Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients

BACKGROUND: Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long-term access in current-day health care, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC-related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited. STUDY OBJECTIVES: To determine the risk of PICC-related BSI in hospitalized patients. STUDY DESIGN: Prospective cohort study using data from two randomized trials assessing the efficacy of chlorhexidine-impregnated sponge dressing and chlorhexidine for cutaneous antisepsis. METHODS: PICCs inserted into the antecubital vein in two randomized trials during from 1998 to 2000 were prospectively studied; most patients were in an ICU. PICC-related BSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of removal and from blood cultures by restriction-fragment DNA subtyping. RESULTS: Overall, 115 patients had 251 PICCs placed. Mean duration of catheterization was 11.3 days (total, 2,832 PICC-days); 42% of the patients were in an ICU at some time, 62% had urinary catheters, and 49% had received mechanical ventilation. Six PICC-related BSIs were identified (2.4%), four with coagulase-negative staphylococcus, one with Staphylococcus aureus, and one with Klebsiella pneumoniae, a rate of 2.1 per 1,000 catheter-days. CONCLUSION: This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation.     

Prospective surveillance study for risk factors of central venous catheter-related bloodstream infections

OBJECTIVE: Risk factors of catheter-related bloodstream infection (CR-BSI) caused by central venous catheter (CVC) use at a university hospital were evaluated. DESIGN: A prospective, observational, hospital-wide study was conducted. SETTING: The study was conducted at a university hospital with 1050 beds. METHODS: Nontunneled catheters were used, and double or triple lumen was observed. Catheters were cultured by semi-quantitative method, and blood cultures were performed if necessary. All epidemiologic and clinical data were recorded without intervention during the study. RESULTS: Over a 1-year period, the study assessed 389 CVCs inserted in 367 patients (mean age 50.9 +/- 18.1 years; 215 [58.6%] men, 152 [41.4%] women). Duration of catheterization was 12.0 +/- 9.9 days. CVCs were inserted into either the subclavian vein (N=263; 67.6%) or the jugular vein (N=128; 32.4%). In 250 episodes (64.3%), antibiotics were used concomitantly. CR-BSI was found in 43 of all CVCs (11.1%). The rate of CR-BSI per 1000 catheter-days was 9.21 for the whole cohort. In multivariable analysis, only renal failure (OR 4.83; CI 1.32-17.66; P=.017) was found to be a risk factor for CR-BSI. CONCLUSION: Renal failure was an independent risk factor for CR-BSI.     

Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence

The widespread use of peripherally inserted central catheters (PICCs) has transformed the care of medical and surgical patients. Whereas intravenous antibiotics, parenteral nutrition, and administration of chemotherapy once necessitated prolonged hospitalization, PICCs have eliminated the need for such practice. However, PICCs may not be as innocuous as once thought; a growing body of evidence suggests that these devices also have important risks. This review discusses the origin of PICCs and highlights reasons behind their rapid adoption in medical practice. We evaluate the evidence behind 2 important PICC-related complications-venous thrombosis and bloodstream infections-and describe how initial studies may have led to a false sense of security with respect to these outcomes. In this context, we introduce a conceptual model to understand the risk of PICC-related complications and guide the use of these devices. Through this model, we outline recommendations that clinicians may use to prevent PICC-related adverse events. We conclude by highlighting important knowledge gaps and identifying avenues for future research in this area.     

