668 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY August 2004

COST–BENEFIT ANALYSIS OF CHLORHEXIDINE

GLUCONATE DRESSING IN THE PREVENTION OF
CATHETER-RELATED BLOODSTREAM INFECTIONS

Albert G. Crawford, PhD; Joseph P. Fuhr, Jr., PhD; Bhaskar Rao, MBA

ABSTRACT
OBJECTIVES: To compare the costs with the benefits of
using chlorhexidine gluconate dressings on central venous
catheters and to determine the effectiveness of these dressings
in reducing local infections and catheter-related bloodstream
infections (CRBSIs), costs, and mortality.
DESIGN: Cost–benefit analysis using randomized, con-
trolled trial data on chlorhexidine dressing prevention of local
infection and CRBSI, data on cost of chlorhexidine dressing versus
standard treatment, data on averted cost of treating local infection
and CRBSI, and data on mortality attributable to CRBSI. Decision
analysis evaluated averted CRBSI treatment cost per patient result-
ing from chlorhexidine dressing use. Sensitivity analyses demon-
strated net benefit of chlorhexidine dressing, varying baseline rate
of CRBSI, incremental cost of treating CRBSI, and number of
catheters, and evaluated mortality preventable through chlorhexi-
dine dressing use, varying baseline rate of CRBSI, number of
catheters, and mortality attributable to CRBSI.
PATIENTS AND SETTING: Patients of all Philadelphia
area hospitals and one Philadelphia academic medical center.
RESULTS: Estimated potential annual U.S. net benefits
from chlorhexidine dressing use ranged from $275 million to
approximately $1.97 billion. Cost–benefit findings persisted in
sensitivity analyses varying baseline rate of CRBSI, incremental
cost of treating CRBSI, and overall number of catheters used.
Preventable mortality analyses showed potential decreases of
between 329 and 3,906 U.S. deaths annually as a result of nation-
wide use of chlorhexidine dressing.
CONCLUSIONS: Chlorhexidine dressings would reduce
costs, local infections and CRBSIs, and deaths. Use of chlorhexi-
dine dressings should be considered to prevent infections among
patients with catheters (Infect Control Hosp Epidemiol 2004;25:
668-674).

Catheters are an essential element of patient care;
however, they also pose risks. Catheter-related blood-
stream infections (BSIs) occur in 3% to 7% of catheteriza-
tions, depending on the type of catheter.1 As reported in
the Centers for Disease Control and Prevention guide-
lines,2 central venous catheter (CVC)–related BSIs affect
an estimated 250,000 hospitalized patients annually.3 The
attributable mortality of CVC-related BSIs is unclear
because not all studies have controlled for severity of ill-
ness. Estimates have ranged between 3% and 35% for all
hospitalized patients with catheter-related BSI. 1,4-6
However, a comprehensive meta-analysis by Byers et al.
found that of 14% of patients with catheter-related BSI who
died, 2.7% (95% confidence interval [CI95], 2.0% to 3.4%) of
the deaths were clinically and temporally related to BSI
and 11.3% were related to the underlying illness. 7
Catheter-related BSI is also significantly associated with
increased hospital stay and cost.8-11 Pittet estimated the
cost of treating catheter-related BSI to be $28,600.12
However, estimates of the attributable cost per CVC-relat-
ed BSI have ranged from $34,508 to $56,000.13,14
Given the costs to providers, patients, and payers, it is
in the interest of everyone to decrease the incidence of
catheter-related BSI. This is critically important, especially
given the current emphasis on increasing patient safety in
hospitals. Although the results of a randomized, controlled
trial including 589 subjects15,16 indicated the clinical
effectiveness of using a chlorhexidine gluconate–impreg-
nated antimicrobial dressing (BIOPATCH Antimicrobial
Dressing, Johnson & Johnson Wound Management,
Ethicon, Inc., Somerville, NJ), financial implications have
not been examined. This article analyzes these implications.

