1. Are Peripheral IVs an Overlooked Source of Infection?
Michelle DeVries MPH, CIC Senior Infection Control Officer Methodist Hospitals Gary, Indiana 1

2. Michelle DeVries is a paid consultant of Ethicon, Inc.
This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for continuing medical education. 2

3. Explore the infection risk of Peripheral Intravenous Catheters
Discuss the impact of PIV infections
Objectives 3

4. Let’s Start with a Definition…
Primary bloodstream infections (BSI)
Laboratory-confirmed bloodstream infections (LCBI) that are not secondary to a community-acquired infection or an HAI meeting CDC/NHSN criteria at another body site
Report BSIs that are central line associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event)
NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line associated
But please note this changes 1/1/2013
Accessed October 19, 2012 4

5. LCBI – Criterion 1
Patient has a recognized pathogen cultured from one or more blood cultures
And
Organism cultured from blood is not related to an infection at another site
Accessed October 19, 2012 5

6. LCBI – Criterion 2
Patient has at least one of the following signs or symptoms: fever (>38⁰C), chills or hypotension
And
Signs and symptoms and positive laboratory results are not related to an infection at another site
Common commensal (i.e. diptheroids [Corynebacterium spp.], Bacillus [not B. antrhacis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S.epidermidis], viridans group sterptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
Accessed October 19, 2012 6

7. CLABSI New clarification in CDC definition:
CLABSI is an LCBI where a central line or umbilical catheter was in place for >2 calendar days, with day or device placement being Day 1
And
A central or umbilical catheter was in place on date of event or day before. If admitted or transferred into facility with central line in place (eg, tunneled or implanted central line), day of first access is considered Day 1.
Accessed October 19, 2012 7

8. A Few More Points… Phlebitis Infection
Inflammation of the walls of a vein
Can be chemical, mechanical or infection- related
Focus today is only on infectious complications
Focus on surveillance definitions because that is what current reporting requirements address 8

9. Why Should You Care About Complications Associated With Non-central Lines?
In 2008 the Center for Medicare and Medicaid Services (CMS) began its program of disallowing reimbursement for vascular catheter-associated infections (note there is no modification for type or location of the catheter or the type--local or bloodstream [BSI]--of infection)
Vascular catheter-related infections would encompass all devices used to access the vasculature without regard to the specific tip location or limiting only to BSIs 9

10. Why Doesn’t Anyone Talk About This?
General belief is that the risk is minimal or non-existent
But almost no one is looking!
Body of research is starting to grow and dispel this myth

11. Maki DG et al., Mayo Clinic Proc 2006;81:1159-1171.

12. Peripheral Venous Catheters (PVCs)
PVCs are most frequently used invasive device in hospitals
Up to 70% of patients require a PVC during their hospital stay
Estimated that PVCs are in place for 15%-20% of total patient-days
No consensus on optimal time point for PVC change, or whether PVC replacement is required at all
Current estimates are that PVC-bloodstream infection incidence density rates are per 1,000 device-days
Zingg W. et al., Int J Antimicrob Agents 2009;34 Suppl4:S38-42.

13. 12% of all device related S. aureus bacteremias were caused by PVCs
Recently Published Article On: Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia
24 S. aureus bacteremias
A rate of 0.07/1000 line days
12% of all device related S. aureus bacteremias were caused by PVCs
Average treatment in this study was 19 days
Some serious complications including two patient deaths and one transfer to hospice
Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6): 13

14. Risk Factors1 Antecubital fossa (67%)
Placement outside of the hospital (16%)
Placement in Emergency Room (67%)
Longer duration of catheterization
46% had duration greater than 3 days
A national survey showed that >90% of PIV infections take place with catheters left in more than 3 days
Risk Factors1
1. Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6): 14

15. Catheter-Related Intravascular Infections in Critical Care Units1
Baleva, et al
6-month prospective study on prevalence of catheter-related infections in their CCU and ICU
1983 patients, all of whom had a peripheral line in place
5/1983 developed bacteremia (0.3%)
One patient died
1. Baleva MEA, et al Catheter-related infections in critical care unit. Phil J Microbiol Infect Dis 1997; 26(2):51-54. 15

16. Strategies for Preventing Intravenous Cannula Infection
Wendy Morris – North Bristol NHS Trust
The Nosocomial Infection National Surveillance Service suggests that “6.2% of hospital-acquired bacteremias may be directly attributable to peripheral IV cannulation.”
Developed a Peripheral Venous Cannulation Policy and Peripheral Cannula Care Plan
Audit using tools including the Saving Lives PIV Cannula Care Bundle
Morris, W et al, Strategies for preventing peripheral intravenous cannula infection. British Journal of Nursing, 2008 (IV THERAPY SUPPLEMENT), Vol 17, No 19 16

