Complications with peripherally inserted central catheters (PICCs) used in hospitalized patients and outpatients: a prospective cohort study
Grau et al. Antimicrobial Resistance and Infection Control
Complications with peripherally inserted central catheters (PICCs) used in hospitalized patients and outpatients: a prospective cohort study
Delphine Grau 0 1 3 4
Béatrice Clarivet 2
Anne Lotthé 0 1 3 4
Sébastien Bommart 5 6
Sylvie Parer 0 1 3 4
0 UMR 5569 HydroSciences Montpellier, Team Pathogènes Hydriques Santé et Environnements, Unit of Bacteriology, Faculté de Pharmacie , Montpellier , France
1 Department of Infection Control and Prevention, CHU of Montpellier , 80 avenue Augustin Fliche, 34295 Montpellier Cédex 5 , France
2 Clinical research and Epidemiology Unit, CHU of Montpellier , Montpellier , France
3 UMR 5569 HydroSciences Montpellier, Team Pathogènes Hydriques Santé et Environnements, Unit of Bacteriology, Faculté de Pharmacie , Montpellier , France
4 Department of Infection Control and Prevention, CHU of Montpellier , 80 avenue Augustin Fliche, 34295 Montpellier Cédex 5 , France
5 PhysMedExp INSERM U1046, UMR9214 CNRS , Montpellier , France
6 Department of Radiology, CHU of Montpellier , Montpellier , France
Background: Peripherally Inserted Central Catheters (PICCs) are widely used for hospitalized patients and among outpatients. Despite many advantages, PICC-related complications can occur such as infection, thrombosis or mechanical complications. We aimed to evaluate rates and nature of PICC-related complications from insertion to removal and analyze risk factors of complications at baseline and during healthcare. Methods: We performed a prospective cohort study looking at PICC-related complication rates in the inpatient and outpatient settings of 163 patients over a 7-month period. Pertinent patient demographics as well as catheterrelated factors were collected. The data were analyzed to identify catheter-related complications using univariate and multivariate analysis. Results: One hundred ninety-two PICCs were monitored for a total of 5218 PICC-days (3337 PICC-days for inpatients, 1881 PICC-days for outpatients). The overall complication rate was 30.2% (11.1 per 1000 PICC-days) with a mean time to onset of 16.1 days. Complications included occlusion (8.9%), accidental withdrawal (8.9%), infections (6.3%) including 9 local infections (4.7%) and 3 bloodstream infections (1.6%), venous thrombosis (1.6%) and hematoma (1%). Complication rate was higher in the hospitalization setting (36.1%; 14.38 per 1000 PICC-days) than in the outpatient setting (19.4%; 3.19 per 1000 PICC-days). Multivariate logistic regression analysis showed that the occurrence of occlusion was significantly associated with an age > 65 years (OR = 4.19; 95% CI [1.1-15.81]) and the presence of a pre-occlusive event the week before PICC removal (OR = 76.35; 95% CI [9.36-622.97]). Conclusions: PICCs appear safe in the inpatient and outpatient settings with low rates of infectious or thrombotic complications. Occlusion and accidental withdrawal were the most common complications, with age > 65 and catheter pre-occlusive event associated with an increased likelihood of catheter occlusion.
PICC-related complications; Prospective follow-up; Inpatient and outpatient settings
PICCs are widely used for patients requiring medium to
long-term intravenous therapy in the inpatient and
outpatient settings. As an alternative to central venous
catheters (CVCs), PICCs allow for administration of medications
requiring central venous access.
PICC-related complications include infection [1–3],
thrombosis [4–6] and mechanical complications (i.e
occlusion, accidental withdrawal) , with global rates of
15.9%, 34% and 40.7% respectively [8–10]. PICC-related
bloodstream infections (BSI) rates of 2.1 per 1000
catheter-days in hospitalized patients and 1.0 per 1000
catheter-days in outpatient setting are reported .
Recent studies suggest that PICC-related BSI are less
frequent than with other CVCs [12–14]. However, Chopra
et al. showed that PICC-related BSI were as frequent as
CVC-related BSI when infection rates were expressed by
catheter-days . Several factors could explain these
diverging results, such as patient populations (oncology,
pediatric patients) and therapies infused (parenteral
nutrition, antibiotics). Moreover, the health-care setting could
be a determinant factor in the occurrence of PICC-related
complications [15, 16].
