Journal of Infectious Diseases & Therapy
Open Access

The use of peripherally inserted central catheter (PICC) lines has steadily grown in hospital settings. Approximately 8% of patients in critical care settings require central venous access during their hospital stay [1]. Peripherally inserted central catheter lines provide several advantages over classical central venous catheters (CVCs): insertion safety, removal safety, and cost-effectiveness. Moreover, a PICC line serves as a multipurpose device, it has an increased dwell time, and it obviates the need for frequent cannulation [2,3].

Indications, contraindications, and potential complications must be considered prior to the insertion of a PICC line. The most common indications for PICC line use include frequent blood sampling and the need to deliver blood components, parenteral nutrition, or treatments considered to be vesicants or irritating (e.g., chemotherapy or antibiotics) [4]. Contraindications for the use of PICC lines include overt sepsis, bacteremia, skin infections, and burns [5,6].

Of all PICC line complications associated with increased morbidity, infections and vein thrombosis are the most important. Depending on a patient's health, these complications may even increase mortality rates [4,7]. According to the Centers for Disease Control and Prevention (CDC), blood stream infections (BSIs) can be defined as the presence of viable bacteria in the blood (i.e., bacteremia) documented by a positive blood culture result [8]. In 2019, Krein et al conducted a multicenter prospective cohort study of the 70-day followup period of 438 patients who had received a PICC line. Over half (61.4%) of the patients reported signs of at least one potentially serious complication such as a BSI (17.6%) or deep vein thrombosis (30.6%) [9].

Other serious and life-threatening complications related to the insertion of PICC lines (e.g., pneumothorax and hemothorax) are exceedingly rare [2]. In a systematic review and meta-analysis of 23 studies conducted by Chopra et al. 13 studies (50,667 patients) concluded that the risk of PICC-related BSIs was 0.91% (95% CI 0.46– 1.79). Other factors associated with PICC line-related BSIs include admission to an intensive care unit (ICU), hospital length of stay (LOS), number of PICC line lumens, and patients with hematological malignancies or individuals receiving chemotherapy [7-20]. For children and infants, PICC lines are considered to be safe and may be used for prolonged periods; the rates of infectious complications of PICC lines are lower t han for tunneled CVCs [17,21-25].

We investigated factors associated with positive blood cultures after PICC line insertion. We also assessed whether pre-PICC blood culture status affects post-insertion BSIs.

Patient selection

We conducted a retrospective record review of all consecutive hospitalized patients who had received PICC lines at King Abdul-Aziz University Hospital (Jeddah, Saudi Arabia).

Inclusion criteria

All patients at King Abdul-Aziz University Hospital who underwent PICC line insertion and were registered in the PICC line database at the interventional radiology from 18 February 2015 through 24 January 2017.

Data collection

We used the interventional radiology database to retrieve patients’ medical record numbers (MRNs). The MRNs were then used to collect additional data from the electronic hospital system: patient age, gender, nationality, presence or absence of chronic diseases (e.g., diabetes, hypertension, heart disease, bone infections, lung infections, and cancer), indication of use, insertion site of the PICC line, hospital LOS, and dwell time of the PICC line in days. The study was approved by the Institutional Review Board of King Abdul-Aziz University Hospital.

Patients’ blood and other culture status

We divided the patients into two groups according to their blood culture status prior to PICC line insertion within the same hospital admission. Individuals with positive blood cultures were placed in the “positive blood culture group”; individuals with negative blood cultures were placed in the “negative blood culture group.” In addition, the results of blood cultures performed during or after PICC line removal were obtained. Other cultures (i.e., urine, stool, sputum, and wound swab cultures) prior to PICC line insertion were obtained as well. Moreover, any fever (defined as >37.8 C) recorded on the same day prior to PICC line insertion was documented, and WBC count prior to PICC line insertion was documented as well.

Statistical analysis

We used SPSS version 20.0 for all of the statistical analyses. The Shapiro-Wilk test was used to test the normality of the study sample. Descriptive statistics (i.e., mean, standard deviation, median, and quartiles) were also calculated as necessary. When the data were not normally distributed, we used the Mann-Whitney U test to compare differences between two independent groups. We used the chi-squared test to test the relationship between two variables. A p-value less than 0.05 was assumed to indicate statistical significance.

The clinical characteristics of the patients are presented in Table 1. The records from a total of 202 patients with inserted PICC lines were analyzed. Most of the patients were between the ages of 15 and 65 (70.8%). Roughly half (57.4%) of the sample was female. Only 46.0% of the patients were of Saudi nationality. About half (58.9%; n=119) of the patients had been diagnosed with an oncological disease, and 62.9% (n=127) of the patients had been diagnosed with an infection. The most common indication for PICC line insertion was total parenteral nutrition (TPN), followed by antibiotic administration (42.1% and 38.1%, respectively). The most frequent blood culture isolates before, during, or after PICC line insertion were coagulase-negative staphylococci. In cultures taken prior to PICC line insertion, Enterococcus faecalis and Staphylococcus aureus were the most common. In cultures obtained while patients had a PICC line, Enterococcus faecalis and Klebsiella pneumoniae were the most common. After removal of a PICC line, Staphylococcus aureus was the most common blood culture isolate.

