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Are Peripheral IVs an Overlooked Source of Infection? 

Michelle DeVries MPH, CICSenior Infection Control OfficerMethodist HospitalsGary, Indiana

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Michelle DeVries is a paid consultant of Ethicon, Inc.

This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for continuing medical education.

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Objectives

• Explore the infection risk of Peripheral Intravenous Catheters

• Discuss the impact of PIV infections

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Let’s Start with a Definition…

• Report BSIs that are central line associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event)

• NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line associated– But please note this changes 1/1/2013

• Report BSIs that are central line associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event)

• NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line associated– But please note this changes 1/1/2013

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf Accessed October 19, 2012

Laboratory-confirmed bloodstream infections (LCBI) that are not secondary to a community-acquired infection or an HAI meeting CDC/NHSN criteria at another body site

Primary bloodstream

infections (BSI)

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LCBI – Criterion 1

Patient has a recognized pathogen culturedfrom one or more blood cultures

And

Organism cultured from blood is not related toan infection at another site

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf Accessed October 19, 2012

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LCBI – Criterion 2

Patient has at least one of the following signs or symptoms: fever (>38 C), chills or hypotension⁰

And

Signs and symptoms and positive laboratory results are not related to an infection at another site

And

Common commensal (i.e. diptheroids [Corynebacterium spp.], Bacillus [not B. antrhacis] spp., Propionibacterium spp.,

coagulase-negative staphylococci [including S.epidermidis], viridans group sterptococci, Aerococcus spp., Micrococcus spp.) is

cultured from two or more blood cultures drawn on separate occasions.

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf Accessed October 19, 2012

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CLABSI

CLABSI is an LCBI where a central line or umbilical catheter was in place for >2 calendar days, with day or device placement

being Day 1

And

A central or umbilical catheter was in place on date of event or day before. If admitted or transferred into facility with

central line in place (eg, tunneled or implanted central line), day of first access is considered Day 1.

http://www.cdc.gov/nhsn/pdfs/training/3-day-Training-final.pdfAccessed October 19, 2012

New clarification in CDC definition:

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A Few More Points…

• Focus on surveillance definitions because that is what current reporting requirements address

• Inflammation of the walls of a vein

– Can be chemical, mechanical or infection-related

– Focus today is only on infectious complications

Phlebitis Infection

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Why Should You Care About Complications Associated With Non-central Lines?

1. In 2008 the Center for Medicare and Medicaid Services (CMS) began its program of disallowing reimbursement for vascular catheter-associated infections (note there is no modification for type or location of the catheter or the type--local or bloodstream [BSI]--of infection)

2. Vascular catheter-related infections would encompass all devices used to access the vasculature without regard to the specific tip location or limiting only to BSIs

Why Doesn’t Anyone Talk About This?

• But almost no one is looking!

• Body of research is starting to grow and dispel this myth

General belief is that the risk is minimal or non-existent

11Maki DG et al., Mayo Clinic Proc 2006;81:1159-1171.

Peripheral Venous Catheters (PVCs)

Zingg W. et al., Int J Antimicrob Agents 2009;34 Suppl4:S38-42.

• PVCs are most frequently used invasive device in hospitals

• Up to 70% of patients require a PVC during their hospital stay

• Estimated that PVCs are in place for 15%-20% of total patient-days

• No consensus on optimal time point for PVC change, or whether PVC replacement is required at all

• Current estimates are that PVC-bloodstream infection incidence density rates are 0.2-0.7 per 1,000 device-days

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Recently Published Article On:

Peripheral Venous Catheter-Related

Staphylococcus aureus Bacteremia

• 24 S. aureus bacteremias

• A rate of 0.07/1000 line days

• 12% of all device related S. aureus bacteremias were caused by PVCs

• Average treatment in this study was 19 days

• Some serious complications including two patient deaths and one transfer to hospice

Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6):579-583

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Risk Factors1Risk Factors1

• Antecubital fossa (67%)

• Placement outside of the hospital (16%)

• Placement in Emergency Room (67%)

• Longer duration of catheterization

– 46% had duration greater than 3 days

– A national survey showed that >90% of PIV infections take place with catheters left in more than 3 days

1. Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6):579-583

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Catheter-Related Intravascular Infections in Critical Care Units1

• 6-month prospective study on prevalence of catheter-related infections in their CCU and ICU

• 1983 patients, all of whom had a peripheral line in place

• 5/1983 developed bacteremia (0.3%)– One patient died

1. Baleva MEA, et al Catheter-related infections in critical care unit. Phil J Microbiol Infect Dis 1997; 26(2):51-54.

Baleva, et al

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Wendy Morris – North Bristol NHS Trust

Strategies for Preventing Intravenous Cannula Infection

• The Nosocomial Infection National Surveillance Service suggests that “6.2% of hospital-acquired bacteremias may be directly attributable to peripheral IV cannulation.”

