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Peripheral Venous Catheter-Related

Staphylococcus aureus Bacteremia
ARTICLE in INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY JUNE 2011
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infection control and hospital epidemiology

june 2011, vol. 32, no. 6

original article

Peripheral Venous Catheter-Related

Staphylococcus aureus Bacteremia
T. Tony Trinh, MD;1 Philip A. Chan, MD;1,4 Omega Edwards, MD;1,4 Brian Hollenbeck, MD;1 Brian Huang, MD;1
Nancy Burdick, RN;2 Julie A. Jefferson, RN, MPH;3 Leonard A. Mermel, DO, ScM1,3,4

objective. Better understand the incidence, risk factors, and outcomes of peripheral venous catheter (PVC)related Staphylococcus
aureus bacteremia.
design. Retrospective study of PVC-related S. aureus bacteremias in adult patients from July 2005 through March 2008. A pointprevalence survey was performed January 9, 2008, on adult inpatients to determine PVC utilization; patients with a PVC served as a cohort
to assess risk factors for PVC-related S. aureus bacteremia.
setting.

Tertiary care teaching hospital.

results. Twenty-four (18 definite and 6 probable) PVC-related S. aureus bacteremias were identified (estimated incidence density, 0.07
per 1,000 catheter-days), with a median duration of catheterization of 3 days (interquartile range, 26). Patients with PVC-related S. aureus
bacteremia were significantly more likely to have a PVC in the antecubital fossa (odds ratio [OR], 6.5), a PVC placed in the emergency
department (OR, 6.0), or a PVC placed at an outside hospital (P p .005 ), with a longer duration of catheterization (P ! .001 ). These PVCs
were significantly less likely to have been inserted in the hand (OR, 0.23) or placed on an inpatient medical unit (OR, 0.17). Mean duration
of antibiotic treatment was 19 days (95% confidence interval, 1523 days); 42% (10/24) of cases encountered complications. We estimate
that there may be as many as 10,028 PVC-related S. aureus bacteremias yearly in US adult hospitalized inpatients.
conclusion. PVC-related S. aureus bacteremia is an underrecognized complication. PVCs inserted in the emergency department or at
outside institutions, PVCs placed in the antecubital fossa, and those with prolonged dwell times are associated with such infections.
Infect Control Hosp Epidemiol 2011;32(6):579-583

Central venous catheter-associated bloodstream infections affect an estimated 41,000 patients per year in US hospitals.1
Although the risk of bloodstream infection associated with
peripheral venous catheter (PVC) use is lower than that associated with other intravascular devices,2 there is far greater
use of these catheters than of central venous catheters
(CVCs),3-6 leading to the potential for serious infections in
large numbers of patients.6,7
Staphylococcus aureus is the second most common cause
of hospital-acquired bloodstream infection,8 and it is the
pathogen most often associated with serious and costly catheter-related bloodstream infections,9 such as endovascular
and disseminated infections.10,11 Patients with PVC-related S.
aureus bacteremia have a higher risk of complications compared with such infections due to other pathogens.6 Thus, we
set out to determine the incidence, risk factors, treatment,
and outcome of PVC-related S. aureus bacteremia at our
hospital.

methods
We retrospectively reviewed adult patients admitted to our
tertiary care hospital from July 1, 2005, through March 31,
2008, with S. aureus bacteremia. An episode of definite PVCrelated S. aureus bacteremia was defined as a patient with
blood cultures growing S. aureus, a PVC tip culture or PVC
insertion site culture growing S. aureus, no other source of
S. aureus bacteremia identified, and physician or intravenous
(IV) nursing team documentation noting the PVC as the
source of bacteremia. A case of probable PVC-related S. aureus bacteremia was defined as a patient with physical findings
suggesting a PVC infection (erythema, induration, phlebitis,
drainage, or palpable cord related to the PVC insertion site);
no other source of bacteremia based on medical record review
but in whom there was no culture of the PVC tip or drainage
from the insertion site; and no physician, nursing, or IV
nursing team documentation that the PVC was the source of
S. aureus bacteremia. Phlebitis was assessed using the Visual

