Preventing PIV Infections

Peripheral Intravenous Line (PIV) complications can be aggravating at best and deadly at worst. To get more information about this topic and to learn about a new invention from 3M, we interviewed Joseph Hommes, VSN, RN, VA-BC, Technical Service Specialist, 3M Medical Solutions Division to find out more.

Please explain PIVs, their complications, and the use of CHG skin preps and regrowth of bacteria.

Peripheral intravenous (PIV) lines are commonly placed in the arm to administer medications and fluids for therapeutic purposes. In fact, they are the most common vascular access procedure performed on hospitalized patients with 60 to 90 percent of patients requiring an IV catheter during their hospital stay.¹

PIVs are often considered lower risk for infection than central lines because of their shorter dwell time and placement,² but PIVs can be associated with preventable complications such as inflammation, dislodgement, phlebitis, and peripheral line-associated bloodstream infections (PLABSI). And like central line-associated bloodstream infections (CLABSI), PLABSI can lead to a rise in patient morbidity, length of stay, and health care costs for the patient and facility.³

The reason why regrowth may occur so quickly even after the use of CHG skin preps is related to the location of the bacteria,⁴ the presence of microbial biofilms on skin,⁵ and the significant variability of bacteria density and species from one person’s skin to another.⁶ Research studies show that up to 20 percent or more of the total skin flora is beyond the reach of routine disinfection. These bacteria are located in skin crevices where lipids and the superficial cornified epithelium protect them; and deep in the roots of hair follicles and sebaceous glands where they cannot be removed without injuring the skin.⁷ According to Gonzalez et al, biofilms with or without underlying dermal disease, will help reduce the efficacy of CHG, which, in turn can contribute to bacterial regrowth.⁸ In the case of peripheral vascular catheter or needleless connector use, the sustained presence of an antimicrobial agent serves to keep the bacterial counts low to absent.⁹

How can health care systems protect patients against these PIVs?

All IVs have the potential to be contaminated through two sources: extraluminal, where bacteria originate on the skin surface and intraluminal, where bacteria enter via the catheter hub or IV access point.

Although PIVs aren’t monitored or researched as frequently as central lines, it’s extremely important that health care facilities and clinicians pay close attention to these lines because approximately 1.6 million PIV infections occur each year globally.¹⁰

A growing interest in comprehensive PIV maintenance bundles is emerging based on different recommendations or practice standards from the Centers for Disease Control and Prevention (CDC) guidelines,¹¹ Infusion Nurses Society (INS),¹² and the Society for Healthcare Epidemiology of America (SHEA) compendium guidelines.¹³ One recently published study from Mercy Hospital in St. Louis, MO found that implementing a comprehensive PIV maintenance bundle was associated with a decrease in the rate of PLABSIs, from 0.57 to 0.11 per 1000 patient days (p < 0.001).¹⁴

Why should health care systems work harder to protect patients against these PIV infections? How dangerous are they?

PLABSI can be incredibly detrimental to both patients and health care facilities. In addition to PLABSI being potentially fatal for some patients, it can significantly impact a facility financially, with some cases costing $10,000 to $20,000 per patient,¹⁵ and up to $40,000 in intensive care unit (ICU) settings,¹⁶ giving hospitals a large incentive to prevent PLABSIs to improve patient outcomes and reduce costs.

What do the 3M antimicrobial PIV dressings do? How is this better than what is otherwise offered? Have you done any research on their effectiveness? If so, can you give me some information about the research and its conclusions?

Short-term PIVs account for a mean of 23 percent of all hospital-acquired CRBSIs.¹⁷ Additionally, one hospital determined that the leading source of health care-acquired S. aureus bloodstream infections over an 8-year period was associated with PIVs due to normal skin flora migrating down the catheter tract through the IV line.¹⁸

Protecting patients from risks associated with PIVs needs to start with the surface of the skin, disinfecting the catheter IV access points and continuing through monitoring the catheter insertion site until it is removed. The latest addition to 3M’s portfolio in the fight against extraluminal contamination of PIVs is the 3M Tegaderm™ Antimicrobial I.V. Advanced Securement Dressing. This dressing provides site visibility, catheter securement, and enables consistent application. Chlorhexidine Gluconate (CHG) is integrated throughout the adhesive to better suppress regrowth of skin flora on prepped skin for up to 7 days as compared to non-antimicrobial dressings.¹⁹ The transparent dressing allows continuous site visibility to enable early identification of complications at the insertion site. It is also designed to minimize catheter movement and dislodgement.

