PICCing the best access for your patient
Critical Care
Journal club critique PICCing the best access for your patient
Mohammed Tariq 1
David T. Huang 0
0 Assistant Professor, Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania , USA
1 Clinical Fellow, Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania , USA
Objective: To determine the risk of PICC-related BSI in hospitalized patients. Design: Prospective cohort study using data from two randomized trials assessing the efficacy of chlorhexidineimpregnated sponge dressing and chlorhexidine for cutaneous antisepsis. Subjects: PICCs inserted into the antecubital vein in two randomized trials conducted from 1998 to 2000 were prospectively studied; most patients were in an ICU. Measurements: PICC-related BSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of removal and from blood cultures, using restriction-fragment DNA subtyping.
-
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 [1].
Peripherally inserted central venous catheters (PICCs) are
widely used for intermediate and long-term access,
especially in the inpatient setting, where they are
increasingly supplanting conventional central venous
catheters (CVCs). Data on the risk of PICC-related
bloodstream infection (BSI) hospitalized patients are limited.
Results: Overall, 115 patients had 251 PICCs placed.
Mean duration of catheterization was 11.3 days (total, 2,832
PICC-days); 42% of the patients were in an ICU at some
point, 62% had urinary catheters, and 49% received
mechanical ventilation. Six PICC-related BSIs were
identified (2.4%), four with coagulase-negative
staphylococcus, one with Staphylococcus aureus, and one
with Klebsiella pneumoniae, for a rate of 2.1 per 1,000
catheter-days.
This prospective study shows that PICCs used in high-risk
hospitalized patients are associated with a rate of
catheterrelated BSI similar to conventional CVCs placed in the
internal jugular or subclavian veins (2 to 5 per 1,000
catheter-days), much higher than with PICCs used
exclusively in the outpatient setting (approximately 0.4 per
1,000 catheter-days), and higher than with cuffed and
tunneled Hickman-like CVCs (approximately 1 per 1,000
catheter-days). A randomized trial of PICCs and
conventional CVCs in hospitalized patients requiring central
access is needed. Our data raise the question of whether
the growing trend in many hospital hematology and
oncology services to switch from use of cuffed and tunneled
CVCs to PICCs is justified, particularly since PICCs are
more vulnerable to thrombosis and dislodgment, and are
less useful for drawing blood specimens. Moreover, PICCs
are not advisable in patients with renal failure and
impending need for dialysis, in whom preservation of
upperextremity veins is needed for fistula or graft implantation.
The use of peripherally inserted central catheters (PICCs)
for intermediate and long-term venous access has
increased steadily over the past decade. Many intensive
care unit (ICU) patients are receiving PICCs even before
they are ready to leave the ICU. Most prior studies
examining PICC-related blood stream infection (PR-BSI)
were retrospective, and nearly all were done in outpatient
settings. Based on these studies, PICCs are widely believed
to be less prone to infection than conventional CVCs.
However, data regarding the risk of infection for PICCs
placed in an ICU setting are relatively scarce. In the current
study, Maki and colleagues [1] investigated the risk of
PRBSI in hospitalized patients, 42% of which were in the ICU.
They did so by examining BSI rates in patients with newly
inserted PICCs, using data from two randomized trials that
assessed different skin preparation and care techniques
[2,3]. While not the primary point of these trials, the methods
used for identifying BSIs and determining if a PICC was to
blame were robust. The authors found an incidence of
PRBSI of 2.1 per 1000 catheter-days. This rate of infection was
substantially higher than has been seen in outpatients and
is equivalent to the rate reported for conventional CVCs.
Furthermore, the authors found a similarly high incidence of
inpatient PR-BSI when pooling results of other, less
methodologically sound, studies.
A few limitations deserve consideration. The two trials from
which this study derived its data were only published in
abstract form. Thus, we do not know many details of the
parent trials that might help in our interpretation of the data,
such as how long subjects were in the hospital or ICU, what
antibiotics they received prior to PICC insertion, or how long
antibiotics were given. Some patients in the parent trials
received conventional CVCs. Rates of CVC-related BSI for
these subjects were not reported and ins (...truncated)