Affiliations: 1. Department of Medicine, Rhode Island Hospital, and Warren Alpert Medical School of Brown University, Providence, Rhode Island;
2. Department of Nursing, Rhode Island Hospital, Providence, Rhode Island; 3. Department of Epidemiology and Infection Control, Rhode Island Hospital,
Providence, Rhode Island; 4. Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island.
Received September 28, 2010; accepted December 18, 2010; electronically published April 29, 2011.
2011 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3206-0007$15.00. DOI: 10.1086/660099

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Infusion Phlebitis score (1, pain and redness around the insertion site; 2, pain, swelling, erythema, and a palpable venous
cord; 3, pain, swelling, erythema, palpable venous cord beyond 3 cm, and the presence of a purulent exudate; 4, all of
the above and evidence of tissue damage). This study was
approved by the Rhode Island Hospital Institutional Review
Board.
Source Identification
Rhode Island Hospital infection control software (Theradoc)
was searched for all microbiologic cultures growing S. aureus
from adult inpatients during the study period. For each patient with S. aureus bacteremia, we reviewed all other cultures
growing S. aureus for 3 months after the S. aureus bacteremia
was documented. Cases of S. aureus bacteremia with a PVC
tip or insertion site wound culture growing S. aureus within
3 days of S. aureus bacteremia were included as cases. Patients
with S. aureus bacteremia without an identified microbiologic
source were further reviewed using electronic patient data. If
there was no identifiable source of bacteremia, we crossreferenced each such case with the IV nursing team records.
Analysis
To estimate total PVC-days during the study period, we used
hospital administrative data to determine the total number
of adult inpatient-days during the study period, and we multiplied that number by the fraction of adult inpatients with
a PVC during a point-prevalence survey we performed on
January 9, 2008, on all adult inpatient units.
Medical record review was performed on all cases of PVCrelated S. aureus bacteremia. Descriptive statistics were generated for demographic and clinical parameters. The MannWhitney U test was used to determine the differences in
duration of catheterization between the patients with PVCrelated S. aureus bacteremia and patients in the PVC pointprevalence survey; otherwise, the Fischer exact test was used.

results
A total of 544 cases of S. aureus bacteremia were identified
(Table 1). Twenty-four (18 definite and 6 probable) PVCrelated S. aureus bacteremias were identified in 24 patients
with a mean age of 63 years (95% confidence interval [CI],
5571 years; Table 2). There were 451,366 adult patient-days
during the study period. In our point-prevalence survey, 298
of 392 of adult inpatients (76%) had a PVC. Thus, during
the study, there were approximately 343,130 PVC-days, leading to an estimated incidence density of PVC-related S. aureus
bacteremia of 0.07 per 1,000 PVC-days.
For 16 of the PVC-related S. aureus bacteremias (67%),
the PVC was placed in our emergency department, 4 (17%)
were placed in an inpatient unit, 2 (8%) were placed by
emergency medical services prior to admission, and 2 (8%)
were placed at outside hospitals. There was no temporal clustering of PVCs inserted in our emergency department that

table 1. Source of Staphylococcus aureus Bacteremia

Source
Soft tissue or bone
CVC or PICCa
Pulmonary
PVC
Endovascular
Urinary tract
Otherb
Unknown

Total
(n p 544)
204
172
88
24
12
12
9
23

(37)
(32)
(16)
(4)
(2)
(2)
(2)
(4)

MSSA
(n p 296)
116
77
43
16
11
8
5
21

(39)
(26)
(15)
(5)
(4)
(3)
(2)
(6)

MRSA
(n p 248)
89
95
45
8
1
4
4
2

(36)
(38)
(18)
(3)
(0.4)
(2)
(2)
(1)

note. Data are no. (%).

a
CVC, central venous catheter; MRSA, methicillin-resistant
Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; PICC, peripherally inserted central catheter;
PVC, peripheral venous catheter.
b
Other includes S. aureus bacteremia associated with injection drug use (6), infected pacemaker (1), traumatic paracentesis (1), or traumatic bladder catheter insertion (1).