17. Pujol: A Comparison of Bloodstream Infections in Central and Peripheral Venous Catheters
Study Design
Prospective study of bloodstream infections (BSIs) in short and mid- line peripheral venous catheters (PVCs) vs central venous catheters (CVCs) among a group of non-intensive care unit patients from October 2001 to March 2003 in a hospital in Spain.
Results
150 vascular catheter-related BSIs in 147 patients: 77 were PVC-BSIs (0.19 per 1,000 patient-days) vs 73 CVC-BSIs (0.18 per 1, 000 patient-days). Patients with PVC-BSIs more often had the catheter placed in the emergency department (42% vs 0 ), had a shorter duration from catheter insertion to BSI (4.9 vs days) and S. aureus as the pathogen (53% vs 33%).
Pujol M et al., J Hosp Infect 2007;67:22-9 17

18. Pujol (continued)
Rates of infection very similar between peripheral and central venous catheters
Difference in onset between lines placed in ER versus inpatient units
Emergency Room: 3.7 days
Nursing units: 5.7 days
S. aureus was more prevalent in peripheral lines, but MRSA was about the same
Patients with S. aureus had more complications than from other organisms
This is significant not only for the patients but for mandatory reporting beginning in two months in the United States
Pujol M et al., J Hosp Infect 2007;67:22-9 18

19. Prevalence of Bloodstream Infections (BSIs) in Central and Peripheral Vascular Catheters
Study Design
Prevalence survey at 72 hospitals in Germany
Results
A total of 14,966 patients were surveyed. Of these 23.9% patients had a non-central catheter and 5.1% had a central catheter. Device utilization was 27.3% for peripheral and 6.1% for central. BSI prevalence was 0.3% for non-central catheters and 0.8% for central catheters.
Conclusion
Peripheral catheters are very prevalent and associated with moderate BSI risk
Wischnewski N. et al., Zentralbl Bakteriol 1998;287: 19

20. Not Without Risk Ritchie 2007 (New Zealand)1 Hong 2008 (Korea)2
Looked at 345 PIVs
22/345 had signs of infections
6/44 in greater than 72 hours
16/301 in less than 72 hours
Hong 2008 (Korea)2
Purulent thrombophlebitis from IV. Positive for C. albicans
Developed fungal spondylitis in vertebrae
Patient died
1. Ritchie, et al. The Auckland City Hospital device Point Prevalence Survey 2005: utilisation and inectius complications of intrasvasular and urinary devices. N Z Med J. 2007; 120:U2683.
2. Hong, et al. Fatal peripheral candidal suppurative thromophlebitis in a postoperative patinet. J Korean Med Sci. 2008; 23:1094. 20

21. Not Without Risk Easterlow 2010 (England)1 Lee 2010 (Taiwan)2
Pre-intervention: 30 MRSA bacteremias – 9 catheter-related
Post-intervention: 14 MRSA bacteremias – 4 definite, 2 possibly catheter-related
Lee 2010 (Taiwan)2
46 cases of soft tissue infections from peripheral lines (over 3-year period)
6 with bacteremia (also with local inflammation)
6 needing surgical debridement for abscess
8 with purulent drainage or cellulitis at insertion site
1 with bacteremia with same pathogen
26 with inflammation (persisting more than 3 days after catheter removal
1. Easterlow, et al. Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs. 2010; 19(5-6):
2. Lee, et al. Risk Factors for peripheral venous catheter infection in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control. 2009; 37(8): 21

22. One More Hospital’s Experience
Period of 6 Years All LCBI Counted
Line types associated with each infection were recorded
Over that time period between 11 and 21% of LCBI had only peripheral access (total of 74 patients)
30 to 47% of patients had multiple lines in place
Majority of those had peripheral as well as central lines
Classified (based on NHSN definition) as CLABSI
(But no proof of which line was truly responsible)
With These Infections, Can’t Reach Zero
House-wide in reduction of CLABSI
PIV-only infections: not yet observed same reduction
M. DeVries, P. Mancos abstract ICAAC 2012.   Non-central line related laboratory confirmed bloodstream infections 22

23. Cochrane Peripheral Vascular Diseases Group
Assessed impact of removing peripheral catheters when clinically indicated versus removing and re-siting routinely
Found no conclusive benefit in changing PIV every 72 hours to 96 hours
Looked at phlebitis as well as bacteremia
Also looked at costs associated with routine changes
Results:
Changing for clinical need rather than on routine schedule reduced the rate of bacteremia 44%
OR = P= 0.37
24% increase in phlebitis in the clinical change group
OR= 1.24 P=0.09
Webster, J., Osborne, S., Rickard, C., Hall, J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. (2010) Cochrane database of systematic reviews (Online), 3, pp. CD   23

