Alternative to IV Filter UsageAuthor(s): Bryan SimmonsSource: Infection Control, Vol. 6, No. 9 (Sep., 1985), pp. 342, 344Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/30148443 .

Accessed: 28/06/2014 11:20

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact support@jstor.org.

.

The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaboratingwith JSTOR to digitize, preserve and extend access to Infection Control.

http://www.jstor.org

This content downloaded from 91.238.114.64 on Sat, 28 Jun 2014 11:20:43 AMAll use subject to JSTOR Terms and Conditions

Letters to the Editor

Alternative to IV Filter Usage To the Editor:

I am writing to address an article that recently appeared in the New England Journal of Medicine and that supported the routine use of IV fil- ters.1 In the article, the authors, Falchuk et al, showed that filters reduced phlebitis but they did not do an analysis of cost-effectiveness. The authors missed the most important consideration concerning IV filters when they failed to discuss cost-effec- tiveness of filters. I disagree with them that the "enormous benefits" of IV fil- ters are likely to override cost con- cerns.

It is important to attempt to limit phlebitis. However, there are better and more cost-effective ways than using filters. Good care of the IV site will not only prevent phlebitis but probably also limit infection.2,3 IV fil- ters have never been shown to prevent infections, which are the most irpor- tant IV-related complication, and are unlikely to do so, given the apparent rarity of infusate-related bac- teremia.4,5 When the authors talk about the systemic manifestations of phlebitis, they leave the impression that filters will prevent infections by preventing phlebitis. While phlebitis can be caused by both infections and particulates, there is no evidence that particulate-related phlebitis leads to infection. It is as easy for me to believe that the inflammatory response to chemical phlebitis will protect against infection as predispose to it. Unfor- tunately, it is not possible by a clinical examination to distinguish infection- related phlebitis from that due to other causes, so one must remove the catheter for clinically-significant phle- bitis.

A pharmacy-based filtration pro- gram is a far more reasonable and cost-effective solution to particulates

than is routine use of IV filters. Drugs known to have high particulate loads can be filtered through a particulate- grade filter incorporated in a needle. By batching multiple orders for the same drug, numerous solutions can be compounded by use of the same filter. In addition, these needle filters cost a fraction of that for in-line IV filters.

Probably the most reasonable approach to preventing particulate- related phlebitis is that taken by the Food and Drug Administration (FDA) and United States Pharmacopeia (USP). They have developed standards that limit the amount of particulates allowed in IV fluids. The papers quoted by Falchuk that show the pres- ence of significant amounts of "starch granules, talc, silica, or glass" in IV fluids all predate the FDA and USP standards (which were finalized in the late-1970s).6 Further, the FDA and USP are in the process of developing standards for particulates in both additives and IV administration tub-

ing.'7 When one considers the costs of IV

filters, one needs to evaluate the costs of the filters themselves as well as costs associated with their use (hidden costs). These filters impede the flow of fluid and, thus, infusion pumps, fre- quent changes of IV tubing, and the time-consuming irrigations of the IV line may all be required. Just the costs of IV filters alone can be staggering. A 120-bed hospital for which I consult was spending $40,000 a year on filters and charging patients over $120,000 a year. Nationwide, costs would be enor- mous. It is estimated that routine use of IV filters could require more than 100 million filters annually.8 Thus, use of filters could cost hospitals $100 to $200 million annually and cost patients three times that amount.

IV filters do reduce concentrations of some drugs.9,10 Unless all drugs are studied for the characteristic of being removed by filters, I do not believe we

can dismiss this problem as insignifi- cant. I am not sure that all physicians will be aware of the problems of filter- ing drugs given in low dosages; some patients may receive sub-therapeutic concentrations of drugs.

Lastly, the phlebitis rate determined in the study by Falchuk was almost surely inflated with what I will call clinically insignificant phlebitis. In order to reduce the number of patients necessary to conclude their study, ie, to increase the power of their study, they apparently used a mini- mal, albeit fair, definition of phlebitis. The clinical significance of mild phle- bitis (eg, mild redness and mild pain) is questionable. Certainly, other expe- rienced investigators have found rates of phlebitis much less than the 57.2% rate reported by Falchuk.3",1,2 One multi-hospital study of IV complica- tions found a phlebitis rate of 2.3%.'s This rate more closely reflects what most clinicians would call significant phlebitis.

Infection control personnel should await more data before using IV filters for all patients. Hospital cost control is an important topic in the 1980s, and infection control personnel should lead the way in this area. Certainly; now is not the time to adopt new expensive procedures unless there is solid evidence that benefits will approach costs; this is why the Centers for Disease Control specifically recom- mends against routine use of IV fil- ters.14

REFERENCES 1. Falchuk KH, Peterson L, McNeil BJ: Micro-

particulate-induced phlebitis. N EnglJ Med 1985; 312:78-82.

