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Flow diagram of included and excluded studies
Figuras y tablas -
Figure 1

Flow diagram of included and excluded studies

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 2

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figuras y tablas -
Figure 3

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

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

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

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 3 All‐cause mortality.
Figuras y tablas -
Analysis 1.3

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

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 4 Catheter‐site infection.
Figuras y tablas -
Analysis 1.4

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

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 5 Skin damage.
Figuras y tablas -
Analysis 1.5

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

Comparison 1 Longer interval (5‐15 days) (intervention) versus shorter interval (2‐5 days) (control), Outcome 6 Pain.
Figuras y tablas -
Analysis 1.6

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

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.

Figuras y tablas -
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
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

Figuras y tablas -
Table 1. Blinding of participants and personnel (performance bias)
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

Figuras y tablas -
Table 2. Blinding of outcome assessment (detection bias)
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]

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