We performed a prospective cohort study of 163 patients
in both the inpatient and outpatient settings over the
period of 7 months to better clarify the impact of
placement setting and patient co-morbidities on the incidence
and nature of PICC-associated complications.
Study design: prospective cohort observational study
An unselected cohort was constituted by including every
consecutive PICC inserted during a four month period
(July through October 2010), regardless of demographic
or medical status of the recipient patient or indication
for PICC use. PICC placement was exclusively
performed by the radiology department of the Montpellier
University Hospital. Every PICC was prospectively and
weekly followed until removal or until the end of the
study in February 2011. Some patients were enrolled
more than once, if they had more than one PICC during
the inclusion period. All patients gave informed consent.
At the time of PICC insertion, we collected data
concerning patients’ demographic characteristics, comorbidities,
immunosuppressive therapy, hospitalization ward and
location of the patient 72 h after insertion. Data concerning
the PICC were also collected: date of insertion, operator
(junior or senior radiologist), treatment indication, rank of
the PICC, device characteristics, compliance with
preoperative antisepsis protocol (Fig. 1), site of insertion,
length and success of the procedure and type of PICC
Data were collected by performing patient chart review
and/or phone calls to healthcare professionals involved in
the patient’s care or directly to the patient. Information
PICC insertion in surgical aseptic conditions:
Cutaneous antisepsis in 4 steps:
skin scrubbing with antiseptic soap
rinsing with sterile water
drying with sterile gauze
applying an alcoholic antiseptic
Valve or port antisepsis before injection
Systematic pulse flushing with 10 ml of sodium chloride solution after
cutaneous antisepsis in 4 steps
occlusive and transparent dressing: change every 3 days
when insertion site is not visible and every 5 days when
Fig. 1 University Hospital of Montpellier recommendations for PICCs insertion and manipulations
was obtained on patient outcome and occurrence of a
catheter dysfunction or signs of infection. Data on PICC
utilization concerned number of daily PICC accesses,
frequency of dressings, type of antiseptic used for
manipulating PICC lines, catheter flushing procedure and
frequency of intravenous administration set change.
An information note about PICC care rules was given
to the patient at time of placement and standardized
protocols of antisepsis and PICC care were available in
healthcare units of our hospital (Fig. 1). In instances of
premature PICC removal, data were collected regarding
the circumstances warranting the removal. If
PICCrelated infection was suspected, insertion site swabbing
and catheter tip culture (according to Brun-Buisson
method) were required, along with blood cultures if
clinically relevant (general infectious symptoms). For
each PICC, data were collected in a standardized
questionnaire which was used throughout PICC follow-up.
The “inpatients” subgroup included all PICCs
monitored from insertion to removal in a health-care setting
and the “outpatients” subgroup included all PICCs
monitored in the outpatient setting. PICCs used alternatively
in hospital and outside were classified in a “mixed
Diagnoses of catheter related infections were established
according to the French definitions:
- Confirmed catheter-related BSI was defined as the
association of a positive blood culture in a patient
having had a central line within 48 h prior to the onset of
symptoms, AND one of the following criteria: 1) a
positive culture of either catheter tip or exit site swabbing
(≥103 CFU/ml) involving the same organism as blood
culture, 2) blood cultures from peripheral venous
puncture and central lines positive with the same organism
with a quantitative ratio (central sample/peripheral
sample) > 5, or 3) a differential time to positivity > 2 h
in favor of central line sample.
- Confirmed catheter-related local infection (LI) was
defined as a positive culture of the PICC segment
(≥103 CFU/ml) with pus emerging from the exit site or a
tunnel infection, with local manifestations of infection but
no general signs of sepsis and negative blood cultures.
When all these criteria were not present or
bacteriological culture not realized, or realized when the patient
was under antibiotic therapy, we classified suspected
infections as “possible infection”. When cultures remained
negative (in the absence of antibiotics) or another cause
of infection was diagnosed, the case was classified as
“infection not confirmed”.
Local inflammation was defined by redness and/or
soreness at the catheter exit site. General inflammatory
signs were defined as isolated fever/chills without focal
signs of infection.
Catheter-related venous thrombosis was defined by
thrombus presence by ultrasonography.
Among catheter dysfunctions, pre occlusive events were
defined as either a significant reduction of infusion flow
or an impairment of blood back-flow. Lumen occlusion
was defined by the permanent inability to flush the
catheter or obtain blood back-flow.
