Comparison of blood stream infection rate between conventional peripherally inserted central line (PICC) and tunneled PICC.

Transcription

1 Comparison of blood stream infection rate between conventional peripherally inserted central line (PICC) and tunneled PICC. Poster No.: C-1015 Congress: ECR 2013 Type: Scientific Exhibit Authors: O. Nawawi, B. J. J. Abdullah, N. Z. Dzul Kifli; Kuala Lumpur/MY Keywords: Infection, Venous access, Fluoroscopy, Interventional vascular DOI: /ecr2013/C-1015 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13

2 Purpose Peripherally inserted central venous catheter (PICCs) are widely used nowadays and serve as an alternative to conventional central venous catheters (CVCs) for providing intermediate and long term venous access in hospital, especially for long term administration of antibiotics, parenteral nutrition and chemotherapy. In many centres including ours, PICC insertion is performed under image guidance in the radiology unit. Among the risks or complications related to PICCs are phlebitis, thrombosis, premature dislodgement, malfunction and central line-associated blood stream infection (CLABSI). The implication of these risks is increased cost in patient management (1-4). Studies have shown that tunneled CVCs have a lower rate of blood stream infection (BSI) compared to conventional CVCs. To the best of our knowledge, there is no data or published paper on tunneled PICC with regards to the infection rate, though there was a study that compared the technique of cuffed and non-cuffed tunnelled PICCs. Most of the studies compared BSI rate between conventional CVC and tunnelled CVC, CVC and conventional PICC or between different types of conventional PICCs (5,6). The purpose of our study was to determine if tunneling can reduce infection rate in PICC by comparing blood stream infection rate between conventional PICC and tunneled PICC. The secondary aims were to compare the catheter-days and time to infection between these two methods, and also to look at other catheter related complication such as local infection, catheter blockage and dislodgement. Methods and Materials Fifty patients with conventional PICC and 50 patients with tunnelled PICC were prospectively studied between the periods of 19 months. They were randomly chosen from patients who were referred to the Biomedical Imaging Department of University Malaya Medical Centre for insertion of PICC. The indications for PICC insertion were for administration of long term antibiotics, chemotherapy, total parenteral nutrition (TPN) or for intravenous access. Exclusion criteria: patients less than 17 years old platelet level of less than 30,000 documented bacteremia/line-related infection within 7 days Page 2 of 13

3 evidence of inflammation over the insertion site were excluded from this study. Informed consent was taken from each patient before enrollment. The tunneled catheters were placed by interventional radiologists using a standardized technique (figure 1-4). Patients were reviewed daily until a PICC-related complication necessitated removal, completion of therapy, death or defined end-of-study date. CLABSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of infection and from blood cultures. For both conventional PICC and tunneled PICC groups, data on demography, underlying diseases, indication for placement of the catheter, catheter placement site, catheter type (Groshong or Polyrad) and dimension (4FR or 5Fr, single or double lumen), vein used, number of days each catheter was in place and time to development of CLABSI were obtained. The CLABSI rate was more accurately expressed in this study as number of cases with CLABSI per 1000 catheter days. Length of time required for the tunneling was also recorded. Statistical analyses were done using SPSS Kaplan-Meier analysis was used to study differences in time to infection and independant t-test was used to compare the catheter dwell time. A p value of <0.05 was considered to be of statistical significance. Images for this section: Page 3 of 13

4 Fig. 1: As in routine practice the upper arm vein was first punctured under ultrasound guidance and a guidewire was passed into the vein. To create the tunnel a skin incision was made about 4-5cm distal to the venous puncture site. A 21G puncture needle (provided in the PICC kit) was then advanced subcutaneously from the skin incision to the guidewire (venous puncture site). Page 4 of 13

5 Fig. 2: The guidewire was then inserted into the emerging needle tip and and threaded through the needle. Subsequently the guidewire was gently pulled from the hub end of the needle and straightened out. The needle was then removed. Page 5 of 13

6 Fig. 3: Peel-away sheath placed over the guidewire and advanced across the subcutaneous tunnel into the vein. Catheter can then be inserted into the peel-away sheath, as per routine practice. Page 6 of 13

