Incidence and risk factors for central venous access device failure in hospitalized adults: A multivariable analysis of 1892 catheters

BACKGROUND

Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion.

OBJECTIVE

To quantify CVAD failure and complications; and identify risk factors.

DESIGNS, SETTINGS, AND PARTICIPANTS

Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations.

RESULTS

In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24-5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68-6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31-6.68), and diabetes (HR 3.25, 95%CI 1.40-7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08-0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14-0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48-33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08-6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections over 18 years in 281 ICUs of 9 Asian countries

BACKGROUND

Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia.

METHODS

From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR).

RESULTS

A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk.

CONCLUSIONS

The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections

SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.

Central venous catheters: Which, when and how

Short-term or long-term CVCs are now considered the standard of practice for the administration of chemotherapy, fluid therapy, antibiotic therapy, and parenteral nutrition. Central venous access catheters are broadly divided into tunneled or non-tunneled catheters. Tunneled catheters can be further subdivided into totally implanted and totally not implanted devices. Device selection generally depends on various factors such as availability of peripheral veins, expected duration of therapy, and desired flow rate. Ultrasound-guided access is the safest technique for central venous access compared to the landmark technique and departments should strive to for a 100% ultrasound guided access. This review gives a basic overview of the differences of CVC catheters including PICCs, Hickman-catheters and port-catheters along with the criteria for CVC selection. It will also describe technical tips on placement of CVCs. Finally, it aims to highlight complications which are associated with CVC placement and options to treat or prevent them.

Clinical factors associated with peripherally inserted central catheters (PICC) related bloodstream infections: a single centre retrospective cohort

BACKGROUND

Despite their spread in daily practice, few data is available on clinical factors associated with peripherally inserted central catheter (PICC)-related bloodstream infections (PR-BSI). We aimed to assess the PR-BSI incidence, microbiology, and factors associated with PR-BSI with a focus on clinical symptoms.

METHODS

We conducted a retrospective cohort study in a French university hospital. We screened all PICC insertions performed from April 1st, 2018, to April 1st, 2019, and included PICC insertions in adult patients. We assessed the PR-BSI incidence, the factors associated with PR-BSI using a Cox model, and negative and positive predictive values (NPVs and PPVs) of each clinical sign for PR-BSI.

RESULTS

Of the 901 PICCs inserted in 783 patients (38,320 catheters days), 214 PICCs (24%) presented with a complication. The most prevalent complication was PR-BSI (1.9 per 1000 catheter days; 8.1% of inserted PICCs ). Enterobacterales (N = 27, 37%) and coagulase negative Staphylococci (N = 24, 33%), were the main microorganisms responsible for PR-BSI. Factors independently associated with occurrence of PR-BSI were fever (hazard ratio 13.21, 95% confidence interval 6.00-29.11, p < 0.001) and chills (HR 3.66, 95%CI 1.92-6.99, p < 0.001). All clinical signs and a duration of PICC maintenance ≥ 28 days, had a low PPVs (≤ 67.1%) but high NPVs (≥ 92.5%) for PR-BSI.

CONCLUSIONS

Monitoring of clinical signs, especially fever and chills, with caution and limitation of device maintenance duration, could improve PICC management.

Impact of number of lumens in central-venous catheters on central-line bloodstream infection (CLABSI) and venous thromboembolism (VTE) risk in patients with acute leukemia

This retrospective study was conducted to determine whether the number of peripherally inserted central-catheter lumens affected the rate of central-line associated bloodstream infections (CLABSIs) in adult patients with acute leukemia. The results show that CLABSI rates were not significantly different between patients with triple-lumen or double-lumen PICCs (22.1% vs 23.4%; P = .827).

Risk factors of catheter- associated bloodstream infection: Systematic review and meta-analysis

INTRODUCTION

The prevalence of catheter-associated bloodstream infections (CLABSI) is high and is a severe health problem associated with an increase in mortality and elevated economic costs. There are discrepancies related to the risk factors of CLABSI since the results published are very heterogeneous and there is no synthesis in the description of all the predisposing factors.

