Peripherally inserted central catheters in patients with AIDS are associated with a low infection rate

Peripherally inserted central catheter-associated bloodstream infection: Risk factors and the role of antibiotic-impregnated catheters for prevention

BACKGROUND

Antimicrobial-impregnated (AIP) peripherally inserted central catheters (PICCs) may lower risk of central line-associated bloodstream infection (CLABSI) compared with nonantimicrobial-impregnated (NAIP) catheters. We sought to assess risk factors for CLABSI with a focus on the effect of AIP PICCs.

METHODS

CLABSI rate was determined among patients who received PICCs from July 2009 through June 2012 using a retrospective study design. A nested case-control study matched for operators (interventional radiology [IR], infectious diseases [IDs], and the nurse venous access team [VAT]) was conducted to assess risks for PICC CLABSI.

RESULTS

Eighty-nine PICC CLABSIs (1.66%) occurred among 5,372 PICC placements a mean of 32 days after placement. Higher infection risk (1.75) was observed for IR-placed PICCs compared with ID-placed PICCs (P = .02). In addition, higher infection risk (4.22) was observed for IR-placed PICCS compared with VAT-placed PICCs (P = .0008). IR-placed NAIP catheters, as indicated by multivariate analysis, revealed a 5.45-fold greater CLABSI risk compared with AIP catheters (P < .0005). Other risk factors included chemotherapy, placement of a tunneled catheter, leukemia, and AIDS.

CONCLUSIONS

PICC CLABSIs were highest among patients receiving NAIP catheters in this large study. Highest risk occurred with placement of a tunneled catheter, AIDS, leukemia, and if the indication for PICC was chemotherapy. Our study suggests that the AIP PICC should be considered in all patients receiving PICCs.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

Quality of Life, Pain Perception, and Distress Correlated to Ultrasound-Guided Peripherally Inserted Central Venous Catheters in Palliative Care Patients in a Home or Hospice Setting

CONTEXT

Intravenous fluid administration with peripherally inserted central venous catheters (PICCs) and midline catheters in palliative care.

OBJECTIVES

To evaluate distress and pain perceived by patients during the positioning of a PICC or midline catheter, both in the home and hospice settings.

METHODS

This was a prospective observational study performed by the Palliative Care Network of Pordenone. In addition to evaluating distress and pain, we monitored patient quality of life and the devices used. Quality of life was measured with the European Organization for Research and Treatment of Cancer-Core 15-Palliative scale.

RESULTS

From May 2012 to July 2013, 48 patients were enrolled in the study. The level of distress during the procedure was null or very low in 95.8% of the patients and completely absent after one week. Pain during insertion was null or very little in 93.8% of the patients and zero after one week in 98% of the patients. Quality of life was significantly improved after one week for certain specific parameters and also globally. The number of catheter days monitored was 3097. The weekly monitoring of the devices revealed a series of minor complications. Only two catheters were removed for serious complications.

CONCLUSION

Our results showed a low impact on pain and distress, a low level of local and systemic complications and a favorable impact on patients' quality of life. However, other studies are necessary to evaluate the cost-effectiveness of the use of these devices and their role in palliative care.

Peripherally Inserted Central Venous Catheter–Associated Bloodstream Infections in Hospitalized Adult Patients

Background.

Limited data on the risk of peripherally inserted central venous catheter-associated bloodstream infections (PICC BSIs) in hospitalized patients are available. In 2007, dedicated intravenous therapy nurses were no longer available to place difficult peripheral intravenous catheters or provide PICC care Barnes-Jewish Hospital.

Objectives.

To determine the hospital-wide incidence of PICC BSIs and to assess the effect of discontinuing intravenous therapy service on PICC use and PICC BSI rates.

Setting.

A 1,252-bed tertiary care teaching hospital.

Methods.

A 31-month retrospective cohort study was performed. PICC BSIs were defined using National Healthcare Safety Network criteria.

Results.

In total, 163 PICC BSIs were identified (3.13 BSIs per 1,000 catheter-days). PICC use was higher in intensive care units (ICUs) than non-ICU areas (PICC utilization ratio, 0.109 vs 0.059 catheter-days per patient-day for ICU vs non-ICU; rate ratio [RR], 1.84 [95% confidence interval {CI}, 1.78-1.91]). PICC BSI rates were higher in ICUs (4.79 vs 2.79 episodes per 1,000 catheter-days; RR, 1.7 [95% CI, 1.10-2.61]). PICC use increased hospital-wide after the intravenous therapy service was discontinued (0.049 vs 0.097 catheter-days per patient-day; P = .01), but PICC BSI rates did not change (2.68 vs 3.63 episodes per 1,000 catheter-days; P = .06). Of PICC BSIs, 73% occurred in non-ICU patients.

