COMMENTARY

The CLEAN Trial Clears Up Questions About Preventing Catheter-Related Infections

Greg Martin, MD

Disclosures

July 01, 2016

Skin Antisepsis With Chlorhexidine-Alcohol Versus Povidone Iodine-Alcohol, With and Without Skin Scrubbing, for Prevention of Intravascular-Catheter-Related Infection (CLEAN): An Open-Label, Multicentre, Randomised, Controlled, Two-by-Two Factorial Trial

Mimoz O, Lucet JC, Kerforne T, et al; CLEAN trial investigators
Lancet. 2015;386:2069-2077

Summary

Catheter-related and central-line-associated bloodstream infections occur in many intensive care unit (ICU) patients and may be life-threatening.[1] Efforts to prevent such infections have focused on sterile barrier precautions during insertion and hygienic maintenance practices. Mimoz and colleagues sought to determine whether chlorhexidine/alcohol is more effective than povidone-iodine/alcohol as a skin antiseptic to prevent catheter-related infections.[2]

The authors randomly assigned 1181 patients to receive those two agents, and also compared skin scrubbing in preparation for the antiseptic application. Chlorhexidine/alcohol was associated with a lower incidence of catheter-related infections (0.28 vs 1.77 per 1000 catheter-days; hazard ratio, 0.15; P < .001). Skin scrubbing was not associated with a significant difference in catheter colonization. Severe skin reactions were more frequent with chlorhexidine/alcohol (3% vs 1%) and led to chlorhexidine discontinuation in two patients.

The authors conclude that for skin antisepsis, chlorhexidine/alcohol provides greater protection against catheter-related infections than povidone-iodine/alcohol.

Viewpoint

Prevention of intravascular catheter-related bloodstream infections is important because they put patients at risk for prolonged hospital stay and death, result in higher healthcare costs, and in some circumstances are publicly reportable as a quality measure for the hospital. This study nicely demonstrates that chlorhexidine/alcohol antisepsis is superior to povidone-iodine/alcohol. Also important, it showed that scrubbing the skin before antiseptic application did not further decrease the infections, and that although adverse skin reactions were uncommon, they were clearly more common with chlorhexidine/alcohol than with povidone-iodine/alcohol.

Even though chlorhexidine is more expensive than povidone-iodine and failed to show superiority in more general prevention of healthcare-associated infections in ICU patients,[3] it is sufficiently superior (~6 times better) to justify its use in preventing catheter-related bloodstream infections among ICU patients with central venous or arterial catheters.

Abstract

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