OBJECTIVE

We aimed to perform a systematic review and meta-analysis to synthesize and establish the risk factors predisposing to CLABSI reported in the literature.

METHOD

This is a systematic review of observational studies following the PRISMA recommendations. MEDLINE and CINAHL databases were searched for primary studies from 2007 to 2021. The protocol was registered in PROSPERO CRD42018083564.

RESULTS

A total of 654 studies were identified, 23 of which were included in this systematic review. The meta-analysis included 17 studies and 9 risk factors were analyzed (total parenteral nutrition (TPN), chemotherapy, monolumen and bilumen catheters, days of catheterization, immunosuppression, kidney disease and diabetes mellitus) due to the homogeneity of their definitions and measurements. The risk factors found to increase the probability of developing CLABSI were TPN, multilumen devices, chemotherapy treatment, immunosuppression and the number of days of catheterization. On the other hand, monolumen devices presented a lower likelihood of triggering this infection.

Catheter-related bloodstream infection associated with multiple insertions of the peripherally inserted central catheter in patients with hematological disorders

Patients with hematological disorders are treated with multiple cycles of chemotherapy. As a result, they often require multiple insertions of the peripherally inserted central catheter (PICC) for prolonged periods of time. Although PICCs have been widely used worldwide in various patients, the safety and feasibility of the multiple insertions of the PICC in this population have not been fully verified. We performed a retrospective analysis to clarify the relationship between complications and multiple PICC insertions in patients with hematological disorders who were treated with either chemotherapy or immunotherapy. A total of 651 PICCs were inserted in 261 patients with a median age of 66 years. Acute myeloid leukemia (AML) and non-Hodgkin's lymphoma were the most common diseases in our patient cohort. The total catheter days (CDs) was 29,485 days, with a median catheter duration of 30 days. The rate of catheter-related bloodstream infection (CRBSI) in our patient cohort at high rate of re-insertion was 2.0/1000 CDs. Although multiple PICC insertions were not a risk factor of CRBSI, our findings suggest that a prolonged catheter dwell time may be associated with CRBSI. AML was an important risk factor of CRBSI. While the PICC dwell time depends on the treatment cycle, our findings indicate that it should be limited to approximately 30 days and catheters may be removed and re-inserted as needed.

ECG-guided PICC insertion using a new silicon catheter with a conductive tip: A retrospective clinical study

OBJECTIVE

Safety and efficacy of ECG-guided PICC insertion using a new silicon catheter with a conductive tip was evaluated in daily practice.

METHODS

A retrospective study was conducted on 1659 patients who accepted successful tip-conductive PICC placement and clinically followed-up until the catheter removal between January 2018 and April 2019. Baseline of patient characteristics, catheter placement characteristics, date of dressing changes as well as records of catheter-related complications were extracted from a special designed mobile APP.

RESULTS

The first-attempt success (success of placing catheter tip to the ideal position by primary indwelling operation) rate of PICC placement was 99.3%. The average duration of PICC placement was 128.7 ± 39.5 days and 1535 patients (92.5%) reached the therapy end-point without any complications and removed the catheter normally. The cumulative rates of total complications were 7.5%, including exit site infection (2.5%), phlebitis (0.9%), DVT (1.0%), catheter malposition (1.1%), catheter breakage (0.1%), and liquid extravasation (1.8%). In multivariable logistic regression analyses, hyperlipidemia, diabetes mellitus, lung cancer, stomach cancer, and lymphoma were significantly associated with increased risk of complications, as the independent risk factors.

CONCLUSIONS

This retrospective clinical study demonstrates that ECG-guided insertion of a new tip-conductive PICC is associated with a high rate of first-attempt success and low rate of catheter related complications.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis

OBJECTIVE

To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults.

DESIGN

A 5-year prospective cohort study.

SETTING

Tertiary-care teaching hospital in Seville, Spain.

