Background
Methods
Systematic search strategy
Eligibility criteria
Study selection and data extraction
Methodological quality assessment
Data synthesis and analysis
Results
Characteristics of the included studies
NO. | Country | Sample size(T/C) | Gender(T/C, %) | Age(T/C) | Inclusion criteria | Exclusion criteria | Intervention | Control | Diagnosis of CRBSI | Catheter types | Follow up |
---|---|---|---|---|---|---|---|---|---|---|---|
Bradley R.S. 2017 [12] | USA | 18/20 | M(33/30) | 49/52 | Adult patients providing consent, non-medicare insurance, or medicare insurance with a supplementary insurance, anticipated duration on home parenteral nutrition(HPN) > 3 m not previously on HPN at Mayo Clinic or elsewhere, patients with single lumen, silicone Hickman ® catheters, and no known alcohol addiction | Failure to provide consent, medicare insurance without supplemental private insurance, patients with a catheter type other than a single lumen Hickman ®, patients who were anticipated to be on HPN for less than three months, pregnant patients, patients who have previously proven addiction and/or dependence to alcohol | 3 ml 70% ethanol lock until next PN infusion | Heparin lock plus saline infusion | (1)Bacteremia or fungemia in a patient who had an intravascular device and > 1 positive blood culture result obtained from the peripheral vein; (2)Clinical manifestations of infection (e.g., fever, chills, and/or hypotension), and no apparent source for blood stream infection other than the central venous catheter. | Single lumen, silicone Hickman ® catheters | NA |
Lavern M.V. 2016 [7] | Canada | 20/19 | M(60/47) | 63/62.3 | Eligible participants were 18 years of age or older with end-stage renal disease and planned vascular access with a catheter or current hemodialysis patients requiring exchange of an existing catheter | (1) they were critically ill in the ICU setting, (2) had acute kidney injury and were unlikely to require prolonged vascular access, (3) had a maturing or planned arteriovenous fistula/graft creation within 2 months, or (4) planned antibiotic treatment courses lasting longer than 4 weeks from the date of the new catheter insertion. | 2.5 ml 30% ethanol/4% sodium citrate for a 6-month period | Heparin 1000 units/mL | Two or more positive blood cultures of the same organism (species, antibiogram) from any source (peripheral or intravascular device cultures) from a patient with clinical and microbiologic data suggesting no other source for the bacteremia except the intravascular device. | Inserted dual-lumen tunneled, cuffed catheters made of carbothane, an alcohol-resistant polymer with silicone extensions (Tal Palindrome, Tyco Healthcare Kendall/Covidien, Mansfield, MA, USA) | If an outcome occurred, an additional 30 days for safety was added |
Bertrand 2015 [6] | France | 730/730 | M(60.8/61.1) | 65/66 | Patients required insertion of DCs with an expected duration of use longer than 48 h in ICU | Ethanol intolerance and pregnancy | 60% wt/wt EL locks for 2 min | 0.9% saline lock | In patients with one or more blood cultures positive for coagulase-negative staphylococci, identity of pulse-field gel electrophoresis patterns in the catheter tip and blood cultures was required for a diagnosis of CRBSI | A nontunneled, nonantimicrobial-impregnated double-lumen dialysis catheters (DC) | Until death or 48 h after ICU discharge |
