PICC-Associated Bloodstream Infections: Prevalence, Patterns, and Predictors

Abstract

BACKGROUND: Growing use of peripherally inserted central catheters (PICCs) has led to recognition of the risk of PICC-associated bloodstream infection. We sought to identify rates, patterns, and patient, provider, and device characteristics associated with this adverse outcome. METHODS: A retrospective cohort of consecutive adults who underwent PICC placement from June 2009 to July 2012 was assembled. Using multivariable logistic and Cox-proportional hazards regression models, covariates specified a priori were analyzed for their association with PICC-associated bloodstream infection. Odds ratios (OR) and hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to express the association between each predictor and the outcome of interest. RESULTS: During the study period, 966 PICCs were inserted in 747 unique patients for a total of 26,887 catheter days. Indications for PICC insertion included: long-term antibiotic administration (52%, n 1⁄4 503), venous access (21%, n 1⁄4 201), total parenteral nutrition (16%, n 1⁄4 155), and chemotherapy (11%, n 1⁄4 107). On bivariate analysis, intensive care unit (ICU) status (OR 3.23; 95% CI, 1.84-5.65), mechanical ventilation (OR 4.39; 95% CI, 2.46-7.82), length of stay (hospital, OR 1.04; 95% CI, 1.02-1.06 and ICU, OR 1.03; 95% CI, 1.02-1.04), PowerPICCs (C. R. Bard, Inc., Murray Hill, NJ; OR 2.58; 95% CI, 1.414.73), and devices placed by interventional radiology (OR 2.57; 95% CI, 1.41-4.68) were associated with PICC-bloodstream infection. Catheter lumens were strongly associated with this event (double lumen, OR 5.21; 95% CI, 2.46-11.04, and triple lumen, OR 10.84; 95% CI, 4.38-26.82). On multivariable analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection. Notably, the HR for PICC lumens increased substantially, suggesting earlier time to infection among patients with multi-lumen PICCs (HR 4.08; 95% CI, 1.51-11.02 and HR 8.52; 95% CI, 2.55-28.49 for doubleand triple-lumen devices, respectively). CONCLUSIONS: PICC-associated bloodstream infection is most associated with hospital length of stay, ICU status, and number of device lumens. Policy and procedural oversights targeting these factors may be necessary to reduce the risk of this adverse outcome. Published by Elsevier Inc. The American Journal of Medicine (2014) 127, 319-328 KEYWORDS: Bloodstream infection; BSI; CLABSI; Infection; Peripherally inserted central catheter; PICC The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Funding: This work was supported by Locally Initiated Project (LIP) Award #41-127 from the Center for Clinical Management Research, VA Ann Arbor Healthcare System. VC is supported by Early Career Awards from the Society of Hospital Medicine and the Research Career Development Core of the Claude D. Pepper Older Adults Independence Center at the University of Michigan. Conflicts of Interest: None. Authorship: All authors had access to the data and played a role in writing this manuscript. Requests for reprints should be addressed to Vineet Chopra, MD, MSc, The Center for Clinical Management Research and The Patient Safety Enhancement Program, The University of Michigan Health System, 2800 Plymouth Road, Building 16 Room 432W, Ann Arbor, MI 48109. E-mail address: vineetc@umich.edu 0002-9343/$ -see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.amjmed.2014.01.001 CLINICAL RESEARCH STUDY Evidence-­‐Based Algorithm for Management of PICC-­‐ Associated DVT Peripherally Inserted Central Catheter-associated Deep Vein Thrombosis: A Narrative Review Nabil Fallouh, MD, MS, Helen M. McGuirk, MPH, Scott A. Flanders, MD, Vineet Chopra, MD, MSc Department of General Medicine, University of Michigan Health System, Ann Arbor; Patient Safety Enhancement Program, Hospital Outcomes Program of Excellence and the Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Mich.