A new study led by Johns Hopkins Children's Center investigators shows that clinicians can reduce the risk of dangerous bloodstream infections in newborns with central venous catheters by ending use of the device as soon as possible, rather than waiting for signs of infection. A description of the study, slated to appear online Nov. 11 in the journal Pediatrics, suggests that caregivers weigh each baby's infection risk daily against the therapeutic benefits that the device provides.
A peripherally inserted central venous catheter, or a "PICC" line, is a tube placed into a blood vessel in the arm or forearm and threaded toward one of the major blood vessels near the lungs and heart to provide an easy temporary portal for medications, food, fluids and blood-draws in critically ill newborns. While lifesaving, the device can pose serious, and even deadly, infection risk because it can get contaminated and allow dangerous bacteria into the patient's bloodstream.
Patient-safety experts have long sought ways to minimize such risk with multi-step protocols that prevent contamination. The new study, however, shows that in addition to device handling, length of use can drive up infection risk even when hygiene protocols are meticulously followed.
"Our findings suggest that device removal should occur as early as possible and occur pre-emptively rather than reactively, after infection sets in and complications develop," says lead investigator Aaron Milstone, M.D., M.H.S., a pediatric infectious disease specialist at the Johns Hopkins Children's Center.
The study, which analyzed the records of nearly 4,000 newborns treated at eight hospitals, found that risk of infection steadily crept up during the first two weeks of use and remained elevated thereafter. Newborns with devices in place for more than one week had twice the infection risk of those whose devices came out within a week.
Infants with devices kept in for two weeks or more had three times the risk of infection of those whose devices came out within the first week. These findings, the research team says, challenge the current practice of keeping devices in place until complications or overt signs of infection develop.
Hand-washing before and after handling the device, scrubbing the device clean before and after use and following other contamination-prevention techniques are critical, but these steps should be coupled with minimizing the duration of device use, the investigators say.
"Infection-prevention maneuvers are essential but as long as the device stays in, the risk of infection is never zero, so daily weighing of the pros and cons of keeping the device in each and every newborn can go a long way toward slashing infection risk," Milstone says.
Each year, the researchers say, 80,000 central line infections occur in the United States with up to one-fifth of infected patients dying. Treating a single bloodstream infection adds nearly $40,000 in medical costs.
The investigators estimate that reducing device use by two days in 200 newborns would prevent one bloodstream infection. These absolute risk-reduction numbers may appear small, the researchers say, but given the human toll and additional treatment cost, preventing even a single episode can have dramatic benefits for the individual patient and, over the long run, for the health care system as a whole.
- Aaron M. Milstone, Nicholas G. Reich, Sonali Advani, Guoshu Yuan, Kristina Bryant, Susan E. Coffin, W. Charles Huskins, Robyn Livingston, Lisa Saiman, P. Brian Smith, and Xiaoyan Song. Catheter Dwell Time and CLABSIs in Neonates With PICCs: A Multicenter Cohort Study. Pediatrics, November 2013
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