Quantitative variables were described as mean (+/-SD) or
median (Q25-Q75) according to normality of distribution.
For each variable, Odds Ratios (ORs) were obtained using
logistic regression with the type of complication as the
dependent variable. Each PICC insertion was considered
as a new event. For each type of complication, a
multivariate logistic model was then performed with all variables
that were close to significance in the first model (p < 0.20).
Otherwise, a p-value <0.05 was used for statistical
significance. All statistical analyses were performed with SAS
software (SAS Institute Inc, Cary, NC).
From 12 July, to 21 October 2010, 194 PICCs were
inserted in 163 patients with a median age of 61.7 years
(range 14–96). Twenty-nine patients had more than one
PICC inserted during this period: 27 patients had 2
PICCs and 2 patients had 3 PICCs. Demographic and
medical characteristics of the population, as well as
indications for PICC use are listed in Table 1.
Two PICCs were lost to follow-up, hence 192 PICCs
were monitored from insertion to removal, for a total of
5218 PICC-days: 3337 PICC-days for inpatients (2700 in
our hospital, 637 in other hospitals) and 1881 PICC-days
for outpatients (Fig. 2). Overall mean PICC dwell time
was 27.2 days (median 17 days; range 2–174), with mean
dwell times of 23 days in the inpatient setting, 27.5 days
in the outpatient setting and 46.9 days in patients
managed in a mixed setting. Longest dwell times (>100 days)
were observed mainly in oncology patients.
Placement conditions and type of PICCs
All PICCs were inserted in the department of radiology,
mostly by trained senior interventional radiologists
(91.2%). Surgical aseptic conditions were reportedly
applied in 100% of cases, in compliance with local
recommendations. The PICC was inserted mostly for multiple
indications (67%). The mean duration of the procedure
was 15.20 min (3–120). No immediate complication was
observed during or after insertion. A majority of PICCs
were single lumen catheters (90.2%), medium size (96.9%
were high flow 5 French devices), with a distal valve
Table 1 Descriptive characteristics of the patient population
who had PICC inserted (n = 163)
Indication for PICC placement*
Total parenteral nutrition
Allo/autogeneic stem cell transplantation
*Total may exceed 100% because many patients had more than one indication
for parenteral treatment
(79.4%) and mainly introduced under echographic control
in the basilic vein (66.5%). Most PICCs were held in place
with sutures (95.9%); 8 PICCs were attached with StatLock
adhesive dressings (StatLock, Bard, Murray Hill, NJ, USA),
which was privileged for young patients (4 had cystic
fibrosis), with a mean PICC dwell time of 16 days, versus
27.7 days with suture.
Modalities of PICC utilization
Frequency of PICC utilization (i.e: number of accesses
per day) decreased over the course of care, with a higher
proportion of seldom or never used PICCs in the
outpatient settings (Fig. 3a and b).
Whatever the care setting, 55% of intravenous
administration sets were replaced every 3–5 days; dressing
frequency, type of antiseptic used and protocol of catheter
flushing complied with local recommendations in 39.5%
of the cases. Alcoholic chlorhexidine was mostly used in
our hospital (78%), while povidone-iodine was mostly
used in outpatient settings (94%).
The global complication rate was 30.2% (11.1 per 1000
PICC-days) with a mean time to onset of 16.1 days. This
rate was higher in the inpatient setting (36.1%; 14.38 per
1000 PICC-days) than in the outpatient setting (19.4%;
3.19 per 1000 PICC-days).
Main complications and outcomes of all monitored
PICCs are shown in Table 2.
Occlusions and accidental withdrawals occurred on
average 16 days and 8 days respectively after PICC
insertion, and the 3 episodes of deep vein thrombosis occurred
4, 5 and 39 days after PICC insertion.
PICC-related infectious complications
Overall, 12 confirmed PICC-related infections (3 BSI and
9 LI) occurred, amounting to an infection rate of 2.3 per
1000 PICC-days. The overall PICC-related BSI and LI
rates were 0.57 and 1.72 per 1000 PICC-days respectively.
All infections but one LI occurred in the inpatient
setting: thus the global infection rates among in- and
outpatients were 3.3 and 0.53 per 1000 PICC-days respectively.
