Date Published: March 7, 2019
Publisher: Public Library of Science
Author(s): Jae Hwan Lee, Eung Tae Kim, Dong Jae Shim, Il Jung Kim, Jong Hyun Byeon, In Joon Lee, Hyun Beom Kim, Young Ju Choi, Jin Hong Lee, Philip Alexander Efron.
To evaluate the prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PBSI) and PBSI-related death in hospitalized adult patients.
A retrospective multicenter cohort of consecutive patients who underwent PICC placement from October 2016 to September 2017 at four institutes was assembled. Using multivariable logistic and Cox-proportional hazards regression models, all risk factors were analyzed for their association with PBSI. Multivariable logistic models were used to evaluate predictors of PBSI-related death.
During the study period, a total of 929 PICCs were inserted in 746 patients for a total of 17,913 catheter days. PBSI occurred in 58 patients (6.2%), with an infection rate of 3.23 per 1,000 catheter days. Number of catheter lumens [double lumen, odds ratio (OR) 5.295; 95% confidence interval (CI), 2.220–12.627; hazard ration (HR) 3.569; 95% CI, 1.461–8.717], PICC for chemotherapy (OR 4.94; 95% CI, 1.686–14.458; HR 7.635; 95% CI, 2.775–21.007), and hospital length of stay (OR 2.23; 95% CI, 1.234–4.049; HR 1.249; 95% CI, 0.659–2.368) were associated with PBSI. Risk factors, such as receiving chemotherapy (OR 54.911; 95% CI, 2.755–1094.326), presence of diabetes (OR 11.712; 95% CI, 1.513–90.665), and advanced age (OR 1.116; 95% CI 1.007–1.238), were correlated with PBSI-related death.
Our results indicated that risk factors associated with PBSI included the number of catheter lumens, the use of PICCs for chemotherapy, and the hospital length of stay. Furthermore, PBSI-related death was common in patients undergoing chemotherapy, diabetics, and elderly patients.
Peripherally inserted central catheters (PICCs) are increasingly used in contemporary medicine because of their characteristics of feasibility, accessibility, safety, versatility, and cost-effectiveness . The growing use of PICCs also stems from the seeming superiority of PICCs to other central venous catheters with respect to risk of hospital-acquired bloodstream infection, which is an important and preventable cause of the morbidity and mortality in hospitalized patients [2, 3]. Possible reasons suggested for this lower risk of infection include the lower bacterial density and lower temperature of the PICC placement site compared with neck or groin placement sites of other central venous catheters . However, recent data from hospitalized patients suggest that PICC-associated blood stream infection (PBSI) rates vary among different patient settings and are actually comparable to blood stream infection rates of standard central venous catheters [1, 4, 5]. Other studies reveal that the PBSI rate is not lower than the central line-associated bloodstream infection (CLABSI) rate, which ranges from 0.6 to 7.4% for catheter days ranging from 0.07 to 2.46 per 1000 days [1, 3, 6–9]. These studies also show that the occurrence of CLABSI is more frequent in patients with intensive care unit (ICU) stays and patients with hematologic malignancies [1, 6–9]. These varying data raise the question of whether PICCs are truly safer than central venous catheters with respect to catheter-associated blood stream infections. Despite several reports regarding risk factors of PBSI in single centers or among oncologic patients [6–8], there has been no investigation evaluating prevalence and predictors of PBSI in varied patient care environments that reflect the real-world situation. Given the important role of CLABSI in patient mortality , there is a surprising paucity of data to specifically identify predictors of PBSI-related death. To better inform clinicians regarding PICC use and improve patient safety, the factors associated with adverse clinical outcome must be elucidated. Consequently, the purpose of this study was to evaluate the prevalence and predictors of PBSI and PBSI-related death in hospitalized adult patients.
Between October 2016 and September 2017, 929 PICCs were placed in 746 individual patients, resulting 17,913 catheter days. Nearly half of the patients had malignant solid tumors (n = 514; 55.4%). The most common indications for PICC insertion were intravenous infusion (56.6%; n = 526), antibiotics therapy (23.5%; n = 218), total parenteral nutrition (TPN; 16.0%; n = 149), and delivery of chemotherapy (3.8%; n = 35). Almost two thirds of catheters were double-lumen devices (62.7%; n = 592), which represents a device-related factor. With respect to provider characteristics, the majority of catheters were placed in the patient’s right upper arm (65.7%, n = 610; Table 1).
In this study, PBSI occurred in 6.2% of patients with total PICC insertion, resulting in an infection rate of 3.23 per 1,000 catheter days. This PBSI rate is higher than that previously reported in single-center studies, which may be due to the heterogeneous patient groups and patient-care environments in our multicenter cohort. One of the hospitals in the multicenter cohort is a national cancer center whose patients primarily had active cancer, and more than half of the patients in our study population had a solid or hematologic malignancy. Moreover, our study only enrolled hospitalized patients who were by definition more susceptible to hospital-acquired infections than outpatients. These results provided a more realistic overview of PICC management in daily practice.