1. 1
Are Peripheral IVs an
Overlooked Source of
Infection?
Michelle DeVries MPH, CIC
Senior Infection Control Officer
Methodist Hospitals
Gary, Indiana

2. 2
Michelle DeVries is a paid consultant of Ethicon, Inc.
This promotional educational activity is brought to you by
Ethicon, Inc. and is not certified for continuing medical
education.

3. 3
Objectives
• Explore the infection risk of
Peripheral Intravenous Catheters
• Discuss the impact of
PIV infections

4. 4
Let’s Start with a Definition…
• Report BSIs that are central line associated (i.e., a central line or
umbilical catheter was in place at the time of, or within 48 hours
before, onset of the event)
• NOTE: There is no minimum period of time that the central line
must be in place in order for the BSI to be considered central line
associated
– But please note this changes 1/1/2013
• Report BSIs that are central line associated (i.e., a central line or
umbilical catheter was in place at the time of, or within 48 hours
before, onset of the event)
• NOTE: There is no minimum period of time that the central line
must be in place in order for the BSI to be considered central line
associated
– But please note this changes 1/1/2013
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Accessed October 19, 2012
Laboratory-confirmed bloodstream infections
(LCBI) that are not secondary to a community-
acquired infection or an HAI meeting CDC/NHSN
criteria at another body site
Primary
bloodstream
infections (BSI)

5. 5
LCBI – Criterion 1
Patient has a recognized pathogen cultured
from one or more blood cultures
And
Organism cultured from blood is not related to
an infection at another site
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Accessed October 19, 2012

6. 6
LCBI – Criterion 2
Patient has at least one of the following signs or symptoms:
fever (>38 C), chills or hypotension⁰
And
Signs and symptoms and positive laboratory results
are not related to an infection at another site
And
Common commensal (i.e. diptheroids [Corynebacterium spp.],
Bacillus [not B. antrhacis] spp., Propionibacterium spp.,
coagulase-negative staphylococci [including S.epidermidis],
viridans group sterptococci, Aerococcus spp., Micrococcus spp.) is
cultured
from two or more blood cultures drawn on separate occasions.
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf
Accessed October 19, 2012

7. 7
CLABSI
CLABSI is an LCBI where a central line or umbilical catheter
was in place for >2 calendar days, with day or device placement
being Day 1
And
A central or umbilical catheter was in place on date of event
or day before. If admitted or transferred into facility with
central line in place (eg, tunneled or implanted central line),
day of first access is considered Day 1.
http://www.cdc.gov/nhsn/pdfs/training/3-day-Training-final.pdf
Accessed October 19, 2012
New clarification in CDC
definition:

8. 8
A Few More Points…
• Focus on surveillance
definitions because that is
what current reporting
requirements address
• Inflammation of the
walls of a vein
– Can be chemical,
mechanical or infection-
related
– Focus today is only on
infectious complications
Phlebitis Infection

9. 9
Why Should You Care About Complications
Associated With Non-central Lines?
1. In 2008 the Center for Medicare and Medicaid Services
(CMS) began its program of disallowing reimbursement
for vascular catheter-associated infections (note there is no
modification for type or location of the catheter or the type--local or
bloodstream [BSI]--of infection)
2. Vascular catheter-related infections would encompass all
devices used to access the vasculature without regard to
the specific tip location or limiting only to BSIs

10. Why Doesn’t Anyone
Talk About This?
• But almost no one is looking!
• Body of research is starting to grow
and dispel this myth
General belief is that the
risk
is minimal or non-existent

11. 11Maki DG et al., Mayo Clinic Proc 2006;81:1159-1171.