The authors are from the Department of Health Policy, Jefferson Medical College, Philadelphia, Pennsylvania. Dr. Fuhr is also from Widener
University School of Business, Chester, Pennsylvania.
Address reprint requests to Albert G. Crawford, PhD, Department of Health Policy, Jefferson Medical College, Suite 115, 1015 Walnut Street,
Philadelphia, PA 19107.
Supported by a grant from Johnson & Johnson Wound Management, Somerville, NJ.
The authors thank the following individuals for their support of this project: David B. Nash, MD, MBA, Dr. Raymond C. and Doris N. Grandon
Professor of Health Policy and Medicine and Chair, Department of Health Policy, Jefferson Medical College, and Chairman, Technical Advisory
Group, Pennsylvania Health Care Cost Containment Council, for serving as Principal Investigator; Neil Goldfarb, Research Program Director,
Department of Health Policy, Jefferson Medical College, for analytical and managerial support throughout the project; Mark Volavka, Director,
Pennsylvania Health Care Cost Containment Council (PHC4), for granting permission to use PHC4 Hospital Discharge data; Sheila A. Murphey,
MD, Infection Control Officer, Thomas Jefferson University Hospital, for providing Infection Control Unit data; and Suzanne Hogan, Analyst,
Financial Administration, Thomas Jefferson University Hospital, for assistance in developing reports on incremental costs of treatment for catheter-
related bloodstream infection.
Vol. 25 No. 8 COST–BENEFIT ANALYSIS OF CHLORHEXIDINE GLUCONATE DRESSING
A strategy for decreasing catheter-related BSI is to
use chlorhexidine dressings. The randomized, controlled
trial reported significant reductions in the incidence of
local catheter-related infection (chlorhexidine dressing =
28.14% and control = 45.24%; P < .001) and catheter-related
BSI (chlorhexidine dressing = 2.37% and control = 6.12%;
P < .05).15,16 The findings of this trial, which have not yet
been published in a peer-reviewed journal, were used in
the current analyses not because they are considered final
and definitive but merely to explore the potential financial
implications of reported prevention rates of this magni-
tude.
METHODS
Decision Model
The analyses in this study employed the hospital
perspective at the national level. This study was designed
to evaluate the net financial benefit of using chlorhexidine
dressings, by combining the results of the randomized,
controlled trial cited above with estimated numbers of
catheters, patients, local infections, and catheter-related
BSIs, and the costs of treating these infections, drawn
from national data, data from hospitals in the Philadelphia
area, and data from an academic medical center in the
Philadelphia area.
The cost–benefit analysis was modeled after the
study by Veenstra et al.1 of the cost-effectiveness of antibi-
otic-coated catheters. Their study included base case and
sensitivity analyses of decreases in the incidence, costs,
and mortality of catheter-related BSI. Their decision
model evaluated the differential outcomes of use of a coat-
ed catheter versus a standard catheter. There are sub-
stantial parallels between the current study and theirs,
with the main difference being chlorhexidine dressings
rather than coated catheters as the alternative to standard
treatment. In each study, the three possible outcomes
were no infection, a local infection, or a catheter-related
BSI (Figure). To evaluate the benefits (ie, averted costs)
associated with using chlorhexidine dressings, a decision
analytic model was developed using TreeAge software
(TreeAge Software, Inc., Williamstown, MA).
Costs
Data on the cost of chlorhexidine dressings were
uniform throughout these analyses. Whereas the effective
life of chlorhexidine dressings of 5 to 7 days was similar
to the average length of hospital stay, the conservative
approach adopted in this study was to assume an average
selling price of $3.75 per chlorhexidine dressing and to
assume 2 uses per catheter site per stay, yielding a total
cost per stay of $7.50. The estimates of the benefits of
chlorhexidine dressings were based on data drawn from
two sources: (1) the published literature and (2) the
statewide Hospital Discharge database maintained by the
Pennsylvania Health Care Cost Containment Council
(PHC4). The latter included all discharges in calendar
years 1997, 1998, and 1999 from hospitals in PHC4
regions 8 and 9—Philadelphia County and its four sur-
669
FIGURE. The decision analysis model. CRBSI = catheter-related blood-
stream infection.
rounding counties in Pennsylvania (ie, Bucks, Chester,
Delaware, and Montgomery).17 Cases analyzed in the
PHC4 data were those with a non-primary International
Classification of Diseases, 9th revision, Clinical
Modification code of 996.62, infection and inflammatory
reaction due to internal prosthetic device, implant, and
graft (vascular other than cardiac). The conservativeness
of these estimates was validated through comparison with
detailed cost data on “definite catheter-related BSIs” iden-
tified by the infection control unit of an academic medical
center located in the Philadelphia area.
The published literature included one rigorous
analysis of the cost of treating local infections, and numer-
ous analyses of the costs of treating catheter-related BSIs.
The benefit of averting a local infection was estimated to
be $400, based on the conservative estimate of $399 devel-
oped by Saint et al.5 This estimate did not include nursing
time, other laboratory tests, or the costs of other supplies
such as gauze or transparent dressing. Maki used the
term “local catheter infection,” which is synonymous with
the term colonization as used in other studies. However,
data on the percentage of colonizations that become local
infections were limited.5 Veenstra et al.1 estimated that
50% of colonizations led to local infections, whereas Saint
et al.5 estimated 40%. We used the more conservative 40%
for our analyses.
Two estimates of the benefit of averting a catheter-
related BSI (ie, incremental costs of treating a catheter-
related BSI) were selected: a low estimate of $8,000 and a
moderate estimate of $25,000. In 1994, Pittet et al.10 esti-
mated the cost of treating catheter-related BSI at $28,600,
based on an additional 8 days in the intensive care unit
(ICU) and 6 days in the general ward. In 2000, Saint et al.5
estimated the incremental cost of treating catheter-related
BSI by multiplying the incremental length of stay by the
then per diem hospital charges at the University of
Washington Medical Center for the ICU and the ward
($1,152 and $375, respectively). Actual costs were esti-
670 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY August 2004

