By Carol A. Kemper, MD, FIDSA
Two-Step Testing for Anal Cancer Screening in HIV
Source: Gaisa M, Deshmukh A, Sigel K, Liu Y. 2024 anal cancer screening guidelines: Analysis of clinical performance and HRA utilization in a large cohort of persons with HIV. Clin Infect Dis. 2025;Feb 3:ciaf052. doi: 10.1093/cid/ciaf052. [Online ahead of print].
In 2024, the International Anal Neoplasia Society published guidance on testing strategies for anal cancer in persons at risk, such as men who have sex with men (MSM) and persons with human immunodeficiency virus (HIV) (PWH). They provided a list of testing options, including anal cytology alone, high-risk human papilloma virus deoxyribonucleic acid (HPV DNA) testing alone, cytology followed by high-risk HPV DNA testing for those with cytological abnormalities (triage), high-risk HPV testing followed by cytology for those with high-risk strains (alternative triage), or concurrent testing with both cytology and HPV DNA. The question became which strategy is best for the “real world” of patient care, both in terms of sensitivity of detection of precancerous lesions and optimizing referrals for high-resolution anoscopy (HRA). Similar to that for cervical cancer, HRA is the best way to visualize and treat high-grade squamous intra-epithelial lesions. Referrals for HRA have outstripped the capacity. While many referrals turn out to be unnecessary, some patients cannot be seen for more than six months.
To assess which testing strategy was ideal, these investigators retrospectively examined their cohort of 1,223 PWH who had concurrent anal cytology, high-risk HPV DNA testing, and HRA biopsy performed between 2012 and 2019. Of these, 1,073 were MSM and 150 (12%) were women. The median age was 45 years. In this cohort, anal cytology was either normal (24%), atypical squamous cells of undetermined significance (ASCUS) (41%), low-grade squamous intra-epithelial lesion (28%), or high-grade squamous intra-epithelial lesion (7%). At the same time, 81% had high-risk HPV DNA detected (36% of which was HPV-16/18). Using HRA screening, histology showed high-grade squamous intra-epithelial lesion in 42%, and no cases of anal cancer were detected.
Using either anal cytology or high-grade HPV (hrHPV) testing alone resulted in a high degree of sensitivity (86% and 96%, respectively) but poor specificity (31% and 29%, respectively). These single test strategies also resulted in the highest number of referrals for HRA (up to 81% of those screened). Cotesting maintained a high degree of sensitivity (88%) but also poor specificity (43%). The most feasible strategies appeared to be either anal cytology, followed by triage for hrHPV testing for ASCUS or greater; or hrHPV testing, followed by anal cytology for those with identified high-risk strains. Each of these latter two approaches resulted in improved specificity with only modest reductions in sensitivity compared with the approaches mentioned earlier, and each resulted in fewer referrals for HRA testing.
Either step-wise approach to anal cancer screening in persons at risk seems the most practical for the usual clinic setting, as opposed to single test strategies or even using both tests concurrently. The highest degree of specificity was the two-tiered approach of anal cytology followed by hrHPV testing (49%), resulting in 65% being referred for HRA. This approach would help relieve delays in HRA screening by prioritizing HRA for those at the highest risk. The authors commented that step-wise testing strategy also helps to provide reassurance for those at lower risk.
Reducing Complications of PICCs
Source: Dobrescu A, Constantin AM, Pinte L, et al. Effectiveness and safety of methods to prevent bloodstream and other infections and noninfectious complications associated with peripherally inserted central catheters: A systematic review and meta-analysis. Clin Infect Dis. 2025; Feb 12:ciaf063. doi: 10.1093/cid/ciaf063. [Online ahead of print].
Use of peripherally inserted central catheters (PICCs) in acutely ill persons has steadily increased in the past decade. At present, approximately 2.5 million people receive a PICC line every year, which is about 1% of the adult population in the United States. Complications of PICC use include phlebitis, thrombophlebitis, bloodstream infection, and PICC migration and occlusion. Efforts have been made to reduce these risks, but questions remain regarding the most effective strategies for improving PICC complications, largely focused on PICC insertion, maintenance, and removal.
These authors provide a systematic review of the literature attempting to answer 25 questions regarding all aspects of PICC line use. The literature was combed for randomized and non-randomized controlled trials published between 1980 and 2024, and a total of 74 publications were selected. Of these, 17 focused on adults alone, one focused on children, and 24 focused on neonates. Most were conducted in high-income countries. Two independent reviewers assessed the risk of bias and the certainty of evidence and tried to identify at least two to three studies for each of the 25 questions. For example, 47 studies addressed 10 of 15 questions on catheter insertion, and 12 studies addressed two of three questions regarding catheter access. However, there was insufficient information to address 12 of the 25 questions.
The strongest evidence showed that ultrasound-guided catheter insertion significantly reduced the risk of phlebitis and venous thromboembolic events (P/VTE) in adults, compared with non-ultrasound placement. Silicone catheters significantly reduced the risk of P/VTE in adults compared with non-silicone catheters. The use of bundled interventions for insertion also was associated with a decreased risk of bloodstream infection and P/VTE, with bundles focused on personal protective equipment (PPE), sterile prep, sterile gloves, ultrasound guidance, and the use of occlusive dressings. Beyond this, the certainty of evidence was less. Closed access systems may reduce the risk of bloodstream infection in adults (0.3% vs. 2.9%) and sepsis in neonates (3.5% vs. 26.7%) compared with open access systems, but the certainty of evidence was lower. Questions about PICC maintenance, flushing, and scheduled removal could not be answered with certainty.
