Ethanol lock is effective on reducing the incidence of tunneled catheter-related bloodstream infections in hemodialysis patients: a systematic review and meta-analysis

Nephrology - Review
  • 58 Downloads

Abstract

Purpose

The purpose of this meta-analysis is to evaluate the effect of ethanol lock on the incidence of catheter-related bloodstream infection (CRBSI) in patients with central venous catheters.

Methods

RCTs comparing ethanol lock with another solution lock for prevention of CRBSI were obtained by searching databases of PubMed, Embase, Web of Science and Cochrane Central Register of clinical trials for eligible randomized controlled trials (inception to December 2017). Two researchers separately selected the RCTs and assessed their quality. Data on patient characteristics and ethanol protocols were collected. The primary outcome was the incidence of CRBSI, and the secondary outcomes were catheter colonization, exit infection and thrombosis.

Results

A total of 2575 patients with 3375 catheters from 7 eligible RCTs were included. Overall, ethanol lock significantly decreased the risk of CRBSI, with RR 0.54 (95% CI 0.38–0.78; I2 = 0%; p = 0.001); no obvious heterogeneity was observed in the fixed-effects model (I2 = 0%). Of note, subgroup analysis demonstrated that ethanol lock conferred significant benefit in studies with tunneled catheters (RR 0.46; 95% CI 0.30–0.72) but not in studies with untunneled catheters. Only two studies provided data regarding catheter colonization, and no significant difference was found (RR, 1.09; 95% CI, 0.87–1.38; I2 = 41%; p = 0.45). Moreover, pooled data did not show significant differences between ethanol and control groups with regard to the incidence of thrombosis (RR 1.05; 95% CI 0.91–1.22; I2 = 0%; p = 0.48).

Conclusions

Our meta-analysis suggests that ethanol lock is effective on reducing the incidence of CRBSI in hemodialysis patients with tunneled central venous catheters.

Keywords

Ethanol lock Catheter-related bloodstream infection Prevention Meta-analysis 

Abbreviations

RCTs

Randomized controlled trials

CVCs

Central venous catheters

CRBSI

Catheter-related bloodstream infection

RR

Risk ratio

CI

Confidence interval

WMD

Weighted mean difference

ARR

Absolute risk reduction

Supplementary material

11255_2018_1855_MOESM1_ESM.doc (28 kb)
Supplementary material 1 (DOC 28 kb)
11255_2018_1855_MOESM2_ESM.doc (32 kb)
Supplementary material 2 (DOC 32 kb)
11255_2018_1855_MOESM3_ESM.doc (222 kb)
Supplementary material 3 (DOC 222 kb)
11255_2018_1855_MOESM4_ESM.doc (32 kb)
Supplementary material 4 (DOC 32 kb)

