Impact of Peripherally Inserted Central Catheters on Catheter-Related Bloodstream Infections - Essay Example

Research Article Critique Impact of Peripherally Inserted Central Catheters on Catheter-Related Bloodstream Infections in the Intensive Care UnitName of the Student Subject Name of the Concerned Professor 6 February, 2009 Statement of the Problem This study by Patel et al investigates the effect of an intervention, that is, a novel central venous catheter insertion design on the catheter related blood stream infection (CRBSI) rates (2007). Vascular access in the form of central venous catheters (CVC) is usually indispensable in critically ill patients requiring intensive care. CVCs may be needed for hemodynamic monitoring or as a route to administer medications, fluids or parenteral nutrition. However, they are a potential source of blood stream infections (BSI). In fact, up to 20-40 percent of blood stream infections in hospitalized patients may be caused due to a CVC (NSW Health 2005). This nosocomial bacteremia is often referred to as 'line sepsis'. Guidelines for the prevention of (CRBSIs) have been formulated by CDC. These are targeted at the intensive care personnel who are involved in the insertion of these catheters and post insertion management and care of these catheters, particularly the nursing staff. It is proposed that in addition to the existing guidelines, this study will provide ample evidence for the use of PICCs in ICU setting to reduce the rate of CRBSI. Review of Literature Almost 12 years back, the use of PICCs was highly favored for cost and safety considerations by a study (Ng et al, 1997). The advantages of PICCs include ease of bedside placement, placement even by non-physicians and a relatively lower risk of complications. Complications of PICCs were studied in 351 patients and were identified to be infection related, phlebitis, vein thrombosis, PICC occlusion, broken or leaking catheter or dislodgement of the catheter (Walshe et al, 2002). However, even the authors concluded that because of their convenience and easily managed complications they should be continued to use. 200 prospective studies were analyzed systematically and it was determined that PICCs used in inpatients (2.1/ 1000 catheter days) had a slightly lower rate of CRBSIs than standard non cuffed and non medicated CVC s placed in subclavian or internal jugular vein(2.7 BSIs /1000 catheter days)(Maki, Kluger, & Crinch, 2006). Whereas, Safdar and Maki (2005) found that CRBSI with PICCs was higher than some of the other CVCs. Thus, more studies are warranted to compare CRBSI rates of PICCs and CICCs and establish a lower rate of infection of PICCs. Study Design and Population The study utilized a central-line database retrospectively, one year prior to and 3 years after the introduction of hemodynamic monitoring with PICCs in a closed, medical-surgical, 20-bed intensive care unit and a 10-bed intermediate care unit of a tertiary-care academic medical institution. CRBSI rates were compared for a 12-month control period and a 36-month intervention period with open-ended PICCs. Thus, it was a retrospective analysis of an interventional study (Patel et al, 2007). 2,474 central vascular catheters were inserted in 1788 critically ill patients (21,919 catheter-days). ). A total of 6210 CICC catheter-days and 15,709 PICC catheter-days were analyzed (Patel et al, 2007). The primary outcome variable was the rate of CRBSI and this was defined as "isolation of the same organism (defined by species and antimicrobial susceptibility pattern) from the colonized catheter (>15 colony-forming units) and one or more peripheral blood cultures within 48 hours in a patient with no alternative source of bacteremia" (CDC, 2002). Since, the primary outcome measure was clearly defined, changes in the values were analyzed statistically and reliability was ensured. However, the blinding status so far as the group allocator or the body who assessed the results is not clear. What indicated the use of PICCs in most of the patients while some still had CICCs in the later years of the study is also not clear. Was there some special indication of CICCs in these patients Accuracy or the internal validity could also have been affected by the differences in the antibiotic usage and the number of chronic renal failure patients in the control and intervention years. It remains to be assessed whether similar results can be duplicated in other settings or even maintained in the same setting over an extended period of time. Catheter colonization was defined as "15 or more colony-forming units per catheter segment by semi quantitative roll-plate method" (CDC, 2002). Indications for removal and culturing of catheter and peripheral blood included insertion site erythema or purulent exudates in patients with clinical sepsis or clinical suspicion of catheter-related sepsis. Secondary outcomes such as the organisms causing infection and the barriers to the use of PICCs were also identified. Data Collection Methods Patient demographics like age, sequential organ failure assessment score [SOFA] score, length of stay in ICU and the hospital were obtained from an ICU quality-assurance database (Patel et al, 2007). CVC data were obtained from a