TABLE 1
ESTIMATES OF MODEL PARAMETERS
Parameter Source Estimate

Chlorhexidine dressing cost Chlorhexidine dressing product literature $3.75 ⫻ 2 = $7.50

Assumption: 2 administrations of chlorhexidine
dressing per catheter site, 1 every 5 to 7 days
Incremental catheter-related BSI treatment cost See METHODS section Low = $8,000
Moderate = $25,000
Catheter-related BSI incidence reduction Chiacchierini et al.15 60.66%
due to chlorhexidine dressing
Mortality attributable to catheter-related BSI Veenstra et al.,1 Saint et al.,5 Wenzel and Edmond,6 Low = 1%
Mermel,4 and Byers et al.7 Moderate = 5%

BSI = bloodstream infection.

mated by multiplying per diem room charges by the then
applicable 0.63 cost-to-charge ratio. The result was an
incremental actual cost of treating catheter-related BSI of
$9,738 for patients who were treated in the ICU and
approximately $6,000 for patients who were treated only
in the general ward and not in the ICU (these estimates
did not include procedure costs or professional costs).
The increase in per diem costs constituted approximately
half of the estimated incremental cost of treating catheter-
related BSI.13 Although there are various estimates of the
percentage of catheter-related BSIs that occur in the ICU,
one recent publication using data from the Surveillance
and Control of Pathogens of Epidemiologic Importance
project estimated that 49.4% of all nosocomial BSIs
occurred in ICUs.6 The estimates for the ICU ($10,000,
which was rounded up from $9,738) and the general ward
($6,000) were averaged (using a 50%/50% split), yielding
the result of $8,000.
The moderate estimate of $25,0003 was based on
the report by the Centers for Disease Control and
Prevention. 2 The Centers for Disease Control and
Prevention publication cited other estimates of the attrib-
utable cost per CVC-associated BSI ranging from $34,508
to $56,000.13,14 As noted above, as early as 1994 Pittet et
al.10 published an estimate of $28,600. Moreover, analyses
of PHC4 data showed a differential in charges between
cases with and without catheter-related BSI of $64,076;
application of a 50% cost-to-charge ratio yielded a cost dif-
ferential due to catheter-related BSI of $32,038. Finally,
analyses comparing the costs, at an academic medical
center in the Philadelphia area, of treating cases with ver-
sus without a non-primary diagnosis of catheter-related
BSI showed differentials far higher than $25,000. All of
these supplementary analyses indicated that the moder-
ate estimate of $25,000 for treating catheter-related BSI
was a conservative one.
Sensitivity Analyses
The sensitivity analyses employed two estimates of
the baseline rate of catheter-related BSI in U.S. hospitals.
One estimate was the rate of 6.12% found in the random-
ized, controlled trial.15,16 The other estimate, approximate-
ly 20% lower, was 5%, the midpoint of the range of 3% to 7%