2. Hershey CO, Tomford JW, McLaren CE, et al: The natural history of intravenous catheter-associated phlebitis. Arch Intern Med 1984; 144:1373-1375.

3. Tomford JW, Hershey CO, McLaren CE, et al: Intravenous therapy team and periph- eral venous catheter-associated complica- tions. Arch Intern Med 1984; 144:1191-1194.

4. Buxton AE, Highsmith AK, Garner JS, et

342

This content downloaded from 91.238.114.64 on Sat, 28 Jun 2014 11:20:43 AMAll use subject to JSTOR Terms and Conditions

al: Contamination of intravenous infusion fluid: Effects of changing administration sets. Ann Intern Med 1979; 90:764-768.

5. Band JD, Maki DG: Safety of changing intravenous delivery systems at longer than 24-hour intervals. Ann Intern Med 1979; 91:1'73-178.

6. Large volume injections for single dose infusion. Nineteenth revision, fifth supple- ment, 1979; 213-214.

7. Particulate matter in small volume injec- tions. Pharmacopeial Forum: Stimuli to the revision process. Nov-Dec 1983; 3729-3742.

8. National Coordinating Committee on Large Volume Parenterals. Problems and

benefits on in-line filtration. NCCLVP Ref- erence number 79-01, 1979.

9. Rusmin S, Welton S, DeLuca P, et al: Effect of inline filtration on the potency of drugs administered intravenously. Am J Hosp Pharm 1977; 34:1071-1074.

10. Bulter LD, Munson JM, DeLuca PP: Effect of inline filtration on the potency of low- dose drugs. Am J Hosp Pharm 1980; 37:935-941.

11. Tully JL, Friedland GH, Baldini LM, et al: Complications of intravenous therapy with steel needles and teflon catheters. AmJ Med 1981; 70:702-706.

12. Maki DG, Weise CE, Sarafin HW: A semi-

quantitative culture method for identifying intravenous-catheter-related infection. N

EnglJ Med 1977; 296:1305-1309. 13. Tager IB, Ginsberg MB, Ellis SE, et al: An

epidemiologic study of the risks associated with peripheral intravenous catheters. AmJ Epidemiol 1983; 118:839-851.

14. Simmons BP, Hooton TM, Wong ES, et al: Guidelines for prevention of intravascular infections. Infect Control 1982; 3:61-67.

Bryan Simmons, MD Director, Infection Control

Methodist Hospital Memphis, Tennessee

Editor's Note: In the February 1985 issue of Infection Control, Figures 1 and 2 in "Resistance to Antibiotics in Clinical Isolates of Klebsiella pneu- moniae"were transposed (Infect Control6(2):65). The Editors apologize for any confusion this may have caused our readers or authors.

Classified Marketplace

INFECTION CONTROL SPECIALIST Mideast Assignments Offering Personal & Professional Growth

Charter Medical Corporation invites you to expand your experience and expertise at Tawam Hospital, our state-of-the-art facility in the United Arab Emirates.

The financial rewards are outstanding and include provided housing, tax sheltered income and the opportunity to become part of a polished team of healthcare professionals who are dedicated adventurers with curiosity and skills to match your own.

Candidates must possess a BS Degree in Nursing, CDC training and 1 year experience.

Please forward resume to: Sharon Dixon, CHARTER MEDICAL CORPORATION, 577 Mulberry St. Macon, GA. 31298

S . @066

EMPLOYMENT OPPORTUNITIES

ASSISTANT NURSE EPIDEMIOLOGIST: RN with BSN and min. of 3 yrs. experience needed to conduct infectious surveillance rounds and act as consultant to other hospital personnel. Com- pletion of CDC course in Epidemiology and/or previous infection control experience highly desirable. To inquire further call Linda Reed, RN, Nurse Recruiter, at (404) 828-3031 or send resume to Medical College of Georgia Hospital and Clinics, Rm. BI-F-206, 15th St., Augusta, GA 30912. EOE/AAP.

RATES: $12.00 per line (line = approx. 60 characters); $60.00 mini- mum; $12.00 extra for confidential box number service. Non- commissionable to agencies.

SEND INSERTION INSTRUCTIONS TO: Classified Marketplace, Infection Control, 6900 Grove Road, Thorofare, NJ 08086.

Be sure to include your telephone number. CALL FOR INFORMA- TION: TOLL-FREE: 800-257-8290, In NJ: 609-848-1000.

344 Letters to the Editor

This content downloaded from 91.238.114.64 on Sat, 28 Jun 2014 11:20:43 AMAll use subject to JSTOR Terms and Conditions