Focused studies aimed at reducing the risk of complications of PICC line use, including prevention strategies, are badly needed. Maybe the take-home lesson here is how common PICC line use is becoming in the acute care setting, and yet we have so much to learn about their care and maintenance. I am constantly reminded by my renal colleagues that the increased use of PICC lines is eroding their ability to provide necessary vascular access for hemodialysis, a “complication” not mentioned here.
Plan for the Lifecycle of a PICC
Source: Garcia T, Septimus EJ, LeDonne J, et al. Prevention of vascular access device-associated hospital-onset bacteremia and fungemia: A review of emerging perspectives and synthesis of technical aspects. Clin Infect Dis. 2025;80(2):444-450.
While the rate of central-line associated bloodstream infection (CLABSI) steadily decreased by 50% in the United States from 2008 to 2016, the subsequent years saw a nearly 50% increase in the standardized infection ratio for CLABSI during the COVID-19 pandemic. The authors explored the possible explanations for this increase, with thoughtful discussion.
The authors proposed that each line be approached as a “lifecycle” of events: assessment of the patient for a line, pre-insertion, insertion, post-insertion (dressing and care and maintenance), and removal. Each segment of the lifecycle should have its own specific recommendations.
The use of vascular access teams with knowledge in patient selection, vascular device options (especially in patients with complex vascular issues), and sophisticated vascular technologies who can assess, insert, monitor, train, and provide daily catheter necessity evaluation are increasingly essential to improving the best practice of line use and reducing complications. These teams are made up of physicians, nurses, and technicians with experience in vascular access. Beginning with the basic question: Is a midline vs. PICC vs. tunneled catheter vs. port a better option for this individual? Understanding specific device uses and outcomes can help avoid unnecessary complications. Although vascular access teams have been recommended by the Centers for Disease Control and Prevention (CDC) since 2002, and increasingly are used by larger flusher facilities, there have been no randomized clinical trials demonstrating their value in reducing complications of vascular access or CLABSI.
The authors reiterate that the use of ultrasound transducers for PICC placement is increasingly considered essential, but less attention may be paid to the high-level disinfection of transducers between patients. Facilities should reassess their best practice for ultrasound-guided insertion procedures and disinfection of equipment and transducer covers.
Daily bathing in the critical care setting in an effort to reduce the risk of colonization or bioburden on patient skin has been shown to reduce the risk of CLABSI. Daily bathing in the critical care setting now is considered an essential practice, to which I would add daily sheet changes and oral care, as well as intranasal mupirocin and chlorhexidine gluconate (CHG). Unfortunately, there are fewer data to support daily bathing in noncritical care patients. One would think that daily baths/showers, pericare, oral care, and fresh sheets and gowns should be a part of any patient hospital experience, whether it is a patient with a central line or recent surgery or dialysis. Clean patients have fewer hospital-acquired infections.
Healthcare systems have worked to develop insertion bundles, and consistent insertion techniques have gone a long way to reducing the risk of CLABSI.
Prevention strategies, including maintenance bundles, and management of occlusive dressings and barrier precautions are essential. Our facility found that new “occlusive” dressing (purported to be even more occlusive) failed miserably if a patient was sweating or drooling on their line; it would peel off within hours. Clearly not an ideal dressing. Staying on top of such details at your facility is essential.
PICC line end dates should be established at the time of insertion, when feasible; removal at the first reasonable opportunity should be anticipated. Nursing experience and training is critical to improved outcomes. Perhaps the increase in hospital acquired infection (HAI) and CLABSI post-pandemic can be traced directly to the recent exodus of nursing staff. In California, this was exacerbated by the Public Health Department stipulation requiring SARS-2-CoV vaccination of all healthcare workers by March 2022, a vaccine that was only marginally effective at preventing COVID. As a result, our facility lost key workers in both the emergency departments and critical care. It is estimated that 100,000 registered nurses left the United States workforce during COVID, taking with them years of experience and a knowledge specific to their facility. By 2027, it is estimated that 900,000 may choose to leave nursing practice. Replacing/maintaining this experience in caring for critically ill patients is essential in reducing the risk of line infection.
One thing I have learned in infection prevention is that no detail is too small, and you cannot make assumptions about care. Small changes in devices, dressings, and specific care can have a big effect on the rate of CLABSI. Our IP team recently discovered a gap in maintenance and dressing changes for dialysis lines, which had been “owned” by the dialysis team. Reasonable enough, but when dialysis was not required or a long weekend occurred, who was assessing the line or the dressing? Now, dialysis line care is included in the competencies for all of the nursing staff, who are responsible for the maintenance and dressing changes for all lines. In 2024, we stopped the nursing staff from drawing cultures directly from a line, which immediately reduced our CLABSI rate — now virtually none of our blood cultures in patients with lines are drawn from the line but drawn by experienced phlebotomists. But then in a contrary twist, an influx of new phlebotomists led to a minor misinterpretation in skin disinfection techniques before peripheral blood culture draws, leading to an increase in contaminated blood cultures in patients with central lines.
Sleuthing out such problems requires a knowledge of your facility, close observation of current practices, and attention to detail.
Carol A. Kemper, MD, FIDSA, is Medical Director, Infection Prevention, El Camino Hospital, Palo Alto Medical Foundation.
Two-Step Testing for Anal Cancer Screening in HIV; Reducing Complications of PICCs; Plan for the Lifecycle of a PICC
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