1. Among 4797 PICC lines examined, the risk of central line associated blood stream infections (CLABSIs) in neonates increased over the first 2 weeks after peripherally inserted central catheter (PICC) placement, and then remained elevated, but steady until removal.
2. Gram-negative CLABSIs occurred more frequently in long-term (> 50 days) PICCs than in those left in place for shorter time periods.
Evidence Rating Level: 2 (Good)
Study Rundown: Peripherally inserted central catheters (PICCs) are often used in the neonatal intensive care unit (NICU) to aid in the delivery of medications and nutrients to neonates. However, PICCs can also be the culprit of central line associated blood stream infections (CLABSIs). This study looked at the temporal relationship between PICC insertion and development of CLABSI. Through this retrospective, multicenter analysis, researchers found an elevated risk of CLABSI when PICC placement went beyond 7 days as opposed to shorter durations. This increase in risk persisted for 2 weeks after placement, and then remained elevated, but stable for the duration of the PICC. While Gram-positive infections were the most common etiology of CLABSIs in PICCs, an increase in Gram-negative infections was noted when PICC duration exceeded 50 days. This study’s multicenter design limited consistency in data collection and reporting across included institutions. This research suggests ongoing attention to necessity of PICCs, and to further quality improvement measures to decrease occurrence of CLABSIs. Given the noted incidence of CLABSIs with PICC dwelling time, the judicious placement and removal of PICCs is warranted to prevent infections.
Study Author, Dr. Aaron M. Milstone, MD MHS, talks to 2 Minute Medicine: Johns Hopkins University, Department of Pediatric Infectious Diseases.
“Our findings suggest that device removal should occur as early as possible and occur pre-emptively rather than reactively, after infection sets in and complications develop. Infection-prevention maneuvers are essential but as long as the device stays in, the risk of infection is never zero, so daily weighing of the pros and cons of keeping the device in each and every newborn can go a long way toward slashing infection risk.”
In-Depth [retrospective cohort]: This multicenter, retrospective cohort study examined the duration of placement of 4797 PICCs inserted in 3967 NICU patients treated at 7 United States institutions from January 2005 to June 2010. Study endpoints were CLABSI and planned PICC removal. National guidelines in 2008 defined a CLABSI as 2 or more blood cultures drawn on separate occasions from a central line that grew common skin bacteria. A total of 149 CLABSIs (3.1% of all PICCs) were diagnosed based on this definition. While 25% of PICCs were left in for ≥ 23 days, the median time of PICC duration was 14 days. The incidence of CLABSI in first 10 days after placement was 1.05 per 1000 catheter days (95% CI: 0.77 – 1.41), which increased to 1.98 (95% CI: 1.44 – 2.66) during days 11-20. The incidence remained elevated, but steady from day 21 through PICC removal. Using Poisson regression analysis, a decrease of 412 catheter days after 14 days of PICC placement would be required to prevent one CLABSI. Though most CLABSIs were secondary to coagulase-negative Staphylococci (32.2%) and Staphylococcus aureus (20.1%), an increase in incidence of Gram-negative CLABSIs was noted in PICCs left in for > 50 days.
By Neha Joshi and Leah H. Carr
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