identified by Veenstra et al.1 The sensitivity analyses also
used two estimates of the cost of catheter-related BSI,
$8,000 and $25,000. The number of CVCs sold annually in
the United States is estimated to be between 3,000,000
and 5,000,000,18,19 thus the sensitivity analyses included
three estimates of the number of catheters used annually
in U.S. hospitals—3,000,000, 4,000,000, and 5,000,000.
The mortality rate attributable to catheter-related
BSI is difficult to estimate. The problem arises because
the exact role that nosocomial infections play in worsen-
ing the outcome of ICU patients is difficult to assess.20
The controversy centers on “whether the critically ill
patients who are infected die as a result of catheter-relat-
ed infection, or whether the infection is a terminal event
that occurs prior to imminent death.”14 Whereas some
studies have found no or a relatively small influence,14,20
other studies have estimated the attributable mortality
rate to be between 3% and 35%.1,4-6 However, the previous-
ly mentioned meta-analysis by Byers et al. found an attrib-
utable mortality rate of 2.7% (CI95, 2.0% to 3.4%).7 Thus, the
sensitivity analyses in this study included two estimates,
1% and 5%.
RESULTS
Table 1 summarizes the parameter estimates
employed in the decision analytic model. Tables 2 and 3
present the results of the decision analyses using the
6.12% and 5% estimates of the baseline rate of catheter-
related BSI, respectively. Each table also presents the dif-
ferential benefits of chlorhexidine dressings, depending
on the use of either the low or the moderate estimate of
averted costs (ie, incremental cost of treating catheter-
related BSI—$8,000 or $25,000). Given the most conserv-
ative scenario studied, a 5% baseline rate of catheter-relat-
ed BSI and the lower incremental cost of treating
catheter-related BSI of $8,000, chlorhexidine dressings
produce an average averted treatment cost of $237.76 per
Vol. 25 No. 8 COST–BENEFIT ANALYSIS OF CHLORHEXIDINE GLUCONATE DRESSING 671

TABLE 2
RESULTS OF THE DECISION ANALYSIS FOR INCREMENTAL COSTS OF $8,000 AND $25,000 FOR TREATING CATHETER-RELATED
BLOODSTREAM INFECTION USING A 6.12% INCIDENCE RATE
Standard Treatment Chlorhexidine Dressing
Catheter- Catheter-
Related Local No Total Related Local No Total
BSI Infection Infection* Cost BSI Infection Infection* Cost

$8,000 incremental cost

Incidence rate 0.0612 0.1810 0.7578 0.0237 0.1126 0.8637
Treatment cost $8,000.00 $400.00 $0 $8,000.00 $400.00 $0
Incidence rate ⫻ treatment cost $489.60 $72.40 $0 $562.00 $189.60 $45.04 $0 $234.64
Averted treatment cost per patient $327.36
$25,000 incremental cost
Incidence rate 0.0612 0.1810 0.7578 0.0237 0.1126 0.8637
Treatment cost $25,000.00 $400.00 $0 $25,000.00 $400.00 $0
Incidence rate ⫻ treatment cost $1,530.00 $72.40 $0 $1,602.40 $592.50 $45.04 $0 $637.54
Averted treatment cost per patient $964.86

BSI = bloodstream infection.