12. Peripheral Venous Catheters (PVCs)
Zingg W. et al., Int J Antimicrob Agents 2009;34 Suppl4:S38-
42.
• PVCs are most frequently used invasive device in hospitals
• Up to 70% of patients require a PVC during their hospital stay
• Estimated that PVCs are in place for 15%-20% of total
patient-days
• No consensus on optimal time point for PVC change, or
whether PVC replacement is required at all
• Current estimates are that PVC-bloodstream infection
incidence density rates are 0.2-0.7 per 1,000 device-days

13. 13
Recently Published Article On:
Peripheral Venous Catheter-Related
Staphylococcus aureus Bacteremia
• 24 S. aureus bacteremias
• A rate of 0.07/1000 line days
• 12% of all device related S. aureus bacteremias
were caused by PVCs
• Average treatment in this study was 19 days
• Some serious complications including two patient
deaths and one transfer to hospice
Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6):579-583

14. 14
Risk Factors1Risk Factors1
• Antecubital fossa (67%)
• Placement outside of the hospital (16%)
• Placement in Emergency Room (67%)
• Longer duration of catheterization
– 46% had duration greater than 3 days
– A national survey showed that >90% of
PIV infections take place with catheters
left in more than 3 days
1. Trinh, et al. Peripheral Venous Catheter-Related Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2011;32(6):579-583

15. 15
Catheter-Related Intravascular Infections
in Critical Care Units1
• 6-month prospective study on prevalence of
catheter-related infections in their CCU and ICU
• 1983 patients, all of whom had a peripheral line in place
• 5/1983 developed bacteremia (0.3%)
– One patient died
1. Baleva MEA, et al Catheter-related infections in critical care unit. Phil J Microbiol Infect Dis 1997; 26(2):51-54.
Baleva, et al

16. 16
Wendy Morris – North Bristol
NHS Trust
Strategies for Preventing
Intravenous Cannula Infection
• The Nosocomial Infection National Surveillance Service
suggests that “6.2% of hospital-acquired bacteremias
may be directly attributable to peripheral IV cannulation.”
• Developed a Peripheral Venous Cannulation Policy
and Peripheral Cannula Care Plan
• Audit using tools including the Saving Lives PIV
Cannula Care Bundle
Morris, W et al, Strategies for preventing peripheral intravenous cannula infection. British Journal of Nursing, 2008 (IV THERAPY SUPPLEMENT), Vol 17, No 19

17. 17
Pujol: A Comparison of Bloodstream Infections in
Central and Peripheral Venous Catheters
Prospective study of bloodstream infections (BSIs) in short and mid-
line peripheral venous catheters (PVCs) vs central venous catheters
(CVCs) among a group of non-intensive care unit patients from
October 2001 to March 2003 in a hospital in Spain.
Pujol M et al., J Hosp Infect 2007;67:22-9
Study Design
150 vascular catheter-related BSIs in 147 patients: 77 were
PVC-BSIs (0.19 per 1,000 patient-days) vs 73 CVC-BSIs (0.18
per 1, 000 patient-days). Patients with PVC-BSIs more often had
the catheter placed in the emergency department (42% vs 0 ),
had a shorter duration from catheter insertion to BSI (4.9 vs 15.4
days) and S. aureus as the pathogen (53% vs 33%).
Results

18. 18
Pujol (continued)
• Rates of infection very similar between peripheral and central
venous catheters
• Difference in onset between lines placed in ER versus inpatient
units
– Emergency Room: 3.7 days
– Nursing units: 5.7 days
• S. aureus was more prevalent in peripheral lines, but MRSA
was about the same
– Patients with S. aureus had more complications than from other
organisms
– This is significant not only for the patients but for mandatory reporting
beginning in two months in the United States
Pujol M et al., J Hosp Infect 2007;67:22-9

19. 19
Prevalence of Bloodstream Infections (BSIs) in
Central and Peripheral Vascular Catheters
Wischnewski N. et al., Zentralbl Bakteriol 1998;287:93-103.
Study Design
Results
A total of 14,966 patients were surveyed. Of these 23.9% patients
had a non-central catheter and 5.1% had a central catheter. Device
utilization was 27.3% for peripheral and 6.1% for central. BSI
prevalence was 0.3% for non-central catheters and 0.8% for central
catheters.
Prevalence survey at 72 hospitals in Germany
Conclusion
Peripheral catheters are very prevalent and associated
with moderate BSI risk

