An increasing number of hospitalised patients require the use of venous access devices (VADs). Intravenous therapy has therefore been a topic of high clinical relevance in recent decades. There are currently several types of catheters, and the choice between them depends on a number of factors:
- Properties of the infusion product
- Duration of the treatment.
The introduction of the PICC has undoubtedly revolutionised long-term intravenous therapy and its use is currently on the rise. A large number of patients, particularly critical, oncology and haematology patients, can benefit from its use in parenteral nutrition (PN), as well as in any other necessary therapy. Insertion can be performed by a qualified nurse at the bedside and PICC use is also associated with greater patient comfort, lower complication rates and reduced costs.
Nevertheless, the PICC can sometimes be associated with infections potentially caused by contamination of the device. Faced with this situation, many professionals opt for catheter removal – however this is not always the best option. We spoke to Maite Parejo, Vascular Access Specialist on the Intravascular Therapy Team at the Sant Joan de Reus Hospital, about the prevalence of infections associated with this intravascular therapy device (1).
What is the prevalence of fever in patients who have a PICC?
It depends on the season. Oddly enough, cases of suspected catheter-related infections are higher during the holiday periods. We measure suspected and confirmed cases per 1,000 days of insertion. For example, in a study carried out in 2017 of 4,300 days of insertion, there were eight suspected cases, representing 2%, and two were actually confirmed, which is the equivalent of less than 0.5%
“There’s a strong tendency to simply remove the catheter when faced with a patient with a fever who has a central VAD.”
Do professionals have a clear idea of how to act in this situation?
My impression, speaking from my own experience in my workplace, is that they don’t. Nurses have received information from the intravascular therapy team on the guidelines to be followed, what vein integrity means and the importance of preserving it, although there still remains much to be done.
But on the practitioner’s side, there is still a strong tendency to simply remove the catheter from a patient with a fever who has a central Vascular Access Device (VAD).Why?
My opinion is that it is very easy for them to remove the catheter and that’s it, they don’t stop to think about the importance of vein integrity or they haven’t considered it. The same was true for nurses until recently, there is no talk or understanding of this topic when studying at university, so it is not given the importance it deserves; no thought is given to the potential for the veins to deteriorate and not recover, resulting in exhaustion of the veins.
No consensus has been reached to avoid this.
“No thought is given to the potential for the veins to deteriorate and not recover, resulting in exhaustion of the veins.”
In your experience, what percentage of PICCs are removed due to fever without confirmation that the device is contaminated?
I have to say that since the introduction of the intravascular therapy team in 2009 the situation has now fundamentally changed due to the information/training on this subject. Initially, 15 out of 250 removals were due to fever and three were confirmed. Today, professionals are generally more cautious and guidelines are followed before a catheter is removed.
The number of removals has fallen considerably, reducing the number of unrelated removals by more than half, although greater emphasis needs to be placed on the subject.
What is the PICC infection rate?
I would say that per 1,000 catheter days, at our hospital, in the last study in 2017 it was around 0.4 per 1,000.
Compared to a central line, or a port?
The port has a similar rate, whereas the rate for the centrally inserted venous catheter (CICC) is higher.
“Two direct blood cultures and two catheter-drawn blood cultures are carried out at the same time”.
What is the protocol in the event of fever in a patient with a PICC?
Two direct blood cultures and two catheter-drawn blood cultures are carried out at the same time, the catheter is sealed and then you wait for the results of the blood cultures.
The direct (peripheral) and central cultures must be collected at the same time, since whether or not the catheter is the cause of the infection, in other words whether it is a CRBSI, will depend on the time to positivity.
If a catheter-related infection (CRBSI) is confirmed, the catheter is removed in a sterile manner. A culture will be carried out of the catheter tip, 3 to 5 cm should be collected and then standard antibiotic treatment is administered via a different access, preferably peripheral. A new central VAD should not be placed until new blood cultures are negative (to avoid new infection and reduce costs, discomfort and so on).
In the event of colonization, a decision will be made as to whether or not to remove the catheter depending on the type of pathogen, the patient’s clinical status, the need for a VAD, and the possibility of placing a new one. If the decision is not to remove it, the catheter will be sealed with the appropriate antibiotic.
(1) Pallejà Gutiérrez, E., López Carranza, M. and Luis Jiménez Vilches, P., 2017. Catéteres Venosos de inserción Periférica (PICC) [Peripherally Inserted Venous Catheters (PICC)]. Nutrición Clínica en Medicina [Clinical Nutrition in Medicine], [online] XI(2), pp.114-127. Available at: <http://www.aulamedica.es/nutricionclinicamedicina/pdf/5053.pdf> [Accessed 15 March 2020].