Conclusions.

PICC use and PICC BSI rates were higher in ICUs; however, most of the PICC BSIs occurred in non-ICU areas. Reduction in intravenous therapy services was associated with increased PICC use across the hospital, but PICC BSI rates did not increase.

Patient- and Device-Specific Risk Factors for Peripherally Inserted Central Venous Catheter—Related Bloodstream Infections

Objective.

To determine the patient- and device-specific risk factors for hospital-acquired peripherally inserted central venous catheter–related bloodstream infections (PICC BSIs) in adult patients.

Design.

Nested case-control study.

Setting.

Barnes-Jewish Hospital, a 1,252-bed tertiary care teaching hospital.

Patients.

Adult patients with PICCs placed from January 1, 2006, through July 31, 2008.

Methods.

PICC BSI cases were identified using the National Healthcare Safety Network definition. Uninfected control patients with PICCs in place were randomly selected at a 3: 1 ratio. Patient- and device-related variables were examined using multivariate analysis.

Results.

The overall PICC BSI rate was 3.13 per 1,000 catheter-days. Independent risk factors for PICC BSIs included congestive heart failure (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.26–3.17];P= .003), intra-abdominal perforation (OR, 5.66 [95% CI, 1.76–18.19];P= .004),Clostidium difficileinfection (OR, 2.25 [95% CI, 1.17–4.33];P= .02), recent chemotherapy (OR, 3.36 [95% CI, 1.15–9.78];P= .03), presence of tracheostomy (OR, 5.88 [95% CI, 2.99–11.55];P< .001), and type of catheter (OR for double lumen, 1.89 [95% CI, 1.15–3.10];P= .01; OR for triple lumen, 2.87 [95% CI, 1.39–5.92];P= .004). Underlying chronic obstructive pulmonary disease (OR, 0.48 [95% CI, 0.29–0.78];P= .03) and admission to surgical (OR, 0.43 [95% CI, 0.24–0.79];P= .006) or oncology and orthopedic (OR, 0.35 [95% CI, 0.13–0.99];P= .05) services were less likely to be associated with having a PICC BSI.

Conclusions.

We identified several novel factors related to PICC BSIs. These factors may inform preventive measures.

Thrombolytic Therapy Using Urokinase for Management of Central Venous Catheter Thrombosis

Purpose:

The management of central venous catheters (CVCs) and catheter thrombosis vary among centers, and the efficacy of the methods of management of catheter thrombosis in CVCs is rarely reported. We investigated the efficacy of bedside thrombolysis with urokinase for the management of catheter thrombosis.

Materials and Methods:

We retrospectively reviewed data from patients who had undergone CVC insertion by a single surgeon in a single center between April 2012 and June 2014. We used a protocol for the management of CVCs and when catheter thrombosis was confirmed, 5,000 U urokinase was infused into the catheter.

Results:

A total of 137 CVCs were inserted in 126 patients. The most common catheter-related complication was thrombosis (12, 8.8%) followed by infection (8, 5.8%). Nine of the 12 patients (75%) with catheter thrombosis were recanalized successfully with urokinase. The rate of CVC recanalization was higher in the peripherally inserted central catheter (PICC) group (87.5%) than the chemoport group (50%). Reintervention for catheter-related thrombosis was needed in only 2.2% of patients when thrombolytic therapy using urokinase was applied. Age <60 years (P=0.035), PICC group (P=0.037) and location of the catheter tip above the superior vena cava (P=0.044) were confirmed as independent risk factors for catheter thrombosis.