7 Fig. 4: Tunneled PICC after removal of peel-away sheath. Page 7 of 13

8 Results Male patients made up 52% of the patient population in the conventional PICC group and 54% in the tunneled group. The mean age in the conventional and tunneled PICC group was 52 years and 47 years respectively. Patients who were diagnosed with infection made up the majority of the study population for both groups (58% in non-tunneled and 50% in tunneled), followed by malignancy (36% in non-tunneled and 46% in tunneled) and others. The main indication for PICC in both groups was for long term antibiotic administration (60% in non-tunneled and 50% in tunneled), followed by chemotherapy administration (25% in non-tunneled and 30% in tunneled). The most frequently used vein in both groups was the basilic vein (52% conventional, 46% tunneled), followed by the brachial vein and cephalic. For both groups the double lumen PICC was more frequently used than the single lumen, with almost equal percentage in each group (64% conventional, 60% tunneled). The average time taken to create the tunnel was 5 minutes. Indwelling time and CLABSI A total of 50 conventional PICC were placed for 1355 catheter-days. Of these, 17 patients (34%) developed infection, for which 6 patients (12%) had a CLABSI, for a rate of 4.4 per 1000 catheter-days. A total of 50 tunneled PICCs were placed for 2352 catheter-days. Of these, 8 patients (16%) developed infection, for which 3 patients (6%) had a CLABSI, for a rate of 1.3 per 1000 catheter-days (see table 1). The mean duration of conventional and tunneled PICC utilization was 27 days and 47 days respectively (p=0.012). The mean time to development of infection was longer in patients with tunneled compared with nontunneled PICC (24 versus 19 days, p=0.7). CONTROL (n=50) TUNNELED (n=50) Local infection 11 (22%) 5 (10%) CLABSI 6 (12%) 3 (6%) No infection 33 (66%) 42 (84%) Table 1: Comparison of infection rate between non-tunneled and tunneled PICC. Patients in the control group developed twice the number of local infection (p= 0.1) and CLABSI (p= 0.3) compared to the tunneled group. Page 8 of 13

9 Six of the CLABSI cases were caused by Gram-positive bacteria (MRSA, n= 3, Leuconostoc spp, n=1, Enterococcus spp, n=1, Staphylococcus aureus, n=1), while the rest were caused by Gram-negative bacterias. All of the CLABSI cases occurred in patients with double lumen PICC. Patients with hematological malignancy requiring PICC for chemotherapy were more prone to develop CLABSI, forming all the CLABSI cases in the tunneled group and 66.6% of the CLABSI cases in the non-tunneled group (odds ratio 7.6, relative risk of 6). No significant difference seen between the 2 groups. See Table 2. Underlying Morbidity Control (no. of patients/ %) CLABSI (no. of patients/ %) Tunneled (no. of patients/ %) CLABSI (no. of patients/ %) Hematological malignancy Non hematological malignancy 11 (22.0) 4 (66.6) 16 (32.0) 3 (100) 7 (14) 1 (16.7) 7 (14.0) 0 Infection 9 (18.0) 1 (16.7) 25 (50.0) 0 Others 3 (6.0) 0 2 (4.0) 0 Total 50 (100.0) 6 (100.0) 50 (100.0) 3 (100.0) Table 2: Underlying morbidity of patient population and CLABSI in both groups. Patients with previous PICC were more likely to develop CLABSI compared to patients with no previous PICC [5 cases (19.2%) compared to 4 cases (5.4%) respectively, p value =0.049, relative risk of 3.56, odds ratio of 4.16)]. See Figure 5. Page 9 of 13

10 Fig. 5: Comparing CLABSI rate in patients with previous PICC and no previous PICC. References: Biomedical Imaging Department, University Malaya, University Malaya Medical Centre - Kuala Lumpur/MY Catheter removal A significantly higher number of catheter removal due to infection was seen in the conventional PICC compared to the tunneled group (70.6% versus 13.3%, p=0.002). No significant difference between the 2 groups with regards to other complications. Three of the tunneled PICC were removed at patient's request due to pain at insertion site. The commonest complication causing catheter removal in tunneled PICC was dislodgement. Complications which warrant catheter removal are summarised in Table 3. Complications Control (No.of patients) Tunneled (No. of patients) Infection 12 2 Dislodgement 2 4 Leakage 2 3 Pain 1 3 Blockage 0 3 Total Table 3: Complications causing catheter removal in both groups. Page 10 of 13