References

  1. 1.
    Mermel LA, Allon M, Bouza E et al (2009) Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 49:1–45CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Rosenthal VD, Guzman S, Migone O et al (2003) The attributable cost, length of hospital stay, and mortality of central line-associated bloodstream infection in intensive care departments in Argentina: a prospective, matched analysis. Am J Infect Control 31:475–480CrossRefPubMedGoogle Scholar
  3. 3.
    Renaud B, Brun-Buisson C (2001) Outcomes of primary and catheter-related bacteremia. A cohort and case-control study in critically ill patients. Am J Respir Crit Care Med 163:1584–1590CrossRefPubMedGoogle Scholar
  4. 4.
    Siempos II, Kopterides P, Tsangaris I et al (2009) Impact of catheter-related bloodstream infections on the mortality of critically ill patients: a meta-analysis. Crit Care Med 37:2283–2289CrossRefPubMedGoogle Scholar
  5. 5.
    Digiovine B, Chenoweth C, Watts C et al (1999) The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 160:976–981CrossRefPubMedGoogle Scholar
  6. 6.
    Rello J, Ochagavia A, Sabanes E et al (2000) Evaluation of outcome of intravenous catheter-related infections in critically ill patients. Am J Respir Crit Care Med 162:1027–1030CrossRefPubMedGoogle Scholar
  7. 7.
    Goey SH, Verweij J, Bolhuis RL et al (1997) Tunnelled central venous catheters yield a low incidence of septicaemia in interleukin-2-treated patients. Cancer Immunol Immunother 44:301–304CrossRefPubMedGoogle Scholar
  8. 8.
    Maki DG, Stolz SS, Wheeler S et al (1994) A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med 22:1729–1737CrossRefPubMedGoogle Scholar
  9. 9.
    Betjes MG (2011) Prevention of catheter-related bloodstream infection in patients on hemodialysis. Nat Rev Nephrol 7:257–265CrossRefPubMedGoogle Scholar
  10. 10.
    Chatzinikolaou I, Finkel K, Hanna H et al (2003) Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections: a prospective, randomized study. Am J Med 115:352–357CrossRefPubMedGoogle Scholar
  11. 11.
    Safdar N, Maki DG (2006) Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infection associated with central venous access devices: a meta-analysis of prospective, randomized trials. Clin Infect Dis 43:474–484CrossRefPubMedGoogle Scholar
  12. 12.
    Ramos ER, Reitzel R, Jiang Y et al (2011) Clinical effectiveness and risk of emerging resistance associated with prolonged use of antibiotic-impregnated catheters: more than 0.5 million catheter days and 7 years of clinical experience. Crit Care Med 39:245–251CrossRefPubMedGoogle Scholar
  13. 13.
    Dixon JJ, Steele M, Makanjuola AD (2012) Anti-microbial locks increase the prevalence of staphylococcus aureus and antibiotic-resistant enterobacter: observational retrospective cohort study. Nephrol Dial Transplant 27:3575–3581CrossRefPubMedGoogle Scholar
  14. 14.
    Balestrino D, Souweine B, Charbonnel N et al (2009) Eradication of microorganisms embedded in biofilm by an ethanol-based catheter lock solution. Nephrol Dial Transplant 24:3204–3209CrossRefPubMedGoogle Scholar
  15. 15.
    Qu Y, Istivan TS, Daley AJ et al (2009) Comparison of various antimicrobial agents as catheter lock solutions: preference for ethanol in eradication of coagulase-negative staphylococcal biofilms. J Med Microbiol 58:442–450CrossRefPubMedGoogle Scholar
  16. 16.
    Onland W, Shin CE, Fustar S et al (2006) Ethanol-lock technique for persistent bacteremia of long-term intravascular devices in pediatric patients. Arch Pediatr Adolesc Med 160:1049–1053CrossRefPubMedGoogle Scholar
  17. 17.
    Oliveira C, Nasr A, Brindle M et al (2012) Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. Pediatrics 129:318–329CrossRefPubMedGoogle Scholar
  18. 18.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151:264–269CrossRefPubMedGoogle Scholar
  19. 19.
    Sanders J, Pithie A, Ganly P et al (2008) A prospective double-blind randomized trial comparing intraluminal ethanol with heparinized saline for the prevention of catheter-associated bloodstream infection in immunosuppressed haematology patients. J Antimicrob Chemother 62:809–815CrossRefPubMedGoogle Scholar
  20. 20.
    Slobbe L, Doorduijn JK, Lugtenburg PJ et al (2010) Prevention of catheter-related bacteremia with a daily ethanol lock in patients with tunnelled catheters: a randomized, placebo-controlled trial. PLoS ONE 5:e10840CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Broom JK, Krishnasamy R, Hawley CM et al (2012) A randomized controlled trial of heparin versus ethanol lock therapy for the prevention of catheter associated infection in haemodialysis patients–the healthy-cath trial. BMC Nephrol 13:146CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Worth LJ, Slavin MA, Heath S et al (2014) Ethanol versus heparin locks for the prevention of central venous catheter-associated bloodstream infections: a randomized trial in adult haematology patients with Hickman devices. J Hosp Infect 88:48–51CrossRefPubMedGoogle Scholar
  23. 23.
    Pérez-Granda MJ, Barrio JM, Munoz P et al (2014) Ethanol lock therapy (E-Lock) in the prevention of catheter-related bloodstream infections (CR-BSI) after major heart surgery (MHS): a randomized clinical trial. PLoS ONE 9:e91838CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Souweine B, Lautrette A, Gruson D et al (2015) Ethanol lock and risk of hemodialysis catheter infection in critically ill patients. A randomized controlled trial. Am J Respir Crit Care Med 191:1024–1032CrossRefPubMedGoogle Scholar
  25. 25.
    Schoot RA, van Ommen CH, Stijnen T et al (2015) Prevention of central venous catheter-associated bloodstream infections in paediatric oncology patients using 70% ethanol locks: a randomised controlled multi-centre trial. Eur J Cancer 51:2031–2038CrossRefPubMedGoogle Scholar
  26. 26.
    Safdar N, O’Horo JC, Ghufran A et al (2014) Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis*. Crit Care Med 42:1703–1713CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Timsit JF, Bruneel F, Cheval C et al (1999) Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 130:729–735CrossRefPubMedGoogle Scholar
  28. 28.
    Randolph AG, Cook DJ, Gonzales CA et al (1998) Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials. Crit Care Med 26:1452–1457CrossRefPubMedGoogle Scholar
  29. 29.
    Weijmer MC, van den Dorpel MA, Van de Ven PJ et al (2005) Randomized, clinical trial comparison of trisodium citrate 30% and heparin as catheter-locking solution in hemodialysis patients. J Am Soc Nephrol 16:2769–2777CrossRefPubMedGoogle Scholar
  30. 30.
    Yahav D, Rozen-Zvi B, Gafter-Gvili A et al (2008) Antimicrobial lock solutions for the prevention of infections associated with intravascular catheters in patients undergoing hemodialysis: systematic review and meta-analysis of randomized, controlled trials. Clin Infect Dis 47:83–93CrossRefPubMedGoogle Scholar
  31. 31.
    Ho KM, Litton E (2006) Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 58:281–287CrossRefPubMedGoogle Scholar
  32. 32.
    Mermel LA, Alang N (2014) Adverse effects associated with ethanol catheter lock solutions: a systematic review. J Antimicrob Chemother 69:2611–2619CrossRefPubMedGoogle Scholar
  33. 33.
    Schilcher G, Schlagenhauf A, Schneditz D et al (2013) Ethanol causes protein precipitation–new safety issues for catheter locking techniques. PLoS ONE 8:e84869CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Abu-El-Haija M, Schultz J, Rahhal RM (2014) Effects of 70% ethanol locks on rates of central line infection, thrombosis, breakage, and replacement in pediatric intestinal failure. J Pediatr Gastroenterol Nutr 58:703–708PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Critical Care MedicineThe First Hospital of Shanxi Medical UniversityTaiyuanPeople’s Republic of China

Personalised recommendations