Conclusion:

Thrombolysis therapy using urokinase could successfully manage CVC thrombosis. Reintervention was rarely needed when a protocol using urokinase was applied for the management of CVC thromboses.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Groshong PICC and home care: an opportunity. Clinical experience after the first 200 implants

Peripherally Inserted Central Catheters (PICC) represent an alternative for critical patient care, and are safer to implant in home patients. The authors report on their experience with the first 200 4 Fr Groshong PICC implanted during the last 18 months. The procedure can be easily applied at home (98% successful implant rate), without the need for fluoroscopic or ultrasound guidance. Moreover, the authors believe that the X-ray control after implant is not strictly necessary. After 11,570 days/catheters, only 5 devices were explanted because of complications: 4 because of sepsis and peripheral phlebitis, and the last was explanted by another medical staff for unclear reasons. The complications needing no explanation were a total of 32: for 12 of them the external portion of tube was damaged during use, while for the other 20 the internal clots were resolved with forced flushing. The authors conclude that Groshong PICC can be considered the gold standard for home care management of critical patients, taking into account the quality of pure silicon, the presence of a valve and the specially-made closed-tip.

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 catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia

BACKGROUND AND OBJECTIVE

Peripherally inserted central venous catheters (PICCs) are alternatives to short-term central venous catheters and provide intravenous access in the acute hospital setting. In this study, we describe the rate of PICC-associated bloodstream infections (BSI).

DESIGN AND SETTING

Prospective cohort study using data on PICC lines reviewed from January to December 2009.

METHODS

The infection control team was responsible for prospective BSI case findings. The infection rate was calculated per 1000 device-days.

RESULTS

During the study period, 92 PICC lines were inserted with a total of 3336 device-days of prospective surveillance. The most frequent reasons for the insertion of the PICC lines were chemotherapy (n=19, 20.7%), intravenous antimicrobial therapy (n=34, 37%), and for patients in the medical intensive care unit (ICU) (n=16, 17.4%). The overall BSI rate was 4.5/1000 PICC days. The PICC line-associated BSI rates for a specific indication were as follows: chemotherapy 6.6/1000 device-days, intravenous antimicrobial therapy 1.2/1000 device-days, medical ICU 7.3/1000 device-days, surgical ICU 4.6/1000 device-days, and total parental nutrition patients 2.4/1000 device-days (P<.001). The rates were not adjusted for patient severity of illness.

CONCLUSIONS

Our data suggest that underlying conditions and indications for the PICC line use may play an important role in the development of BSI.

The Use of Peripherally Inserted Central Catheters in Cancer Patients

From 2002 to 2006, 524 cancer patients who underwent PICC insertion by nursing staff were studied. 568 PICCs were in place for a total of 32068 days (mean duration: 56 days; range: 1 to 487 days). The complication rates were phlebitis – 24.07%, broken/leaking catheter – 12.33%, accidental removal – 7.44%, occlusion – 14.68%, and infection – 1.77%. Group A patients who underwent PICC insertion for the major purpose of receiving repeated chemotherapy had higher incidences of phlebitis, broken/leakage catheter and infection. Group B patients who underwent PICC insertion for the major purpose of hospice care had a higher incidence of accidental removal.

Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist?

BACKGROUND

Peripherally-inserted central venous catheters (PICCs) are frequently used in hospitals for central intravenous access. These catheters may offer advantages over traditional central catheters with respect to ease of placement and decreased complication rates. However, hospital physicians have not traditionally been trained to place PICCs.

METHODS

We trained 3 of 5 hospitalists to place PICCs in our small university-affiliated community hospital as we converted from a house physician model to a hospitalist model for inpatient care. We then looked retrospectively at the rates of all PICC and other central catheter placements as well as the number of femoral and nonfemoral catheter days for the 18-month period prior to and after the inception of the hospitalist program.

RESULTS

Comparing the periods prior to and after the inception of the hospitalist program, the total number of central catheter placements doubled and the PICC rate rose from 20% to 80% of all central catheters. The rate of femoral and subclavian catheter placements decreased by approximately 50% and the rate of internal jugular catheter placement was roughly unchanged. There was also a fall in the number of femoral catheter days and a great increase in the number of total nonfemoral catheter days. The rate of catheter-related bacteremia remained low and did not appear to increase.

CONCLUSIONS

PICCs may be a safe and easy alternative to centrally placed catheters for the hospital physician attempting to secure central intravenous access and may lead to a decrease in the need for more risky central venous catheter (CVC) insertions.

