If the patient has bacteremia and Vancomycin has just been started, do you wait for the blood cultures to come back negative or insert the PICC to avoid giving Vancomycin in a PIV?
I am confused. Why would the PICC need to be removed and another one inserted if the cultures are negative? I presume you are talking about blood cultures. If they are negative, then would the patient even require antibiotics, especially vancomycin, for a lengthy course of therapy? What am I missing? Lynn
According to the study guide for the Vascular Access Certification exam, a PIV is recommended for sepsis or bacteremia unless an antimicrobial PICC is used. This statement is vague and does not give specifics, like if the antibiotic ordered is Vanco then it is better to place the PICC quickly due ot the risk involved with a vesicant.
I have not studied for the VA-BC exam but am definitely not sure about what reference they are using for making such a recommendation. When working on the INS Standards, I tried to locate a reference giving clear evidence on the issue of placing a new CVAD of any kind when cultures were positive for any type of organism. Such a recommendation could not be found thru the literature published up to early 2010. The closest I can come to finding anything about this is the set of guidelines from IDSA. Check out this reference but there are no definitive instructions as it depends upon the infecting organism and the stability of the patient and the type of CVAD. Lynn
1.Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009;49(1):1-45.
Sepsis or bacteremia usually requires an extended 10 to 14 day tx with antibiotics...at least in peds...I don't know why it would be different in adults. We delay PICC placement until peripheral blood cultures are negative because of the risk of the organism seeding to the catheter. If seeding occurs the patient can still have negative blood cultures so it may not be clear until antibiotics have been stopped and the bacteria then proliferates causing the patient to be symptomatic again. In those patients in whom we placed PICCs before we got culture results, we did indeed have to remove the PICC, wait for negative cultures and then replace line. This is regardless of the antibiotic ordered. Usually cultures clear within 48 to 72 hours after the start of antibiotics
I understand that part but that was not what I was understanding fron the previous message which stated the PICC would be removed IF the culture was negative. Lynn
That's very infomative. I provide services in Ltachs & Snif's, many of the pt's we see that are bacteremic sometimes septic, these patients are long term vent, chronic vegatative, they always have some type of positive cult. They are folks who did not have a living will., it's a viscious circle, uti, sputum, blood,wound, c-diff--- it's sad. Many times the nurses are unable to place a PIV, that's why they order a PICC. These facilities don't have infusion teams in house. The alternative for them is to send the pt out. I see your point though. That is a problem with contrating PICC services, you miss the follow up.
We also have a number of chronic home vent kids and this is a challenge with them as it can be with any patient who undergoes frequent and numerous or prolonged hospitalizations. The organism involved may indeed affect the decision making if the situation is such that obtaining access is so insurmountable that to remove and replace lines is not feasible. Now that these kind of patients (including kids) seem to be surviving their veins, it can come down to a decision of treat with whatever line is there or not be able to successfully treat at all. Very frustrating situation especially for those of us who carry the responsibility of providing that access.
We also have a number of chronic home vent kids and this is a challenge with them as it can be with any patient who undergoes frequent and numerous or prolonged hospitalizations. The organism involved may indeed affect the decision making if the situation is such that obtaining access is so insurmountable that to remove and replace lines is not feasible. Now that these kind of patients (including kids) seem to be surviving their veins, it can come down to a decision of treat with whatever line is there or not be able to successfully treat at all. Very frustrating situation especially for those of us who carry the responsibility of providing that access.
I think this all starts with far too many venipuncture attempts by unskilled staff nurses, absurb policies requiring staff nurses to make a high number of attempts before calling for help, structuring of teams that are only allowed to do PICC insertions and prohibited from doing anything else (yes, I have seen this happen), staff nurses not recognizing serious complications with the appropriate rapid interventions, etc. There are so many causes of vein wasting and it is leading to patients such as what has been described here. Lynn
Yes, Lynn, you are right and this is one of my several soapboxes. I have worked for years (decades actually) to promote the idea (and reality) of having a full service vascular access team providing the same standard of care to all patients around the clock. Instead of making forward strides, it has actually gone backwards. And yes, sometimes appropriate decisions are not made until I intervene on behalf of the patient (and nurse). I try to empower nurses to set limits (beyond the two sticks per nurse policy by saying no at the onset) and not be pushed to maintain peripheral access at all cost but it is not easy to develop that confidence to speak up especially among new nurses who are coming on board all the time.
I guess I've gone slight off topic. Sorry about that and about the double posts below.
Our ID docs recommend giving ABX for 48 hours via PIV (if PIV access is possible) to decrease seeding of a line. If a PIV is not possible, we recommend a non-tunneled catheter for short term, then change to a PICC after ABX have been given for the 48 hours or when cultures are negative.
Do you know if this practice is based on published evidence? If so, could you share those references? Or is this practice based on the experience of your ID docs? Thanks, Lynn
I put the PICC in, I don't like giving Vanco through PIV. I see ID's order a PICC then dc it & replace it with a new PICC when the cx come back neg.