PATIENTS

Adult patients undergoing PICC insertion.

METHODS

Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis.

RESULTS

In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications.

CONCLUSIONS

PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

Previous peripherally inserted central catheter (PICC) placement as a risk factor for PICC-associated bloodstream infections

BACKGROUND

Peripherally inserted central catheter (PICC) -associated bloodstream infection (BSI) is a concern.

METHODS

A case-control study was conducted to assess risk factors for PICC-associated BSI.

RESULTS

A total of 1,215 cases and 31,874 catheter days were analyzed. In total, 54 cases of PICC-associated BSI were detected giving an infection rate of 1.69 per 1,000 catheter-days. The most frequently isolated pathogens were coagulase-negative staphylococci (26%), followed by Enterococcus species (22%), Candida species (17%), and Staphylococcus aureus (11%). Multivariable analysis identified the significant risk factors for PICC-associated BSI as a prior PICC placement (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.36-4.53), medical department admission (OR, 1.89; 95% CI, 1.03-3.46), and older age (OR, 1.03; 95% CI, 1.00-1.05). With increasing frequency of previous PICC placement, the rates of PICC-associated BSI increased: 3.5% (31/883) without previous placement, 7.6% (13/171) in once, and 9.9% (9/32) in twice or more.

DISCUSSION

The previous PICC placement was an independent risk factor for PICC-associated BSI and the risk proportionally rose with the increasing frequency of prior PICC placement.

CONCLUSIONS

Patients with repeatedly inserted PICC should be managed more carefully for prevention and should be monitored for the development of PICC-associated BSI.

Randomized multicenter study on long-term complications of peripherally inserted central catheters positioned by electrocardiographic technique

BACKGROUND

The intracavitary electrocardiogram (IC-ECG) method has been used for the tip location of central venous access devices for the advantage of being safe, accurate and highly cost effective. However, long-term follow-up is rare. This randomized clinical trial aimed to evaluate the long-term complications of peripherally inserted central catheters (PICCs) positioned by the IC-ECG method.

METHODS

We randomized 2250 patients who needed PICC placement to either a landmark length estimation supplemented by IC-ECG positioned group (ECG group) or the traditional landmark length estimation alone group (control group) in a 2:1 allocation. Post-procedural chest X-rays were applied to confirm tip position. Follow-up was performed monthly to six months. Standard statistics analyses were performed with the SAS 9.13 software, and p < 0.05 was considered significant.

RESULTS

As evaluated by post-procedural chest X-ray, tip location in the ECG group had a first-attempt success (catheter tip located at optimal position) of 91.7% (95% confidence interval (CI): 90.3%-93.1%), significantly higher than 78.9% (95% CI: 76.0%-81.9%) observed in the control group (p < 0.001). At six-month follow-up, in the control group, frequency of total complications was 9.5%, including the exit site infection (4.0%), phlebitis (1.3%), deep venous thrombosis (1.5%), liquid extravasation (2.9%) and mechanical failure (1.9%). The IC-ECG group had significantly lower rates of complications (6.4%, p < 0.001), including the exit site infection (2.7%, p > 0.05), phlebitis (1.1%, p > 0.05), deep venous thrombosis (1.2%, p > 0.05), liquid extravasation (2.4%, p > 0.05) and mechanical failure (1.2%, p > 0.05). In the univariable logistic regression analysis, ECG method, other diseases and upper arms were the independent protective factors, and the number of adjustment procedures (n ≥ 2) were the independent risk factors of the complications.

CONCLUSIONS

The intra-procedural tip location by IC-ECG is more safe and accurate than the traditional method of verifying tip location only post-procedurally, by chest X-ray.

