OBJECTIVES:To assess the clinical effectiveness and cost-effectiveness of central venous catheters (CVCs) treated with anti-infective agents in preventing catheter-related bloodstream infection (CRBSI). DATA SOURCES:Major electronic databases were searched from 1985 to August 2005. REVIEW METHODS:The systematic clinical and economic reviews were conducted according to accepted procedures. Only full economic evaluations (synthesis of costs and benefits) comparing the use of anti-infective central venous catheters (AI-CVCs) with untreated CVCs or other treated catheters were selected for inclusion in the economic review. RESULTS:A total of 32 trials met the clinical inclusion criteria. Seven different types of AI-CVC were identified, with the most frequently tested being chlorhexidine and silver sulfadiazine (CHSS) (externally treated), CHSS (externally and internally treated) and minocycline rifampicin (internally and externally treated). In general, the trials were of a poor quality in terms of reported methodology, microbiological relevance and control of confounding variables. The pooled result suggests a statistically significant advantage for AI-CVCs in comparison to standard catheters in reducing CRBSI [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.34 to 0.60, 24 studies, I-squared = 0%, fixed effects]. Analysis by subgroups of catheters demonstrates that antibiotic-treated catheters and catheters treated internally and externally decrease CRBSI rates significantly (OR 0.26, 95% CI 0.15 to 0.46, six studies, I-squared = 0%, fixed effects, and OR 0.43, 95% CI 0.26 to 0.70, nine studies, I-squared = 0%, fixed effects, respectively). Catheters treated only externally demonstrate a wider CI and non-significant effect (OR 0.67, 95% CI 0.43 to 1.06, nine studies, I-squared = 0%, fixed effects). A treatment effect was also found for trials with an average duration of between 5 and 12 days, and for the one study with a mean duration of over 20 days. There was a statistically significant treatment effect for both femoral and jugular insertion sites and for those studies reporting a mix of insertion sites. The treatment effect was not observed in trials using exclusively subclavian insertion sites. Of the four trials that compared treated catheters, one reported a benefit of antibiotic-treated catheters over catheters treated externally with CHSS. All three sensitivity analyses testing for study design differences reported a statistically significant treatment effect. The review was limited owing to the quality of the trials included, marked differences in the definitions and methods of diagnosis of CRBSI, and inconsistent reporting of risk factors and patient population factors. Furthermore, two-thirds of trials were commercially funded. The economic performance (cost-effectiveness and potential cost-savings) of using AI-CVCs to reduce the number of CRBSIs in patients requiring a CVC was also reviewed. Results show that the use of AI-CVCs instead of standard CVCs can lead to a reduction in CRBSIs and decreased medical costs. To complement the reviews, a basic decision-analytic model was constructed to explore a range of possible scenarios for the NHS in England and Wales. Results show that for every patient who receives an AI-CVC there is an estimated cost-saving of 138.20 pounds. The multivariate sensitivity analyses estimate potentially large cost-savings, depending on the size of the population, under a wide range of cost and clinical assumptions. However, those considering the purchase of AI-CVCs should ensure that their patient populations and the important characteristics of local clinical practice are indeed similar to those described in this economic evaluation. CONCLUSIONS:Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective. Pragmatic research related to the effectiveness of bundles of care that may reduce rates of CRBSI is also warranted.

译文

目的:评估用抗感染药治疗的中心静脉导管(CVC)在预防导管相关的血流感染(CRBSI)方面的临床效果和成本效益。
数据来源:从1985年到2005年8月,检索了主要的电子数据库。
审查方法:根据公认的程序进行系统的临床和经济审查。只有将将抗感染中心静脉导管(AI-CVC)与未经治疗的CVC或其他经过治疗的导管的使用进行比较的全面经济评估(成本和收益的综合)才被选入经济评估。
结果:总共32项试验符合临床纳入标准。鉴定出七种不同类型的AI-CVC,最常测试的是洗必太和磺胺嘧啶银(CHSS)(外部治疗),CHSS(外部和内部治疗)和米诺环素利福平(内部和外部治疗)。总体而言,就报告的方法学,微生物学相关性和混杂变量的控制而言,这些试验的质量较差。汇总结果表明,与标准导管相比,AI-CVC在降低CRBSI方面具有统计学上的显着优势[比值比(OR)0.45,95%置信区间(CI)0.34至0.60,24个研究,I平方= 0%,固定效果]。导管亚组的分析表明,抗生素治疗过的导管和内外治疗过的导管显着降低了CRBSI率(OR 0.26,95%CI 0.15至0.46,六项研究,I平方= 0%,固定效应,OR 0.43,95 %CI 0.26至0.70,九项研究,I平方= 0%,分别为固定效应)。仅经外部治疗的导管显示出较宽的置信区间,且无显着影响(OR为0.67,95%置信区间为0.43至1.06,九项研究,I平方= 0%,固定效应)。对于平均持续时间为5至12天的试验以及平均持续时间超过20天的一项研究,也发现了治疗效果。股骨和颈静脉插入部位以及报告混合插入部位的研究在统计学上均具有显着的治疗效果。在仅使用锁骨下插入位点的试验中未观察到治疗效果。在比较经治疗的导管的四项试验中,有一项报告指出,与经CHSS外部治疗的导管相比,经抗生素治疗的导管有益处。针对研究设计差异的所有三个敏感性分析测试均报告了统计学上显着的治疗效果。由于包括的试验质量,CRBSI的诊断定义和诊断方法存在明显差异以及危险因素和患者人群因素的报告不一致,因此该审查受到了限制。此外,三分之二的试验是由商业资助的。还审查了使用AI-CVC减少需要CVC的患者中CRBSI数量的经济表现(成本效益和潜在的成本节省)。结果表明,使用AI-CVC代替标准CVC可以减少CRBSI并降低医疗成本。为了补充评论,构建了基本的决策分析模型,以探索英格兰和威尔士的NHS的各种可能方案。结果表明,每位接受AI-CVC的患者估计可节省138.20磅。多元敏感性分析估计,在广泛的成本和临床假设下,取决于人群的规模,可能会节省大量成本。但是,考虑购买AI-CVC的人员应确保其患者人数和当地临床实践的重要特征确实与本经济评估中所述的相似。
结论:总体而言,AI-CVC具有临床效果且相对便宜,因此可以证明将其整合到临床实践中是合理的。但是,在没有适当使用其他实践护理措施的情况下使用这些抗感染导管在预防CRBSI方面仅会取得有限的成功。需要进行比较试验来确定哪一种治疗过的导管最有效。还必须进行与可能降低CRBSI发生率的护理捆绑的有效性相关的务实研究。

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