led to S. aureus bacteremias. Eleven of the 24 PVCs (46%)

were in the right antecubital fossa, 5 (21%) in the right forearm, 1 (4%) in the right hand, 5 (21%) in the left antecubital
fossa, 1 (4%) in the left forearm, and 1 (4%) in the left hand.
The mean visual phlebitis score was 3 (95% CI, 2.43.4).
Compared with the those in the point-prevalence survey, patients with PVC-related S. aureus bacteremia were more likely
to have the PVC inserted in the emergency department or at
an outside hospital and more likely to have the PVC in the
antecubital fossa (Table 3). The median duration of PVC
dwell time before the blood culture was obtained that grew
S. aureus was 3 days (interquartile range [IQR], 36 days),
compared with a median duration of PVC placement of 1
day (IQR, 12 days) in the point-prevalence survey (P !
.001).
The mean hospital duration for patients with PVC-related
S. aureus bacteremia was 15 days (95% CI, 1019). The mean
prescribed antibiotic course was 19 days (95% CI, 1523).
Eight patients and 1 patient had transthoracic and transesophageal echocardiograms, respectively; none revealed vegetations. Ten (42%) patients encountered complications. Two
patients required incision and drainage of the PVC insertion
site, 3 patients developed complications related to antibiotic
therapy (Clostridium difficile colitis in 2 patients and 1 patient
with upper-extremity deep venous thrombosis related to the
peripherally inserted central catheter for intravenous antibiotics), 2 patients died, and 1 was discharged to hospice
care.

discussion
In our study, 12% of S. aureus catheter-related bacteremias
were due to PVCs, similar to 11% reported by others12 but
in contrast to another study that found an equal number of
S. aureus bacteremias due to PVCs and CVCs.13 Our study
reaffirms the substantial medical burden that arises from these

staphylococcus aureus bacteremia

581

table 2. Characteristics of Peripheral Venous Catheter (PVC)Related Staphylococcus aureus

Bacteremia Cases
Patient characteristics
Mean age, years (95% CI)
Female
Male
Clinical setting of PVC insertion
Emergency department
Inpatient medical unit
Rescue
Outside hospital
Anatomical site of PVC insertion
Right hand
Right antecubital area
Right forearm
Left hand
Left antecubital area
Left forearm
Clinical and microbiological characteristics
Mean duration of PVC insertion prior to PVCrelated S. aureus bacteremia, days (95% CI)
Mean visual infusion phlebitis score (95% CI)a
Yes
No

Definite
(n p 18)

Probable
(n p 6)

Total
(n p 24)

63 (5570)
5 (28)
13 (72)

65 (3595)
1 (17)
5 (83)

63 (5571)
6 (25)
18 (75)

13 (72)
4 (22)
1 (6)
0

3 (50)
0
1 (17)
2 (33)

16
4
2
2

(67)
(17)
(8)
(8)

1
10
3
0
3
1

(17)
(6)

0
1
2
1
2
0

(17)
(33)
(17)
(33)

1
11
5
1
5
1

(4)
(46)
(21)
(4)
(21)
(4)

3.8 (35)
3 (23)
7 (39)
11 (61)

4
3
1
5

(27)
(24)
(17)
(83)

4
3
8
16

(36)
(34)
(33)
(67)

(6)
(56)
(17)

note. Data are no. (%) unless otherwise indicated. CI, confidence interval.
a
Visual infusion phlebitis score: 1 pain or redness around insertion site; 2 pain, swelling,
redness, palpable venous cord; 3 pain, swelling, induration, redness, palpable venous cord beyond
3 cm, presence of pus; 4 all of the above and presence of tissue damage.

infections, as 42% of our patients with PVC-related S. aureus

bacteremia encountered complications.
More PVCs causing S. aureus bacteremia were placed in
the emergency department than PVCs in our point-prevalence survey, consistent with findings of emergent catheter
insertion increasing the risk of phlebitis14 and independently
increasing the risk of catheter colonization or local infection.15
A greater than expected number of PVC-related S. aureus
bacteremias involved catheters in the antecubital fossa, possibly related to an increased risk of phlebitis at this site16 and
cannulation of veins in areas of joint flexion.17 It is unknown
whether the antecubital fossa has a greater density of S. aureus
colonization than do other upper-extremity sites or whether
it is more difficult to maintain dressing placement at this site.
The median duration of time between PVC placement and
the first positive blood culture growing S. aureus was 3 days
(IQR, 36 days); however, 46% of patients with PVC-related
S. aureus bacteremia had a PVC duration greater than 3 days.
A meta-analysis suggests that changing PVCs every 3 days
does not reduce infection risk.18 However, in a national survey, in more than 90% of PVC-associated sepsis cases, the
PVC was in situ for 3 or more days,3 and there is an independent linear relationship between PVC infectious complications and dwell time.19 Thus, the meta-analysis may have
been underpowered to address the issue as a result of a small