Prevalence and predictors of peripherally inserted central venous catheter associated bloodstream infections in cancer patients: A multicentre cohort study

Despite increasing use, the exact prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PICC-CLABSI) in hospitalized patients with cancer are not elucidated.This retrospective cohort study included consecutive patients who underwent peripherally inserted central catheter (PICC) placement in 4 institutions (during 12 months in 3 hospitals and 10 months in 1 hospital). The prevalence of PICC-CLABSI was evaluated. The association between predictors and PICC-CLABSI were analyzed using Cox proportional hazards regression models and Kaplan-Meier survival analysis with log-rank tests.During the study period, 539 PICCs were inserted in 484 patients for a total of 10,841 catheter days. PICC-CLABSI occurred in 25 (5.2%) patients, with an infection rate of 2.31 per 1000 catheter days. PICC for chemotherapy (hazards ratio [HR] 11.421; 95% confidence interval (CI), 2.434-53.594; P = .019), double lumen catheter [HR 5.466; 95% CI, 1.257-23.773; P = .007], and PICC for antibiotic therapy [HR 2.854; 95% CI, 1.082-7.530; P = .019] were associated with PICC-CLABSI.PICC for chemotherapy or antibiotics, and number of catheter lumens are associated with increased risk of PICC-CLABSI in cancer patients. Careful assessment of these factors might help prevent PICC-CLABSI and improve cancer patients care.

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.

Knowledge, attitude, and practice toward the daily management of PICC in critically ill cancer patients discharged from intensive care units

Background

Peripherally inserted central catheters (PICCs) are widely used in critically ill cancer patients. We aimed to investigate the status of knowledge, attitude, and practice (KAP) toward the daily management of PICCs in critically ill cancer patients discharged from intensive care units.

Methods

Totally, 152 critically ill cancer patients discharged from two intensive care units in China were surveyed using a self-administered KAP questionnaire. Patients' demographics and PICC-related KAP scores were collected and analyzed using independent-samples t-test and multivariate stepwise linear regression analysis.

Results

All 152 patients completed the survey. The mean KAP scores were 32.61±3.80 points, 28.11±3.18 points, and 44.31±3.98 points, respectively. KAP scores were found to have significant positive correlations with each other (P<0.05). The major factors influencing the total KAP score were the PICC indwelling time and the patient's educational degree, age, and place of residence (P<0.05).

Conclusion

We noted that KAP status toward the daily management of PICC in critically ill cancer patients discharged from intensive care units is not optimistic and needs to be further improved. Attention should be paid to the health education patterns of KAP, and individualized instruction should be pursued.

Risk of Venous Thromboembolism Following Peripherally Inserted Central Catheter Exchange: An Analysis of 23,000 Hospitalized Patients

BACKGROUND

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.

METHODS

We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.

RESULTS

Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).

CONCLUSION

Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.

Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study

BACKGROUND

The guidelines for peripherally inserted central catheters (PICCs) recommend avoiding insertion if the anticipated duration of use is =5 days. However, short-term PICC use is common in hospitals. We sought to identify patient, provider, and device characteristics and the clinical outcomes associated with short-term PICCs.

METHODS

Between January 2014 and June 2016, trained abstractors at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites collected data from medical records of adults that received PICCs during hospitalization. Patients were prospectively followed until PICC removal, death, or 70 days after insertion. Multivariable logistic regression models were fit to identify factors associated with short-term PICCs, defined as dwell time of =5 days. Complications associated with short-term use, including major (eg, venous thromboembolism [VTE] or central lineassociated bloodstream infection [CLABSI]) or minor (eg, catheter occlusion, tip migration) events were assessed.

RESULTS

Of the 15,397 PICCs placed, 3902 (25.3%) had a dwell time of =5 days. Most (95.5%) short-term PICCs were removed during hospitalization. Compared to PICCs placed for >5 days, variables associated with short-term PICCs included difficult venous access (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.40-1.69), multilumen devices (OR, 1.53; 95% CI, 1.39-1.69), and teaching hospitals (OR, 1.25; 95% CI, 1.04-1.52). Among those with short-term PICCs, 374 (9.6%) experienced a complication, including 99 (2.5%) experiencing VTE and 17 (0.4%) experiencing CLABSI events. The most common minor complications were catheter occlusion (4%) and tip migration (2.2%).