20. 20
Not Without Risk
1. Ritchie, et al. The Auckland City Hospital device Point Prevalence Survey 2005: utilisation and inectius complications of
intrasvasular and urinary devices. N Z Med J. 2007; 120:U2683.
2. Hong, et al. Fatal peripheral candidal suppurative thromophlebitis in a postoperative patinet. J Korean Med Sci. 2008; 23:1094.
Ritchie 2007 (New Zealand)1
• Looked at 345 PIVs
– 22/345 had signs of infections
• 6/44 in greater than 72 hours
• 16/301 in less than 72 hours
Hong 2008 (Korea)2
• Purulent thrombophlebitis from IV. Positive for C. albicans
• Developed fungal spondylitis in vertebrae
• Patient died

21. 21
Not Without Risk
1. Easterlow, et al. Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs. 2010; 19(5-6):721-727.
2. Lee, et al. Risk Factors for peripheral venous catheter infection in hospitalized patients: a prospective study of 3165 patients. Am J Infect Control. 2009;
37(8): 683-686.
Easterlow 2010 (England)1
• Pre-intervention: 30 MRSA bacteremias – 9 catheter-related
• Post-intervention: 14 MRSA bacteremias – 4 definite, 2
possibly catheter-related
Lee 2010 (Taiwan)2
• 46 cases of soft tissue infections from peripheral lines (over 3-year period)
– 6 with bacteremia (also with local inflammation)
– 6 needing surgical debridement for abscess
– 8 with purulent drainage or cellulitis at insertion site
• 1 with bacteremia with same pathogen
– 26 with inflammation (persisting more than 3 days after catheter removal

22. 22
One More Hospital’s Experience
Period of 6 Years All LCBI
CountedLine types associated with each infection were recorded
Over that time period between 11 and 21% of LCBI had only
peripheral access
(total of 74 patients)
30 to 47% of patients had multiple lines in place
–Majority of those had peripheral as well as central lines
–Classified (based on NHSN definition) as CLABSI
(But no proof of which line was truly responsible)
With These Infections, Can’t
Reach ZeroHouse-wide in reduction of CLABSI
PIV-only infections: not yet observed same reduction
M. DeVries, P. Mancos abstract ICAAC 2012. Non-central line related laboratory
confirmed bloodstream infections

23. 23
Cochrane Peripheral Vascular Diseases
Group
• Assessed impact of removing
peripheral catheters when
clinically indicated versus
removing and re-siting routinely
• Found no conclusive benefit in
changing PIV every 72 hours to
96 hours
• Looked at phlebitis as well as
bacteremia
• Also looked at costs associated
with routine changes
Webster, J., Osborne, S., Rickard, C., Hall, J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. (2010) Cochrane database of
systematic reviews (Online), 3, pp. CD007798.
Results:
•Changing for clinical need rather
than on routine schedule reduced
the rate of bacteremia 44%
– OR = 0.57 P= 0.37
•24% increase in phlebitis in the
clinical change group
– OR= 1.24 P=0.09

24. 24
CDC Recommendation
• “ There is no need to replace peripheral catheters more frequently than
every 72-96 hours to reduce risk of infection and phlebitis in adults [36,
140, 141]. Category 1B”
• “No recommendation is made regarding replacement of peripheral
catheters in adults only when clinically indicated [142–144]. Unresolved
issue”
• “Replace peripheral catheters in children only when clinically indicated
[32, 33]. Category 1B”
• “Some studies have suggested that planned removal at 72 hours vs.
removing as needed resulted in similar rates of phlebitis and catheter
failure [142–144]. However, these studies did not address the issue of
CRBSI, and the risk of CRBSIs with this strategy is not well studied.”
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Accessed October 19, 2012.