Survey of the long-term use of peripherally inserted central venous catheters in children with cancer: experience in a developing country

Peripherally inserted central catheters (PICCs) have been used for many years in developed countries, but few studies have been focused on children with cancer in developing countries. In this study, we assessed the feasibility of PICCs and determined the rate of PICC-related complications in children with cancer. We prospectively followed all children with cancer over 3 years of age who received chemotherapy and PICC placement in our cancer center between June 2003 and May 2007. The date of last follow-up was January 31, 2008. A total of 119 PICCs were inserted into 116 patients during the 48-month period. PICCs were placed in 113 of 119 attempts, yielding an insertion rate of 95.0%. The 113 PICCs were in place for a total 26,721 catheter days (median time, 246 d; range, 8 to 455 d). The 113 PICCs had 53 overall complications, for a rate of 1.98/1000 catheter days. Twenty-one (18.6%) PICCs were removed because of complication with a rate of 0.79/1000 catheter days. The most common reason for PICC removal was breakage/leakage. An infection requiring PICC removal occurred in 4 patients. This study demonstrated relatively low complication rate and long duration for PICCs in children with cancer over 3 years of age in our hospital.

The efficacy of upper arm placement of peripherally inserted central catheters using bedside ultrasound and microintroducer technique

In one hospital in southern Georgia, the review and analysis of 500 peripherally inserted central catheter procedural attempts by designated, specialty nurses using microintroducer technique and ultrasound guidance revealed an overall catheter placement success rate of 94.6%. This research analysis also provided information on the disposition of those 6-French dual-lumen and triple-lumen, power-injectable peripherally inserted central catheters actually placed in situ on subjects who remained hospitalized or within the hospital's rehabilitation facility. Of the 422 catheters removed, none exhibited signs or symptoms of mechanical phlebitis, and one tested positive per laboratory analysis for organisms confirming infection.

Randomized controlled trial of peripherally inserted central catheters vs. peripheral catheters for middle duration in-hospital intravenous therapy

INTRODUCTION

Intravenous (i.v.) therapy may be associated with important catheter-related morbidity and discomfort. The safety, efficacy, comfort, and cost-effectiveness of peripherally inserted central catheters (PICCs) were compared to peripheral catheters (PCs) in a randomized controlled trial.

METHODS

Hospitalized patients requiring i.v. therapy >or= five days were randomized 1:1 to PICC or PC. Outcomes were incidence of major complications, minor complications, efficacy of catheters, patient satisfaction, and cost-effectiveness.

RESULTS

60 patients were included. Major complications were observed in 22.6% of patients in the PICC group [six deep venous thrombosis (DVT), one insertion-site infection] and 3.4% of patients in the PC group [one DVT; risk ratio (RR) 6.6; P = 0.03]. Superficial venous thrombosis (SVT) occurred in 29.0% of patients in the PICC group and 37.9% of patients in the PC group (RR 0.60; P = 0.20). Patients in the PICC group required 1.16 catheters on average during the study period, compared with 1.97 in the PC group (P < 0.04). The mean number of venipunctures (catheter insertion and blood sampling) was 1.36 in the PICC group vs. 8.25 in the PC group (P < 0.001). Intravenous drug administration was considered very or quite satisfying by 96.8% of the patients in the PICC group, and 79.3% in the PC group. Insertion and maintenance mean cost was 690 US$ for PICC and 237 US$ for PC.

DISCUSSION

PICC is efficient and satisfying for hospitalized patients requiring i.v. therapy >or= five days. However, the risk of DVT, mostly asymptomatic, appears higher than previously reported, and should be considered before using a PICC.

Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer

BACKGROUND

A long term venous access device is essential in children with malignancies for the safe administration of medication and to avoid repeated painful venipunctures. The advantage of peripherally inserted central venous catheters (PICC) over conventional central venous catheter (CVC) is easy bedside insertion without need for general anesthesia and theatre time. The purpose of this study was to evaluate our experience with PICCs particularly with regard to catheter life, reason for removal and complications in children suffering from various malignancies.

PROCEDURE

A retrospective analysis of all PICCs inserted in children with cancer was done with regard to the demographic data, catheter life, reason for removal, and complications. The latter two were evaluated in association with patient age, catheter days, and year of insertion.

RESULTS

Of 127 catheters inserted in 127 children, median catheter life was 161 days with a total of 18,955 catheter days (for 124 patients, 3 lost to follow-up). Elective removal occurred in 63/101 (62.4%) PICCs and removal due to complications resulted in a complication rate of 2.41 per 1,000 catheter days. The common reasons for catheter removal were suspected infection, breakage/leakage, dislodgement, phlebitis, and occlusion with rates of 1.27, 0.57, 0.31, 0.06, and 0.06 per 1,000 catheter days, respectively.

