Peripherally Inserted Central Line Catheters following Hand and Wrist Infections

Background:

Hand and wrist infections may cause varying degrees of morbidity requiring antibiotic therapy of variable duration and often operative intervention. Peripherally inserted central line catheters (PICCs) are placed when an extended course of intravenous antibiotics is anticipated. The present study aims to analyze utilization and impact of PICC placement on the management of hand, wrist, and forearm infections.

Methods:

The PearlDiver Patients Records Database was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors with PICC utilization, complications, readmissions, and length of stay (LOS).

Results:

A total of 24,665 patients with an upper extremity infection were included in the study. Ultimately, 416 patients required a PICC placement (1.69%). Patients with older age, male gender, certain medical comorbidities, and infection involving deeper structures were more likely to require a PICC. Ninety-day all-cause medical complication rates were significantly higher for the PICC group (19.7% versus 6.7%) compared to those without. Any hospital readmission rates were significantly higher for PICC group at 90 days (28.4% versus 6.3%) and 1 year (35.8% versus 10.9%). Readmission rates remained slightly higher at 1 year for both groups. The PICC group demonstrated significantly longer LOS by 2 days (7.72 days versus 5.14 days).

Conclusion:

While not required for the majority of hand, wrist, and forearm infections, PICC placement is associated with increased medical complications, more frequent hospital readmissions, and longer LOS.

Takeaways

Question: What is the implication of PICC placement on management of patients with upper extremity infections?

Findings: Only a small fraction of patients (1.69%) with upper extremity infections require PICC placement. Those with older age, male gender, certain medical comorbidities, and deeper infections are more likely to require PICC. PICC is associated with higher rates of any 90-day medical complication rates, readmission rates, and length of stay (LOS).

Meaning: PICC should be used judiciously in upperextremity infections given its associations with higher complications and longer LOS.

INTRODUCTION

Hand, wrist, and forearm infections are common injuries that can lead to a significant loss of function if not treated properly. Deep infections of the tendon spaces, osteomyelitis, or necrotizing soft tissue infection may require multiple procedures, extensive reconstruction, or even amputation. Such infections also have significant economic impact; while simple outpatient treatment for superficial infection may not bare a similar financial burden, deeper infections that may require transfer to a tertiary hospital with multiple operative treatments and peripherally inserted central line catheter (PICC) placement for prolonged intravenous (IV) antibiotic therapy can lead to a significant health care cost.¹ Currently, there are no well-documented studies that specifically look into overall health care cost burden for hand, wrist, and forearm infections. However, a previous study that assessed the cost of dog or cat bites to the hand showed that injuries requiring hospital admission, surgical debridement, and 6 weeks of IV antibiotic therapy can be as high as $81,926.² In addition, lost productivity can cost more than the direct health care cost, given that the majority of the hand infection cases occur in younger, working population with a mean age of 40.³ One study showed that up to 56% of the total cost for hand and wrist injuries was due to lost productivity cost.^3,4 Factors that contribute to the severity of a hand infection include the virulence of the causal pathogen, anatomic location of the infection, presence of foreign bodies, and host immunocompetency.⁵ Without prompt and proper treatment, hand, wrist, and forearm infection can potentially result in extensive morbidity and even amputation.⁶

The two mainstays of treatment for hand infections are antibiotic therapy and operative intervention for source control and identification of a causal pathogen. Mild infections that present early are often amenable to nonoperative treatment alone and can be managed on an outpatient basis with immobilization, elevation, and antimicrobial therapy, whereas severe infections often necessitate hospital admission. Operative interventions such as incision and drainage (I&D) or debridement of devitalized tissue may be necessary in a severe hand or wrist infection, or if an infection fails to improve with antibiotic therapy alone.^7,8 Intraoperative cultures provide the advantage of delivering targeted medical therapy. However, empiric antibiotics should be administered as early as possible while awaiting definitive culture results and sensitivities.⁹

Based on intraoperative findings and clinical progression, some hand, wrist, and forearm infections may necessitate an extended course of parenteral antibiotic treatment up to 4‐6 weeks in duration, which is often delivered via PICC. The utilization of PICC related to patient factors and procedural details associated with PICC placement is not well established, and consequently, the present study aims to determine the patient and disease-specific factors associated with PICC placement for the management of hand, wrist, and forearm infections. Furthermore, the study aims to determine the impact of PICC placement on medical complications, hospital admissions, and length of hospital stay.

METHODS

A commercially available, proprietary, national insurance claims-based database, PearlDiver Patients Records Database (www.pearldiverinc.com; PearlDiver Inc., Colorado Springs, Colo.), was queried to identify patients who underwent treatment for infection of the hand, wrist, and forearm between 2010 and 2018. (See table, Supplemental Digital Content 1, which shows definitions, http://links.lww.com/PRSGO/C264.) This database contains patient records, which are deidentified, anonymous, and compliant with the privacy rules of the Health Information Portability and Accountability Act, and are, therefore, exempt from review by an institutional review board. The database contains patient demographics, comorbidities, diagnoses, and procedural coding, among numerous other data. This database may be queried via International Classification of Diseases, 9th Revision and 10th Revision and procedures or current procedural terminology (CPT) codes. The database information spans all United States patients insured from 2010 to 2018, and patients can be tracked across all locations (inpatient, outpatient, etc) throughout the database years.

CPT codes were used to identify patients who had undergone operative procedures for I&D of the hand, wrist, and forearm. (See table, Supplemental Digital Content 1, http://links.lww.com/PRSGO/C264.) Patients were excluded for absence of valid age or gender information. Patients were excluded if they were not active in the database for 1 year after the CPT code for incision, and drainage was recorded.