CONCLUSION

Short-term use of PICCs is common and associated with patient, provider, and device factors. As PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary.

From Nano to Micro: using nanotechnology to combat microorganisms and their multidrug resistance

The spread of antibiotic resistance and increasing prevalence of biofilm-associated infections is driving demand for new means to treat bacterial infection. Nanotechnology provides an innovative platform for addressing this challenge, with potential to manage even infections involving multidrug-resistant (MDR) bacteria. The current review summarizes recent progress over the last 2 years in the field of antibacterial nanodrugs, and describes their unique properties, mode of action and activity against MDR bacteria and biofilms. Biocompatibility and commercialization are also discussed. As opposed to the more common division of nanoparticles (NPs) into organic- and inorganic-based materials, this review classifies NPs into two functional categories. The first includes NPs exhibiting intrinsic antibacterial properties and the second is devoted to NPs serving as a cargo for delivering antibacterial agents. Antibacterial nanomaterials used to decorate medical devices and implants are reviewed here as well.

The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice.

SUMMARY

Background Peripherally inserted central catheters (PICCs) are associated with upper extremity deep vein thrombosis (DVT). We developed a score to predict risk of PICC-related thrombosis. Methods Using data from the Michigan Hospital Medicine Safety Consortium, image-confirmed upper-extremity DVT cases were identified. A logistic, mixed-effects model with hospital-specific random intercepts was used to identify factors associated with PICC-DVT. Points were assigned to each predictor, stratifying patients into four classes of risk. Internal validation was performed by bootstrapping with assessment of calibration and discrimination of the model. Results Of 23 010 patients who received PICCs, 475 (2.1%) developed symptomatic PICC-DVT. Risk factors associated with PICC-DVT included: history of DVT; multi-lumen PICC; active cancer; presence of another CVC when the PICC was placed; and white blood cell count greater than 12 000. Four risk classes were created based on thrombosis risk. Thrombosis rates were 0.9% for class I, 1.6% for class II, 2.7% for class III and 4.7% for class IV, with marginal predicted probabilities of 0.9% (0.7, 1.2), 1.5% (1.2, 1.9), 2.6% (2.2, 3.0) and 4.5% (3.7, 5.4) for classes I, II, III, and IV, respectively. The risk classification rule was strongly associated with PICC-DVT, with odds ratios of 1.68 (95% CI, 1.19, 2.37), 2.90 (95% CI, 2.09, 4.01) and 5.20 (95% CI, 3.65, 7.42) for risk classes II, III and IV vs. risk class I, respectively. Conclusion The Michigan PICC-DVT Risk Score offers a novel way to estimate risk of DVT associated with PICCs and can help inform appropriateness of PICC insertion.

A Model to Predict Central-Line-Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score

BACKGROUND Peripherally inserted central catheters (PICCs) are associated with central-line-associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed. OBJECTIVE To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual's risk of PICC-CLABSI prior to device placement. METHODS Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values. RESULTS Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56-1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration. CONCLUSION The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary. Infect Control Hosp Epidemiol 2017;38:1155-1166.

Understanding percutaneous and subcutaneous central venous access devices

Central venous access devices (CVADs) are commonly used in the inpatient and outpatient settings. Physician assistants must understand CVADs' indications, intended uses, functional lifespans, complications, and indications for removal. This article describes common CVADs used for administering medications, nutrition, and chemotherapy, and for hemodialysis and venous access for laboratory sampling.

Defining the Specialty of Vascular Access through Consensus: Shaping the Future of Vascular Access

The Association for Vascular Access (AVA) is an organization of health care professionals founded in 1985 to support and promote the specialty of vascular access. The mission of AVA is to distinguish the vascular access specialty and define standards of vascular access through an evidence-based approach designed to enhance health care. There is little guidance for multidisciplinary procedures/practice, and this is the case for vascular access. There are also inconsistencies and conflicts in terminology. Additionally, there is no consensus of vascular access as a specialty. It is the focus of AVA to promote consistency in vascular access practice. This document embraces a common title for a clinician with knowledge and skills in the area of vascular access. This establishes a new paradigm that will strengthen the advancement of the vascular access specialty.