The BSI occurred 6, 9 and 39 days after insertion; the
mean time to onset for the 9 LI was 17 days. With respect
to microbiology, 2 BSI were caused by coagulase-negative
staphylococci and 1 by Candida albicans. Seven additional
cases were possible infections according to definition: 4
inpatients presented a possible BSI, and 3 outpatients a
possible LI. Nineteen PICCs were removed as a matter of
principle in febrile patients, but infection was not
Forty-two pre-occlusive events occurred, with 55% of
these occurring within the first week after insertion.
Preocclusive events were managed by pulsed normal saline
flush and/or heparin flush. Seventeen catheters (8.9%)
were ultimately occluded, 16 of which had had a
Twenty-five patients (15.3%) presented local or general
inflammatory signs, with onsets occurring mostly within
the first 4 weeks of PICC use. Interestingly, in 14 cases
Lost to follow-up: n=2
Fig. 2 Study flow chart
*Unprogrammed removal: PICCs removed for suspected or confirmed complications and accidental
Fig. 3 a: Frequencies of PICC utilization in Montpellier university hospital (inpatient setting group). b: Frequencies of PICC utilization in the
PICCs still in place
at the end of the
study: n=4 (2.1%)
General population PICCs monitored in the PICCs monitored in the PICCs monitored in mixed
(n = 192) inpatient setting (n = 133) outpatient setting (n = 31) health-care settings (n = 28)
Confirmed infections, value (%)
PICC-related BSI, value (%)
PICC-related LI, value (%)
Possible infections, value (%)
Infection not confirmed, value (%)
Deep vein thrombosis, value (%)
Hematoma, value (%)
Occlusions, value (%)
Accidental withdrawals, value (%)
Other causes of removal:
End of treatment, value (%)
Other programmed removal, value (%)
(56%), these precursor inflammatory signs were not
followed by a positive diagnosis of catheter-related
Univariate and multivariate analysis
The univariate comparison of baseline patient
characteristics between inpatient and outpatient subgroups
showed significant differences concerning the number of
cases of solid tumor (12 vs 29% respectively) and cystic
fibrosis (0 vs 12.9%). Concerning infusion therapy,
hydration was more frequent among inpatients (60.9 vs
16.1%) and so was total parenteral nutrition (27.1 vs
6.5%). The small number of outpatients did not allow to
statistically compare subgroups in terms of outcome and
Multivariate logistic regression analysis performed on
the whole study population showed that the occurrence
of PICC-related occlusion was significantly associated
with 2 risk factors: age > 65 years (OR = 4.19; 95% CI
[1.1–15.81]), and presence of a pre-occlusive event the
week before PICC removal (OR = 76.35; 95% CI [9.36–
622.97]). Interestingly, catheter dwell time was not
associated with any of the complications.
Our single-center prospective study describes an
unselected cohort of patients, among the first to benefit from
PICCs in our hospital in 2010. As is still the case in our
institution, PICC were placed exclusively by trained
radiologists, and not by dedicated teams at patients’ bedside
as in other countries. This specific procedure can limit
the generalizability of our data.
Since then, to our knowledge, no prospective follow-up
study has evaluated PICC complications among
hospitalized and outpatients, regardless of the type of medication
infused and patients’ conditions.
In the absence of published guidelines for healthcare
professionals using PICCs at the time of this study, our
hospital’s Infection Control and Interventional Radiology
Departments had established local recommendations for
PICC care, including a leaflet for home care. However, all
the healthcare professionals were not yet familiar with
these best practice rules, which could in part explain the
high complication rate, although similar to rates reported
in other studies [9, 17–19].
Guidelines for PICC care are now better defined and
protocolized . Recent studies suggest lower incidence
rates of PICC-related complications, probably due to
several technological novelties, better respect of the maximal
sterile barrier precautions and improvement of
compliance with evidence-based recommendations regarding
catheter management in selected populations [8, 11, 21].
Bertoglio et al. documented 15% of complications leading
to catheter removal in cancer patients but still concluded
that PICCs represent safe devices for chemotherapy
delivery, in particular during the first months after
insertion . In pediatric outpatients receiving parenteral
antibiotic therapy, Kovacich et al. reported that 8% of
PICCs required removal due to a complication (4.6 per
1000 catheter-days), underlining the need to discuss the
relevance of PICC insertion and maintenance in
children . These studies underscore the importance of
the type of patients, infused therapies and best practice
In our study, incidence of lumen occlusions was high
(8.9%), leading to catheter removal in all cases. Recent
studies showed occlusion rates of 2.4% and 6% among
hospitalized patients [19, 22] and 4.5% and 7.4% among
outpatients [16, 24]. Our multivariate analysis identified
age > 65 years and the presence of a pre-occlusive event
as risk factors of lumen occlusion. In our study, catheter
occlusion occurred on average 16 days after PICC
placement, and was not associated with longer dwell times.