*Includes no infection with catheter colonization and without catheter colonization.

TABLE 3
RESULTS OF THE DECISION ANALYSIS FOR INCREMENTAL COSTS OF $8,000 AND $25,000 FOR TREATING CATHETER-RELATED
BLOODSTREAM INFECTION USING A 5% INCIDENCE RATE
Standard Treatment Chlorhexidine Dressing
Catheter- Catheter-
Related Local No Total Related Local No Total
BSI Infection Infection* Cost BSI Infection Infection* Cost

$8,000 incremental cost

Incidence rate 0.0500 0.1810 0.7690 0.0237 0.1126 0.8637
Treatment cost $8,000.00 $400.00 $0 $8,000.00 $400.00 $0
Incidence rate ⫻ treatment cost $400.00 $72.40 $0 $472.40 $189.60 $45.04 $0 $234.64
Averted treatment cost per patient $237.76
$25,000 incremental cost
Incidence rate 0.0500 0.1810 0.7690 0.0237 0.1126 0.8637
Treatment cost $25,000.00 $400.00 $0 $25,000.00 $400.00 $0
Incidence rate ⫻ treatment cost $1,250.00 $72.40 $0 $1,322.40 $592.50 $45.04 $0 $637.54
Averted treatment cost per patient $684.86

BSI = bloodstream infection.

*Includes no infection with catheter colonization and without catheter colonization.

patient receiving a catheter. Given the least conservative
scenario studied, a 6.12% baseline rate of catheter-related
BSI and the moderate incremental cost of treating
catheter-related BSI of $25,000, the average averted treat-
ment cost per patient rises to $964.86.
In Tables 4 and 5, the analyses are extended to
evaluate the annual costs, benefits, and net benefits of
using chlorhexidine dressings prophylactically with all
central arterial and venous catheters in U.S. hospitals.
The number of catheters was divided by 2.4 to estimate
the number of patients receiving a catheter, based on the
randomized, controlled trial data on catheters per
patient.15,16 In 12 sensitivity analyses, 3 parameters were
varied. Table 4 used the randomized, controlled trial
baseline rate of catheter-related BSI of 6.12%, whereas
Table 5 used the rate of 5%. For each table, the projected
number of catheterizations in U.S. hospitals was varied
from 5,000,000 down to 4,000,000 and then down to
3,000,000. The differential results based on either the low
($8,000) or the moderate ($25,000) estimate of incremen-
tal costs of treating catheter-related BSI are also present-
ed. In these 12 analyses, estimates of the net benefits per
year of nationwide use of chlorhexidine dressings ranged
from approximately $275 million (with the 5% baseline
672 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY August 2004

TABLE 4
RESULTS OF THE COST–BENEFIT ANALYSIS WITH SENSITIVITY ANALYSES VARYING THE NUMBER OF CATHETERS AND THE INCREMENTAL
COST OF TREATING CATHETER-RELATED BLOODSTREAM INFECTION USING A 6.12% INCIDENCE RATE*
$8,000 $25,000
5,000,000 4,000,000 3,000,000 5,000,000 4,000,000 3,000,000
Catheters Catheters Catheters Catheters Catheters Catheters

No. of patients 2,083,333 1,666,667 1,250,000 2,083,333 1,666,667 1,250,000

Chlorhexidine dressing costs $37,500,000 $30,000,000 $22,500,000 $37,500,000 $30,000,000 $22,500,000
Chlorhexidine dressing savings $682,000,000 $545,600,000 $409,200,000 $2,010,125,000 $1,608,100,000 $1,206,075,000
Net benefit $644,500,000 $515,600,000 $386,700,000 $1,972,625,000 $1,578,100,000 $1,183,575,000

*In all instances, the number of catheters was divided by 2.4.