Antimicrobial activity and cytocompatibility of silver nanoparticles coated catheters via a biomimetic surface functionalization strategy

Catheter-related bloodstream infections are a significant problem in the clinic and may result in a serious infection. Here, we developed a facile and green procedure for buildup of silver nanoparticles (AgNPs) on the central venous catheters (CVCs) surface. Inspired by mussel adhesive proteins, dopamine was used to form a thin polydopamine layer and induce AgNPs formation without additional reductants or stabilizers. The chemical and physicochemical properties of AgNPs coated CVCs were characterized by scanning electron microscopy, X-ray photoelectron spectroscopy, Raman spectroscopy, and water contact angle. The Staphylococcus aureus culture experiment was used to study the antibacterial properties. The cytocompatibility was assessed by water soluble tetrazolium salts (WST-1) assay, fluorescence staining, and scanning electron microscopy analysis. The results indicated that the CVCs surface was successfully coated with compact AgNPs. AgNPs were significantly well separated and spherical with a size of 30–50 nm. The density of AgNPs could be modulated by the concentration of silver nitrate solution. The antibacterial activity was dependent on the AgNPs dose. The high dose of AgNPs showed excellent antibacterial activity while associated with increased cytotoxicity. The appropriate density of AgNPs coated CVCs could exhibit improved biocompatibility and maintained evident sterilization effect. It is promising to design mussel-inspired silver releasing CVCs with both significant antimicrobial efficacy and appropriate biological safety.

Risk factors for central line-associated bloodstream infections in the era of prevention bundles

Little is known about central line-associated bloodstream infection risk factors in the bundle era. In our case-control investigation, we found that independent risk factors for central line-associated bloodstream infection at our center included the number of recent lab tests, catheter duration, and lack of hemodynamic monitoring as the insertion indication. Infect Control Hosp Epidemiol 2014;00(0): 1-3.

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.

Peripherally Inserted Central Catheter Use in Skilled Nursing Facilities: A Pilot Study

OBJECTIVES

To describe patterns of use, care practices, and outcomes related to peripherally inserted central catheter (PICC) use in skilled nursing facilities (SNFs).

DESIGN

Prospective cohort study.

SETTING

Two community SNFs.

PARTICIPANTS

Adult SNF residents with PICCs (N = 56).

MEASUREMENTS

Information on indication for PICC use, device characteristics (e.g., lumens, gauge), and participant data (comorbidities, medications) were obtained from medical records. Care practices (e.g., frequency of flushing, dressing care) and problems related to PICCs were recorded. Major (central line-associated bloodstream infection, venous thromboembolism, catheter dislodgement) and minor (migration, dressing disruption, lumen occlusion, exit site infection) complications and process measures (flushing of PICC, assessment of necessity) were recorded. Bivariate analyses with t-tests, chi-square tests, or Fischer exact tests were used for continuous and categorical data.

RESULTS

Participants were enrolled from two SNFs. The most common indication for PICC use was intravenous antibiotic delivery. The average PICC dwell time was 43 days, and most devices were single-lumen PICCs. Major and minor complications were common and occurred in 11 (20%) and 18 (32%) participants, respectively. Occlusion (23%, n = 13), accidental dislodgement (12%, n = 7), and dressing disruption (11%, n = 6) were the commonest complications observed. Documentation regarding catheter care practices occurred in 41% of cases.

CONCLUSION

Quality improvement efforts that seek to benchmark practice, identify gaps, and institute efforts to improve PICC care and practice in SNFs appear necessary.

Peripherally Inserted Central Catheter-Related Infections in a Cohort of Hospitalized Adult Patients

PURPOSE

To determine the incidence and the risks factors of peripherally inserted central catheter (PICC)-related infectious complications.

