For many years, we have overlooked the infection risk associated with peripheral IV (PIV) catheters while focusing exclusively on infection risk associated with central vascular access devices. Our attention must include both! While there is no doubt that published rates of central line associated bloodstream infection (CLABSI) were far too high, we must take a closer look at the rates of BSI that are associated with PIV catheters as well. Unfortunately, there is very little prospective data on actual PIV-BSI rates. There are 2 unique studies on Staphylococcus aureus BSI that used retrospective data to analyze the problem. These studies reported similar processes and outcomes. Both studies used medical records to identify patients with S. aureus BSI and correlated blood culture results with clinical data. Trinh, et.al, reported 24 cases of S. aureus BSI related to PIV catheters. They reported these patients to be more likely to have the PIV inserted in the emergency department or outside the hospital and to have the PIV placed in the antecubital fossa. Of all S. aureus BSI, 12% were caused by PIV catheters. Using this data and data on all US hospital adult discharges, these researchers estimated that as many as 10,000 PIV-BSIs from S. aureus alone happen in US hospitals. Austin, et.al, reported 34 of 445 (7.6%) of all S. aureus BSI were related to thrombophlebitis at a PIV catheter site. The length of the bacteremic period was longer in patients with PIV-BSI, primarily caused by methicillin-resistant S. aureus BSI. Most cases were caused by PIV catheters inserted in the proximal forearm and antecubital fossa. Also, most cases were due to thrombophlebitis at old PIV sites. No guidelines recommend frequent monitoring of previous PIV catheter sites for developing or worsening signs and symptoms of thrombophlebitis, however this study indicates the necessity for monitoring sites after PIV removal. The bottom line is the need for careful aseptic technique with each PIV catheter insertion. Don’t use veins of the antecubital fossa. One or two swipes on the skin with an alcohol pad is not sufficient. Touching the prepped site with gloved fingers can only be done when wearing sterile gloves. All methods of infection prevention must be used. Hospitals are no longer reimbursed for treating infections associated with any type of vascular access device, including PIV-BSI. Strict attention to PIV catheter insertion and maintenance is just as important as the attention we now give to central VADs. Short Peripheral Intravenous Catheters and Infections Trinh, T. T., Chan, P. A., Edwards, O., Hollenbeck, B., Huang, B., Burdick, N., . . . Mermel, L. A. (2011). Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America, 32(6), 579. Austin, E. D., Sullivan, S. B., Whittier, S., Lowy, F. D., & Uhlemann, A.-C. (2016). Peripheral intravenous catheter placement is an underrecognized source of Staphylococcus aureus bloodstream infection. Paper presented at the Open forum infectious diseases. Online Course Updated - Peripheral IV Therapy in AdultsOne of our most popular courses has been updated with content that incorporates the 2016 Infusion Therapy Standards of Practice. Start out on the right track with this basic course. If you are new to IV therapy, this course will provide the needed information about all steps in process of patient assessment, planning what is needed, performing the procedures and assessing the outcomes. Click here to learn more!
Joni
2/9/2017 06:52:38 am
Lab draws may also contribute to bsi.
Lynn Hadaway
2/12/2017 11:19:35 pm
Yes, any catheter manipulation can lead to contamination and BSI, however, there is an increasing amount of evidence on using short peripheral catheters for obtaining blood samples. The 2016 INS Standard on Phlebotomy was greatly expanded in this area.
Claire Rickard
2/11/2017 07:30:54 pm
Great article as always Lyn. In these articles did they have the numbers on how many PIVs overall were inserted in the hospital in the ACF vs hand etc? Could it be they saw more infections in the ACF, because they place more IVs there overall? Or do you think that in the ACF there is more micromotion of the IV in and out of the vein, which annoys the local skin bacteria and encourages them to enter the blood? I'm interested, as always, in your thoughts :D C
Lynn Hadaway
2/12/2017 11:19:19 pm
Hi Claire, good to hear from you. The 2 studies in my blog was only a retrospective analysis of S. aureus BSI from all sources. Then they assessed medical records on these patients and reported on those connected to a PIV. So no data at all on the total number of PIVs, etc. One was done in 2011 from Len Mermel's group in Rhode Island. He is a well known epidemiologist and thought leader on all things related to CRBSI. I was struck by these similarites of upper arm/AC sites being the most common in both studies. I know that in the USA, we use far too many sites in the ACF. ER relies on that site heavily, using the reason/excuse that the patient may need a CT with contrast and that is where Radiology wants it. Yet the radiology guidelines state upper forearm or ACF for power injection of contrast. Our skill level for palpating and locating veins in the forearm is very low because nurses are not taught this skill in school. If they can't see the vein, they will not try to find one in other places. And the arm movement can cause that catheter to move in and out of the puncture site causing skin organisms to enter the site. So here in the USA, I think it is all of these reasons. We still do not have adequate data to answer these main questions. Sites at areas of joint flexion are much more prone to nerve injuries and infiltration/extravasation yet we continue to use them. Just a few days ago, I had to persuade an ER nurse not to use the ACF on my sister. It is very frustrating. Comments are closed.
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Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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May 2019
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