TABLE 5
RESULTS OF THE COST–BENEFIT ANALYSIS WITH SENSITIVITY ANALYSES VARYING THE NUMBER OF CATHETERS AND THE INCREMENTAL
COST OF TREATING CATHETER-RELATED BLOODSTREAM INFECTION USING A 5% INCIDENCE RATE*
$8,000 $25,000
5,000,000 4,000,000 3,000,000 5,000,000 4,000,000 3,000,000
Catheters Catheters Catheters Catheters Catheters Catheters

No. of patients 2,083,333 1,666,667 1,250,000 2,083,333 1,666,667 1,250,000

Chlorhexidine dressing costs $37,500,000 $30,000,000 $22,500,000 $37,500,000 $30,000,000 $22,500,000
Chlorhexidine dressing savings $495,333,333 $396,266,667 $297,200,000 $1,426,791,667 $1,141,433,333 $856,075,000
Net benefit $457,833,333 $366,266,667 $274,700,000 $1,389,291,667 $1,111,433,333 $833,575,000

*In all instances, the number of catheters was divided by 2.4.

rate of catheter-related BSI, 3,000,000 catheters used per DISCUSSION

year, and the $8,000 incremental cost of treating catheter-
related BSI) to $1.97 billion (with the 6.12% baseline rate
of catheter-related BSI, 5,000,000 catheters used per year,
and the $25,000 incremental cost of treating catheter-
related BSI).
Projections of reductions in the mortality rate attrib-
utable to catheter-related BSI that could result from wide-
spread adoption of chlorhexidine dressings rather than
standard treatment are presented in Tables 6 and 7. Table
6 used the 6.12% baseline rate of catheter-related BSI
(matching the rate for standard treatment in the random-
ized, controlled trial) and the assumption that the rate of
catheter-related BSI declined by 61.3% (based on the ran-
domized, controlled trial results of a decline from 6.13% to
2.37%).15,16 Table 7, on the other hand, used the 5% base-
line rate of catheter-related BSI and the assumption that
the rate of catheter-related BSI declined by 52.60% (based
on a decline from 5% to 2.37%). When the contents of both
Table 6 and Table 7 are considered, the reduction in
deaths that could follow widespread use of chlorhexidine
dressings ranges from 329 (with the 5% baseline rate of
catheter-related BSI, 3,000,000 catheters used per year,
and the 1% attributable mortality rate) to 3,906 (with the
6.12% baseline rate of catheter-related BSI, 5,000,000
catheters used per year, and the 5% attributable mortality
rate).
A randomized, controlled trial15,16 demonstrated the
clinical effectiveness of chlorhexidine dressings in reduc-
ing the incidence of local infections and catheter-related
BSIs. The current study extended that work by estimating
potential financial benefits of chlorhexidine dressings.
Given the clinical effectiveness of chlorhexidine dress-
ings and their relatively low costs, the benefits of wide-
spread use could be great. Estimates of the annual net
benefits of nationwide use range from $275 million to
$1.97 billion.
Additionally, the randomized, controlled trial showed
a reduction in mortality.15,16 Although those researching
cost-effectiveness have not reached consensus about how
to evaluate mortality in financial terms, decreasing mor-
tality is clearly a benefit from the perspectives of society,
patients, providers, and payers. The application of attrib-
utable mortality rates of 1% and 5% and relative reductions
of catheter-related BSI incidence rates of 52.60% and
61.27% revealed potential decreases of approximately 300
to 3,900 deaths annually as a result of widespread use of
chlorhexidine dressings.
Several methodologic limitations restrict the gener-
alizability of these findings. First, the analyses relied on
estimates, not precise data, regarding total number of
catheters used annually in the United States, total number
of patients catheterized, baseline rates of catheter-related
Vol. 25 No. 8 COST–BENEFIT ANALYSIS OF CHLORHEXIDINE GLUCONATE DRESSING 673