We hypothesize that, because of the novelty of PICCs at
the time of the study, healthcare professionals did not
always follow instructions for the prevention of catheter
obstruction and possibly did not heed the warning signs
requiring timely prevention measures to be taken.
French guidelines have since recommended systematic
pulse flushing with saline after every use, heparin being
used only as salvage therapy in some cases of lumen
occlusion. Some published studies underline the role of
nursing expertise in minimizing costs and complications
and promote dedicated teams for safe PICC
management [25, 26].
The second mechanical complication was accidental
withdrawal of the catheter, which was as common as
catheter occlusions (8.9%) and occurred mainly among
hospitalized senior patients (mean age 70 years) with
PICCs fixed on the skin by sutures. To prevent
accidental removals, appropriate protection of the dressing is
needful, particularly among elderly patients with
Concerning infections, we found a PICC-related BSI
rate of 0.57 per 1000 PICC-days, which is lower than
reported in the literature. For instance, Alenjo et al. reported
an overall PICC-BSI rate of 3.13 per 1000 PICC-days in
inpatients, higher in the ICU (4.79 per 1000 PICC-days)
than in the non-ICU (2.78 per 1000 PICC-days) ;
Chopra et al. also pointed out the ICU as risk factor for
infectious complications with a PICC-BSI rate of 2.16 per
1000 PICC-days . However, these differences can be in
part explained by differing definitions of catheter-related
BSIs between countries. Indeed, French studies that
surveyed PICC-related complications among inpatients
showed BSI rates comparable to ours [7, 9, 29, 30].
The prospective design of the study allowed us to
register early local inflammatory signs in 25 PICCs (13% of the
cohort), and to determine that less than half of these
developed a confirmed infection. Moreover, 19 catheters
were unnecessarily removed for suspected infections that
were not confirmed. This underscores the need to apply
rigorous diagnostic procedures for catheter-related
infections (including differential blood cultures and insertion
site swabbing), even if PICCs are seemingly easier to
replace than CVCs.
We found a low incidence of symptomatic PICC-related
venous thrombosis (1.6%; 0.57 per 1000 PICC-days). This
result was similar to the incidence rate reported in the
study of Kabsy et al. among oncologic patients (1.9%)
but lower than in other published studies [5, 30, 31].
Turcotte et al. argued that, whereas the risk of
infections related to CVCs and PICCs was similar,
thrombotic complications were more frequent with PICCs
and proposed a tailored approach in the choice of the
most appropriate catheter .
We observed higher complications rates among
hospitalized patients (14.38 per 1000 PICC-days) than in the
outpatient settings (3.19 per 1000 PICC-days), with all the
confirmed infections and 4/7 possible infections occurring
in the inpatient settings. Smith et al. reported a 10-fold
greater risk of PICC-BSI among hospitalized patients than
outpatients and Chopra et al. demonstrated that PICCs
were associated with a lower risk of infections (0.5%) that
CVCs (2.1%) in outpatients [15, 32]. In our study, this can
be explained by the differences between our in- and
outpatient populations: the former had significantly more
parenteral nutrition and daily catheter accesses, both
known risk factors for catheter-related infections [11, 33].
Moreover, we might have underestimated the incidence of
infectious complications, as PICC segments were not
systematically cultured in the outpatient setting.
In conclusion, this prospective study with a high-definition
follow-up of every patient, allowed us to register precursor
signs which were significantly related to later occurring
complications such as lumen occlusion. PICCs appear safe
to use in the outpatient setting, with acceptably low rates
of infectious or thrombotic complications. Catheter
occlusion and accidental withdrawal were the most common
complications, both potentially avoidable with appropriate
BSI: Bloodstream infection; CVCs: Central venous catheters; LI: Local infection;
ORs: Odds Ratios; PICCs: Peripherally inserted central catheters
Thanks to the team of the Radiology Department of the CHU of Montpellier.
Availability of data and materials
Please contact author for data requests.
DG, AL, and SP designed the study. DG and SB collected data and DG carried
out the study. BC realized statistical analysis, and all the authors gave final
approval of the version to be published.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This observational study did not interfere with the routine care of patients and
did not require the agreement of the ethical committee of our institution.
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