Risk of Catheter-Related Blood Stream Infections with PICC Lines in Hospitalized Patients
Abstract & Commentary
By James E. McFeely, MD, Medical Director Critical Care Units, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor for Critical Care Alert.
Dr. McFeely reports no financial relationship to this field of study.
Synopsis: In this study using data from two randomized trials of peripherally inserted PICC line-related blood stream infections (BSIs), the rate of catheter-related BSIs was similar to those with conventional central venous lines, and much higher than rates published for PICC lines used exclusively in the outpatient setting.
Source: Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128:489-495.
Peripherally Inserted Central Venous Catheters (PICCs) are now routinely used in ICUs for long-term central venous access. Their popularity has increased because of assumed relative increased safety of insertion, particularly at the brachial vein site, together with published evidence of a lower rate of catheter-related BSI as compared with conventional central venous catheters (CVCs). PICCs tend to be placed on a non-emergent basis, most often when prolonged need for central venous access is anticipated.
Safdar and Maki analyzed data from 2 prospective randomized trials designed to assess the efficacy of chlorhexidine in reducing catheter-related infection rates. One hundred-fifteen patients were studied, with a total of 251 PICC lines placed. The mean duration of catheterization was 11.3 days. Forty-two percent of the patients were in the ICU; 62% had urinary catheters; and 49% had received mechanical ventilation. Patients had other risk factors known to be associated with increased catheter-related infections, including diabetes, hypoalbuminemia, and elevated APACHE II scores (mean, 12.6 ± 7.0).
Using standard definitions of catheter tip colonization and BSI, the 2 studies employed rigorous microbiological methods, including pulsed-field gel electrophoresis, to show concordance between catheter and blood culture organisms. A total of 6 PICC-related BSIs were identified for a rate of 2.1 per 1,000 catheter days. This rate is similar to that previously identified for conventional CVCs placed in the internal jugular or subclavian site, and significantly higher than in previously-published reports of PICC lines used in the outpatient setting (0.4 per 1,000 catheter days). Of note, all 6 PICC-related BSIs occurred in the control groups in the two studies.
Commentary
At some institutions, PICC lines have become the non-emergent line of choice in the ICU for patients in need of long-term venous access. The PICC line theoretically has a lower insertion complication rate. By avoiding the subclavian and internal jugular sites, pneumothorax risk and risk of puncturing a major artery are both substantially reduced. Moreover, based on past literature primarily in outpatient oncology settings, it has been hoped that the rate of BSI rate would also be decreased.
It should come as no surprise, however, that the Safdar and Maki study suggests a similar infection rate in the critical care setting between PICC and CVC lines. This was a mixed patient population, with a variety of risk factors known to increase infection risk. Further, PICC lines and CVCs are frequently placed by different hospital staff, using different techniques; the insertion site may also be cared for in a different manner.
Although we must be careful not to extrapolate from a small number of events (6 BSIs), this study is suggestive enough to compel a future prospective trial to further elucidate the various complication rates of PICC line in a critical care setting. Until further studies are conducted, I recommend that PICC lines and other CVCs in your ICUs be separately tracked for rates of utilization, infection, and venous thrombosis. The data are likely to be mixed; I would predict significantly lower pneumothorax and arterial puncture rates with PICCs, but similar thrombosis and infection rates. Device research performed outside the ICU should not be extrapolated to our patient population without rigorous evaluation of outcomes in the ICU setting.
Peripherally Inserted Central Venous Catheters (PICCs) are now routinely used in ICUs for long-term central venous access.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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