vascular access database maintained prospectively for all patients undergoing CVC placement in the ICU or intermediate care unit. Average of the median reported cost and attributable mortality per CRBSI were used to calculate the cost and the mortality attributed to central venous catheters (Patel et al, 2007). PICC began to be indicated for central venous pressure monitoring after January 1, 2001. Prior to this, an existing CVC (CICCs and closed-ended PICCs) database was examined for 12 months to establish baseline utilization and safety data. For the next three years, namely 2001, 2002 & 2003, a highly proficient intravascular access team performed the insertion of open-ended PICCs. Data Analysis Procedures The authors used median and percentile (range, 10% to 90%) to present all the continuous variables and Student t test or the Wilcoxon rank sum test to analyze them. Actual numbers as well as percentages represented the categorical variables which were analyzed by the [chi] or Fisher exact test. The control group for all comparisons was the central-line infection prevention (CLIP) year 2000 cohort. Comparison of LOS was done with a nonparametric test of the median (number of points above median). All statistical tests were 2-tailed, and were considered statistically significant at P < 0.05. JMP statistical software version 5.1.1 (SAS Institute Inc, Cary, NC) was utilized for data analysis and statistical measurements (Patel et al, 2007). All the statistical tests that were used to analyze the data were appropriate for the study. Results The number of CICC insertions and the median dwell time was reduced from 6.4 days per line during the control year (2000) to 3.2 days during PICC intervention year 3 (2003) (50% decrease; P < 0.001). Correspondingly, during this same interval, there was an 81% reduction in CRBSIs per catheter-day (from 1.6 CRBSIs to 0.3 per 1000 catheter-days; P < 0.001) despite no observable associated decrease in CICC catheter colonization. Coagulase-negative Staphylococcus species were held responsible as being the most common cause of bacteremia (83%) and CVC colonization (67%)(Patel et al, 2007).. Strengths and Limitations of the Study This study was performed in a 20 beds ICU and 10 bed intermediate care unit and a team of 5 critical care therapists performed all the CVC insertions with all antiseptic precautions. Standard definitions for CRBSI as proposed by the CDC and used in the National Nosocomial Infection Surveillance System were used. Throughout the 4 years of study, a CVC maintenance and insertion education program was continued for ICU personnel. There was no change in other factors, such as staffing ratios, hand hygiene, nutritional protocols, or clinical studies. Although, concurrent controls were not there, the data for the control year was compared with the following 3 intervention years. As reported by the researchers, there were a few limitations of the scientific merits of this study which could have led to the certain variations in the study results. As the study design was retrospective and there was a lack of concurrent controls and blinding, a causal association between the use of PICCs and the reduction of CRBSIs cannot be confirmed with absolute certainty (Patel et al, 2007). However, as the rate of infection decreased with the increasing proportion of PICCs utilized with a high degree of significance suggested by the statistical analysis, an association is strongly suggested. A lack of adequate representation of patient population in other practice settings could have placed another limitation on this study as it was conducted in a single tertiary care teaching institution. Conclusion In conclusion, the research findings support the use of peripherally inserted central venous catheters over centrally inserted central venous catheters in ICUs to reduce the rate of catheter related blood stream infections. In addition, more research is required to establish a causal relationship between the decreased rates of infection and PICCs. Further studies can also help to overcome the barriers to the widespread use of PICCs that have been identified by this study. References: 1. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002; 51(No.RR-10): [Appendix A]. 2. Maki, D. G.; Kluger, D. M: Crinch, C. J. The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies Mayo Clin Proc. - September 2006; 81(9):1159-1171 3. Ng, P. K.; Ault, M.; Ellrodt, A. G.; Maldonado, L. Peripherally inserted central catheters in general medicine. Mayo Clinic Proceedings March 1997; 72(3): 225-233 4. NSW Health (2005). NSW Health. Infection control program quality monitoring indicators. Version 2 user's manual. NSW Health. 5. Patel, B. M.; Dauenhauer, C. J.; Rady, M. Y.; Larson, J. S.; Benjamin, T. R.; Johnson, D. J.; Helmers, R. A. Impact of Peripherally Inserted Central Catheters on Catheter-Related Bloodstream Infections in the Intensive Care Unit. J Patient Saf 2007;3:142Y148 6. Safdar, N.; Maki, D.G. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients.Chest. 2005; 128: 489-495. 7. Walshe, L. J.; Malak, S. F; Eagan, J; Sepkowitz, K. A.Complication Rates among Cancer Patients with Peripherally Inserted Central Catheters. J Clin Oncol . 2002 20:3276-3281. Read More