Trying to keep up with the published studies and guidelines for preventing catheter-related bloodstream infection is a challenge. The confusion is compounded by many unanswered questions. One of the most frequently discussed questions currently is when to insert some type of central vascular access device (CVAD) in a patient with positive blood cultures.
A patient presenting with clinical signs and symptoms of infection may be at risk for sepsis requiring blood cultures followed by infusion of several liters of IV fluids and broad-spectrum antibiotics. Within reason, this patient is likely to require several days or even weeks of infusion therapy. The concern is colonization and subsequent bacteremia from the CVAD with the subsequent risk of a CLABSI that will be counted against the hospital. But you have to find some way to infuse fluids and medications quickly. A short peripheral catheter is inserted but, once the plan of care is known, can this be changed to a more appropriate type of CVAD if needed? This question falls in the area of CLABSI prevention; however, no set of standards or guidelines have addressed this issue due to the lack of published data. A recent comprehensive narrative literature review was published in 2018 by multiple well-known epidemiologist. They state that the only sure way to prevent any catheter related complication is to avoid inserting a catheter. Use of peripheral veins instead of insertion of a CVAD is suggested as a way to prevent all complications. But serious, life-threatening or life-altering complications do occur with peripheral catheters. This article goes on to review other issues such as the insertion sites, ultrasound use, cutaneous antisepsis, chlorhexidine bathing and dressings, impregnated catheter materials, antimicrobial lock solutions, and many other aspects. But this article does not address CVAD insertion in the presence of bacteremia or positive blood cultures. 1 A literature search revealed one study that may be the first step toward answering this question. This is a retrospective analysis of 357 patients with Staphylococcus aureus bacteremia (SAB). Two groups were identified – those with a PICC inserted within 48 hours of the first positive blood culture and those with a PICC insertion later but before completion of the IV antibiotics. No PICC-BSIs were found; there was 1 S. aureus positive catheter tip, but this was a patient in the late PICC insertion group and negative blood cultures for 5 days prior to PICC removal. The authors stated that their data suggested “that the risk of PICC infection secondary to SAB in the presence of effective antimicrobial therapy is low, and there was no apparent increased risk with early PICC insertion or insertion during bacteremia.” 2 This is a retrospective analysis with all its inherent limitations, but it is a start to answer this question. Early insertion of a PICC could save peripheral veins, increase the safety and reliability of antibiotic infusion, and facilitate early discharge to an alternative setting to continue therapy. Click on the references below to retrieve these articles. Share these with the licensed independent practitioners in your facility and start the discussion. It might not change your practice immediately, but open communication about practice issues is always a good thing. 1. Timsit J, Rupp M, Bouza E, et al. A state of the art review on optimal practices to prevent, recognize, and manage complications associated with intravascular devices in the critically ill. Intensive care medicine. 2018. 2. Stewart JD, Runnegar N. Early use of peripherally inserted central catheters is safe in Staphylococcus aureus bacteraemia. Internal medicine journal. 2018;48(1):44-49.
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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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