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LETTERS: M Ruddy and C C Kibbler Removing intravascular lines at 72 hours allows need for antibiotics to be reassessed BMJ 1998; 316: 1825a [Full text]

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Routine peripheral line changes probably do not reduce infection.

Carl Pritchard   (17 June 1998)

Routine peripheral line changes probably do not reduce infection. 17 June 1998
Carl Pritchard, Senior House Officer Intensive Care Unit, Portsmouth Hospitals. Send response to journal: Re: Routine peripheral line changes probably do not reduce infection.	Ruddy and Kibbler’s suggested that peripheral venous lines should be changed routinely at 48-72hrs, both to reduce the occurrence of catheter related bacteraemia (CR-BSI) and to stimulate a review of the need for intravenous antibiotics1. With regard to the infection issue, it has long been the practice, especially in ICUs to routinely change central venous lines (CVCs) at set times. Recent evidence has suggested that this policy may not benefit patients2. While risk of infection is related to duration of catheterisation – it has been more recently noted that the risk is related to the time the patient is catheterised rather than the duration of the individual catheter3-4. Recent trials comparing routine changes and changes only when the patient shows signs of infection have indicated minimal if any benefit from routine changes5,6. Additionally this probably detracts from the need to change an intravascular line immediately of unexplained signs develop. Such trials have not, to my knowledge, been conducted on peripheral lines. While phlebitis probably would improve, there is no relation between infection and phlebitis and it seems unlikely that, if routine changes do not improve the risk with CVCs, it will improve the risk for peripheral lines. The guideline paper from the American CDC does state that peripheral lines should be rotated to prevent phlebitis2. There is no direct evidence that this will reduce infection. Also some trials (in children) suggest that the infection rate does not increase over 48hrs7. That greatest benefit with regard to infection would be from greater awareness of the need to change lines early when signs of systemic infection develop, to remove them rapidly when no longer required but most importantly – better aseptic technique in insertion. Most lines are colonised within a few hours of insertion. Better technique, including the use of hand washing, gloves, skin prep. etc., is a far more important issue than duration. Their second suggested benefit of routine changes was the review of the need for antibiotics. The vast majority of intravenous lines are sited by PRHOs; often with minimal time to consider the need for it and often in-patients they do not know. It seems unlikely with current practice that they will be able to make sensible considered decisions, meaning that unnecessary therapies may continue, or be stopped far to early. Antibiotic therapy should be reviewed daily by the patient’s own team and sensible plans of duration both iv and total made then – or better still – when therapy commences. It seems unlikely that routine changes will fulfil either of the very desirable benefits suggested. 1. Ruddy M, Kibbler C. Removing intravascular lines at 72 hours allows need for antibiotics to be reassessed. BMJ 1998; 316:1825-6. (13th June). 2. Pearson M L. Guidelines for prevention of intravascular device-related infections. Am J Infect Control. 1996;24:262-93. 3. Elliott T S J,Faroqui M H. Infections and Intravascular Devices. British J Hospital Medicine. 1992;48(8):496-502. 4. Stenzel J P, Green T P, Fuhrman B P, Carlson P E, Marchessault R P. Percutaneous central venous catheterisation in a paediatric intensive care unit: a survival analysis complications. Critical Care Medicine. 1989;17(10):984-8. 5. Cobb D K, High K P, Sawyer R G, Sable C A, Adams R B, Lindley D A, Pruett T L, Schwenzer K J, Farr B M. A controlled trial of scheduled replacement of central venous and pulmonary artery catheters. NEJM 1992;327(15):1062-8. 6. Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter related sepsis: prospective randomised study of three methods of long term catheter maintenance. Critical Care Medicine. 1990;18(10):1073-9. 7. Garland J S, Dunne W M, Havens P, Hintermeyer M,Bozzette M A, Wincek J, Bromberger T, Seavers M. Peripheral intravenous catheter complications in critically ill children: a prospective study. Paediatrics. 1992;89(6 pt 2):1145-50.