24. CDC Recommendation
“ There is no need to replace peripheral catheters more frequently than every hours to reduce risk of infection and phlebitis in adults [36, 140, 141]. Category 1B”
“No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [142–144]. Unresolved issue”
“Replace peripheral catheters in children only when clinically indicated [32, 33]. Category 1B”
“Some studies have suggested that planned removal at 72 hours vs. removing as needed resulted in similar rates of phlebitis and catheter failure [142–144]. However, these studies did not address the issue of CRBSI, and the risk of CRBSIs with this strategy is not well studied.”
Accessed October 19, 2012. 24

25. INS Standards
“Routine site care and dressing changes are not performed on short peripheral catheters unless the dressing is soiled or not longer intact.”
“The nurse should consider replacement of the short peripheral catheter when clinically indicated and when infusion treatment does not include peripheral parenteral nutrition.”
“The nurse should not routinely replace short peripheral catheter in pediatric patients.”
“If a catheter related bloodstream is suspected, consideration should be given to culturing the catheter after removal.”
Infusion Nursing Standard of Practice, Journal of Infusion Nursing ; (34) 1S 25

26. What Could Be Causing These Infections? Back To Basics

27. The Origin of Microrganisms Causing CRBSI1
YOUR FLORA OR MINE 2
Contaminated Infusate
<1% 3
Skin
Organisms
60% 1
Contaminate d Catheter Hub
12%
Unknown = 28%
Fibrin Sheath,
Thrombus
Skin
Vein
Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with nuncuffed short-term central venous catheters. Int Care Med. 2004; 30:62-67.

28. Microbial Source of Catheter-Related Blood Stream Infections
EXTRALUMINAL COLONIZATION
INTRALUMINAL COLONIZATION
Catheter
Hub
Skin
Skin
Vein
Extraluminal biofilm:
Major source of CRBSI within first week of catheterization in short-term catheters
Major source of tunnel infections in long-term catheters
Intraluminal biofilm:
Major source of CRBSI after 1 week in both short- and long-term catheters
1. Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal.  2005;5(3)  ©2005  Medscape. Posted 08/18/

29. Technology’s Role
What are you doing for the PIVs that are staying in longer then 72 hours to reduce skin colonization?
There are products out there that can help reduce the skin flora if you are leaving your catheters in for long periods of time, i.e.
Biopatch® Protective Disk with CHG is the only product indicated to reduce CRBSI
Indicated to use on IV catheters (Proper Size 4151 for ≤6 Fr catheter)
Its up to you to decided what fits best in your hospital’s protocol
Look at the evidence
Look at product indications 29

30. Reporting…
NHSN/CMS/JC/Health departments, etc only require reporting central line associated bloodstream infections
Just need to meet the definition PLUS have a central line in place
No requirement for “proof” that the central line was the source or for any evidence of local site infection
You can still meet the definition for a LCBI and not have a central line in place, but it is not analyzed and no benchmarks are available within NHSN
These are what can be referred to as non-central line associated, laboratory confirmed bloodstream infections 30

31. CDC Recommendation
Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Category IA
Ideally, this involves auditing actual care
Morris, et al describe using audit results as educational material and making them widely available
Easterlow (2010. Journal of Clinical Nursing), et al demonstrated poor baseline compliance with care of peripheral lines
The author’s institution periodically conducts audits of peripheral maintenance bundle as well as the more standard central line maintenance bundle
This data can have large impact on identifying areas needing further review or education
Accessed October 19, 2012. 31

32. CMS and Peripheral Lines
Starting January 1, 2013 all MRSA blood isolates are reportable via NHSN to CMS
Both community onset and healthcare associated must be reported
House-wide (not just ICU) isolates must be reported from all inpatient locations
Not just CLABSIs are counted, so any infections associated with peripheral vascular access will also be reported
Starting back in 2008, non-payment also includes vascular catheter related infections; CLABSIs reported through NHSN are only part of this data set
Any coded vascular access related infections are also included in this category
Not limited to only central lines
Accessed October 19, 2012. 32

33. Review
According to some studies, the longer a Peripheral Venous Catheters stays in place the higher the chance there is for an infection and possible mortality
There have been recent changes to guidelines to allow a longer dwell time for these catheters
Main bacteria causing these infection is Staphylococcus coming from skin flora intra or extra luminal
Come Jan 1st 2013 any positive blood cultures from Methicillin- Resistant Staphylococcus aureus must be reported to CMS
Surveillance, training and technology are areas to look to help get an understanding and reduction of these infections 33
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