It’s important to note that peripheral line bundles should also include disinfection and protection at all intraluminal access points too. Using a peripheral line bundle that includes 3M Curos™ Disinfecting Caps for Needleless Connectors and 3M Curos Tips™ Disinfecting Cap for Male Luers provides effective disinfection of catheter IV access points. Effective disinfection of needleless connectors and male luers on PIV lines has been associated with a significant decrease in primary PLABSI.²⁰

What else do you think is important for people to know about PIV bloodstream infections?

It’s critical for clinicians to better understand that PIVs are responsible for a significant number of total infections. According to a recent survey of 650 U.S. infection preventionists and clinicians, only 60 percent of infection preventionists are familiar with their facility’s PLABSI prevention protocols and procedures, yet 56 percent of all respondents believe that PLABSI poses a real threat to patient safety.²¹

With up to 90 percent of patients requiring a PIV during their hospital stay,²² clinicians should be paying closer attention to PIV care, making it a central part of their infection risk reduction programs. To get started, free educational courses about how to address clinical challenges associated with PIVs are available at 3M’s online learning platform, 3M Health Care Academy.

Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs. 2015; 38(3): 189-203.
Hadaway L. Short Peripheral intravenous catheters and infections. J Infus Nurs. 2012; 35(4): 230-240.
Kilgore, M. and Brossette, S. Cost of bloodstream infections. Am J Infect Control. 2008; 36: S172 (e171-e173).
Selwyn, S and Ellis, H. Skin Bacteria and Skin Disinfection Reconsidered, British medical journal, 1972, 1, 136-140.
Gonzalez T, Biagini, Myers JM, Herr AB and Hershey K. Staphylococcal biofilms in atopic dermatitis. Curr Allergy Asthma Rep (2017) 17: 81.
Gao Z, Tseng, C-h, Pei Z and Blaser MJ Molecular analysis of human forearm superficial skin bacterial biota. Proc Natl Acad Sci USA (2007) 104: 2927-2932.
Selwyn, S and Ellis, H. Skin Bacteria and Skin Disinfection Reconsidered, British medical journal, 1972, 1, 136-140.
Gonzalez T, Biagini, Myers JM, Herr AB and Hershey K. Staphylococcal biofilms in atopic dermatitis. Curr Allergy Asthma Rep (2017) 17: 81.
Casey AL, Karpanen TH, Nightingale P, and Elliott TSJ. An invitro comparison of standard cleaning to a continuous passive disinfection cap for the decontamination of needle free connectors. Antimicrobial Resist Infect Ctrl (2018) 7:50.
Assumes median PVC infection incidence 0.2% (Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs. 2015; 38(3): 189-203.); and average PVC dwell time of 3 days.
Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Gorski L. A., Hadaway L., Hagle M., McGoldrick M., Orr M., Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1-S159. https://www.ins1.org/Default.aspx?TabID=251&productId=113266
Society for Healthcare Epidemiology of America (SHEA). Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, 2014. http://www.shea-online.org/index.php/practice-resources/priority-topics/compendium-of-strategies-to-prevent-hais
Duncan, M, Bernatchez, S.F. et al. A Bundled Approach to Decrease the Rate of Primary Bloodstream Infections Related to Peripheral Intravenous Catheters The Journal of the Association for Vascular Access, Volume 23, Issue 1, 15 – 22.
Kilgore, M. and Brossette, S. Cost of bloodstream infections. Am J Infect Control. 2008; 36: S172 (e171-e173).
Elward, A.M., Hollenbeak, C.S., Warren, D.K., and Fraser, V.J. Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics. 2005; 115: 868–872.
Mermel L. Short-term peripheral venous catheter-related bloodstream infections: A systematic review. Clin Infect Dis. 2017; 65(10):1757-62
Mestre G, Berbel C, Tortajada P, et al. Successful multifaceted intervention aimed to reduce short peripheral venous catheter-related adverse events: A quasiexperimental study. Am J Infect Control. 2013;41: 520-526.
3M data on file.
3M data on file.
Survey of 650 infection preventionists and clinicians, commissioned by 3M and conducted by a third-party research firm in April 2018, Human Factors and the Future of Infection Prevention, 2018. 3M data on file.
Znigg, Walter et al, peripheral venous catheters: an under-evaluated problem. International Journal of Antimicrobial Age sj. Volume l34 S38-S42.