Reconsider routine change for peripheral IV catheters

Source: Bregenzer T, et al. Is routine replacement of peripheral catheters necessary? Arch Intern Med 1998; 158:151-156.

In order to determine the relationship between catheter-related complications and duration of peripheral catheter insertion, Bregenzer and colleagues conducted a prospective, observational study of all patients in whom peripheral cannulation was performed. Catheters were left in place for the duration of intravenous therapy or until a complication occurred; routine catheter changes at 72 hours were not performed. They entered 451 patients receiving 665 catheters into the study; a total of 609 were evaluable. After catheter removal, the investigators cultured all catheters using the semi-quantitative method. Overall, 386 catheters were in place for three days or less, and 223 were in place for more than three days. Complications occurred in 156 catheterization episodes (25.6%), including 120 episodes of phlebitis (19.7%), 35 episodes of obstruction (5.7%), and 42 semi-quantitative cultures yielding 15 or more colonies per plate (6.9%). Only four of the colonized catheters showed clinical evidence of phlebitis; there were no episodes of catheter-related bacteremia. Kaplan-Meier curves demonstrated a linear rate of occurrence of phlebitis, obstruction, and colonization to day 14. Day-specific risk did not increase for any adverse outcome after the second day.

Comment by Robert Muder, MD, hospital epidemiologist at the Pittsburgh VA Medical Center.

Studies of IV therapy performed in the 1970s demonstrated that a sharp increase in peripheral catheter infection occurred after 48 hours of catheterization. The Centers for Disease Control and Prevention, therefore, recommends that peripheral intravenous catheters be rotated to a new site at 48-72 hours. However, newer catheter materials, such as Teflon and polyurethane, appear to reduce the risk of phlebitis and bacteremia.¹ The results reported by Bregenzer and colleagues suggest that routine rotation of peripheral catheters may not decrease the incidence of catheter-related complications, and that catheters could, in many patients, remain in place until a complication occurred, or until the end of therapy for as long as 14 days. Controlled trials have clearly shown that such a strategy is effective in the management of central venous catheters.² Reducing the need for rotation of peripheral catheters would clearly reduce the cost, effort, and patient discomfort associated with repeated needlesticks.

However, I believe it is premature to abandon the practice of routine peripheral catheter changes just yet. The current study involved only 223 catheters in place for more than three days; of these, only 82 were in place for six to 10 days and 26 for 11-15 days. Finally, it should be noted that catheter care was standardized and meticulous during the conduct of this study. The importance of meticulous catheter insertion and care is supported by the observation that institution of a full-time IV therapy team is followed by a dramatic decrease in catheter-related infections.³ Bregenzer and co-authors make the appropriately restrained conclusion that their results support the conduct of a randomized clinical trial to definitively settle the issue of routine rotation of peripheral catheters. I agree.

References

1. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters: A randomized controlled trial. Ann Intern Med 1991; 114:845-854.

2. Cobb DK, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992; 327:1,062-1,068.

3. Miller JM, et al. Reduction in nosocomial intravenous-device related bacteremias following institution of an intravenous therapy team. J Intravenous Nurs 1996; 2:103-106.

Stosor V, Peterson LR, Postelnick M, et al. Enterococcus faecium bacteremia: Does vancomycin resistance make a difference? Arch Intern Med 1998; 158:522-527.

In a word, yes. The authors concluded that vancomycin-resistant enterococci (VRE) infection is a serious and costly complication of prolonged hospitalization in severely debilitated patients. Previous treatment with parenteral vancomycin appears to be a major factor in the acquisition of VRE bacteremia.

"As a medical community we must be more judicious in the use of this antibiotic as well as other extended-spectrum antimicrobial agents," they note. "This study reinforces the serious nature of the problem of reemerging pathogens with multiple drug resistance and suggests that future resources and efforts must be directed at finding more efficacious therapy plus preventing further nosocomial spread of this pathogen.

The authors retrospectively analyzed the epidemiological characteristics of 32 episodes of bacteremia caused by vancomycin-susceptible E. faecium (VSE) and 21 caused by VRE. An intra-abdominal site was the most common source of bacteremia in both groups. All of the VRE and 78% of VSE bacteremia cases were nosocomially acquired. Previous administration of vancomy cin and indwelling bladder catheters were associated with VRE bacteremia. Despite similar severity-of-illness scores, only 24% of those with VRE survived, as opposed to 59% of the patients with VSE. In 62% of the patients with VRE sepsis, death was related to the bacteremia. Patients infected with VRE had longer hospitalizations than those with VSE (34.8 vs. 16.7 days, respectively). The average hospitalization cost for a VRE patient was more than $27,000 higher than the cost for a patient with VSE bloodstream infection ($83,897 vs. $56 707, respectively).