TABLE 6
DEATHS PREVENTABLE THROUGH THE USE OF CHLORHEXIDINE DRESSING WITH SENSITIVITY ANALYSES VARYING THE NUMBER OF
CATHETERS AND THE MORTALITY RATE ATTRIBUTABLE TO CATHETER-RELATED BLOODSTREAM INFECTION USING A 6.12% INCIDENCE RATE
Baseline No. of Catheter- Mortality Rate
No. of Related BSIs Averted Attributable to
No. of No. of Catheter- Using Chlorhex- Catheter-Related BSI
Catheters Patients Related BSIs idine Dressing 1% 5%

5,000,000 2,083,000 127,500 78,125 781 3,906

4,000,000 1,666,667 102,000 62,500 625 3,125
3,000,000 1,250,000 76,500 46,875 469 2,344

BSI = bloodstream infection.

TABLE 7
DEATHS PREVENTABLE THROUGH THE USE OF CHLORHEXIDINE DRESSING WITH SENSITIVITY ANALYSES VARYING THE NUMBER OF
CATHETERS AND THE MORTALITY RATE ATTRIBUTABLE TO CATHETER-RELATED BLOODSTREAM INFECTION USING A 5% INCIDENCE RATE
Baseline No. of Catheter- Mortality Rate
No. of Related BSIs Averted Attributable to
No. of No. of Catheter- Using Chlorhex- Catheter-Related BSI
Catheters Patients Related BSIs idine Dressing 1% 5%

5,000,000 2,083,000 104,167 54,792 548 2,740

4,000,000 1,666,667 83,333 43,833 438 2,192
3,000,000 1,250,000 62,500 32,875 329 1,644

BSI = bloodstream infection.

BSIs and total number of catheter-related BSIs, incremen-
tal costs of treating catheter-related BSI, and mortality
attributable to catheter-related BSI. For example, the
numbers of catheter-related BSIs incorporated in the sen-
sitivity analyses were considerably lower than various
estimates of annual catheter-related BSIs in the United
States.1,5,19 Also, the cost data were not adjusted for infla-
tion, thus underestimating the benefits of chlorhexidine
dressings. Still, the sensitivity analyses varied several
parameters and then tested the degree to which the
results changed. Confidence in the results is justified to
the degree that there is no reversal in the direction and
significance of the findings in the sensitivity analyses.
Second, the data employed to test the validity of the
national estimates on treatment costs were drawn from
hospitals in only one metropolitan area—Philadelphia.
Third, the study extrapolated findings of a randomized,
controlled trial regarding the reduction in the catheter-
related BSI incidence rate among 589 subjects to the
entire population of patients in U.S. hospitals.15,16 The
decision analyses, cost–benefit analyses, and preventable
death analyses all depended on the results of this ran-
domized, controlled trial. Moreover, the severity of illness
of patients in the randomized, controlled trial may impact
the generalizability of its results. Although the two clinical
centers had differing levels of severity of illness at base-
line, treatment effects were seen at both sites. However, it
is unclear whether patients in the randomized, controlled
trial were representative of patients receiving CVCs
nationally. An additional limitation of these analyses is
that the randomized, controlled trial results employed
have not yet been published in a peer-reviewed journal,
although they have been presented at a scientific confer-
ence.16
There is evidence supporting both the clinical effec-
tiveness and the cost-effectiveness of using chlorhexidine
dressings in the prevention of catheter-related BSI. From
a cost–benefit standpoint, compared with standard treat-
ment, chlorhexidine dressings appear to produce better
outcomes, including both clinical benefits and financial
savings. Potential net cost savings in the United States
annually ranged from $275 million to $1.97 billion. These
cost–benefit findings held true in sensitivity analyses
varying three key parameters—baseline rate of catheter-
related BSI, overall number of catheters used in the
United States per year, and incremental costs of treating
catheter-related BSI. Moreover, preventable death analy-
ses, employing two estimates of attributable mortality,
showed potential decreases of between 329 and 3,906
deaths annually as a result of nationwide use of chlorhex-
idine dressings. These data suggest that expanded use of
chlorhexidine dressings in U.S. hospitals could be benefi-
cial.
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