Long-term efficacy of chlorhexidine-containing cutaneous dressings on ventriculostomy-related infection: a 10-year before-and-after study

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OBJECTIVE: Growing evidence suggests that dressings containing chlorhexidine-gluconate (CHX) have the potential to lower the incidence of external ventricular drain (EVD)-associated infections (EVDAIs). A previous prospective randomized trial (NCT02078830) detected significant reductions in bacterial cutaneous and catheter colonization. However, the study was underpowered to demonstrate significant clinical efficacy. The present study aimed to report infection rates within the same institution before and after the abovementioned randomized controlled trial (RCT) with consecutive introduction of CHX-containing dressings for silver-coated EVDs as the standard of care after the trial had been completed. METHODS: This study was a retrospective (2009-2013) and prospective (2014-2018) analysis of patients who underwent silver-coated EVD insertion. The control group consisted of patients treated from January 2009 to February 2016, when the CHX dressings were not in use. The study group consisted of patients treated between October 2013 and December 2018, including the RCT period when CHX dressings were introduced. The primary endpoint was the diagnosis of EVDAI. Comparisons were made by modeling the outcome with multivariable logistic regression analysis. Regression coefficients estimates (RCE) and inverse probability weighting (IPW) were implemented to adjust for confounding. Statistical significance was set at p ≤ 0.05. RESULTS: In total, 258 of 362 (72%) patients with overall 2373 cumulative EVD days were eligible for analysis, of whom 152 (59%) received a CHX dressing. Overall EVDAI rates (20/106 [19%] vs 12/152 [8%]), the prevalence per 100 persons (19 vs 8), and the incidence per year (2.64 vs 1.50), as well as per 10 person-days (0.20 vs 0.09), were halved after the introduction of CHX dressings, resulting in an unadjusted absolute risk reduction of 11% and a number needed to treat of 9. Fewer permanent cerebrospinal fluid diversion procedures due to postinfectious hydrocephalus were necessary (7/106 [7%] vs 6/152 [4%]). The adjusted RCE and IPW analysis confirmed the potential of CHX dressings to reduce the odds of EVDAIs with OR 0.415 (95% CI 0.186-0.927) and OR 0.429 (95% CI 0.264-0.533), respectively. CONCLUSIONS: The occurrence of EVDAIs was significantly reduced when using additional CHX dressings (8%), compared to silver-coated EVDs alone (19%), without extending antibiotic prophylaxis or using antibiotic-impregnated catheters as a valid alternative in terms of antibiotic stewardship. This finding should encourage the neurosurgical community to generate more awareness in using and evaluating postoperative measures that prevent this impactful complication in further research.

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