Reineke A 2015 [8] | Netherlands | 153/154 | M(58/56) | 9.8/7.8 | Paediatric oncology patients (1–18 years) with a newly inserted, tunnelled central venous catheters (CVC) | ≤1 year at diagnosis, a primary immunological disorder, an ethanol allergy or a CVC inserted in a vessel with previously confirmed thrombosis | 70% ethanol locks for 2 h | 100 IU/ml heparin locks | At least one of the following criteria: (1) recognised pathogen cultured from ≥1 blood cultures, not related to an infection at another site (2) Clinical manifestations of infection and a common skin microorganism (such as coagulase-negative staphylococci (CoNS), diphtheroids, Bacillus spp., or micrococci) cultured from ≥2 blood cultures drawn on separate occasions | Tunnelled CVC(port-a-cath (PAC) or Broviac) | Time to CABSI or death due to CABSI, during a maximum follow-up period of six months |
L.J. Worth 2014 [16] | Australia | 42/43 | M(28/24) | 47.0/48.1 | Patients with haematological malignancy or planned BMT were eligible for enrolment at time of insertion of a dual lumen, non-antibiotic-impregnated, tunnelled, cuffed, intravascular catheter (Hickman catheter) into subclavian or internal jugular veins, where the intended period of catheterization was 30 days. | NA | 70% ethanol locks for 2 h | Heparinized saline | A positive blood culture with a recognized pathogen or common commensal, with confirmation of infection by isolation of the same organism following culture of catheter tip, or a differential time to positivity for centrally and peripherally drawn blood cultures of 2 h | A dual lumen, non-antibiotic-impregnated, tunnelled, cuffed, intravascular catheter (Hickman catheter) | Until a device-related bloodstream infection occurred, or planned study end-date |
Sishir 2014 [15] | India | 35/35 | NA | NA | Hemodialysis population | NA | 70% ethanol lock for 20 min | Heparin lock (1000 U/ml) | NA | Double lumen polyurethane hemodialysis cathete | NA |
Mara 2014 [14] | Spain | 113/87 | M(55/54) | 67.3/65.2 | Recent MHS admission with Central Vascular Catheters (CVC) inserted >48 h; Age >18 years; No evidence or suspicion of CRBSI at enrolment: No signs of infection neither general nor at catheter site entrance | Allergy or intolerance to ethanol or chronic liver disease;Pregnancy | 70% ethanollock for 2 h | Conventional catheter-care | Microbiologically proven CRBSI considered when the same microorganism was recovered from blood and a catheter tip within less than 8 days. | Conventionalcatheter | Enrolled patients were prospectively followed for the occurrence of CR-BSI until catheter withdrawal, hospital discharge or death |
Jennifer K 2012 [13] | Australia | 25/24 | M(52/46) | 52/64 | Adults > 18 years, the presence of a tunnelled intravenous catheter and the ability to give informed consent | Pregnancy or breast feeding, religious or personal objection to the use of ethanol, intolerance of ethanol, and a history of an exit site, tunnel or blood stream infection associated with the current catheter. | 70% ethanol for 48 h | Thrice weekly standard heparin locks(Heparin sodium 5000 U/Ml) | (1)Positive blood cultures for the presence of bacteria with or without Clinical manifestations of infection | A tunnelled central venous catheter | NA |
Lennert Solbbe 2010 [11] | Netherlands | 226/222 | M(57.5/56.3) | 51.7/49.8 | Eligible study-participants were all consecutive adult (age>17 years) hematology patients with a tunnelled silicone CVC, inserted in the preceding 72 h before study-entry | Patients with an alcohol-intolerance or concomitant treatment with metronidazole | 70% ethanol lock for 15 min per day | 0.9% NaCl | A positive central or peripheral blood culture; For (coagulase-negative staphylococci) or other skin-colonizers, 2 blood cultures had to be positive when no peripheral cultures were available [19] | A tunnelled silicone CVC | NA |
