Catheter Duration and CLA-BSI Risk

Sengupta A, Lehmann C, Diener-West M, Perl TM, Milstone AM. Catheter duration and risk of CLA-BSI in neonates with PICCs. Pediatrics. 2010 Apr;125(4):648-53. Epub 2010 Mar 15. PubMed | Journal

OBJECTIVE: To determine whether the risk of central line-associated bloodstream infections (CLA-BSIs) remained constant over the duration of peripherally inserted central venous catheters (PICCs) in highrisk neonates.
PATIENT AND METHODS: We performed a retrospective cohort study of NICU patients who had a PICC inserted between January 1, 2006, and December 31, 2008. A Poisson regression model with linear spline terms to model time since PICC insertion was used to evaluate potential changes in the risk of CLA-BSI while adjusting for other variables.
RESULTS: Six hundred eighty-three neonates were eligible for analysis. There were 21 CLA-BSIs within a follow-up period of 10 470 catheterdays. The incidence of PICC-associated CLA-BSI was 2.01 per 1 000 catheter-days (95% confidence interval [CI]: 1.24 -3.06). The incidence rate of CLA-BSIs increased by 14% per day during the first 18 days after PICC insertion (incidence rate ratio [IRR]: 1.14 [95% CI: 1.04 -1.25]). From days 19 through 35 after PICC insertion, the trend reversed (IRR: 0.8 [95% CI: 0.66-0.96]). From days 36 through 60 after PICC insertion, the incidence rate of CLA-BSI again increased by 33% per day (IRR: 1.33 [95% CI: 1.12-1.57]). There was no statistically significant association between the risk of CLA-BSI and gestational age groups, birth weight groups, or chronological age groups.
CONCLUSIONS: Our data suggest that catheter duration is an important risk factor for PICC-associated CLA-BSI in the NICU. A significant daily increase in the risk of CLA-BSI after 35 days may warrant PICC replacement if intravascular access is necessary beyond that period.

Comment: The issue of whether to replace catheters after a set dwell period has has been the subject of NICQ listserve queries in the past; responses have indicated a range in practice among units. Perhaps we now have an evidence-based answer that clears the air?

This study reported that catheter duration (longer than 35 days) is a risk factor for PICC-associated CLA-BSI, BUT other studies have suggested catheter dwell time is not a risk factor for infection as pointed out in a comment published in the same journal issue. (Richter and Brilli cited Mahieu et al, Smith et al and Stenzel et al in their comments) The question of whether to limit dwell time based on BSI risk would seem to remain enigmatic. Richter and Brilli go on to cite improvement experience that focuses on other more important practice changes in the effort to prevent infection - these are consistent with PBPs used in NICQ 2009.
Jim Handyside

Additional Comments:

July 13, 2010
05:12 PM

Don't forget that there is also an added risk of infection associated with removing and replacing a catheter. Not infrequently, we see a baby develop sepsis the day AFTER his PICC is removed! I agree that a daily assessment of whether a catheter is needed is a necessary and appropriate measure to limit infections. But this study has not convinced me to start abritrarily removing and replacing PICCs at 35 days when they are still needed.

Andy Kairalla
Editor

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