number of catheters in place beyond 3 days and the low risk

of bloodstream infection.
We found 0.06 PVC-related S. aureus bacteremias per 1,000
catheter-days. The true incidence may have been underestimated because of our retrospective study design and the tendency for clinicians to overlook a PVC as a source for bacteremia. Another limitation of our study was the comparison
group, which was based on a 1-day point-prevalence survey;
as such, this may not have been a representative sample of
patients with uninfected PVCs.
Various hospital PVC care campaigns have reduced risk of
PVC infections. Intravenous nursing teams reduce the risk
of PVC infections,20-22 and this may relate to better compliance with relocating PVCs within 72 hours or within 24 hours
for emergently inserted PVCs.23 Insertion of a PVC after hand
hygiene with an alcohol waterless antiseptic or after donning
gloves is independently associated with lower risk of infectious complications.19 PVCs are often in situ, despite being
unused for 2 or more days,23,24 and quality improvement efforts can eliminate such idle catheters.24 Other interventions
can reduce the risk of such infections.25,26
PVC infections have been deemphasized, as most of our
national and local preventative efforts have focused on CVCs.
We documented 24 PVC-related S. aureus bacteremias involving 77,852 adult hospital discharges. There was a mean

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june 2011, vol. 32, no. 6

table 3. Comparison of Peripheral Venous Catheters (PVCs) Associated with Documented Staphylococcus aureus Bacteremia and
PVCs without Associated Documented S. aureus Bacteremia

Anatomical site of PVC insertion

No. of PVCs
Hand
Antecubital area
Forearm
Location of PVC insertion
No. of patients with a PVC
Emergency department
Inpatient medical unit
Rescue
Outside hospital
Operating room or radiology
Unknown
Duration of PVC insertion
Median, days (IQR)

PVC-related S. aureus
bacteremia

PVC without S. aureus

bacteremiaa

24
2 (8)
16 (67)
6 (25)

317b
91 (29)
75 (24)
151 (48)

1.00
0.23
6.45
0.37

24
16
4
2
2
0
0

298
79
170
7
0
18
24

1.00
6.03
0.17
4.03

(67)
(17)
(8)
(8)

3 (36)

Exact odds ratio

(95% CI)
(reference)
(0.20.95)
(2.4718.02)
(0.121.00)

(6)
(8)

(reference)
(2.310.76)
(0.040.53)
(0.3822.76)
...
0 (03.06)
0 (02.19)

1 (12)

...

(27)
(57)
(2)

P valueb

.03
!.001

.03

!.001
!.001

.7
.005
.3
.4
!.001

note. Data are no. (%) unless otherwise indicated. CI, confidence interval; IQR, interquartile range.
a
PVCs identified in a point-prevalence survey; some patients had more than 1 PVC.
b
Fischers exact test

of 32,529,144 adult patient discharges from US hospitals from

2005 through 2007.27 Thus, we estimate that there may be as
many as 10,028 PVC-related S. aureus bacteremias each year
in adults hospitalized in the United States. One study found
that having a PVC was independently associated with a lower
risk of S. aureus bacteremia.28 However, the risk posed by
PVCs must be viewed on a national scale since many patients
have a PVC during their hospital stay. Our study suggests
that hospitals should assess their risk of PVC-related infections and initiate interventions to mitigate risk if such infections are found. Minimizing PVC placement in the antecubital fossa, consideration for removing catheters within
24 hours if they were placed under emergent conditions, and
strong consideration for replacing PVCs after a 72-hour dwell
time will reduce risk of infection in adult patients.

acknowledgments
We appreciate the secretarial support of Nicole Lundstrom; the statistical
assistance of Jason Machan, PhD (Rhode Island Hospital and Warren Alpert
Medical School of Brown University); and the nurses who kindly carried out
the point-prevalence survey.
Financial support. This study had no external funding.
Potential conflicts of interest. L.A.M. has received research support from
Theravance and Pfizer and has served as a consultant for CorMedix, Ash
Access, Semprus, CareFusion, Bard, and Catheter Connections. None of these
activities involved peripheral intravenous catheters. All other authors report
no conflicts of interest relevant to this article.
Address correspondence to Leonard Mermel, DO, ScM, Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Providence, RI
02903 (lmermel@lifespan.org).

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