Frequency of dressing changes for central venous access devices on catheter‐related infections

Nicole C Gavin; Joan Webster; Raymond J Chan; Claire M Rickard

doi:10.1002/14651858.CD009213.pub2

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Figure 1

Flow diagram of included and excluded studies

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 1 Catheter related blood stream infection.

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Analysis 1.2

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 2 Suspected catheter related blood stream infection.

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Analysis 1.3

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 3 All‐cause mortality.

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Analysis 1.4

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 4 Catheter‐site infection.

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Analysis 1.5

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 5 Skin damage.

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Analysis 1.6

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 6 Pain.

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Summary of findings for the main comparison. Longer intervals (5‐15 days) (intervention) versus shorter intervals (2‐5 days) (control) between dressing changes for preventing catheter‐related infection in people with central venous access devices

Patient or population: patients with a central venous access device Setting: Hospital or community settings in Europe Intervention: longer intervals between dressing changes (5 ‐ 15 days) (intervention) Comparison: shorter intervals between dressing changes (2 ‐ 5 days) (control)
Outcomes	Relative effect (95% CI)	*Anticipated absolute effects^ (95% CI)**			Quality of the evidence (GRADE)	What happens
		Without longer interval (5 ‐ 15 days)	With longer interval (5 ‐ 15 days)	Difference
Catheter‐related blood stream infection (CRBSI) assessed with: as defined by CDC (2002) follow up: median 11 days № of participants: 995 (1 RCT)	RR 1.42 (0.40 to 4.98)	Study population			⊕⊕⊝⊝ LOW ^{1 2}	Longer intervals between dressing changes may have little or no effect on catheter‐related blood stream infection
		8 per 1000	12 per 1000 (3 to 41)	4 more per 1000 (5 fewer to 33 more)
All‐cause mortality assessed with: unclear follow up: range 48 hours after discharge from ICU to 120 days № of participants: 896 (3 RCTs)	RR 1.06 (0.90 to 1.25)	Study population			⊕⊕⊝⊝ LOW ^{3 4}	Longer intervals between dressing changes probably have little or no effect on death from any cause
		354 per 1000	375 per 1000 (318 to 442)	21 more per 1000 (35 fewer to 88 more)
Skin damage № of participants: 1587 (4 RCTs) Follow up: unclear	Not estimable	Skin damage was reported in four studies. Two provided data but their results were not combined due to inconsistency of size and direction of the effects. One study in children found less skin damage in the longer interval group (8/56) compared with the shorter interval group (24/56). Rates of skin damage in one study in adults were similar (7/39 in longer interval versus 6/42 in shorter interval).⁹			⊕⊝⊝⊝ VERY LOW ^{5 6 7}	It is uncertain whether longer (compared with shorter) intervals between dressing changes reduce skin damage
Pain № of participants: 193 (2 RCTs) Follow up: unclear	RR 0.80 (0.46 to 1.38)	Study population			⊕⊕⊝⊝ LOW ^{1 7 8}	It is uncertain whether longer (compared with shorter) intervals between dressing changes affect pain on dressing removal
		347 per 1000	278 per 1000 (160 to 479)	69 fewer per 1000 (187 fewer to 132 more)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded for risk of bias due to lack of blinding of participants and personnel and for a probable unit of analysis error (individual participants randomised but numbers of infections reported) ² Downgraded for serious imprecision: result consistent with a reduction in CRBSI or an almost 5 fold increase ³ Downgraded for risk of bias due to lack of blinding of participants and personnel ⁴ Downgraded for imprecision: result consistent with a 10% reduction in mortality or a 25% increase ⁵ Downgraded twice for serious risk of bias: risk of performance bias due to lack of blinding of participants and personnel; different dressings were used in response to skin damage ⁶ Downgraded for inconsistency: experimental and control groups were different between studies and frequency of dressing changes overlapped between longer and shorter groups ⁷ Downgraded for imprecision ⁸ Downgraded for risk of bias: blinding of outcome assessment not described ⁹ Data from two additional RCTs could not be extracted and used within the analysis. One study presented toxicity on a 5‐point scale and reported no differences between groups. We are unable to use the data from the fourth study due to the 2 x 2 factorial design.

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Table 1. Blinding of participants and personnel (performance bias)

	Benhamou 2002	Engervall 1995	Rasero 2000	Timsit 2009	Vokurka 2009
CRBSI	Not applicable	Not applicable	Not applicable	High risk	Not applicable
Suspected CRBSI	High risk	High risk	Not applicable	Not applicable	Not applicable
All‐cause mortality	Low risk	Low risk	Not applicable	Low risk	Not applicable
Catheter‐site infection	High risk	High risk	High risk	High risk	High risk
Skin damage	High risk	Not applicable	High risk	High risk	High risk
Pain	HIgh risk	Not applicable	Not applicable	Not applicable	High risk
Quality of life	Not applicable	Not applicable	Not applicable	Not applicable	Not applicable
Cost	Not applicable	Not applicable	High risk	Not applicable	Not applicable

Table 1. Blinding of participants and personnel (performance bias)

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Table 2. Blinding of outcome assessment (detection bias)

	Benhamou 2002	Engervall 1995	Rasero 2000	Timsit 2009	Vokurka 2009
CRBSI	Not applicable	Not applicable	Not applicable	Low risk	Not applicable
Suspected CRBSI	Unclear risk	Unclear risk	Not applicable	Not applicable	Not applicable
All‐cause mortality	Low risk	Low risk	Not applicable	Low risk	Not applicable
Catheter‐site infection	Unclear risk	Unclear risk	Unclear risk	Low risk	Unclear risk
Skin damage	Unclear risk	Not applicable	Unclear risk	Unclear risk	Unclear risk
Pain	Unclear risk	Not applicable	Not applicable	Not applicable	Unclear risk
Quality of life	Not applicable	Not applicable	Not applicable	Not applicable	Not applicable
Cost	Not applicable	Not applicable	Unclear risk	Not applicable	Not applicable

Table 2. Blinding of outcome assessment (detection bias)

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Comparison 1. Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Catheter related blood stream infection Show forest plot	1	995	Risk Ratio (M‐H, Fixed, 95% CI)	1.42 [0.40, 4.98]

2 Suspected catheter related blood stream infection Show forest plot	2	151	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.23, 2.10]

3 All‐cause mortality Show forest plot	3	896	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.90, 1.25]

4 Catheter‐site infection Show forest plot	2	371	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.71, 1.63]

5 Skin damage Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Pain Show forest plot	2	193	Risk Ratio (M‐H, Random, 95% CI)	0.80 [0.46, 1.38]

Comparison 1. Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control)

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