Infection Rate Low With Peripheral and Nontunneled CVCs Nontunneled Catheters

CHICAGO—Central venous catheters (CVCs) used to deliver chemotherapy to cancer patients traditionally have been long-term tunneled or surgically implanted ports. These types of central venous catheters were reported as early as the 1970s to be associated with the lowest levels of infection and the greatest durability.

However, according to findings from a pair of studies conducted at M.D. Anderson Cancer Center, peripherally inserted central venous catheters and nontunneled subclavian central venous catheters have such low rates of catheter-related bloodstream infection and low costs that they may be considered as alternatives to standard central venous catheters for cancer patients who must receive chemotherapy over prolonged periods.

Findings from these studies were reported by Issam Raad, MD, professor of internal medicine, M.D. Anderson Cancer Center, at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC abstracts 2045 and 2049).

Peripherally inserted lines, first used in the 1940s by cardiologists, were dismissed in the mid-1970s because of concerns about phlebitis. Interest reemerged in the 1990s because peripheral CVCs could be inserted by nurses, keeping costs down, and unlike other venous catheters, they did not contribute to intrathoracic complications, such as pneumothorax or hemithorax. Peripheral lines nevertheless were still plagued by occurrences of phlebitis and an occasional malpositioning of the catheter, Dr. Raad said.

The M.D. Anderson researchers conducted a prospective observational study involving 14,530 peripherally inserted lines, 2,148 ports, and 882 tunneled central venous catheters, which were inserted by the hospital’s infusion therapy team between 1988 and 1996.

Patients receiving peripheral lines were followed for more than 1.67 million catheter days, compared with 956,322 days for patients with ports and 260,456 days for patients with tunneled central venous catheters.

The investigators found that the rate of phlebitis was significantly higher in patients who had peripheral lines than in those who had either ports or tunneled central venous catheters (P < .001).

Although the consensus of opinion is that peripheral lines should be maintained for only 6 to 8 weeks while chemotherapy is being given, 2,870 peripherally inserted CVCs in the study had a catheter dwelling time of more than 6 months, 999 stayed in for more than 1 year, and one lasted 2,447 days.

The difference in mean catheter dwelling time for the three types of central venous catheters was statistically significant, with peripheral lines remaining in place for an average of 117 days while tunneled CVCs lasted an average of 300 days and ports an average of 450 days.

Both tunneled central venous catheters and ports were associated with an extremely low rate of catheter-related bloodstream infection: 0.0074 per 1,000 catheter days for ports and 0.042 for tunneled central venous catheters. The rate of infection associated with peripherally inserted lines was slightly higher, at 0.065 per 1,000 catheter days, but the difference was not significant.

The cost of inserting peripheral lines was considerably less than that of the other two central venous catheters. The average cost was $582 for peripheral lines, compared with $3,306 for tunneled central venous catheters and $4,316 for ports.

Because of the low rate of catheter-based bloodstream infections and low cost, Dr. Raad concluded, therefore, that peripherally inserted lines should be considered for cancer patients who require chemotherapy for 4 to 6 months.

Nontunneled CVCs

Nontunneled central venous catheters also had a low risk of catheter-related bloodstream infection in a second study reported at ICAAC. This study evaluated 20,041 nontunneled central venous catheters in comparison with the same 2,148 ports and 882 tunneled central venous catheters from the peripheral CVCs study.

The risk of catheter-related bloodstream infection per 1,000 catheter days was not significantly different for tunneled and nontunneled subclavian catheters (0.042 and 0.073 , respectively, P = .071), but the risk was higher for nontunneled catheters when compared with ports (0.073 vs 0.0074, P < .0001). Nontunneled catheters tended to remain in place longer than peripheral lines; the average duration was about 5 months (149 days), compared with 300 days for tunneled catheters and 450 days for ports.

The cost of using nontunneled subclavian catheters, from previously reported data, was slightly higher than that for peripheral lines. The estimated cost for inserting nontunneled subclavian catheters was $808, while Hickman catheters cost $3,306 and ports cost $4,316.

The risk of phlebitis and thrombosis was comparable for all three types of catheters. However, in this large cohort of patients, the risk of bloodstream infection was comparable for nontunneled and tunneled catheters. Nontunneled catheters, therefore, could be maintained cost effectively for months in cancer patients, Dr. Raad said.