2. Financial
Disclosure
• Disclosure
– Literature
search
commissioned
and
funded
by
BD
Medical,
Inc.
– Lynn
Hadaway
is
a
paid
consultant
for
BD
Medical,
Inc.
3. Peripheral
IV
Catheters
• 1.7
Billion
sold
worldwide
– 330
million
sold
annually
in
the
USA
• Even
small
rates
equal
large
number
of
infec6ons
• Many
unanswered
ques6ons
about
outcomes
with
their
use
– Very
liPle
aPen6on
to
infec6on
risks
• Integra6ve
literature
review
to
thoroughly
evaluate
what
is
known
5. Literature
Review
1400
4
case
reports
abstracts
reviewed, 45
met
22
descrip6ve
studies
inclusion
1
cohort
study
588
studies
3
case
controlled
studies
examined
criteria
1
correla6on
study
9
randomized
controlled
trials
4
systema6c
literature
reviews
1
meta-‐analysis
Final
report
will
be
published
in
Journal
of
Infusion
Nursing,
July/August
2012
6. Literature
Review
• 22
countries
– Canada
– Lebanon
– Spain
– Scotland
– Taiwan
– Israel
– Uganda
– Chile
– Korea
– Germany
– Barxil
– USA
– United
– Switzerland
– Italy
Kingdom
– Netherlands
– Australia
– Turkey
– England
– Austria
– New
Zealand
– Japan
7. Types
of
Infec6ons
• Local
infec6ons
(case
reports)
• Celluli6s
and
sob
6ssue
infec6ons
• Osteomyeli6s
• 3
children
with
osteomyeli6s
in
close
proximity
to
peripheral
catheter
site;
skin
organisms
lead
to
thrombophlebi6s
and
then
osteomyeli6s
8. Types
of
Infec6ons
• Phlebi6s/thrombophlebi6s
– Ranges
from
2%
to
80%
– 5%
to
25%
of
peripheral
catheters
colonized
with
bacteria
at
removal
– No
data
on
rates
of
each
type
of
phlebi6s
• Suppura6ve
thrombophlebi6s-‐
purulent
drainage
from
inser6on
site
9. Types
of
Infec6ons
–
BSI/Bacteremia
Systema6c
Literature
Review
(Maki,
2006)
• Studies
from
January
1966-‐July
1,
2005
• 110
studies
of
plas6c
catheters
• 10,910
catheters;
28,720
device-‐days
• 13
BSIs
=
pooled
mean
rate
of
0.1
event
per
100
devices
• 0.4
pooled
mean
events
per
1000
device
days
• Lowest
rates
of
all
devices
by
percentage
10. Types
of
Infec6ons
–
BSI/Bacteremia
Lowest
Rates
but
High
Absolute
Numbers
• 330
million
catheter
sold
annually
in
USA
• 2
aPempts,
2
catheters
per
site
• 165
million
inserted
• 165,000
pa6ents
with
BSI
annually
11. Types
of
Infec6on
–
BSI/Bacteremia
• Retrospec6ve
• 544
cases
analysis
of
S.
• 18
definite,
6
probably
cases
of
bacteremia
aureus
related
to
short
peripheral
IV
catheters
bacteremia
• 12%
of
all
S.
aureus
bacteremias
from
July
2005
• 67%
of
definite
cases
inserted
in
Emergency
thru
March
Dept;
46%
in
right
antecubital,
21%
in
leb
2008
antecubital
• Calculated
rate
of
0.06
bacteremias
per
1000
• Blood
and
catheter
days
catheter
6p
• Annual
adult
pa6ent
discharge
data
from
USA
cultures
• Es6mated
10,028
S.
aureus
bacteremias
correlated
to
annually
in
hospitalized
adults
clinical
findings
12. Author,
Year,
Numbers
PVC
Infection
Rates
Reported
Country
Maki,
USA,
2006
110
studies
0.1
BSIs
per
100
devices
Literature
review
10,910
PVCs
0.4
mean
#
BSIs
per
1000
device
days
spanning
38.5
years
28,720
device-‐days
Pujol,
Spain,
2007
147
patients
PVC=
77
(51%)
or
0.19
cases/1000
patient
days
Descriptive
study
over
CVC=
73
(49%)
or
0.18
cases/1000
18
months
patient
days
Nahirya,
Uganda,
2008
391
PVC
cultured
81
(20.72%)
colonized
PVC
tip
catheter
tip,
hub,
and
44
(11.25%)
colonized
PVC
hub
blood
19
(4.86%)
with
same
organism
at
tip
and
hub
16
(4.09%)
PVC
tip
with
same
organism
as
blood
7
(1.79%)
with
same
organisms
at
tip,
hub
and
in
blood
13. Author,
Year,
Numbers
PVC
Infection
Rates
Reported
Country
Lee,
Taiwan,
2009
3165
patients
with
160/162
PVCs
(98.8%)
with
phlebitis;
6538
PVCs
showed
no
microbiological
evidence
of
Semi-‐quantitative
infection
culture
of
all
catheters
No
purulent
exit
site
infection
at
removal.
No
CRBSI
Webster,
Australia,
6
RCTs
comparing
Catheter
related
bacteremia:
2010
routine
change
at
• Low
risk
population
=
1/1000
device
_ixed
time
interval
vs
days
in
both
groups
when
clinically
• High
risk
population
=
7/1000
indicated
device
days
in
routine
removal
3455
participants
group;
4/1000
removal
when
1
trial
in
England
clinically
indicated
5
in
Australia
4
published
2
unpublished
14. BSI/Bacteremia
–
USA
• Retrospec6ve
• 544
cases
analysis
of
S.