Table 1: Clinical characteristics of patients.

Table 2 lists the factors that predict positive blood cultures during or after PICC line insertion. A statistically significant relationship between nationality and PICC-related BSI was observed. Individuals of non-Saudi nationality with positive blood cultures constituted 43.1% of the sample; Saudi nationals constituted only 28.0% of the sample (p=0.025).

Table 2: Determining relationship between predictor variables and the outcome variable blood culture positive either during or after removal of PICC line.

The BSI rate in patients who had received or still currently had a PICC line was significantly associated with increased dwell time of catheterization (29 days for positive blood cultures compared with 18 days in negative cultures; p=0.0001) and increased LOS (87 days for positive blood cultures compared with 41 days for negative blood cultures; p=0.0001).

Other factors, including prior positive cultures, high WBC counts, gender, age, medical diagnosis, location of the catheter, indication of use, and co-morbidities, were not statistically significant.

Peripherally inserted central catheter lines are used often in hospitals; BSIs are the complication of most concern. There is a general belief that PICC line insertion in patients with bacteremia will predispose them to PICC line infections. Consequently, the practice at some centers is to delay PICC line insertion until the infection has been resolved. Furthermore, this practice is consistent with most guidelines, which are based on expert consensus [11]. Currently, the literature contains no evidence to support or reject this practice. A recent study by Stewart et al. concluded that the placement of PICC lines among patients with Staphylococcus aureus bacteremia is very safe and does not increase the rate of subsequent infection related to PICC line insertion [12].

In this study, we retrospectively reviewed the records of 202 patients with PICC lines at King Abdulaziz University Hospital in order to identify factors associated with the development of BSIs related to PICC line insertion. The development of a BSI either during or after the removal of a PICC line was strongly associated with the dwell time of the PICC line (p=0.0001). We noted a median dwell time of 29 days for a PICC line. In a retrospective study conducted by Yap et al., 88 PICC lines were inserted in 73 patients [13]. These authors found a median dwell time of 44 days. In Cheong et al.’s retrospective study, 27 PICC lines were inserted in 17 patients. Cheong et al. found that the median dwell time was 20 days; moreover, the mean time that elapsed until a complication occurred was 27.5 days [14]. Our study suggests that removing a PICC line in 29 days will decrease the rate of PICCrelated BSIs.

Nationality (i.e., Saudi vs. non-Saudi) was another variable that we found to be associated with an increased risk of BSIs (p=0.025). Based on our results, non-Saudi patients were more likely to have positive blood cultures either during or after PICC line insertion. This discrepancy may be explained by language barriers, which may lead to poor adherence to instructions.

Furthermore, hospital LOS appeared to have a significant, direct effect on the development of BSIs during or after the removal of a PICC line (p<0.0001). In addition, the median LOS for patients with BSIs was significantly longer than for patients without BSIs (87 vs. 41 days, respectively). A retrospective cohort study by Chopra et al. found that hospital LOS was associated with an increased risk of PICC lineassociated BSIs, which is consistent with our findings.

Other variables—such as age, gender, cancer status, overall infection, chronic diseases, indication of use, site of insertion, WBC count prior to PICC line insertion, febrile status on the same day of PICC insertion, and cultures (e.g., blood, urine, wound, and sputum) prior to PICC line insertion—were not significantly associated with an increased risk of BSIs during or after the removal of a PICC line. As noted previously, this study suggests that PICC line insertion among patients with bacteremia is safe and not associated with an increased risk of a BSI either during or after the removal of a PICC line. Therefore, there is no obvious reason to delay the insertion of a line. This conclusion is supported by a retrospective study that revealed that no relationship between early or late insertion of a PICC line among patients with bacteremia and an increased risk of PICC line-associated BSIs [12]. Furthermore, another cohort study conducted in both inpatient and outpatient settings found that PICC-related BSIs were less likely to occur than other complications [15].

There are multiple limitations to our study. First, this investigation was a retrospective study, which means that not all information was available. This situation exists because of poor documentation and/or a lack of data entry in electronic records. Documentation in our electronic hospital system did not start until 2015; therefore, we were unable to include patients treated earlier. We were only able to collect information for 202 patients, which is not a very large sample size for drawing conclusions regarding a population. Furthermore, this study was only conducted at one health center; it should be extended to include other health centers. Nevertheless, we have a sufficiently large sample size for our purposes.

We have demonstrated statistically significant risks of BSIs during and after the removal of PICC lines; these risks are associated with increased dwell times of the PICC lines, increased hospital LOS, and non-Saudi nationality. Positive blood cultures during or after the removal of PICC lines were not significantly dependent on prior positive cultures. We recommend the removal or exchange of a PICC line if one is needed for more than one month. We also suggest decreasing the hospitalization period to less than three months, if possible, and using more effective ways to communicate with non- Saudi patients. Ultimately, policies delaying PICC line insertion in patients with bacteremia should be reconsidered.