• Developed a Peripheral Venous Cannulation Policy and Peripheral Cannula Care Plan

• Audit using tools including the Saving Lives PIV Cannula Care Bundle

Morris, W et al, Strategies for preventing peripheral intravenous cannula infection. British Journal of Nursing, 2008 (IV THERAPY SUPPLEMENT), Vol 17, No 19

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Pujol: A Comparison of Bloodstream Infections in Central and Peripheral Venous Catheters

Prospective study of bloodstream infections (BSIs) in short and mid-line peripheral venous catheters (PVCs) vs central venous catheters (CVCs) among a group of non-intensive care unit patients from October 2001 to March 2003 in a hospital in Spain.

Pujol M et al., J Hosp Infect 2007;67:22-9

Study Design

150 vascular catheter-related BSIs in 147 patients: 77 were PVC-BSIs (0.19 per 1,000 patient-days) vs 73 CVC-BSIs (0.18 per 1, 000 patient-days). Patients with PVC-BSIs more often had the catheter placed in the emergency department (42% vs 0 ), had a shorter duration from catheter insertion to BSI (4.9 vs 15.4 days) and S. aureus as the pathogen (53% vs 33%).

Results

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Pujol (continued)

• Rates of infection very similar between peripheral and central venous catheters

• Difference in onset between lines placed in ER versus inpatient units– Emergency Room: 3.7 days– Nursing units: 5.7 days

• S. aureus was more prevalent in peripheral lines, but MRSA was about the same– Patients with S. aureus had more complications than from other

organisms– This is significant not only for the patients but for mandatory reporting

beginning in two months in the United States

Pujol M et al., J Hosp Infect 2007;67:22-9

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Prevalence of Bloodstream Infections (BSIs) in Central and Peripheral Vascular Catheters

Wischnewski N. et al., Zentralbl Bakteriol 1998;287:93-103.

Study Design

Results

A total of 14,966 patients were surveyed. Of these 23.9% patients had a non-central catheter and 5.1% had a central catheter. Device utilization was 27.3% for peripheral and 6.1% for central. BSI prevalence was 0.3% for non-central catheters and 0.8% for central catheters.

Prevalence survey at 72 hospitals in Germany

ConclusionPeripheral catheters are very prevalent and associated with moderate BSI risk

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Not Without Risk

1. Ritchie, et al. The Auckland City Hospital device Point Prevalence Survey 2005: utilisation and inectius complications of intrasvasular and urinary devices. N Z Med J. 2007; 120:U2683.2. Hong, et al. Fatal peripheral candidal suppurative thromophlebitis in a postoperative patinet. J Korean Med Sci. 2008; 23:1094.

Ritchie 2007 (New Zealand)1

• Looked at 345 PIVs– 22/345 had signs of infections

• 6/44 in greater than 72 hours • 16/301 in less than 72 hours

Hong 2008 (Korea)2

• Purulent thrombophlebitis from IV. Positive for C. albicans

• Developed fungal spondylitis in vertebrae

• Patient died

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Not Without Risk

1. Easterlow, et al. Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs. 2010; 19(5-6):721-727. 2. Lee, et al. Risk Factors for peripheral venous catheter infection in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control. 2009; 37(8): 683-686.

Easterlow 2010 (England)1

• Pre-intervention: 30 MRSA bacteremias – 9 catheter-related

• Post-intervention: 14 MRSA bacteremias – 4 definite, 2 possibly catheter-related

Lee 2010 (Taiwan)2

• 46 cases of soft tissue infections from peripheral lines (over 3-year period)– 6 with bacteremia (also with local inflammation)– 6 needing surgical debridement for abscess– 8 with purulent drainage or cellulitis at insertion site

• 1 with bacteremia with same pathogen

– 26 with inflammation (persisting more than 3 days after catheter removal

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One More Hospital’s Experience

Period of 6 Years All LCBI CountedLine types associated with each infection were recorded

Over that time period between 11 and 21% of LCBI had only peripheral access (total of 74 patients)

30 to 47% of patients had multiple lines in place–Majority of those had peripheral as well as central lines–Classified (based on NHSN definition) as CLABSI

(But no proof of which line was truly responsible)

With These Infections, Can’t Reach Zero

House-wide in reduction of CLABSI

PIV-only infections: not yet observed same reduction

M. DeVries, P. Mancos abstract ICAAC 2012.   Non-central line related laboratory confirmed bloodstream infections

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Cochrane Peripheral Vascular Diseases Group

• Assessed impact of removing peripheral catheters when clinically indicated versus removing and re-siting routinely

• Found no conclusive benefit in changing PIV every 72 hours to 96 hours

• Looked at phlebitis as well as bacteremia

• Also looked at costs associated with routine changes

Webster, J., Osborne, S., Rickard, C., Hall, J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. (2010) Cochrane database of systematic reviews (Online), 3, pp. CD007798. 

