During the study period, 2592 PICCs were placed in 1819 children (). The median age at the time of PICC insertion was 6 years (interquartile range [IQR], 0–13 years). More than half (55.5%) of the patients were male. The median length of hospital stay was 12 days (IQR, 6–31 days), and the median PICC dwell time was 13 days (IQR, 7–21 days). Eight hundred eight children were admitted to the PICU, and their median ICU length of stay was 11 days (IQR, 4–24 days). The majority of PICCs were inserted for administration of antibiotics (52.3%). Most children in the cohort had an underlying chronic complex condition, including cardiovascular (42.4%), respiratory (14.5%), neuromuscular (14.9%), and multiple (26.3%) conditions.
Demographic and Catheter Characteristics of 1819 Hospitalized Children with 2592 Peripherally Inserted Central Venous Catheters (PICCs)
Of the 2592 PICCs studied, 1463 (56%) were placed in 1011 children without PICU exposure during their hospitalization. In this group, the median age was 9 years (IQR, 2–14 years). The median length of hospital stay was 7 days (IQR, 4–13 days), and the median PICC dwell time was 13 days (IQR, 7–20 days). The majority of PICCs were inserted for administration of antibiotics (71.3%), and most were placed in the upper extremity (80.7%).
Overall, 116 CLABSIs occurred in 44,972 catheter-days. The CLABSI incidence rate (IR) in the entire cohort was 2.58 cases per 1000 catheter-days (95% confidence interval [CI], 2.07–3.00 cases per 1000 catheter-days). In patients without PICU exposure during their hospitalization, 37 CLABSIs occurred in 22,799 catheter-days (IR, 1.49 cases per 1000 catheter-days; 95% CI, 1.00–1.92 cases per 1000 catheter-days). The time to development of a CLABSI was shorter in patients with PICU exposure than in those without PICU exposure (P < .01 by log rank test) . We estimate that 20.5% (95% CI, 16.6% –27.7%) of children with PICU exposure would have had a CLABSI if their PICC remained indwelling for 40 days.
Time to PICC-Associated CLABSI (in days) in Hospitalized Children with and without PICU Exposure.
Among the CLABSIs, the most common organisms identified were coagulase-negative staphylococci (18 cases [13.6%]), followed by Candida parapsilosis (17 [12.9%]) . The majority of infections in children without PICU exposure were caused by gram-positive organisms (58%), whereas gram-negative organisms (38%) and fungi (35%) were responsible for most of the CLABSIs in children with PICU exposure.
Pathogens Causing Central Line–Associated Bloodstream Infection (CLABSI) in Hospitalized Children with Peripherally Inserted Central Catheters (PICCs)
Univariate analysis of potential risk factors for CLABSI in the entire cohort and children without PICU exposure are displayed in . For the entire cohort, the incidence of CLABSI was highest among children <1 year of age. Patients with a PICC dwell time of ≥21 days had a higher risk of CLABSI, compared with those with a dwell time <21 days. Other risk factors included lower extremity as site of insertion and administration of parenteral nutrition as indication for PICC insertion. In patients without PICU exposure, risk factors for CLABSI included younger age, underlying malignancy, and metabolic conditions (IRR, 3.11 [95% CI, 1.47–6.70] and 6.20 [95% CI, 2.41–15.91], respectively), lines inserted in the lower extremity (IRR, 3.08; 95% CI, 1.09–8.76), and history of PICC complicated by a CLABSI (IRR, 9.14; 95% CI, 2.81–29.75). Longer PICC dwell time was not associated with increased risk for CLABSI in this subpopulation.
Univariate Analysis for Risk Factors Associated with Central Line–Associated Bloodstream Infections (CLABSIs) in Hospitalized Children with Peripherally Inserted Central venous Catheters (PICCs)
shows the multivariable analysis with the entire cohort. After adjusting for other variables, patients with a PICC dwell time of ≥21 days had a higher risk of CLABSI, as opposed to those with a catheter dwell time of <21 days (IRR, 1.53; 95% CI, 1.05–2.26). Patients that had a PICC inserted for administration of parenteral nutrition had a higher risk of CLABSI, compared with those that had a PICC placed for intravenous access (IRR, 2.24; 95% CI, 1.31–3.84). Patients with PICU exposure had an 80% increased risk of developing a CLABSI, compared with those with no PICU exposure, after adjusting for other confounders (IRR, 1.80; 95% CI, 1.18–2.75). Patients with an underlying metabolic condition were at increased risk for CLABSI (IRR, 2.07; 95% CI, 1.14–3.74). Patients with an underlying respiratory condition were at lower risk for CLABSI, but this association may be confounded by a high antibiotic use in this population. Having a previous PICC complicated by CLABSI was also an independent risk factor for CLABSI. After adjusting for other variables, there was still a trend that age >1 year was associated with decreased risk for CLABSI; however, it was no longer statistically significant. Similarly, PICCs inserted in the lower extremity were no longer associated with increased risk for CLABSI in the adjusted analysis, nor were PICCs removed <10 days before insertion of the present PICC.
Multivariable Analysis for Risk Factors for Central Line–Associated Bloodstream Infections (CLABSIs) in Hospitalized Children with Peripherally Inserted Central Venous Catheters (PICCs)