Volume 199 - Issue 11
Prevention of peripheral intravenous catheter-related bloodstream infections: the need for routine replacement
Authors: Claire M Rickard, Joan Webster and E Geoffrey Playford
Med J Aust 2013; 199 (11): 751-752. || doi: 10.5694/mja13.11352
Published online: 16 December 2013
Published online: 16 December 2013
In reply: It is untrue that new recommendations for clinically indicated peripheral intravenous catheter (PIVC) replacement
are based on phlebitis alone.
A Cochrane systematic review considered catheter-related bloodstream infection (BSI) data
from five randomised controlled
trials (4806 patients) and found no evidence for the effectiveness of routine replacement (P = 0.64).1 The largest trial (3283 patients) studied both catheter-related BSIs and all-cause BSIs, finding no disadvantage to clinically ...
In reply: It is untrue that new recommendations for clinically indicated peripheral intravenous catheter (PIVC) replacement are based on phlebitis alone.
A Cochrane systematic review considered catheter-related bloodstream infection (BSI) data from five randomised controlled trials (4806 patients) and found no evidence for the effectiveness of routine replacement (P = 0.64).1 The largest trial (3283 patients) studied both catheter-related BSIs and all-cause BSIs, finding no disadvantage to clinically indicated PIVC removal compared with routine replacement.2 If anything, the doubling of BSI rates with routine replacement (9/1690 v 4/1593) suggested that it was the additional insertion procedures that led to increased risk of microbial entry into blood.
Replacement of PIVCs is an intervention. Interventions are tested with the least risk of bias via systematic reviews and meta-analyses. The randomised controlled trials included in the Cochrane review were prospectively registered, with data collected by research nurses, from patients in the intervention groups with those in concurrent control groups, in multiple hospitals and the home setting.2-6 In the Lancet trial, BSIs were assessed by an infectious diseases physician blind to dwell time.2 Survival analysis assessed the true risk over time per patient, not simply crude incidence per catheter.
In their letter, Collignon and colleagues present low-level evidence — retrospective data from one hospital — with no randomisation, control group, blinding or power calculations, and no information about the total number of PIVCs inserted in the hospital or their insertion and maintenance practices.
Based on the high-level evidence, practitioners should ensure that patients avoid a repeated, painful and ineffective procedure. Medical and surgical residents and trainees are busy enough without perpetuating unnecessary routine PIVC replacements.
Competing interests
No relevant disclosures.
References
- Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2010; (3): CD007798. CHDIGACG
- Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 2012; 380: 1066-1074.
- Webster J, Lloyd S, Hopkins T, et al. Developing a Research base for Intravenous Peripheral cannula re-sites (DRIP trial). A randomised controlled trial of hospital in-patients. Int J Nurs Stud 2007; 44: 664-671.
- Webster J, Clarke S, Paterson D, et al. Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. BMJ 2008; 337: a339.
- Van Donk P, Rickard CM, McGrail MR, et al. Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: a randomized controlled trial. Infect Control Hosp Epidemiol 2009; 30: 915-917.
- Rickard CM, McCann D, Munnings J, et al. Routine resite of peripheral intravenous devices every 3 days did not reduce complications compared with clinically indicated resite: a randomised controlled trial. BMC Med 2010; 8: 53. CBBCGIBI