11 Conclusion In this study, tunneled PICC showed a significantly longer catheter-days compared to the non-tunneled PICC (mean 47 days versus 27 days). Previous studies reported that longer catheter dwell time posed higher risk of infection (7,8). However our findings indicate otherwise. Although the total dwell time of tunnelled PICC was 997 days longer compared to the non-tunnelled group the rate of local infection and CLABSI in the tunneled group was half of that in the conventional group. The survival analysis also showed a longer time to infection for tunneled PICC compared to conventional PICC, with mean time to development of infection of 24 days for tunneled PICC as opposed to 19 days for tunnelled PICC. Although this value had not reached statistical significance, it perhaps had contributed to the significantly lower rate of catheter removal caused by local infection compared to the non tunneled group. The tunneling procedure was very well tolerated by patients and only added approximately 5 minutes to the standard procedure time. However tunneling did not contribute much to the stability of the PICC (4 out of 50 tunnelled PICC dislodged), possibly because we only used standard PICC and not the modified cuffed PICC as described in previous study (9). There was also slightly higher number of other complications which are directly related to catheter care seen in the tunneled group such as leakage and blockage, however these have not contributed significantly to catheter removal. Although there was no significant difference in the infective complications of patients with underlying hematological malignancy between the tunneled and non-tunneled group, they formed the majority of the combined CLABSI cases (7 out of 9 cases). This is in concordance with previous study which showed that patient with underlying malignancy are at higher risk of developing CLABSI in PICC and non tunneled CVC (10). All of our CLABSI cases involved dual-lumen silicone catheter likely because all of the infected cases were patients with underlying malignancy who required multiple port for chemotherapy and blood taking. The use of multi-lumen catheters have been shown to have higher rates of infection as stated by other randomized control trial (11). For this reason, a single-lumen catheter is recommended unless multiple ports are essential for patient management. It interesting to note that there was a strong association between history of previous PICC insertion and CLABSI in general. Similar association had been reported by previous investigators (8,12). Page 11 of 13

12 This study showed that tunneling had not significantly reduced the rate of CLABSI in PICC. However it did contribute significantly in increasing the catheter dwell time and in reducing removal of catheter caused by infection. In view of the ease of performing this procedure and the potential cost saving benefits, we would recommend this procedure in patients requiring PICC. References 1. Digiovine B, Chenoweth C, Watts C, Higgins M. The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. American journal of respiratory and critical care medicine. [Research Support, U.S. Gov't, P.H.S.] Sep;160(3): Mermel LA. Prevention of intravascular catheter-related infections. Annals of internal medicine. [Meta-Analysis] Mar 7;132(5): Saint S, Savel RH, Matthay MA. Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections. American journal of respiratory and critical care medicine. [Research Support, U.S. Gov't, Non-P.H.S. Research Support, U.S. Gov't, P.H.S. Review] Jun 1;165(11): Warren DK QW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Critical care medicine. August 2006;34(8): Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clinic proceedings Mayo Clinic. [Research Support, Non-U.S. Gov't Review] Sep;81(9): Al Raiy B, Fakih MG, Bryan-Nomides N, Hopfner D, Riegel E, Nenninger T, et al. Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters. American journal of infection control. [Comparative Study] Mar;38(2): McLaws ML, Berry G. Nonuniform risk of bloodstream infection with increasing central venous catheter-days. Infect Control Hosp Epidemiol Aug;26(8):715-9 Page 12 of 13

13 8. Advani S, Reich NG, Sengupta A, Gosey L, Milstone AM. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit. Clin Infect Dis 2011 May;52 (9): J.B. Selby Jr DJC, G. Koenig. Peripherally inserted tunnelled catheters: a new option for venous access. Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy Jul;10(4): Worth LJ, Seymour JF, Slavin MA. Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. [Comparative Study] Jul;17(7): Zürcher M TM, Walder B. Colonization and bloodstream infection with single- versus multi-lumen central venous catheters: a quantitative systematic review. Anesthesia and analgesia. 2004;99: ) 12. Kelly M, Conway M, Wirth K, Potter-Bynoe G, Billet AL, Sandora TJ. Moving CLABSI prevention beyond the intensive care unit: risk factors in pediatric oncology patients. Inf Control and Hosp Epid Nov;32(11): Personal Information Page 13 of 13