CONCLUSION

We found PICC to be a convenient, cheap, safe, and reliable device for long term intravenous access in children with malignancies. This was possible with the help of dedicated catheter care nurses.

Continuous-infusion penicillin home-based therapy for serious infections due to penicillin-susceptible pathogens

To evaluate the feasibility of continuous-infusion (CI) penicillin in the treatment of serious bacterial infections, consecutive adult patients with deep-seated infections due to penicillin-susceptible pathogens were treated with CI aqueous penicillin G in a home-based programme, and their treatment outcomes were reviewed. Thirty-one patients with microbiologically proven infections completed the planned course of treatment. Twenty of 31 (65%) were followed for at least 2 months thereafter, and all remained free of relapse. One patient had fever attributable to penicillin hypersensitivity, two patients developed catheter-site infections and one patient developed catheter-related bacteraemia. Thus, CI penicillin is feasible for the home-based treatment of a variety of deep-seated infections with minimal toxicity.

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.

Long-term use of peripherally inserted central venous catheters for cancer chemotherapy in children

BACKGROUND

Peripherally inserted central venous catheters (PICCs) have been increasingly used in pediatric patients. However, little is known about the incidence and risk of complications when using this device in children with cancer. The purposes of this study are to assess the feasibility of PICCs and to determine the risk factors for PICC-related complications in pediatric patients with various types of malignancies.

PATIENTS AND METHODS

We attempted to place PICCs in 53 patients with a median age of 5 years ranging from 2 months to 20 years. PICCs were used to administer fluid, parenteral nutrition, anticancer agents, antibiotics, and blood products and also for the through-line blood sampling. The duration of catheterization and the incidence of PICC-related complications requiring removal were retrospectively evaluated in association with the diagnosis, sex, age and body weight of the patients, size, insertion site and tip location of the catheters, type of treatment, and duration of leukopenia.

RESULTS

PICCs were successfully placed in 109 of 112 attempts (97.3%) in 53 patients, and they were followed for a total of 11,797 catheter days (median placement, 87 days; range, 3 to 512 days). Fifty five PICCs (50.5%) were removed as a result of PICC-related complications with a rate of 4.66 per 1,000 catheter days. The most common reasons for catheter removal were occlusion (n=18), breakage/leakage (15), and infection (10). More than 70% of such complications occurred more than 30 days after placement. The catheter tip location in the superior vena cava or the right atrium might decrease the risk of complications. Other parameters did not influence the incidence of complications.

CONCLUSIONS

PICCs were found to provide a reliable access for prolonged intravenous administration and blood sampling in children intensively treated for hematologic and solid malignancies, thus leading to a reduction of physical pain and psychological stress in such patients. However, the long-term placement of PICCs may also be related to an increased risk of complications.

High rate of complications associated with peripherally inserted central venous catheters in patients with solid tumours

BACKGROUND

Peripherally inserted central catheters (PICC) have been used extensively as a cost-effective and safe form of medium-term intravascular access. There are only limited data about complications of PICC lines in oncology patients despite theoretical concerns about the higher risks of complications in these patients as a result of cancer itself and cancer therapy.

AIMS

To document the frequency and type of PICC complications in patients with solid tumours.

METHODS

All patients with solid tumours who were treated at Flinders Medical Centre, Adelaide, South Australia, Australia between January 2000 and March 2001 were included in a retrospective review of PICC complications.

RESULTS

Twenty-seven PICC lines were inserted in 17 patients; 40.7% (11/27) of PICC lines developed complications requiring early removal of the PICC. Complications encountered were sepsis (systemic and cellulitis), thrombosis, blockage and leakage. Septic complications were found at a rate of 8/1000 PICC days or 25.7% (7/27) of PICC inserted. The median dwell time was 20 days. The mean time for a complication to occur was 27.5 days.

CONCLUSIONS

The present study demonstrates a high rate of complications, which is higher than the complication rates reported in studies of non-oncology patients. PICC lines should be used with caution in patients with solid tumours. Prospective studies of the factors influencing the incidence of complications might be warranted.

Complication rates among cancer patients with peripherally inserted central catheters

PURPOSE

Peripherally inserted central catheters (PICCs) are frequently used to deliver outpatient courses of intravenous therapy. However, the rates and risks of complication for this device have not been well-studied. Our objective was to determine the incidence and risk factors of PICC-related complications with a 1-year prospective observational study.

