Epidemiology of and Risk Factors for Central Line Associated Blood Stream Infections (CLABSI) in Hospitalized Children with Peripherally Inserted Central Venous Catheters (PICCs)

Background: PICCs are widely used for intermediate and long term intravenous access in children and infants. The current understanding of the epidemiology of and risk factors for infectious complications of PICCs in hospitalized children is based only on limited data. More evidence could assist infection prevention strategies.

Objective: To determine the incidence and risk factors of PICC-associated CLABSIs in hospitalized children.

Methods: We performed a retrospective review of all hospitalized children who had a PICC inserted between January 1, 2003 and December 31, 2009 at The Johns Hopkins Hospital. Children in the neonatal ICU (intensive care unit) were excluded from this study. CLABSIs were defined using current National Healthcare Safety Network definitions. We used univariate and multivariable Poisson regression models to identify risk factors for PICC-associated CLABSIs. 

Results: 2,592 PICCs were placed in 1,819 children during the study period. There were 116 CLABSIs in the follow up period of 44,972 catheter days. The CLABSI incidence rate (IR) was 2.58 per 1,000 catheter days (95% confidence interval [CI] 2.07-3.00). After adjusting for age, sex, underlying complex chronic conditions, previous PICCs and site of PICC insertion; independent predictors of CLABSI included PICC dwell time greater than 21 days  (IR ratio [IRR] 1.52, 95% CI 1.10-2.36), previously infected PICC (IRR 2.47, 95% CI 1.17-5.23) and pediatric ICU exposure during hospitalization (IRR 1.80, 95% CI 1.18-2.76). PICCs inserted for antibiotic use were associated with lower risk of CLABSI as compared to PICCs inserted for other indications such as parenteral nutrition, intravenous access and chemotherapy. Children with no ICU exposure (n=1463) had a lower CLABSI rate [IR 1.49 per 1,000 catheter days, 95%CI 1.00-1.92] compared to those children with ICU exposure. Risk factors for CLABSI in children without ICU exposure included indications for catheterization other than antibiotic use (IRR 4.08, 95%CI 2.10-7.93), underlying malignancy (IRR 6.20, 95%CI 2.41-15.91) and metabolic conditions (IRR 3.11, 95%CI 1.47-6.70), PICCs inserted in the lower extremity (IRR 3.08, 95%CI 1.08-8.76) and previously infected PICCs (IRR 9.14, 95%CI 2.81-29.75). 

Conclusions: Our data suggest that longer PICC dwell time, placement of PICCs primarily for indications other than antibiotics, previously infected PICCs and ICU exposure are all risk factors for PICC-associated CLABSIs. Incidence rates of CLABSIs may be lower in hospitalized children without ICU exposure. These data provide a starting point to help direct efforts to eliminate PICC-associated CLABSIs within specific hospitalized pediatric patient populations.