Central Line–Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit

Clinical Infectious Diseases, May 2011

Background. Increasingly, peripherally inserted central venous catheters (PICCs) are placed for prolonged intravenous access. Few data exist regarding risk factors for central line–associated bloodstream infection (CLABSI) complicating PICCs in hospitalized children, especially children hospitalized outside the intensive care unit (ICU). Methods. We identified all children with a PICC inserted at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 and used Poisson regression models to identify risk factors for PICC-associated CLABSIs. Results. A total of 2592 PICCs were placed in 1819 children. One hundred sixteen CLABSIs occurred over 44,972 catheter-days (incidence rate [IR], 2.58 cases per 1000 catheter-days; 95% confidence interval [CI], 2.07–3.00 cases per 1000 catheter-days). Independent predictors of CLABSI in the entire cohort included PICC dwell time of ≥21 days (IR ratio [IRR], 1.53; 95% CI, 1.05–2.26), parenteral nutrition as indication for insertion (IRR, 2.24; 95% CI, 1.31–3.84), prior PICC-associated CLABSI (IRR, 2.48; 95% CI, 1.18–5.25), underlying metabolic condition (IRR, 2.07; 95% CI, 1.14–3.74), and pediatric ICU exposure during hospitalization (IRR, 1.80; 95% CI, 1.18–2.75). Risk factors for CLABSI in children without PICU exposure included younger age, underlying malignancy and metabolic conditions, PICCs inserted in the lower extremity, and a prior PICC-associated CLABSI. Conclusions. Prolonged catheter dwell time, pediatric ICU exposure, and administration of parenteral nutrition as the indication for PICC insertion are important predictors of PICC-associated CLABSI in hospitalized children. A careful assessment of these risk factors may be important for future success in preventing CLABSIs in hospitalized children with PICCs.

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Central Line–Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit

Sonali Advani 0 2 4 5 7 8 9 10 Nicholas G. Reich 0 2 3 4 7 8 9 10 Arnab Sengupta 0 2 4 5 7 8 9 10 Leslie Gosey 0 1 2 4 7 8 9 10 Aaron M. Milstone 0 2 3 4 5 6 7 8 9 10 0 izations and collaborative groups have successfully 1 Vascular Access Team, The Johns Hopkins Hospital 2 Received 10 December 2010; accepted 10 February 2011. Epidemiology , 200 North Wolfe St , Rubenstein 3141, Baltimore, MD 21287 3 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health 4 Central line-associated bloodstream infections (CLABSIs) account for significant morbidity , mortality, and fi- nancial costs [1, 2]. The Centers for Disease Con- trol and Prevention (CDC) estimated that , in 2002 5 Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine 6 Department of Hospital Epidemiology and Infection Control, The Johns Hopkins Hospital , Baltimore, Maryland 7 hospitalized patients outside the ICU [3, 7]. Peripherally inserted central venous catheters (PICCs) represent a large proportion of all central venous cath- 8 despite reports that as many as 60% of CLABSIs occur in 9 have targeted intensive care unit (ICU) patients [6] 10 reduced CLABSI rates with use of evidence-based rec- Background. Increasingly, peripherally inserted central venous catheters (PICCs) are placed for prolonged intravenous access. Few data exist regarding risk factors for central line-associated bloodstream infection (CLABSI) complicating PICCs in hospitalized children, especially children hospitalized outside the intensive care unit (ICU). Methods. We identified all children with a PICC inserted at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 and used Poisson regression models to identify risk factors for PICC-associated CLABSIs. Results. A total of 2592 PICCs were placed in 1819 children. One hundred sixteen CLABSIs occurred over 44,972 catheter-days (incidence rate [IR], 2.58 cases per 1000 catheter-days; 95% confidence interval [CI], 2.07-3.00 cases per 1000 catheter-days). Independent predictors of CLABSI in the entire cohort included PICC dwell time of >21 days (IR ratio [IRR], 1.53; 95% CI, 1.05-2.26), parenteral nutrition as indication for insertion (IRR, 2.24; 95% CI, 1.31-3.84), prior PICC-associated CLABSI (IRR, 2.48; 95% CI, 1.18-5.25), underlying metabolic condition (IRR, 2.07; 95% CI, 1.14-3.74), and pediatric ICU exposure during hospitalization (IRR, 1.80; 95% CI, 1.18-2.75). Risk factors for CLABSI in children without PICU exposure included younger age, underlying malignancy and metabolic conditions, PICCs inserted in the lower extremity, and a prior PICCassociated CLABSI. Conclusions. Prolonged catheter dwell time, pediatric ICU exposure, and administration of parenteral nutrition as the indication for PICC insertion are important predictors of PICC-associated CLABSI in hospitalized children. A careful assessment of these risk factors may be important for future success in preventing CLABSIs in hospitalized children with PICCs. - eters (CVCs) inserted. PICCs have become increasingly popular in pediatrics in ICU and non-ICU settings. These catheters are nontunneled and noncuffed, and prolonged use may predispose them to bacterial colonization and biofilm formation [8, 9]. PICCs have been associated with a greater risk of infection, compared with cuffed and tunneled CVCs, in hospitalized patients [9]. PICCs are frequently inserted in patients outside the ICU for administration of antibiotics, chemotherapy, and parenteral nutrition. Few data exist regarding risk factors for CLABSIs in hospitalized children with PICCs, and less is known about infectious complications of PICCs in children hospitalized outside the ICU. The objectives of our study were to fill 2 important knowledge gaps by identifying risk factors for CLABSIs in hospitalized children with PICCs and to determine factors associated with CLABSI in children with PICCs without ICU exposure. MATERIALS AND METHODS Setting and Participants We identified children admitted to the Childrens Center at The Johns Hopkins Hospital (Baltimore, MD) from 1 January 2003 through 31 December 2009 who had a PICC placed by the pediatric PICC Team. The PICC Team consisted of 2 full-time nurses dedicated to inserting PICCs for all patients in the Childrens Center, except those in the neonatal ICU. CLABSI determinants in the neonatal ICU have been described elsewhere [10], and this population was excluded from the current study. The PICC Team prospectively follows up children in whom they inserted a PICC. They maintain a database that includes indications for PICC insertion. The PICC Team reviews medical records of patients from whom PICCs are removed in the hospital to document complications, including infections, line infiltrations, phlebitis, thrombosis, leakage, occlusion, dislodgement, or breakage, and they contact home care companies or health care providers to determine catheter d (...truncated)


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Sonali Advani, Nicholas G. Reich, Arnab Sengupta, Leslie Gosey, Aaron M. Milstone. Central Line–Associated Bloodstream Infection in Hospitalized Children with Peripherally Inserted Central Venous Catheters: Extending Risk Analyses Outside the Intensive Care Unit, Clinical Infectious Diseases, 2011, pp. 1108-1115, 52/9, DOI: 10.1093/cid/cir145