• 18
definite,
6
probably
cases
of
bacteremia
aureus
related
to
short
peripheral
IV
catheters
bacteremia
• 12%
of
all
S.
aureus
bacteremias
from
July
2005
• 67%
of
definite
cases
inserted
in
Emergency
thru
March
Dept;
46%
in
right
antecubital,
21%
in
leb
2008
antecubital
• Calculated
rate
of
0.06
bacteremias
per
1000
• Blood
and
catheter
days
catheter
6p
• Annual
adult
pa6ent
discharge
data
from
USA
cultures
• Es6mated
10,028
S.
aureus
bacteremias
correlated
to
annually
in
hospitalized
adults
clinical
findings
15. Pathophysiology
• Not
well
understood
• Most
likely
mechanism
of
peripheral
catheter-‐BSI
– Coloniza6on
of
the
vascular
catheter
tract
– Biofilm
forma6on
– Occurs
during
inser&on
and
manipula&on
– No
evidence
about
the
connec6on
between
thrombophlebi6s
and
BSI
(Zingg
&
PiPet,
2009)
16. Iden6fied
Clinical
Issues
–
Catheter
Design
• Ported
catheters
– German
study
found
27%
of
pa6ents
with
possible
infec6on
from
ported
catheters
(Grune,
2004)
• 2495
catheters,
1582
pa6ents
• 104
events
per
1000
catheter
days
• Fever
and
local
signs
and
symptoms
• No
culture
data
provided
17. Iden6fied
Clinical
Issues
–
Skin
An6sepsis
• No
studies
suppor6ng
applica6on
technique
– Circular
mo6on
or
back
and
forth?
• Specific
agents,
applica6on
&
drying
6me
• Venipuncture
for
blood
culture
and
blood
donor
collec6on
focuses
on
skin
an6sepsis
with
chlorhexidine
gluconate
18. Iden6fied
Clinical
Issues
–
Skill
of
Inserters
Taiwanese
study
(Lee,
2009)
• By
emergency
dept
nurses
–
3.7%
with
phlebi6s
• By
IV
nurses
–
2.1%
with
phlebi6s
• All
phlebi6s
was
considered
to
be
infec6ous
• 160/162
phlebi6s
cases
had
microbial
evidence
of
coloniza6on
• No
purulence
or
BSIs
reported
USA
study
(Palefski,
2001)
• 639
catheters
inserted
by
IV
nurses;
137
inserted
by
generalists
nurses
• 36%
by
generalist
nurses,
20%
by
IV
nurses
removed
for
complica6on
• No
reports
of
infec6on
in
either
group
19. Iden6fied
Clinical
Issues
–
Predisposi6on
to
Phlebi6s
Higher
rates
with
more
than
1
catheter
site
• 1st
catheter
with
phlebi6s
=
5.1
X
more
likely
to
have
phlebi6s
with
subsequent
catheter
• Pain
on
infusion
with
1st
catheter
=
11.7
X
more
likely
with
subsequent
catheters
(Palefski,
2001)
• 1st
catheter
–
phlebi6s
rates
of
2.7%
• 2
or
more
catheters
=
phlebi6s
rate
of
13.4%
(Gallant,
2006)
20. Iden6fied
Clinical
Issues
–
Vein
Visualiza6on
Technology
Infrared
light
• No
infec6on
data
reported
yet
• ED
physicians
inser6ng
18
g
into
deep
basilic
or
brachial
veins
• Chlorhexidine
skin
prep,
sterile
coupling
gel,
sterile
transparent
dressing
covering
probe
Ultrasound
• No
infec6ons,
47%
with
infiltra6ons
within
24
hours
(Dargin,
2009)
–
2
studies
• Retrospec6ve
data
on
804
ED
pa6ents
• 402
with
tradi6onal
methods;
3
skin/sob
6ssue
infec6ons
• 402
with
ultrasound;
nonsterile
glove
and
nonsterile
bacteriosta6c
lubricant
gel;
2
skin/sob
6ssue
infec6ons
(Adhikari,
2010)
21. Iden6fied
Clinical
Issues
–
Catheter
Stabiliza6on
Catheter
with
Tradi6onal
catheter
hub
Mul6ple
studies
on
stabiliza6on
plamorm
plus
with
stabiliza6on
device
securement
dressing
added
stabiliza6on
devices
• None
have
included
data
on
any
type
of
infec6ons
• Fewer
unplanned
restarts
due
to
phlebi6s
reported
22. Issues
Iden6fied
• Many
prac6ce
differences
between
countries
• Varia6ons
in
study
design
• Varia6ons
in
data
analysis
– Infec6ous
episodes
per
1000
catheter
days
vs
1000
pa6ent
days
23. Issues
Iden6fied
• No
data
on
each
type
of
phlebi6s
– Mechanical
• Catheter
size
in
rela6on
to
vein
diameter
• Catheter
stabiliza6on
– Chemical
• pH
• Osmolarity
• Vesicant
nature
– Infec6ous
24. Unanswered
Ques6ons
• Many
aspects
are
NOT
addressed
in
studies
– Hand
hygiene
– Catheter
and
site
selec6on
– Skin
an6sepsis
– Catheter
stabiliza6on
– Catheter
dressing
– Use
of
add-‐on
devices
(e.g.,
extension
sets,
needleless
connectors)
– Catheter
removal
– Tourniquet
use
–
single
pa6ent?
– Source
of
flush
solu6on
–
single
dose
container?
25. Peripheral
Catheters
Cause
Infec6on
Exact
number
and
rates
are
hard
to
determine
with
current
studies
Pathophysiology
is
not
well
understood
Many
cases
go
undetected
Preven6on
is
dependent
upon
knowledge
and
skill
of
caregiver
following
published
standards
and
guidelines
More
studies
are
needed!!