PATIENTS AND METHODS

All PICCs inserted in adult and pediatric patients at Memorial Sloan-Kettering Cancer Center (MSKCC) were followed prospectively. The device insertion team, inpatient nurses, and various home-care companies and outside institutions collected longitudinal data.

RESULTS

Three hundred fifty-one PICCs were inserted during the study period and followed for a total of 10,562 catheter-days (median placement, 15 days; range, 1 to 487 days). Two hundred five PICCs (58%) were managed by home-care companies and outside institutions, and 146 PICCs (42%) were managed exclusively at MSKCC. For these 205 PICCs, 131 nurses from 74 home-care companies and institutions were contacted for follow-up clinical information. In all, 115 (32.8%) of 351 PICCs were removed as a result of a complication, for a rate of 10.9 per 1,000 catheter-days. Patients with hematologic malignancy or bone marrow transplant were more likely to develop a complication, whereas those with metastatic disease were less likely.

CONCLUSION

Complications occur frequently among cancer patients with PICCs, and long-term follow-up is onerous. Despite a high complication rate, the ease of insertion and removal argues for continued PICC use in the cancer population.

Infectious complications of venous access devices

Infection represents one of the most common venous access device (VAD)-related complications requiring catheter removal. Recognition of such complications is essential to provide appropriate therapy in the setting of active infection. This article reviews the definition of various types of infections, as well as reviewing the diagnosis, prevention, and treatment of VAD-related infections.

Trends in bacteraemia on the haematology and oncology units of a UK tertiary referral hospital

As part of ongoing surveillance of infection in the haematology and oncology units at Belfast City Hospital, microbiologically documented bloodstream infections over three 12-month periods 1994/5, 1998/9 and 1999/00 were reviewed. Gram-positive organisms were the most common cause of blood stream infection in the haematology unit causing 66%, 56% and 64% of episodes of monomicrobial bacteraemia in 1994/5, 1998/9 and 1999/00, respectively. In haematology patients, enterococci have emerged as an important cause of bacteraemia, with increasing levels of glycopeptide resistance, and the 'non-fermenting Gram-negative rods other than Pseudomonas aeruginosa' are an increasingly common cause of monomicrobial and polymicrobial bacteraemia. In oncology patients, Gram-negative organisms (predominantly enterobacteriaceae) were more common than Gram-positive organisms, causing 50% and 54% of monomicrobial bacteraemia in 1998/9 and 1999/00, respectively. Changes in patient population, underlying diseases and chemotherapeutic agents may explain these findings. The spectrum of infection seen in haematology and oncology patients changes as management evolves. Ongoing co-operation between haematologists, oncologists and microbiologists is important to detect trends in epidemiology, which can be used to design empirical antibiotic regimens and guide infection control policies.

Catheter-related bloodstream infections in HIV-infected patients

Bloodstream infections (BSI) constitute a significant public health problem and represent an important cause of morbidity and mortality in hospitalized patients, with an approximate incidence of one episode per hundred hospital admissions. Studies on BSI in HIV+ patients have identified central venous catheters (CVC) as a risk factor, with an attributable mortality rate of 10-20%. The long-term CVC-related infection risk appeared to be 5 to 10-fold higher with respect to the infection rates among HIV- patients. CVC associated infection rate ranges from 1.3 to 12 infections per 1,000 catheter-days. Staphylococcus aureus is the most common etiologic agent causative of CVC-related BSI, likely the result of the high skin and nasal carriage of this organism among HIV+ patients, mostly intravenous drug users. Coagulase-negative staphylococci are also frequently identified as cause of CVC-related BSI, likely the result of breaches in infection control measures and in antiseptic technique during CVC management. Treating bacteremia without catheter removal would be optimal, but the reported efficacy of systemic antibiotic therapy alone is only 25-32%. Conversely, recent studies have shown that, using an antibiotic-lock procedure, up to 90% of HIV-infected and uninfected patients achieved complete eradication of catheter-related BSIs without catheter removal. Clinical trials using new materials such as covalently linked heparin on the CVC surface, electrically charged CVC, novel topical agents that interfere with bacterial colonization, antiadhesin molecules and agents that block the gene expression involved in the biofilm formation, are all needed to reduce the high catheter-related infection risk among HIV+ patients.