Peripherally inserted central venous catheters for treatment of cystic fibrosis

Patients who have cystic fibrosis (CF) are frequently hospitalized for long-term intravenous (IV) treatment. We evaluated clinical effectiveness of the Drum-Cartridge Catheter (Abbott Laboratories) for such patients. The catheter is placed peripherally under local anesthesia via an antecubital vein into the superior vena cava or right atrium. Patients who were more than 10 years of age and who were hospitalized for IV antibiotic therapy and/or IV hyperalimentation were studied. All but 2 patients had CF. Using an aseptic technique the catheters were inserted into the basilic or cephalic vein. Chest radiographs were used to confirm the final location of the catheter. Catheters were used to administer IV antibiotics, hyperalimentation, and lipids. There were 38 catheterizations in 23 patients; several patients had repeated insertions at later admissions. The success rate of insertion was 86% with 31 of the 38 insertions initially located either in the superior vena cava or right atrium. Mean duration of catheterization was 15.4 days (range 5-49 days). No major complications such as sepsis, catheter or clot embolism, pneumothorax, vascular perforation, or hemorrhage occurred in the patients who had DF. Complications that required displacement of catheter into the axillary vein (1 patient), and cracked catheter hub (1 patient). This study shows that the Drum-Cartridge Catheter can be used easily for IV therapy of patients who have CF for a long duration, repeatedly, and with no major complications.     

重症监护室老年患者中心静脉导管相关血流感染的危险因素

目的探讨重症监护室（ICU）老年患者导管相关血流感染（CRBSI）的危险因素。方法ICU90例老年住院患者接受中心静脉置管,分为导管相关性血流感染（CRBSI）组和无感染（对照）组。CRBSI组患者为ICU住院的行深静脉置管伴CRBSI的病例（n=45）,而对照组为同期ICU住院的行深静脉置管但无CRBSI的病例（17=45）,采用回顾性和病例对照的研究方法,对两组患者进行风险困素分析。结果两组患者基础疾病构成、年龄、性别、感染前导管留鼍时间、机械通气、完全肠外营养、尿管留置等的差异无统计学意义（P〉0．05）。与对照组比较,CRBSI组使用碳青霉烯类抗生素、操作熟练程度、置管部位、低白蛋白血症、贫血、APACHEII评分差异有统计学意义（P〈0．01、P〈0．05）。使用碳青霉烯类抗生素、操作者、低A蛋白血症、APACHEII评分是CRBSI独立危险因素。结论碳青霉烯类抗生素使用、操作者人员熟练程度、低白蛋A血症及APACHEII评分是ICU老年患者CRBSI的独立危险因素。     

New choices for central venous catheters: potential financial implications

OBJECTIVE: To determine the cost-effectiveness of the newer antiseptic and antibiotic-impregnated central venous catheters (CVCs) relative to uncoated CVCs and to each other. DESIGN: Decision model analysis of the cost and efficacy of CVCs coated with either chlorhexidine silver sulfadiazine (CSS) or rifampin-minocycline (RM) at preventing catheter-related bloodstream infections (CRBSIs). The primary outcome is the incremental cost (or savings) to prevent one additional CRBSI. Model estimates are derived from prospective trials of the CSS and RM CVCs and from other studies describing the costs of CRBSIs. Setting and patients: Hypothetical cohort of 1,000 patients requiring placement of a CVC. INTERVENTIONS: In the model, patients were managed with either an uncoated CVC, CSS CVC, or RM CVC. Measurements and main results: The incremental cost-effectiveness of the treated CVCs was calculated as the savings resulting from CRBSIs averted less the additional costs of the newer devices. Sensitivity analysis of the effect of the major clinical inputs was performed. For the base case analysis, we assumed the incidence of CRBSIs was 3.3% with traditional catheters and that the CSS and RM CVC conferred a relative risk reduction for the development of CRBSIs of 60% and 85%, respectively. Despite their significantly higher cost than older catheters, both novel CVCs yield significant savings. Employing either of the treated CVCs saves approximately $10,000 per CRBSI prevented (relative to standard catheters). Comparing the RM CVC to the CSS CVC revealed the RM product to be economically superior, saving nearly $9,600 per CRBSI averted and $81 per patient in the cohort. For sensitivity analysis, we adjusted all model variables by 50% individually and then simultaneously. This demonstrated the model to be most sensitive to the cost of a CRBSI; however, with all inputs skewed by 50% against both the CSS CVC and the RM CVC, these devices remained economically attractive. Under this scenario, use of either treated device was less costly. CONCLUSIONS: Utilization of antiseptic and antibiotic-impregnated CVCs represent an attractive alternative for the prevention of CRBSIs and may lead to significant savings. Of the two newer, coated devices, the RM CVC performs better financially. These observations hold over a range of estimates for our model inputs.     