"Although our patients with VRE were just as likely to receive aggressive antibiotic therapy combined with removal of foreign bodies and surgical drainage, the high mortality in this group likely reflects the lack of effective therapy for VRE bloodstream infection," they conclude. "In addition to the high mortality, we demonstrated substantial additional hospitalization costs associated with VRE bacteremia. In today's health care environment, understanding the financial impact of this multidrug-resistant organism is crucial since controlling infection with VRE becomes both medically necessary and economically important."

Rutala WA, Gergen MF, Jones JF, et al. Levels of microbial contamination on surgical instruments. Am J Infect Control 1998; 26:143-145

Properly cleaned non-lumen used surgical instruments carry a low bioburden of organisms that are relatively nonpathogenic, raising the question of whether current Food and Drug Administration sterilization requirements may be too stringent and not reflective of clinical practice, the authors report.

"New low-temperature sterilization technologies are likely to be highly effective in preventing cross-transmission of infection via nonlumen medical instruments," the authors report. "The FDA should base its test parameters for approval of sterilization processes on scientifically obtained and clinically relevant data."

The authors ascertained the microbial load and type of organisms on used surgical instruments following standard cleaning, which consisted of the use of a washer sterilizer followed by sonic cleaning. The microbial load remaining on used surgical instruments after cleaning was as follows: 36 (72%) instruments had 0 to 10 colony-forming units (CFU); seven (14%) instruments had 11 to 100 CFU; and seven (14%) instruments had more than 100 CFU. Organisms contaminating the instruments included coagulase-negative staphylococcus (56%), followed by Bacillus (22%) and diphtheroids (14%). No other microbes were isolated from more than 4% of the instruments.

Low-temp sterilization may fail FDA criteria

Current sterilization guidelines recommend that because of the risk of cross-infection, all critical items (i.e., items that contact a sterile tissue) should be sterilized between patient uses. Among the FDA's stringent criteria are that the articles selected for each material should exhibit design configurations that provide the greatest challenge to the penetration of the sterilant (i.e., lumens), the most resistant test organism must be used, an organic load must be present, the inocula must be allowed to dry, and the inocula must be placed on various locations on the test article, including those least favorable to penetration and to contact with the sterilant.

"Not surprisingly, all currently available low-temperature sterilization processes may fail under these stringent test conditions," the authors note.

Soife NE, Borzak S, Edin BR, et al. Prevention of peripheral venous catheter complications with an intravenous therapy team: A randomized controlled trial. Arch Intern Med 1998; 158:473-477.

An intravenous therapy team significantly reduced both local and bacteremic complications of peripheral IV catheters, the authors report. Timely replacement of the catheter appeared to be the most important factor in reducing the occurrence of complication.

More than 25 million patients have peripheral intravenous (IV) catheters placed each year in U.S. hospitals. Infusion therapy is believed to account for one-third of all nosocomial bacteremias.

The authors performed a randomized, prospective, controlled study in a university-affiliated hospital to determine whether the use of an IV therapy team decreases peripheral venous catheter-related complications in adult medical patients. Patients were randomized to undergo peripheral catheter insertion and/or maintenance either by the IV team or by medical house staff. A dedicated observer reviewed catheter sites daily; findings were applied to a scoring system to define the severity of complications. Bacteremic complications were reviewed by a physician.

"This study demonstrated that the work of an IV therapy team can significantly reduce local and infectious complications of peripheral IV cathe ters," the authors report. "The overall local complication rate was 21.7% in house staff catheters and 7.9% in IV team catheters. For each day observed, the local complication rate was higher in the house staff catheters, which also had a significantly higher rate of multiple complications."

Since it has been estimated that a primary bacteremia adds 7.4 days to the average hospital stay, preventing the cost of these complications and of potential medico-legal expenses could offset part of the cost of an IV team, the authors note. Though they did not include a cost-benefit analysis in the study, they conclude that an "IV team may save more than it costs, but this is difficult to prove."

Less tangible but very important effects of a team include improving house staff morale. In a satisfaction survey, medical house staff reported that the IV nurses were more successful with difficult catheter insertions, that patient-house staff and nurse-house staff relations improved, and that levels of house staff frustration decreased. An IV team may increase educational time for house staff, but ultimately provides important quality assurance by instructing and evaluating other hospital personnel and students on aseptic techniques and proper IV insertion and maintenance.