25. 25
INS Standards
• “Routine site care and dressing changes are not performed on
short peripheral catheters unless the dressing is soiled or not
longer intact.”
• “The nurse should consider replacement of the short
peripheral catheter when clinically indicated and when infusion
treatment does not include peripheral parenteral nutrition.”
• “The nurse should not routinely replace short peripheral
catheter in pediatric patients.”
• “If a catheter related bloodstream is suspected, consideration
should be given to culturing the catheter after removal.”
Infusion Nursing Standard of Practice, Journal of Infusion Nursing. 2011; (34) 1S

26. What Could Be Causing These Infections?
Back To Basics

27. Unknown =
28%
33
Skin
Organism
s
60%
Skin
Vein
Fibrin
Sheath,
Thrombus
Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with nuncuffed short-term central venous
catheters. Int Care Med. 2004; 30:62-67.
11
Contaminat
ed Catheter
Hub
12%
22 Contaminate
d Infusate
<1%
The Origin of
Microrganisms
Causing CRBSI1 YOUR
FLORA
OR MINE

28. 1. Ryder, MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal. 2005;5(3)
©2005 Medscape. Posted 08/18/2005. http://www.medscape.com/viewarticle/508109.
Extraluminal biofilm:
•Major source of CRBSI within
first week of catheterization in
short-term catheters
•Major source of tunnel infections
in long-term catheters
Microbial Source of
Catheter-Related Blood Stream Infections
Skin
Vein
CatheterHub
Skin
EXTRALUMINAL
COLONIZATION
INTRALUMINAL
COLONIZATION
Intraluminal biofilm:
•Major source of CRBSI after
1 week in both short- and
long-term catheters

29. 29
Technology’s Role
• What are you doing for the PIVs that are staying in longer then 72 hours to reduce skin
colonization?
• There are products out there that can help reduce the skin flora if you are leaving your
catheters in for long periods of time, i.e.
– Biopatch® Protective Disk with CHG is the only product indicated to reduce CRBSI
– Indicated to use on IV catheters (Proper Size 4151 for 6 Fr catheter)≤
• Its up to you to decided what fits best in your hospital’s protocol
– Look at the evidence
– Look at product indications

30. 30
Reporting…
• NHSN/CMS/JC/Health departments, etc only require
reporting central line associated bloodstream infections
– Just need to meet the definition PLUS have a central line in place
– No requirement for “proof” that the central line was the source or
for any evidence of local site infection
• You can still meet the definition for a LCBI and not have a
central line in place, but it is not analyzed and no
benchmarks are available within NHSN
– These are what can be referred to as non-central line
associated, laboratory confirmed bloodstream infections

31. 31
CDC Recommendation
• Ideally, this involves auditing actual care
– Morris, et al describe using audit results as educational material and
making them widely available
– Easterlow (2010. Journal of Clinical Nursing), et al demonstrated poor
baseline compliance with care of peripheral lines
– The author’s institution periodically conducts audits of peripheral
maintenance bundle as well as the more standard central line
maintenance bundle
• This data can have large impact on identifying areas needing further
review or education
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Accessed October 19, 2012.
Periodically assess knowledge of and adherence to
guidelines
for all personnel involved in the insertion and maintenance
of intravascular catheters. Category IA

32. 32
CMS and Peripheral Lines
• Starting January 1, 2013 all MRSA blood isolates are reportable
via NHSN to CMS
– Both community onset and healthcare associated must be reported
– House-wide (not just ICU) isolates must be reported from all inpatient locations
– Not just CLABSIs are counted, so any infections associated with peripheral
vascular access will also be reported
• Starting back in 2008, non-payment also includes vascular catheter related
infections; CLABSIs reported through NHSN are only part of this data set
– Any coded vascular access related infections are also included in this category
– Not limited to only central lines
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Accessed October 19, 2012.

33. 33
Review
• According to some studies, the longer a Peripheral Venous Catheters
stays in place the higher the chance there is for an infection and
possible mortality
• There have been recent changes to guidelines to allow a longer dwell
time for these catheters
• Main bacteria causing these infection is Staphylococcus coming from
skin flora intra or extra luminal
• Come Jan 1st 2013 any positive blood cultures from Methicillin-
Resistant Staphylococcus aureus must be reported to CMS
• Surveillance, training and technology are areas to look to help get an
understanding and reduction of these infections
©Ethicon, Inc. 2012 BP-404-12