Is it safe to insert a Peripherally Inserted Central Catheter (PICC) line in a patient with Gram-Negative Bacillus (GNB) bacteremia?

PICC Line Insertion in Patients with Gram-Negative Bacillus Bacteremia

It is generally safe to insert a PICC line in a patient with GNB bacteremia, provided the patient is on appropriate systemic antibiotic therapy and the bacteremia is not catheter-related. However, timing and clinical context are critical—ideally, PICC placement should be delayed 2-3 days after initiating antibiotics if there is no urgent indication, and the patient should have clinical improvement with negative repeat blood cultures when feasible. 1

Key Decision Framework

When PICC Placement is Appropriate with GNB Bacteremia:

• Patient is on appropriate systemic antibiotics targeting the identified GNB organism 2
• Bacteremia is NOT catheter-related (i.e., source is pneumonia, urinary tract, intra-abdominal, etc.) 3
• Clinical improvement is evident (defervescence, hemodynamic stability, improving inflammatory markers)
• No complications present such as endocarditis, suppurative thrombophlebitis, or metastatic infection 2
• The indication for PICC is compelling (prolonged antibiotics for osteomyelitis, difficult venous access, vesicant medications) 1

When to Exercise Extreme Caution or Delay:

• Persistent bacteremia despite appropriate antibiotics—this suggests either inadequate source control or a complicated infection 2
• Polymicrobial bacteremia including GNB, which increases the risk of catheter-related infection (OR 4.04) 3
• Stenotrophomonas maltophilia bacteremia, which has a 5.78-fold increased association with catheter-related infection 3
• High bacterial load (>1000 CFUs in blood cultures), which predicts catheter involvement (OR 4.39) 3
• Neutropenia, which paradoxically is more associated with non-catheter sources but increases overall infection risk 3

Guideline-Based Management of GNB Bacteremia with Central Catheters

The ESMO guidelines provide clear direction for managing existing catheters with GNB bacteremia, which informs the decision about new PICC placement:

• Systemic antibiotic therapy is mandatory for all GNB bacteremia 2
• Catheter salvage can be attempted with antibiotic lock therapy (ALT) if the catheter is already in place, though this is a weaker recommendation (Level III, C evidence) 2
• Combined antibiotic therapy should be used in patients with recent infection or colonization with multidrug-resistant GNB 2

This suggests that unlike S. aureus bacteremia (where catheter removal is mandatory) 2, GNB bacteremia does not automatically contraindicate central venous access.

Optimal Timing Strategy

For infections requiring prolonged antibiotics (e.g., osteomyelitis), PICC placement should be done within 2-3 days of admission if there is no bacteremia. 1 When bacteremia IS present:

1. Initiate appropriate antibiotics immediately based on culture and sensitivity 2
2. Wait 48-72 hours to document clinical response and ideally obtain negative repeat blood cultures
3. Ensure source control of the primary infection site
4. Then proceed with PICC placement using maximal sterile barrier precautions 2

Risk Mitigation Strategies

Catheter Selection to Minimize Infection Risk:

• Prefer single-lumen PICCs unless multiple ports are essential (each additional lumen increases infection risk) 1, 4
• Consider antimicrobial-impregnated PICCs in high-risk patients, which show a 5.45-fold reduction in CLABSI risk compared to non-impregnated catheters 5
• Choose right-sided placement over left to reduce thrombosis risk 1, 6

Insertion Technique:

• Use maximal sterile barrier precautions including cap, mask, sterile gown, sterile gloves, and full-body drape 2
• Prepare skin with >0.5% chlorhexidine with alcohol for antisepsis 2
• Use ultrasound guidance to minimize insertion attempts and mechanical complications 2

High-Risk Patient Populations Requiring Extra Vigilance:

The MPC (Michigan PICC-CLABSI) score identifies patients at elevated risk for PICC-associated bloodstream infection 4:

• Hematological cancer (3 points) 4
• CLABSI within 3 months of PICC insertion (2 points) 4
• Multilumen PICC (2 points) 4
• Solid cancers with ongoing chemotherapy (2 points) 4, 5
• Receipt of total parenteral nutrition through the PICC (1 point) 4
• Presence of another CVC at time of PICC placement (1 point) 4

For every point increase in the MPC score, the hazard ratio of CLABSI increases by 1.63. 4

Common Pitfalls to Avoid

Do not place a PICC if the patient has ongoing bacteremia from an existing catheter-related infection—this represents seeding of the bloodstream from an infected device, and placing a new catheter creates a new nidus for infection. 3

Do not assume all GNB bacteremia is low-risk—certain organisms like S. maltophilia have much higher association with catheter-related infection and warrant more caution. 3

Do not place PICCs in patients with chronic kidney disease stages 3-5 requiring imminent dialysis, as this preserves veins for fistula creation. 1

Avoid left-sided PICC placement when possible due to higher thrombosis rates. 6

Do not use femoral sites for central access in adults, as infection rates are significantly higher. 2

Monitoring After Placement

• Evaluate the catheter insertion site daily by palpation through dressing to detect tenderness 2
• Remove the PICC immediately if signs of infection develop (warmth, tenderness, erythema, purulent drainage) 2
• Obtain paired blood cultures (one from PICC, one peripheral) if catheter-related infection is suspected 2
• Monitor for thrombosis, which occurs at a rate of 4.98 per 1000 PICC days and is the most common complication 7

The average time to PICC-associated bloodstream infection is 14 days, with 85% caused by Gram-negative rods in some series. 7 The overall PICC-associated BSI rate is approximately 1.34-1.69 per 1000 catheter days. 7, 8