Injury Care Solutions Group: PICC LINE INFECTIONS AND SEPTIC SHOCK

Hospitalized patients who suffer a hospital-acquired septic shock are at risk of permanent injury to any of their organ systems. Hospital-acquired sepsis is associated with increased severity of illness compared to community-acquired sepsis and is considered by most to be a unique clinical entity.

“Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity,” published in Chest, Volume 165, Issue 6, June 2024, describes the increased risks:

“Although most sepsis episodes are caused by an infection beginning before presentation to the hospital, up to one-quarter of sepsis cases develop during hospitalization.

In contrast, hypotension, impaired gas exchange, and normothermia or hypothermia are more common in patients with hospital-onset sepsis. Severity of illness is generally higher in patients with hospital-onset sepsis, with a greater number of dysfunctional organ systems than those with community-onset sepsis.

Because hospital-onset sepsis is more commonly complicated by neurologic, cardiovascular, respiratory, and renal dysfunction, these patients require vasopressors, mechanical ventilation, and renal replacement therapy (dialysis) nearly twice as often as those with community-onset sepsis.”

Time to first dose of antibiotics in hospital-acquired septic shock increases the risk of death 7.6% each hour, in a linear fashion, during the first 6 hours.^[1] The survival benefit of prompt antibiotic administration in patients located in the hospital, whether sepsis was identified in the emergency department, the wards, or the ICU, and that “delay in antibiotic administration has a significant negative impact on survival across all locations in a hospital and across severity of illness measured by organ dysfunction.^[2]

Experts in infectious disease medicine may be necessary to analyze the timeliness of the first dose and the selection of empirical antibiotics, as well as the causation of the injuries that result, understanding that failures in care are not uncommon.

“Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis,” published in Annals of ATS Volume 20, Number 9, September 2023.

“The adjusted probability of antimicrobial initiation within 3 hours of sepsis onset exhibited a fivefold difference, ranging from 13.3% for sepsis onset at 6 A.M. to 72.4% for sepsis onset at 2 P.M.

Adherence to guideline-recommended care bundles of antimicrobial initiation within 1 and 3 hours of sepsis onset followed similar trends of decline throughout the night shift, suggesting the presence of an accumulating barrier to prompt clinical care. These findings persisted in analyses restricted to patients with the highest severity of illness and were consistent across several sensitivity analyses.”

Since July 31, 2008, the Center for Medicare & Medicaid Services has included vascular-catheter-associated bloodstream infection as a Serious Reportable Event, also referred to as a “Never Event”. Care bundles for the care of PICC lines, Mid-lines, and other central lines have been implemented by hospitals, and there has been a decrease in infection observed with all of these intravascular devices.^[3] Despite PICC lines and midline intravenous catheter devices being on the market for decades, only recently has it been described that midlines are associated with less of a risk of major device complications, such as catheter-related bloodstream infection or catheter-related venous thromboembolism, than PICC lines.^[4]

Central-line associated bloodstream infections increase the length of stay during acute hospitalizations by 22.1 days, as reported in a systematic review of the literature involving 45,080,370 hospitalized patients. Hospital-acquired infections are often multidrug-resistant and are associated with an increased length of stay and increased cost. Compounding the problem is that initial gram-negative organisms, bloodstream infection involving E. coli, Klebsiella pneumoniae, and Enterobacter, are associated with recurrent gram-negative bloodstream infection.^[5] Endocarditis is a complication of central venous catheter bloodstream infections, with a 20.8% death rate despite appropriate antibiotic therapy.^[6^]

Experts in Central-line associated bloodstream infections:

Despite the known risks of vascular-catheter associated bloodstream associated with polyurethane and silicone PICC lines, midlines, and other intravascular-catheter devices hospitals have been slow to move to superhydrophilic catheter material, that are engineered to mimic the body’s chemistry, that prevent both platelets and bacteria from adhering to the catheter tubing that prevent thrombosis, occlusion, and bloodstream infections. Hospitals appear to be unaware of the estimated 50% reduction in cost after factoring in infections, catheter-related thrombosis (blood clots), and occlusion, all of which lead to patient suffering, extended length of hospitalization, and death.^[7] This is despite the growing risk of gram-negative multidrug-resistant organisms and fungi such as Candida auris.^[8] This is despite neonates surviving sepsis being at a higher risk of poorer neurodevelopmental outcomes.^[9]

Central-line associated bloodstream infections will require experts in biomaterials, interventional radiology, infectious disease, hematology, and life care planners, and is complex litigation that is proceeding forward today, given the risk of central-line associated bloodstream infections and a safer alternative design of the tubing that is available.

^[1] Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589–1596

^[2] Ferrer, MD, Ph.D., et al. Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock From the First Hour: Results From a Guideline-Based Performance Improvement Program. Critical Care Medicine. August 2014, Vol. 42, No. 8.

^[3] Reynolds, et al. Care Bundles and Peripheral Arterial Catheters: A Scoping Review. JAVA. Vol. 28, No. 3, 2023.

^[4]

^[5] Thaden, et al., Increased Costs Associated with Bloodstream Infections Caused by Multidrug-Resistant Gram-Negative Bacteria Are Due Primarily to Patients with Hospital-Acquired Infections. Antimicrobial Agents and Chemotherapy. March 2017. Vol 61, Issue 3, e01709-16.

^[6] Endocarditis Complicating Central Venous Catheter Bloodstream Infections: A Unique Form of Health Care Associated Endocarditis” in Clin. Cardiol. 32, 12, E48-E54

^[7] Moureau, et al. Integrative Review: Complications of Peripherally Inserted Central Catheters (PICC) and Midline Catheters with Economic Analysis of Potential Impact of Hydrophilic Catheter Material. Int J Nurs Health Care Res 5: 1347.

^[8] Changing Trends in the Sources and Volumes of Clinical Cultures with Candida auris at a Large Health System, 2019-2023.

^[9] Ong, Seng, et al.