prior to catheter insertion.
Synthesis of Findings
Based upon the findings of the study, an advanced practice response may be formulated from the research to answer the original clinical problem. In summary, the initial clinical problem was "What are the most effective antiseptic techniques to use to minimize risk of infection from use of intravenous catheters?" The synthesis of the research suggests the following guidelines as a result:
Povidone Iodine may not be as effective as chlorhexidine in reducing the numbers...
It is also less effective at reducing the risk of infection from siting these catheters. Therefore povidone Iodine should not be used in isolation as a means of disinfecting skin prior to catheterization.
Chlorhexidine is effective in reducing both colonization of catheters and the risk of contracting infection from catheterization. Therefore it is recommended that chlorhexidine be used in preference to povidone solution alone in sterilization prior to catheterization. This should be used according to the manufacturers' recommendations to ensure maximum effectiveness.
There is evidence to suggest that the combination of chlorhexidine antiseptic techniques and povidone Iodine techniques may result in a greater reduction of infections than either technique alone. Therefore it would be recommended that if resources allow the patient should receive chlorhexidine antiseptic treatment followed by povidone Iodine antiseptic treatment. Both should be applied according to manufacturer's recommendations.
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CDC. (2002). Guidelines for Prevention of Intravascular Catheter-Related Infections. Morbidity and Mortality Weekly Report; Recommendations and Reports, 51 (RR-10), 1-34.
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Chaiyakunapruk, N., Veenstra, P.D.L., Lipsky, P.B.A., & Saint, M.S., MD. (2002). Chlorhexidine Compared with Providone-iodine Solution for Vascular Catheter-Site Care: A Meta-Analysis. Annals of Internal Medicine, 136, 792-801.
FDA Mission. (n.d.). Retrieved February 6, 2006, from FDA Web site: http://www.fda.gov/opacom/morechoices/mission.html
Hadaway, L. (2006). Keeping Central Line Infections at Bay. Nursing, 36 (4), 58-64.
Hibbard, JS. (May/June 2005). Analyses comparing the antimicrobial activity and safety of current antiseptic agents; a review. Journal of Infusion Nursing, 28 (3), 194-207.
Humar, a., et al. (2000). Prospective Randomized Trial of 10% Providone-Iodine versus 0.5% Tincture of Chlorhexidine as Cutaneous Antisepsis for Prevention of Central Venous Catheter Infection. Clinical Infectious Diseases, 31, 1001-1007.
Krein, S.L., Hofer, T.P., Kowalski, C.P., Olmsted, R.N., Kauffman, C.A., Forman, J.H., Banaszak-Holl, J. And Saint, S. (2007) Use of central venous catheter-related bloodstream infection prevention practices by U.S. hospitals. Mayo Clinical Proceedings, 82(6), 672-678.
Langaartner, J., Linde, H-J., Lehn, N., Reng, M., Scholmerich, J. And Gluck, T. (2004) Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonization of central venous catheters. Intensive Care Medicine, 30, 1081-1088.
LeBlanc, a and Cobett, S. (1999) IV site infection: A prospective, randomized clinical trial comparing the efficacy of three methods of skin antisepsis. Canadian Intravenous Nurses Association Journal, 15, 48-50.
Legras, a., Cattier, B., Dequin, P.F., Boulain, T. And Perrotin, D. (1997) Etude prospective randomisee pour la prevention des infections liees aux catheters: chlorhexidine alcoolique contre polyvidone iodee. Reanimation et Urgences, 6, 5-11.
Maki, D.G., Ringer, M. And Alvarado, C.J. (1991) Prospective randomized trial of povidone-iodine, alcohol and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet, 338, 339-343.
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Meffre, C., Girard, R., Hajjar, J. And Fabry, J. (1995) Is peripheral venous catheter colonization related to the antiseptic used for disinfection of the insertion site? Povidone-iodine vs. alcoholic chlorhexidine: a multicenter randomized prospective study. Hygienes, 9, 45.
Miller, D.L., MD, & O'Grady, N.P., MD. (2003). Guidelines for the Prevention of Intravascular Catheter-related infections: Recommendations Relevant to Interventional Radiology. Journal of Vascular and Interventional Radiology, 14 (Suppl.), s355-s358.
Mimoz, O., Pieroni, L., Lawrence, C., Edouard, a., Costa, Y., Samii, K. et al. (1996) Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Critical Care in Medicine, 24, 1818-1823.
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Sheehan, G., Leicht, K., O'Brien,…
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