Defining bloodstream infections related to central venous catheters in patients with cancer: a systematic review

The objective of this review was to determine whether consistent definitions were used in published studies of bloodstream infections due to central venous catheters in patients with cancer (ie, catheter-related or catheter-associated bloodstream infections). Review of 191 studies reporting catheter-related or catheter-associated bloodstream infections in patients with cancer revealed a lack of uniformity in these definitions. We grouped definitions by type, with 39 articles failing to cite or report a definition. Definitions included those of the Centers for Disease Control and Prevention (n = 39) and the Infectious Diseases Society of America (n = 18). The criteria included in the definitions in studies were also tabulated. Clinical manifestations were frequently included. Definitions used have been highly variable; comparability of risk factors, incidence, management, and outcomes of such infections is difficult to achieve across studies. Future research should focus on development of a common definition of catheter-related and catheter-associated bloodstream infections for both adults and children with cancer.     

Peripherally inserted central catheter-related bloodstream infection caused by <Emphasis Type="Italic">Kocuria marina</Emphasis> in an elderly man

Background

Kocuria species are Gram-positive, aerobic cocci, and members of the Micrcoccaceae family that are known to be opportunistic pathogens. Although there have been sporadic reports of infections caused by Kocuria species, little is known regarding their human pathogenicity and clinical characteristics.

Case report

We herein report a case of a peripherally inserted central catheter (PICC)-related bloodstream infection caused by Kocuria marina in a 90-year-old Japanese with multiple cancer. The patient, who was admitted due to adhesive intestinal obstruction, suddenly developed sepsis on day 29 following admission. Three sets of blood cultures and a culture of the PICC tip revealed the growth of Gram-positive cocci arranged in clusters. The patient improved quickly after treatment with an antimicrobial agent and catheter removal. The organism was identified as Kocuria varians using the MicroScan Walkaway system and K. varians/Kocuria rosea with a 99.7% probability using an API Staph system. However, 16S rRNA gene sequencing analysis identified the pathogen as K. marina.

Conclusion

Although K. marina is a rare pathogen, physicians should consider it in case of catheter-related infections in patients with serious underlying conditions. As commercial identification systems can misidentify species within the Kocuria genus, the use of genomic methods such as 16S rRNA sequencing and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry may be useful for the precise identification of Kocuria to the species level.

     

Peripherally inserted central venous catheters decrease central line-associated bloodstream infections and change microbiological epidemiology in adult hematology unit: a propensity score-adjusted analysis

Annals of Hematology - Peripherally inserted central venous catheters (PICCs) have a potential advantage in preventing central line-associated bloodstream infection (CLABSI) compared with the...     

Peripherally inserted central catheter-related bloodstream infections in patients with hematological malignancies: A retrospective 7-years single-center study

ObjectivesWe sought to investigate the nature and incidence of bloodstream infection complications and to identify the risk factors of central catheter-related bloodstream infections (CRBSI).MethodsDuring the study period, 291 consecutive patients with hematological malignancies who underwent PICC placement were retrospectively enrolled. We analyzed the covariates that were specified a priori for their association with CRBSI through multivariate Cox proportional hazards regression models. The association between each predictor and the related outcome was expressed using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs).ResultsOf 391 peripherally inserted central catheter (PICCs) were inserted in 291 patients for a total of 63,714 catheter days during 7 years, with an infection rate of 0.71/1,000 catheter days. Among the patients with hematological malignancies, those with acute leukemia were prone to CRBSI. Having previous bloodstream infection (BSI) (HR 18.139; 95% CI, 8.19-40.174; P < .0001), the number of PICCs insertions (HR 4.695; 95% CI, 1.842-11.967; P = .001) (twice), (HR 6.794; 95% CI, 1.909-24.181; P = .003) (≥3 times) were significantly associated with CRBSI. Not accompanied by chronic comorbidities (HR 0.34; 95% CI, 0.131-0.887; P = .028) and longer duration of PICC use (days) (HR 0.997; 95% CI, 0.994-0.999; P = .008) might be protective factors preventing CRBSI.ConclusionsOur finding suggests that previous BSI and a higher number of PICC insertions are associated with an increased risk of CRBSI. A lack of chronic comorbidities may help prevent CRBSI.     