Margie Hood RN
I am confused. Why would the PICC need to be removed and another one inserted if the cultures are negative? I presume you are talking about blood cultures. If they are negative, then would the patient even require antibiotics, especially vancomycin, for a lengthy course of therapy? What am I missing? Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
According to the study guide for the Vascular Access Certification exam, a PIV is recommended for sepsis or bacteremia unless an antimicrobial PICC is used. This statement is vague and does not give specifics, like if the antibiotic ordered is Vanco then it is better to place the PICC quickly due ot the risk involved with a vesicant.
Thanks,
Tami
I have not studied for the VA-BC exam but am definitely not sure about what reference they are using for making such a recommendation. When working on the INS Standards, I tried to locate a reference giving clear evidence on the issue of placing a new CVAD of any kind when cultures were positive for any type of organism. Such a recommendation could not be found thru the literature published up to early 2010. The closest I can come to finding anything about this is the set of guidelines from IDSA. Check out this reference but there are no definitive instructions as it depends upon the infecting organism and the stability of the patient and the type of CVAD. Lynn
1. Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009;49(1):1-45.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Sepsis or bacteremia usually requires an extended 10 to 14 day tx with antibiotics...at least in peds...I don't know why it would be different in adults. We delay PICC placement until peripheral blood cultures are negative because of the risk of the organism seeding to the catheter. If seeding occurs the patient can still have negative blood cultures so it may not be clear until antibiotics have been stopped and the bacteria then proliferates causing the patient to be symptomatic again. In those patients in whom we placed PICCs before we got culture results, we did indeed have to remove the PICC, wait for negative cultures and then replace line. This is regardless of the antibiotic ordered. Usually cultures clear within 48 to 72 hours after the start of antibiotics
I understand that part but that was not what I was understanding fron the previous message which stated the PICC would be removed IF the culture was negative. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Angela,
That's very infomative. I provide services in Ltachs & Snif's, many of the pt's we see that are bacteremic sometimes septic, these patients are long term vent, chronic vegatative, they always have some type of positive cult. They are folks who did not have a living will., it's a viscious circle, uti, sputum, blood,wound, c-diff--- it's sad. Many times the nurses are unable to place a PIV, that's why they order a PICC. These facilities don't have infusion teams in house. The alternative for them is to send the pt out. I see your point though. That is a problem with contrating PICC services, you miss the follow up.
FYI I have a living will.
Margie Hood RN
It's the antibiotic stewartship thing, after a good bout of Vanco they get c-diff.
Margie Hood RN
We also have a number of chronic home vent kids and this is a challenge with them as it can be with any patient who undergoes frequent and numerous or prolonged hospitalizations. The organism involved may indeed affect the decision making if the situation is such that obtaining access is so insurmountable that to remove and replace lines is not feasible. Now that these kind of patients (including kids) seem to be surviving their veins, it can come down to a decision of treat with whatever line is there or not be able to successfully treat at all. Very frustrating situation especially for those of us who carry the responsibility of providing that access.
We also have a number of chronic home vent kids and this is a challenge with them as it can be with any patient who undergoes frequent and numerous or prolonged hospitalizations. The organism involved may indeed affect the decision making if the situation is such that obtaining access is so insurmountable that to remove and replace lines is not feasible. Now that these kind of patients (including kids) seem to be surviving their veins, it can come down to a decision of treat with whatever line is there or not be able to successfully treat at all. Very frustrating situation especially for those of us who carry the responsibility of providing that access.
I think this all starts with far too many venipuncture attempts by unskilled staff nurses, absurb policies requiring staff nurses to make a high number of attempts before calling for help, structuring of teams that are only allowed to do PICC insertions and prohibited from doing anything else (yes, I have seen this happen), staff nurses not recognizing serious complications with the appropriate rapid interventions, etc. There are so many causes of vein wasting and it is leading to patients such as what has been described here. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Yes, Lynn, you are right and this is one of my several soapboxes. I have worked for years (decades actually) to promote the idea (and reality) of having a full service vascular access team providing the same standard of care to all patients around the clock. Instead of making forward strides, it has actually gone backwards. And yes, sometimes appropriate decisions are not made until I intervene on behalf of the patient (and nurse). I try to empower nurses to set limits (beyond the two sticks per nurse policy by saying no at the onset) and not be pushed to maintain peripheral access at all cost but it is not easy to develop that confidence to speak up especially among new nurses who are coming on board all the time.
I guess I've gone slight off topic. Sorry about that and about the double posts below.
Our ID docs recommend giving ABX for 48 hours via PIV (if PIV access is possible) to decrease seeding of a line. If a PIV is not possible, we recommend a non-tunneled catheter for short term, then change to a PICC after ABX have been given for the 48 hours or when cultures are negative.
Do you know if this practice is based on published evidence? If so, could you share those references? Or is this practice based on the experience of your ID docs? Thanks, Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861