Q J Med 2002; 95: 412-413
© 2002 Association of Physicians
Correspondence |
Septic discitis and other complications of peripheral venous cannulation
Department of Infection and Tropical Medicine
Birmingham Public Health Laboratory, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham
Sir,
We read with interest the recent report of a case of multi-level septic discitis with olecranon bursitis following infection at the site of intravenous cannulation.1 Two years ago, we had a similar case which led us to consider whether peripheral venous catheters (PVCs) are as harmless as generally believed. Here we briefly present a case of an infected PVC resulting in Staphylococcus aureus bacteraemia and metastatic septic arthritis, psoas abscess and septic discitis. We then outline the results of a survey we performed to look at the complications secondary to PVC use in a district hospital.
A 53-year-old man, with a history of ischaemic heart disease, presented with chest pain, and had a PVC inserted. On day 6 of his admission, he became unwell with fevers, and was noted to have cellulitis at the site of his PVC. His fevers continued, and by day 11 he had a painful right wrist, elbow and ankle, and his C-reactive protein, which was normal on admission, was 365 mg/l. S. aureus was cultured from blood and from pus aspirated from his elbow. Treatment was started with intravenous flucloxacillin and fucidic acid, but there was further clinical deterioration, and the patient required admission to the Intensive Care Unit for circulatory support. Computerized tomography revealed a psoas abscess, pus from which grew S. aureus. Magnetic resonance imaging of the cervical, dorsal and lumbar spine showed evidence of septic discitis at C6/7 and L5/S1. Flucloxacillin and ficidic acid were continued for a total of 3 months, and the patient was eventually discharged home well, after a prolonged hospital stay of 43 days.
We prospectively surveyed 146 PVCs in 102 people admitted to general medical wards and found a significant number of serious complications. Forty-five (31%) of the PVCs were complicated by thrombophlebitis (defined as two or more of tenderness, erythema, pain, swelling, purulence and a palpable venous cord), and six (4%) were complicated by cellulitis. There were two episodes of catheter-related blood stream infection (defined as a positive semi-quantitative catheter culture and a positive blood culture for the same species, in the absence of clinical, microbiological or autopsy results to suggest another source of bacteraemia). Such complications have an associated morbidity and mortality, prolong hospital stays and increase hospital costs. A number of measures were identified that could reduce the frequency of complications. A total of 95 days were recorded when the PVCs were in place but not in use. Unnecessary intra-venous cannulation must be avoided, and PVCs must be removed as soon as they are no longer required. Although 96% of the PVCs were dressed with appropriate sterile transparent dressings, half the insertions sites were obscured by bandages, which were not routinely removed, preventing regular inspection of the site and early detection of complications. In previous studies, where PVCs were inserted by a small team using strict aseptic techniques, no episodes of catheter-related blood stream infection were detected, despite over 3000 catheters studied.2,3 Thus attention to strict aseptic technique needs to be employed when inserting PVCs to reduce the rate of serious complications.
A recent report from the National Audit Office concludes that hospital-acquired infections (HAI) cause ‘avoidable adverse effects ... on patients' standard of care and health outcomes’. The report estimates that 9% of in-patients at any one time have an HAI, equating to approximately 100,000 infections per year. The cost of treating these infections, including extended length of stay, is difficult to measure, but estimates put the figure at as high as £1000 m each year. The report also concludes that approximately 30% of HAI could be avoided by better application of existing knowledge and realistic infection control practices.4
Medical staff must remember that although peripheral venous catheters are used frequently, and provide an easy means of venous access for the administration of drugs and fluids, their use is associated with serious complications. A PVC should only be inserted when there is a definite indication, careful aseptic technique must be used when inserting a PVC and it must be removed as soon as it is no longer required.
References
1.
Hatton M, Gupta M, Balint P, Field M. Septic discitis presenting following intravenous cannulation. Q J Med2002; 95:189–91.
2. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. Ann Intern Med1991; 114:845–54.
3.
Maki DG, Ringer M. Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters: gauze, a transparent polyurethane dressing, and an iodophor-transparent dressing. JAMA1987; 258:2396–403.
4. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. Report by the Comptroller and Auditor General, HC 230 Session 1999–00. 17 February 2000.
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