Risk factors for peripherally inserted central catheter (PICC)-associated infections in patients receiving chemotherapy and the preventive effect of a self-efficacy intervention program: a randomized controlled trial
Introduction
Cancer is a common disease with high morbidity and mortality. Long treatment courses and frequent punctures increase the risk of vessel injury, which causes significant discomfort to patients (1,2). A peripherally inserted central catheter (PICC) for chemotherapy administration effectively reduces frequent punctures and ensures the safety of chemotherapy drugs, providing a long-term treatment option for cancer patients while reducing discomfort (3). Under the situation of continuous infusion of chemotherapeutics, or irritating and corrosive chemotherapeutics, the PICC was needed for the success of implementation of chemotherapy. Recent studies (4,5) show that PICCs effectively reduce discomfort, punctures, and phlebitis and are therefore widely used in clinical practice. However, A recent study (6) show that catheter-associated infection is one of the most common complications of a long PICC indwelling time, which affects treatment outcomes, prolongs hospital stays, increases medical expenses, and causes significant inconvenience to patients. Therefore, PICC-associated infections and relevant risk factors are hot topics among clinical researchers. The rate of complications at catheter insertion was 5.8% for PICC (7). Previous study (8) show that appropriate interventions in chemotherapy patients with an indwelling PICC reduce complication and infection rates during chemotherapy by improving patients’ self-management. Self-efficacy refers to the subjective judgment of self-perception of successful completion of a certain goal or behavior, which can reflect the subjective evaluation and cognition of the individual’s own behavioral ability. Self-efficacy intervention has been widely used in multiple types of cancers, and satisfactory results have been achieved in the nursing of patients with malignant tumors. In the present study, a retrospective analysis on the occurrence of PICC-related infections in chemotherapy patients was performed in our hospital in recent years. We aimed at to study the independent risk factors of PICC-related infection in chemotherapy patients to control the occurrence of infection effectively, which might provide novel principles on clinical prevention, and therapy of PICC-related infections. The results are reported below. We present the following article in accordance with the CONSORT reporting checklist (available at https://dx.doi.org/10.21037/apm-21-1848).
Methods
General information
This was a two-parallel randomized controlled trial. The allocation ratio was closed to 1:1 (79:80). Using a convenience sampling method, we selected 159 cancer patients who received chemotherapy at our hospital between July 2017 and December 2018 and randomly divided the patients to an observation group (n=79) and a control group (n=80) using a random number table. The observation group included 19 men and 60 women aged 50.51±7.02 years, and the control group included 21 men and 59 women aged 38.97±6.89 years. The inclusion criteria (9) included (I) a malignant tumor and an indwelling PICC; (II) a PICC indwelling for one week or more without any complications; and (III) consciousness with the ability to express ideas. The exclusion criteria included (I) allergies to catheter materials; (II) skin damage at the puncture site; (III) coagulation disorders or severe bleeding disorders; or (IV) any other infection. The study was approved by the Ethics Committee of Affiliated Hospital of Nantong University. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from all patients. The patients’ general information was comparable between the two groups (P>0.05).
Study methods
Control group: a conventional intervention, including instructions at discharge, general care, diet management, chemotherapy-related care, and mental care, was provided.
Observation group: a self-efficacy intervention was provided, including (I) a self-efficacy healthcare team with self-efficacy training, including 1 group leader and 5 responsible nurses; (II) an individualized health plan and a behavior contract with each patient to encourage and affirm self-efficacy behaviors, including monthly meetings to watch and discuss home care videos of PICC patients to educate patients and facilitate peer face-to-face communications to help patients improve confidence and live with their condition; and (III) individualized education to teach PICC maintenance and self-management techniques and build rapport with the patient to work together to achieve the treatment goals.
Sex, puncture site, PICC indwelling time, steroid use, immunity, white blood cell (WBC) counts, and history of diabetes were recorded and analyzed to develop intervention strategies. Samples from patients with PICC-associated infections were tested to identify pathogens. The General Self-Efficacy Scale (GSES) was used to assess self-efficacy at discharge and at month 1 after discharge. The primary endpoint was the occurrence of PICC-associated infection. The secondary endpoints were catheter blockage and catheter displacement.
Statistical analysis
SPSS v18.0 (Chicago, USA) was used for statistical analysis. Measurement data were expressed as the mean ± standard deviation () and analyzed with independent sample t-tests (intergroup comparisons) or paired t-tests (intragroup comparisons). Count data were expressed as a frequency (percent) [n (%)] and analyzed with the χ2 test. P<0.05 was considered statistically significant.
Results
A total of 159 cancer patients who received chemotherapy at our hospital between July 2017 and December 2018 and randomly divided the patients to an observation group (n=79) and a control group (n=80). The basic characters of the two groups were similar and comparable (P>0.05) (Table 1) (Figure 1).