Results:

•Changing for clinical need rather than on routine schedule reduced the rate of bacteremia 44%

– OR = 0.57 P= 0.37

•24% increase in phlebitis in the clinical change group

– OR= 1.24 P=0.09

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CDC Recommendation

• “ There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults [36, 140, 141]. Category 1B”

• “No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [142–144]. Unresolved issue”

• “Replace peripheral catheters in children only when clinically indicated [32, 33]. Category 1B”

• “Some studies have suggested that planned removal at 72 hours vs. removing as needed resulted in similar rates of phlebitis and catheter failure [142–144]. However, these studies did not address the issue of CRBSI, and the risk of CRBSIs with this strategy is not well studied.”

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdfAccessed October 19, 2012.

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INS Standards

• “Routine site care and dressing changes are not performed on short peripheral catheters unless the dressing is soiled or not longer intact.”

• “The nurse should consider replacement of the short peripheral catheter when clinically indicated and when infusion treatment does not include peripheral parenteral nutrition.”

• “The nurse should not routinely replace short peripheral catheter in pediatric patients.”

• “If a catheter related bloodstream is suspected, consideration should be given to culturing the catheter after removal.”

Infusion Nursing Standard of Practice, Journal of Infusion Nursing. 2011; (34) 1S

What Could Be Causing These Infections?Back To Basics

Unknown = 28%

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Skin

Organisms60%

Skin

Vein

Skin

Vein

Fibrin Sheath,ThrombusFibrin Sheath,Thrombus

Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with nuncuffed short-term central venous catheters. Int Care Med. 2004; 30:62-67.

11Contaminate

d Catheter Hub

12%

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Contaminated Infusate

<1%

The Origin of MicrorganismsCausing CRBSI1 YOUR

FLORA OR MINE

1. Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal.  2005;5(3) ©2005  Medscape. Posted 08/18/2005. http://www.medscape.com/viewarticle/508109.

Extraluminal biofilm:•Major source of CRBSI within first week of catheterization in short-term catheters•Major source of tunnel infections in long-term catheters

Microbial Source ofCatheter-Related Blood Stream Infections

Skin

Vein

CatheterHub

Skin

EXTRALUMINAL COLONIZATION

INTRALUMINAL COLONIZATION

Intraluminal biofilm:•Major source of CRBSI after1 week in both short- and long-term catheters

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Technology’s Role• What are you doing for the PIVs that are staying in longer then 72 hours to reduce skin

colonization?

• There are products out there that can help reduce the skin flora if you are leaving your catheters in for long periods of time, i.e.

– Biopatch® Protective Disk with CHG is the only product indicated to reduce CRBSI

– Indicated to use on IV catheters (Proper Size 4151 for ≤6 Fr catheter)

• Its up to you to decided what fits best in your hospital’s protocol – Look at the evidence

– Look at product indications

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Reporting…

• NHSN/CMS/JC/Health departments, etc only require reporting central line associated bloodstream infections– Just need to meet the definition PLUS have a central line in place– No requirement for “proof” that the central line was the source or

for any evidence of local site infection

• You can still meet the definition for a LCBI and not have a central line in place, but it is not analyzed and no benchmarks are available within NHSN– These are what can be referred to as non-central line

associated, laboratory confirmed bloodstream infections

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CDC Recommendation

• Ideally, this involves auditing actual care– Morris, et al describe using audit results as educational material and

making them widely available– Easterlow (2010. Journal of Clinical Nursing), et al demonstrated poor

baseline compliance with care of peripheral lines– The author’s institution periodically conducts audits of peripheral

maintenance bundle as well as the more standard central line maintenance bundle

• This data can have large impact on identifying areas needing further review or education

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdfAccessed October 19, 2012.

Periodically assess knowledge of and adherence to guidelines

for all personnel involved in the insertion and maintenance of intravascular catheters. Category IA

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CMS and Peripheral Lines

• Starting January 1, 2013 all MRSA blood isolates are reportable via NHSN to CMS– Both community onset and healthcare associated must be reported– House-wide (not just ICU) isolates must be reported from all inpatient locations– Not just CLABSIs are counted, so any infections associated with peripheral

vascular access will also be reported

• Starting back in 2008, non-payment also includes vascular catheter related infections; CLABSIs reported through NHSN are only part of this data set– Any coded vascular access related infections are also included in this category– Not limited to only central lines

http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdfAccessed October 19, 2012.

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Review

• According to some studies, the longer a Peripheral Venous Catheters stays in place the higher the chance there is for an infection and possible mortality

• There have been recent changes to guidelines to allow a longer dwell time for these catheters

• Main bacteria causing these infection is Staphylococcus coming from skin flora intra or extra luminal

• Come Jan 1st 2013 any positive blood cultures from Methicillin- Resistant Staphylococcus aureus must be reported to CMS

• Surveillance, training and technology are areas to look to help get an understanding and reduction of these infections

©Ethicon, Inc. 2012 BP-404-12