MATERIALS AND METHODS

Medical charts of every in-patient that underwent a PICC insertion in our hospital between January 2010 and October 2013 were reviewed. All PICC-related infections were recorded and categorized as catheter-related bloodstream infections (CR-BSI), exit-site infections, and septic thrombophlebitis.

RESULTS

Nine hundred and twenty-three PICCs were placed in 644 unique patients, mostly male (68.3%) with a median age of 58 years. 31 (3.4%) PICC-related infections occurred during the study period corresponding to an infection rate of 1.64 per 1000 catheter-days. We observed 27 (87.1%) CR-BSI, corresponding to a rate of 1.43 per 1000 catheter-days, 3 (9.7%) septic thrombophlebitis, and 1 (3.2%) exit-site infection. Multivariate logistic regression analysis showed a higher PICC-related infection rate with chemotherapy (odds ratio (OR) 7.2-confidence interval (CI) 95% [1.77-29.5]), auto/allograft (OR 5.9-CI 95% [1.2-29.2]), and anti-coagulant therapy (OR 2.2-95% [1.4-12]).

CONCLUSION

Chemotherapy, auto/allograft, and anti-coagulant therapy are associated with an increased risk of developing PICC-related infections.

CLINICAL ADVANCE

Chemotherapy, auto/allograft, and anti-coagulant therapy are important predictors of PICC-associated infections. A careful assessment of these risk factors may be important for future success in preventing PICC-related infections.

PICC-associated bloodstream infections: prevalence, patterns, and predictors

BACKGROUND

Growing use of peripherally inserted central catheters (PICCs) has led to recognition of the risk of PICC-associated bloodstream infection. We sought to identify rates, patterns, and patient, provider, and device characteristics associated with this adverse outcome.

METHODS

A retrospective cohort of consecutive adults who underwent PICC placement from June 2009 to July 2012 was assembled. Using multivariable logistic and Cox-proportional hazards regression models, covariates specified a priori were analyzed for their association with PICC-associated bloodstream infection. Odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to express the association between each predictor and the outcome of interest.

RESULTS

During the study period, 966 PICCs were inserted in 747 unique patients for a total of 26,887 catheter days. Indications for PICC insertion included: long-term antibiotic administration (52%, n = 503), venous access (21%, n = 201), total parenteral nutrition (16%, n = 155), and chemotherapy (11%, n = 107). On bivariate analysis, intensive care unit (ICU) status (OR 3.23; 95% CI, 1.84-5.65), mechanical ventilation (OR 4.39; 95% CI, 2.46-7.82), length of stay (hospital, OR 1.04; 95% CI, 1.02-1.06 and ICU, OR 1.03; 95% CI, 1.02-1.04), PowerPICCs (C. R. Bard, Inc., Murray Hill, NJ; OR 2.58; 95% CI, 1.41-4.73), and devices placed by interventional radiology (OR 2.57; 95% CI, 1.41-4.68) were associated with PICC-bloodstream infection. Catheter lumens were strongly associated with this event (double lumen, OR 5.21; 95% CI, 2.46-11.04, and triple lumen, OR 10.84; 95% CI, 4.38-26.82). On multivariable analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection. Notably, the HR for PICC lumens increased substantially, suggesting earlier time to infection among patients with multi-lumen PICCs (HR 4.08; 95% CI, 1.51-11.02 and HR 8.52; 95% CI, 2.55-28.49 for double- and triple-lumen devices, respectively).

CONCLUSIONS

PICC-associated bloodstream infection is most associated with hospital length of stay, ICU status, and number of device lumens. Policy and procedural oversights targeting these factors may be necessary to reduce the risk of this adverse outcome.

Incidence of Nonelective Removal of Single-Lumen Silicone and Dual-Lumen Polyurethane Percutaneously Inserted Central Catheters in Neonates

Objective: To compare the incidence of nonelective removal of single-lumen silicone and dual-lumen polyurethane percutaneously inserted central catheters (PICCs).

