What’s New in the Patient Safety World
June 2014
Update on PICC-associated Bloodstream Infections
In our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we challenged the view widely held by clinicians that PICC (peripherally inserted central catheter) lines are safer than the more traditional central lines. The potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. True, the most feared complications of those central line insertions (pneumothorax for the subclavian line, carotid arterial puncture for the jugular line) are not seen with PICC insertions but a host of serious potential complications are associated with PICC’s. We noted studies done by Chopra and colleagues (Chopra 2013a) that showed PICCs were associated with a more than two-fold increased risk of deep vein thrombosis. (OR 2.55) and another (Chopra 2013b) that found no significant difference in CLABSI rate between the CVC and PICC groups.
Now yet another study from Chopra and colleagues (Chopra 2014) has characterized some of the factors associated with PICC-associated bloodstream infections. They retrospectively reviewed data on 966 PICC lines in 747 patients over a 3-year period. The indications for PICC insertion were: long-term antibiotic administration (52%), venous access (21%), total parenteral nutrition (16%), and chemotherapy (11%).
Overall, 6% of PICC
lines were associated with bloodstream infection, with an infection rate of
2.16 per 1000 catheter days. The median time to infection was 10 days.
While multiple factors
correlated with bloodstream infection on bivariate analysis, only hospital
length of stay, ICU status, and number of PICC lumens remained significantly
associated with PICC bloodstream infection on multivariable analysis. Most
notably the hazard ratio for bloodstream infections increased over 4 times with
double lumen catheters and over 8 times with
triple lumen catheters.
The authors also
found a significant association between time to infection and the number of
catheter lumens, i.e. the higher the number of lumens the shorter the time to
infection.
The authors question
the use of PICC lines at all in critically ill or immune-suppressed patients.
The authors suggest potential approaches to limit use of multiple lumen
catheters, such as limiting their availability or enhancing the physician
decision making process for these. They also strongly recommend use of
interventions to limit the duration of PICC lines, such as reminders, automatic
stop orders, electronic surveillance for PICC presence, etc.
References:
Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet 2013; 382(9889): 311-325
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960592-9/fulltext
Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013; 34(9): 908-918
Chopra V, Ratz D, Kuhn L, et al. PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors. American Journal of Medicine 2014; 127(4): 319–328
http://www.amjmed.com/article/S0002-9343%2814%2900029-1/fulltext
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