Effect of preventive measures against central venous catheter-related infection: retrospective study in our division for recent 10 years

A study was made of 2202 central venous catheters (CVC), which were inserted for recent 10 years, to know the effect of preventive measures against CVC-related infection. We divided 10 years in 3 periods: 1987-1990 (the first period), 1991-1993 (the second period), and 1994-1996 (the third period). Preventive measures such as thorough antiseptic precaution, shortening of CVC dwelling time, and prohibition of injection from three-way stopcocks were taken after the second period. In the third period, semiclosed infusion system (I-system) was introduced to our division. A febrile catheterized patient (higher than 38 degrees C) was diagnosed as CVC-related infection when the fever dropped immediately (within 72 hours) after removal of CVC, or when the tip of the CVC was positive for culture. The rate of CVC-related infection in the second (9.9%) or the third (7.3%) period was significantly lower than that (14.0%) of the first period (p < 0.05 and p < 0.001, respectively). The mean dwelling time of CVC was 31.5 days for the first period, 27.0 days for the second period, and 24.8 days for the third period. The rate of long-term dwelling catheters (more than 29 days) in the second (34.5%) or the third (28.7%) period was significantly lower than that (40.5%) in the first period (p < 0.01 and p < 0.001, respectively). The index of CVC-related infection (incidence of infection per 1,000 days) was 4.8 for the first period, 3.7 for the second period, and 2.9 for the third period. The rate of infection of short-term dwelling CVC (less than 28 days) in the second (9.5%) or the third (6.3%) period was significantly lower than that (16.0%) of the first period (p < 0.01 and p < 0.001, respectively). As to cultures of CVC and/or blood sample, the isolation rate of fungi decreased significantly (p < 0.001), and that of gram-negative rods showed a tendency to increase after the second period. It was concluded that shortening of CVC dwelling time and application of semiclosed infusion system were effective to reduce the rate of CVC-related infection.     

Genotypic study documents divergence in the pathogenesis of bloodstream infection related central venous catheters in neonates

ObjectiveTo investigate the pathogenesis of bloodstream infection by Staphylococcus epidermidis, using the molecular epidemiology, in high-risk neonates.MethodsWe conducted a prospective study of a cohort of neonates with bloodstream infection using central venous catheters for more than 24 h. “National Healthcare Safety Network” surveillance was conducted. Genotyping was performed by DNA fingerprinting and mecA genes and icaAD were detected by multiplex-PCR.ResultsFrom April 2006 to April 2008, the incidence of bloodstream infection and central venous catheter-associated bloodstream infection was 15.1 and 13.0/1000 catheter days, respectively, with S. epidermidis accounting for 42.9% of episodes. Molecular analysis was used to document the similarity among six isolates of bloodstream infection by S. epidermidis from cases with positive blood and central venous catheter tip cultures. Fifty percent of neonates had bloodstream infection not identified as definite or probable central venous catheter-related bloodstream infection. Only one case was considered as definite central venous catheter-related bloodstream infection and was extraluminally acquired; the remaining were considered probable central venous catheter-related bloodstream infections, with one probable extraluminally and another probable intraluminally acquired bloodstream infection. Additionally, among mecA+ and icaAD+ samples, one clone (A) was predominant (80%). A polyclonal profile was found among sensitive samples that were not carriers of the icaAD gene.ConclusionsThe majority of infections caused by S. epidermidis in neonates had an unknown origin, although 33.3% appeared to have been acquired intraluminally and extraluminally. We observed a polyclonal profile between sensitive samples and a prevalent clone (A) between resistant samples.     

