For a staph bacteremia, the patient will probably get Vanco for 4-6 weeks.
A PICC is the best CVAD to deliver this type of infusion therapy. The key
is to make sure that the patient is no longer bacteremic. In other words,
the appropriate blood cultures have been drawn (at least 2 peripheral BCs),
all other sources of bactermia have been identified and removed or treated,
appropriate antibiotic therapy has been initiated, the patient is no longer
febrile (we like to wait at least 24 hours), and then the nurse (or other)
can place the PICC.
I've asked Dr. Maki, our infectious disease MDs, and other ID MDs at
conferences and they all agree: There are no studies looking at the
optimal and safest time to insert a CVAD, especially a PICC, if the patient
is bacteremic. They usually feel that it is prudent to wait til the above
steps have been taken to prevent the new device from being colonized with
staph. Once a catheter is colonized it is very difficult to eradicate.
You can initiate this discussion with your microbiology lab director (as I
did with mine), this ID doc, and your infection control nurses. If there is
an Infection Prevention Committee, you can run this policy by them for their
stamp of approval. It would be a general guideline, not a mandated policy
for the PICC nurses and referring physicians to consider. Of course all
factors must be considered for every patient who is bacteremic, and there
will be exceptions to this policy, eg, the febrile, bacteremic patient with
NO peripheral veins for IV access.
I would NOT have a policy without approval from some of the key decision
making bodies in your institution. If the issues are presented well, and
they understand your dilemma, they will likely support your well-thought out
policy. You can emphasize that you want to do what is best for the
patient, and not have them get a PICC inserted only to have it removed 48
hours later because the patient is still running fevers.
This is just a suggestion but one we have discussed ad naseum at our
institution.
Nadine Nakazawa, RN
PICC Program Coordinator
Stanford Hospital
From: "DS BROADHURST" <[EMAIL PROTECTED]>
To: "Kilbourne, Susan" <[EMAIL PROTECTED]>, [EMAIL PROTECTED]
Subject: Re: bacteremia and PICCs
Date: Fri, 13 Oct 2006 15:52:50 -0700 (PDT)
Will follow with interest others responses as this has been a grey area for
us as well.
I suggest you check out the Guidelines for Intravascular Catheter
Infections, by Mermel, L et al. (Journal of Intravenous Nursing, 2001, May
June I believe- don't have the article here at home). The recommendation
(& again I can't quote the article- the statement is in one of the tables
though) was basically that in the event of catheter-related bloodstream
infections, catheters may be replaced once appropriate systemic antibiotic
therapy is intitiated. (Let me know if you can't locate the article & I'll
verify the reference for you.)
Daphne Broadhurst RN
Ottawa ON
----- Original Message ----
From: "Kilbourne, Susan" <[EMAIL PROTECTED]>
To: [EMAIL PROTECTED]
Sent: Friday, October 13, 2006 3:30:33 PM
Subject: bacteremia and PICCs
I am hoping soemone can help me out here. Our Infectious Disease Doc is
recommending I write a policy about not placing PICCs in patient's with
bacteremia especially staph. I have never gotten a very clear picture of if
it is OK or not. If a patient needs central access so they can receive long
term antibiotics to cure this problem, isn't a PICC the best bet? I don't
feel it is our VAT nurses decision to overide physicians orders. I guess
what I need is literature to back me up one way or another...Help!
Sue Kilbourne
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