Table 1
| Factors | Control group (n=80) | Observation group (n=79) |
|
P |
|---|---|---|---|---|
| Age | 48.97±6.89 | 50.51±7.02 | 1.396 | 0.165 |
| Gender | ||||
| Male | 21 | 19 | 0.102 | 0.749 |
| Female | 59 | 60 | ||
| Education | ||||
| ≤ Junior high school | 17 | 16 | 0.155 | 0.925 |
| Senior high school-bachelor | 38 | 36 | ||
| ≥ Bachelor | 25 | 27 | ||
| Complication | ||||
| Diabetes | 39 | 37 | 0.290 | 0.591 |
| Hypertension | 28 | 32 | ||
| Smoke | ||||
| Yes | 14 | 16 | 0.197 | 0.657 |
| No | 66 | 63 | ||
| Cancer type | ||||
| Nasopharyngeal cancer | 22 | 19 | 0.960 | 0.987 |
| Breast cancer | 18 | 17 | ||
| Lung cancer | 12 | 13 | ||
| Lymphoma | 10 | 13 | ||
| Esophagus cancer | 7 | 8 | ||
| Colorectal cancer | 7 | 6 | ||
| Other types | 4 | 3 | ||
| PICC time | ||||
| Once | 54 | 49 | 0.547 | 0.592 |
| ≥2 times | 26 | 30 | ||
| Puncture position | ||||
| Basilic vein | 42 | 37 | 0.340 | 0.672 |
| Brachial vein | 38 | 42 | ||
| Hormone application | ||||
| Yes | 47 | 49 | 0.271 | 0.433 |
| No | 33 | 30 | ||
| PICC indwelling time (d) | ||||
| >30 | 54 | 49 | 0.529 | 0.497 |
| ≤30 | 26 | 30 | ||
| Immunologic function | ||||
| Normal | 43 | 41 | 0.474 | 0.621 |
| Weak | 37 | 38 | ||
| White blood cell count (×109/L) | ||||
| ≤3.0 | 35 | 31 | 0.541 | 0.769 |
| >3.0 | 45 | 49 |
Infection rate
Among the 159 patients receiving chemotherapy, 26 (16.35%) experienced PICC-associated infections.
Pathogens
Pathogens including gram-positive bacteria (13, 50.00%), gram-negative bacteria (8, 30.77%), and fungi (5, 19.23%) were identified.
Univariate analysis of PICC-associated infections
Univariate analysis showed that sex, puncture site, and steroid use were unrelated to PICC-associated infections (P>0.05), whereas PICC indwelling time, WBC counts, a history of diabetes, and immunity were significantly related to PICC-associated infections (P<0.05) (Table 2).
Table 2
| Item | No infection (n=133) | Infection (n=26) | χ2 | P |
|---|---|---|---|---|
| Sex | 1.477 | 0.224 | ||
| Male | 31 (23.31) | 9 (34.62) | ||
| Female | 102 (76.69) | 17 (65.38) | ||
| Puncture site | 0.010 | 0.922 | ||
| Basilic vein | 60 (40.11) | 12 (46.15) | ||
| Steroid use | 73 (54.89) | 14 (53.85) | ||
| Brachial vein | 0.627 | 0.428 | ||
| Yes | 92 (69.17) | 20 (76.92) | ||
| No | 41 (30.83) | 6 (23.08) | ||
| PICC indwelling time (days) | 8.136 | 0.004* | ||
| ≤30 | 48 (36.09) | 2 (7.69) | ||
| >30 | 85 (63.91) | 24 (92.31) | ||
| Immunity | 16.404 | <0.001* | ||
| Normal | 83 (62.41) | 5 (19.23) | ||
| Low | 50 (37.59) | 21 (80.77) | ||
| WBC counts (×109/L) | 3.961 | 0.047* | ||
| ≤3.0 | 46 (34.59) | 19 (73.08) | ||
| >3.0 | 87 (65.41) | 7 (26.92) | ||
| History of diabetes | 3.853 | 0.050* | ||
| Yes | 59 (44.36) | 17 (65.38) | ||
| No | 74 (55.64) | 9 (34.62) |
*, P≤0.05 (statistically significant). PICC, peripherally inserted central catheter.
Self-efficacy scores before and after the intervention
No significant between-group difference was observed before the intervention (P>0.05). After the intervention, the self-efficacy score was improved in both groups, especially in the observation group (P<0.05, Table 3).
Table 3
| Group | n | Self-efficacy score |
|
P | |
|---|---|---|---|---|---|
| At discharge | Month 1 after discharge | ||||
| Control group | 59 | 18.56±3.56 | 28.45±5.12 | 15.226 | 0.000* |
| Observation group | 60 | 18.45±4.02 | 24.12±3.89 | 9.591 | 0.000* |
|
|
0.194 | 6.441 | |||
| P | 0.845 | 0.000 | |||
*, P≤0.05 (statistically significant).