An evaluation of peripherally inserted central venous catheters for children with cancer requiring long-term venous access

Long-term venous access is essential when treating malignant diseases. We reviewed our experience with peripherally inserted central venous catheters (PICC) in children suffering from various malignancies with regard to catheter life, reasons for removal, and complications. Ninety-three PICCs were inserted in 78 children. Median catheter life was 162 days (range 6–575 days) with a total of 16,266 catheter days. Seventy-five PICCs (80.6%) had been placed until the elective removal or patients’ death, whereas 18 PICCs (19.4%) were removed due to PICC-related complications; a rate of 1.11 per 1,000 catheter days. Complications requiring removal of PICCs included infection (n = 12), occlusion (n = 3), dislodgement (n = 2), and phlebitis (n = 1) with rates of 0.74, 0.18, 0.12 and 0.06 per 1,000 catheter days, respectively. We conclude that PICC provides reliable long-term intravenous access in children suffering from malignancies.     

Effectiveness of impregnated central venous catheters for catheter related blood stream infection: a systematic review

PURPOSE OF REVIEW: Clinicians need information on the relative effectiveness of different types of impregnated central venous catheter for serious infection and their relative costs and adverse effects in order to decide which type, if any, to use. RECENT FINDINGS: We systematically reviewed 37 randomized controlled trials involving 11 586 patients. Only seven studies were classified as good on all measures of study quality. Compared with standard catheters, significant and substantial reductions in catheter-related blood stream infection were found for heparin-coated and antibiotic-impregnated central venous catheters. We found no statistically significant benefits of antiseptic central venous catheters, coated with chlorhexidine and silver sulphadiazine, or sliver-impregnated central venous catheters, compared with standard catheters. The few 'head-to-head' comparisons confirmed the benefits of antibiotic impregnation compared with chlorhexidine and silver sulphadiazine or silver impregnation, but no significant difference was found for heparin-coated compared with silver-impregnated central venous catheters. No studies reported serious adverse events, but there is some evidence of antibiotic resistance from in-vitro studies. No impregnated central venous catheter exists for neonates weighing less than 3 kg, and few studies have been undertaken in larger children. SUMMARY: The most promising options for reducing catheter-related blood stream infection are heparin-coated or antibiotic-impregnated central venous catheters. Large, high-quality randomized controlled trials are needed to evaluate which of these methods is most effective for reducing clinically important consequences of catheter-associated infection.     

Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review

BACKGROUND: Catheter-related infections cause increased morbidity, mortality, and health care costs. Infection control experts advocate using maximal sterile barriers to reduce the incidence of these infections. Low compliance rates suggest that clinicians are not convinced or are not aware that available data support adopting this more cumbersome, time-consuming, and relatively more expensive technique. Accordingly, we conducted a systematic, evidence-based review of the medical literature to determine the value of maximal sterile barriers. DATA SOURCES: We used multiple computerized databases, reference lists of identified articles, and queries of prominent investigators. STUDY SELECTION: We selected studies comparing infectious outcomes using maximal sterile barriers versus using less stringent sterile barrier techniques during central venous catheter insertion. DATA SYNTHESIS: We found only 3 primary research studies. Although each study suggests maximal sterile barriers may reduce infectious complications, the evidence supporting this conclusion is incomplete. The only randomized controlled trial limited enrollment to ambulatory oncology patients. These 3 studies differed notably in their patient populations, research designs, and health care settings. CONCLUSION: The medical literature suggests maximal sterile barriers are advantageous in at least one setting and may be useful in others. While we believe the available evidence does support the use of maximal sterile barriers during routine insertion of central venous catheters, prospective studies and economic analyses would better clarify its value.