Sanders 2008 [10] | New Zealand | 32/28 | M(53/57) | 52.4/47.2 | An age >18 years or older and admission as an inpatient to receive intensive chemotherapy likely to produce neutropenia (<0.5 × 109 L) for the treatment of haematological disease, including haematopoietic stem cell transplantation. | Abnormal liver function tests or a history of alcohol abuse | 70% ethanol for 2 h | Control | The culture of a recognized pathogen from one or more blood cultures, unrelated to infection at another site [18]. | Identical dual lumen Hickman central venous catheters | The study period ended with either diagnosis of CABSI, removal or failure of catheter, discharge from hospital, death or end of study period after an arbitrary 30 days. |
Risk of bias
CRBI
NO. | Ethanol lock(n) | Control(n) |
---|---|---|
Bradley R.S. 2017 [12] | Candida species(2); Staphylococcus species(1); Escherichia coli plus Klebsiella species plus Pseudomonas(1). | Unidentified gram positive cocci |
Lavern M.V. 2016 [7] | NA | Klebsiella Pneumonia |
Bertrand 2015 [6] | Staphylococcus epidermidis(20) Staphylococcus aureus(2) Enterococcus species (0) Other coagulase negative Staphylococci(31) Other Gram-positive (5) Escherichia coli (2) Proteus species (0) Pseudomonas aeruginosa (10) Enterobacterspecies (2) Other Gram-negative (2) Fungi (5) Polymicrobial(20) | Staphylococcus epidermidis(9) Staphylococcus aureus(0) Enterococcus species (1) Other coagulase negative Staphylococci(27) Other Gram-positive (6) Escherichia coli (1) Proteus species (2) Pseudomonas aeruginosa (9) Enterobacterspecies (0) Other Gram-negative (3) Fungi (3) Polymicrobial(17) |
Reineke A 2015 [8] | Staphylococcus epidermidis(2) Other coagulase-negative Staphylococc(4) Staphylococcus aureus(0) Streptococcus parasanguis(1) Other alpha-haemolytic streptococci (1) Enterococcus faecalis(0) Bacillus sp.(0) Streptomyces sp.(0) Escherichia coli(1) Citrobacter freundii(1) Brevundimonas vesicularis(1) Gram-negative rod (1) Polymicrobial(3) Candida sp.(1) | Staphylococcus epidermidis(1) Other coagulase-negative Staphylococc(8) Staphylococcus aureus(2) Streptococcus parasanguis(0) Other alpha-haemolytic streptococci (0) Enterococcus faecalis(1) Bacillus sp.(2) Streptomyces sp.(1) Escherichia coli(3) Citrobacter freundii(0) Brevundimonas vesicularis(0) Gram-negative rod (0) Polymicrobial(0) Candida sp.(2) |
L.J. Worth 2014 [16] | Coagulase-negative Staphylococcus spp. (3), Staphylococcus aureus (1), Listeria monocytogenes (1), Klebsiella pneumoniae (2), Escherichia coli (1), Pseudomonas aeruginosa (1), E. coli (2)and C. glabrata (1). | Coagulase-negative Staphylococcus spp. (7), Staphylococcus aureus (1), Enterococcus faecium (1), Klebsiella pneumoniae (2), Escherichia coli (1), Pseudomonas aeruginosa (1), Enterobacter cloacae(1), E. coli and E. faecium (1), and Candida parapsilosis (1). |
Sishir 2014 [15] | NA | NA |
Mara 2014 [14] | Gram positive cocci(0) Enterobacteriaceae(2) Gram negative non-fermenting rods(0) Fungi(0) | Gram positive cocci(1) Enterobacteriaceae(2) Gram negative non-fermenting rods(1) Fungi(0) |
Jennifer K 2012 [13] | Staphylococcus aureus(1) | Staphylococcus aureus(1) Enterobacter cloacae(1) Staphylococcus hominis (1) |
Lennert Solbbe 2010 [11] | n = episodes Coagulase-negative staphylococci.(49) Other skin colonizers(2) Staphylococcus aureus(2) Other gram-positive cocci(12) Gram-negatives(4) Polymicrobial(20) Yeasts(2) | n = episodes Coagulase-negative staphylococci.(57) Other skin colonizers(2) Staphylococcus aureus(3) Other gram-positive cocci(10) Gram-negatives(5) Polymicrobial(13) Yeasts(1) |
Sanders 2008 [10] | n = episodes A-haemolytic Streptococcus(1) Streptococcus group B (agalactiae)(0), S. epidermidis(0), Staphylococcus aureus(0), Stomatococcus rothia mucilaginosa(1), Escherichia coli(1), Pseudomonas aeruginosa(0), Klebsiella pneumoniae(0), non-speciated Gram-negative bacilli(0). | n = episodes A-haemolytic Streptococcus(1) Streptococcus group B (agalactiae)(1), S. epidermidis(3), Staphylococcus aureus(1), Stomatococcus rothia mucilaginosa(0), Escherichia coli(4), Pseudomonas aeruginosa(1), Klebsiella pneumoniae(1), non-speciated Gram-negative bacilli(1). |