Complication rate
Catheter infection, catheter blockage, and catheter displacement occurred in both groups, but the incidence was lower in the observation group (P<0.05) (Table 4).
Table 4
| Group | n | Catheter infection | Catheter blockage | Catheter displacement | Total |
|---|---|---|---|---|---|
| Observation group | 59 | 4 (15.38) | 1 (1.02) | 2 (16.67) | 7 (16.67) |
| Control group | 60 | 22 (84.62) | 5 (6.09) | 10 (83.33) | 37 (88.10) |
| χ2 | 15.562 | 1.527 | 5.783 | 31.662 | |
| P | <0.001* | 0.217 | 0.016* | <0.001* |
*, P≤0.05 (statistically significant).
Discussion
For cancer patients, chemotherapy through a PICC effectively reduces discomfort associated with frequent punctures and has been widely used to support long-term application and chemotherapy administration, providing a safe, reliable, and long-term infusion route (10-12). However, PICCs are invasive and have a high risk of infection, which may affect treatment outcomes. A variety of complications after long-term catheterization was observed at the meanwhile, such as such as bleeding at the puncture site, mechanical phlebitis, local infection, catheter blockage, catheter drift or prolapse, catheter rupture or rupture, the most important of which is catheter-related infection. Catheter related blood stream infections (CRBSI) is an important complication of long-term deep vein catheterization and the most serious complication after PICC puncture (13). Due to tumor patients have poor immunity and long chemotherapy time, PICC-associated infection may make the treatment situation more complicated and severely destroy the patient's quality of life. Therefore, risk factors for PICC-associated infections should be investigated, and targeted intervention measures must be developed to manage and prevent infection (14,15).
This study showed that 26 of 159 PICC patients (16.35%) experienced PICC-associated infections; the pathogens identified included gram-positive bacteria (13, 50.00%), gram-negative bacteria (8, 30.77%), and fungi (5, 19.23%), suggesting that nurses should focus on hygiene and sterile techniques during PICC insertion to minimize the likelihood of infection. Univariate analysis showed that PICC indwelling time, steroid use, WBC counts, a history of diabetes, and immunity were risk factors for PICC-associated infections. This finding can be explained by (16,17) cancer patients often having physiological dysfunction and consumption syndrome, as well as chronic diseases such as hypertension and diabetes, resulting in a weakened ability to fight germs and low immunity due to long-term chemotherapy, which increases the risk of bacterial infection. The following interventions are recommended for cancer patients undergoing chemotherapy through a PICC to reduce the risk of infection (18-20): (I) comprehensive evaluation of the patient’s physical condition and infection-related factors before PICC insertion; (II) a standardized PICC procedure, regular staff training, and compliance with disinfection and sterile procedures; and (III) standardized PICC maintenance and close monitoring of redness and swelling at the puncture site with a documented maintenance schedule.
Studies (21,22) show that self-efficacy interventions enhance self-efficacy, self-management, patient confidence, and patient-nurse relationships during chemotherapy through a PICC. Moreover, nurses supervise and encourage patients to engage in PICC care via ongoing monitoring, which improves patient confidence and encourages patients to live with their conditions. This study showed that a self-efficacy intervention improved self-efficacy scores, suggesting that self-efficacy interventions improve self-efficacy and self-management of indwelling PICCs. Moreover, self-efficacy interventions significantly reduce the complication rate (16.67% vs. 88.10%), suggesting that self-efficacy interventions reduce the complication rate associated with indwelling PICCs. Taken together, the risk factors for infection in PICC nursing process are mainly related to the nursing staff's puncture skills, catheter care level, catheter indwelling time, strict aseptic operation and other factors. It is necessary to improve the nursing work standards and working rules for the above points. Moreover, personnel conduct professional skills training is important to reduce the risk of infection and reduce the suffering of patients.
In summary, for cancer patients undergoing chemotherapy through a PICC, self-efficacy interventions improve self-management and reduce complications. PICC indwelling time, WBC count, a history of diabetes, and immunity are independent risk factors for PICC-associated infections, suggesting that sterile procedures should be followed and PICC maintenance should be standardized to reduce the risk of PICC-associated infections.
Acknowledgments
Funding: (I) Nantong Science and Technology Bureau Project (JCZ19044); (II) Youth Program of Nantong Municipal Health Commission of Jiangsu Province (QA2019001); (III) General Program of Nantong Municipal Health Commission of Jiangsu Province (MB2019011).
Footnote
Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://dx.doi.org/10.21037/apm-21-1848
Trial Protocol: Available at https://dx.doi.org/10.21037/apm-21-1848
Data Sharing Statement: Available at https://dx.doi.org/10.21037/apm-21-1848
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/apm-21-1848). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of Affiliated Hospital of Nantong University. Written informed consent was obtained from all patients.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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