Study Design: A prospective cohort study was conducted with neonates in whom 247 PICC lines had been successfully inserted. Patients were assigned to either the single-lumen silicone group or the dual-lumen polyurethane group and nonelective removal incidence was compared using a logistic regression model.

Results: Incidence of nonelective removal in dual-lumen polyurethane PICCs (n =91) was 48.3% versus 34% in single-lumen silicone PICCs (n =156). Thus, dual-lumen polyurethane catheters had a significantly increased chance of nonelective removal compared with single-lumen silicone PICCs (P =.004). The most usual complication in dual-lumen polyurethane PICCs was suspected catheter-related bloodstream infection; in single-lumen silicone PICCs it was external rupture.

Conclusions: Dual-lumen polyurethane PICCs are associated with higher rates of nonelective removal and complications such as suspected catheter-related bloodstream infection. Cautious nursing care is necessary to prevent complications.

The descriptive epidemiology of central line-associated bloodstream infection among patients in non-intensive care unit settings

OBJECTIVE

To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events.

DESIGN

One-year descriptive review.

SETTING

A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds.

PATIENTS

Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting.

METHODS

The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded.

RESULTS

A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; [Formula: see text]). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM.

CONCLUSIONS

CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.

Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: results of a national survey

BACKGROUND

A Michigan survey found variation in hospitalist-reported experience, practice, opinions, and knowledge related to peripherally inserted central catheters (PICCs). Whether these findings reflect a national trend is unknown.

OBJECTIVE

To investigate self-reported PICC practice among adult hospitalists in the United States.

METHODS

Society of Hospital Medicine-administered, anonymous, Web-based survey of practicing, adult, non-Michigan hospitalists.

RESULTS

Of the 2112 hospitalists who were sent an electronic invitation, 381 completed the online survey (18%). Eighty-six percent of hospitalists reported having placed a PICC solely for venous access (vs specific indications such as long-term antibiotics or parenteral nutrition). Eighty-two percent reported having cared for a patient who specifically requested a PICC. Only 25% of hospitalists reported examining PICCs for evidence of external problems, whereas 57% admitted to having, at least once, forgotten about the presence of a PICC. Only 9% of respondents knew that PICC tip verification was performed primarily to prevent venous thromboembolism. Finally, 42% of participants indicated that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and/or avoidable.

CONCLUSIONS

This national survey highlights several potential opportunities to improve hospitalist PICC practices. A research agenda dedicated to this issue is necessary to improve patient safety and hospital-based practice.

Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey

BACKGROUND

Peripherally inserted central catheters (PICCs) are commonly inserted during hospitalization for a variety of clinical indications.

OBJECTIVE

To understand hospitalist experience, practice, knowledge, and opinions as they relate to PICCs.

DESIGN AND SETTING

Web-based survey of hospitalists in 5 healthcare systems (representing a total of 10 hospitals) across Michigan.

RESULTS

The overall response rate was 63% (227 hospitalists received invitations; 144 responded). Compared with central venous catheters, hospitalists felt that PICCs were safer to insert (81%) and preferred by patients (74%). Although 84% of respondents reported that placing a PICC solely to obtain venous access was appropriate, 47% also indicated that 10%-25% of PICCs inserted in their hospitals might represent inappropriate placement. Hospitalist knowledge regarding PICC-related venous thromboembolism was poor, with only 4% recognizing that PICC-tip verification was performed principally to prevent thrombosis. Furthermore, several potential practice-related concerns were identified: one-third of hospitalists indicated that they never examine PICCs for externally evident problems, such as exit-site infection; 48% responded that once inserted, they did not remove PICCs until a patient was ready for discharge; and 51% admitted that, at least once, they had "forgotten" that their patient had a PICC.

CONCLUSIONS

Hospitalist experiences, practice, opinions, and knowledge related to PICCs appear to be variable. Because PICC use is growing and is often associated with complications, examining the impact of such variation is necessary. Hospitals and health systems should consider developing and implementing mechanisms to monitor PICC use and adverse events.