Primary end points of the study were the utilization of PICCs following operative procedures for infections of the hand, wrist, and forearm. Secondary end points of the study included the rates of subsequent 90-day overall complications, 90-day and 1-year hospital readmissions, and postoperative length of stay. Demographic data on age, gender, comorbidities, procedures, and physician specialty were reported.

R Project for Statistical Computing software (https://www.r-project.org/), available through the PearlDiver database, was used for all statistical analyses. Epidemiologic data were analyzed to report descriptive statistics, as appropriate. Logistic regression analysis was utilized to evaluate the association of patient-related risk factors, including demographic variables and comorbidities, with the association of hospital readmission and complication rates on the utilization of PICC placement. Odds ratios were calculated from the regression analysis, and a corresponding 95% confidence interval and P value were also calculated for each patient-related risk factor. For all statistical calculations, P less than 0.05 was considered statistically significant.

RESULTS

A total of 24,665 patients were included in this study. Among those, 416 patients required a PICC (1.69%) while the remaining 24,249 patients (98.31 %) did not. Baseline characteristics for both PICC and no-PICC groups were analyzed (Table 1). Patients who were older and male gender were more likely to require PICC placement. Patients with certain medical comorbidities were more likely to require PICC insertion as well, which included congestive heart failure (CHF), coronary artery disease (CAD), chronic kidney disease (CKD), diabetes mellitus (DM), hypertension (HTN), and degenerative diseases like osteoarthritis (OA), rheumatoid arthritis (RA), and gout. Not surprisingly, PICC group had higher CCI (Charlson Comorbidity Index) scores (mean CCI of 1.90 versus 0.94).

Table 1.

Patient Demographics and Comordities

Characteristics and Comorbidities	With PICC	Without PICC	P
	416	24,249
Age
Mean (range)	51.78 (1–80)	45.97 (0–80)
Median	55	49
1 QR–3 QR	43–63	31–61
Gender
Male	238	12,167	<0.001
Female	178	12,096	<0.001
Region
Northeast	96	5111	0.35
Midwest	136	5505	0.22
South	131	9767	<0.001
West	53	3831	0.1
Comorbidities
Asthma	55	3567	0.44
CHF	75	2134	<0.001
CAD	127	5109	<0.001
CKD	111	3104	<0.001
Chronic obstructive pulmonary disease	144	7742	0.27
DM	214	8515	<0.001
HTN	315	13,732	<0.001
Obesity	129	6920	0.29
OA	214	7658	<0.001
RA	38	1045	<0.001
Tobacco use	169	8352	0.01
Gout	52	1643	<0.001
Chondrocalcinosis	#	176	<0.001
Drug use	99	4963	0.11
Charlson comorbidity index	1.90 ± 2.65	0.94 ± 1.81

#, less than 11 per cell and cannot disclose to protect patient confidentiality.

Likewise, certain CPT codes were more likely to require PICC (Table 2). Procedures involving hand/forearm or deeper structures like I&D of deep abscess/hematoma of forearm and wrist (19.0% versus 9.2, PICC versus no PICC, and RR of 2.1), I&D of tendon sheath and/or palm (18.5% versus 8.5%, PICC versus no PICC, and RR of 2.2), and incision of bone cortex of forearm/wrist (3.4% versus 0.6%, PICC versus no PICC, and RR 5.3) or hand or finger (11.8% versus 2.0%, PICC versus no PICC, and RR 6) were more likely to require PICC. Procedures limited to digits such as simple drainage of finger abscess (11.8% versus 53.4%, PICC versus no PICC, and RR 0.2) were less likely to require a PICC.

Table 2.

Hand and Forearm Infection Procedures with and without PICC Line Placement

CPT Code	Procedure	With PICC, N (% Absolute Risk)	Without PICC, N (% Absolute Risk)	Relative Risk (95% Confidence Interval)
Total n		416	24,249
25028	I&D forearm and/or wrist; deep abscess or hematoma	79 (19.0)	2223 (9.2)	2.1 (1.69–2.54)
25031	Incision and drainage forearm and/or wrist; bursa	#	108 (0.5)	n/a
25035	Incision deep bone cortex forearm and/or wrist (eg, osteomyelitis or bone abscess)	14 (3.4)	154 (0.6)	5.3 (3.9–9.8)
25040	Arthrotomy radiocarpal or midcarpal joint with exploration drainage or removal of foreign body	28 (6.7)	705 (2.91)	2.3 (1.61–3.34)
26010	Drainage of finger abscess; simple	49 (11.8)	12,954 (53.4)	0.2 (0.17–0.29)
26011	Drainage of finger abscess; complicated (eg, felon)	89 (21.4)	4696 (19.4)	1.1 (0.92–1.33)
26020	Drainage of tendon sheath digit and/or palm each	77 (18.5)	2071 (8.5)	2.2 (1.76–2.66)
26025	Drainage of palmar bursa; single bursa	#	320 (1.3)	n/a
26030	Drainage of palmar bursa; multiple bursa	#	106 (0.4)	n/a
26034	Incision bone cortex hand or finger (eg, osteomyelitis or bone abscess)	49 (11.8)	480 (2.0)	6 (4.51–7.85)
26035	Decompression fingers and/or hand injection injury (eg, grease gun)	#	105 (0.4)	n/a
26037	Decompressive fasciotomy hand (excludes 26,035)	#	327 (1.4)	n/a

#, Fewer than 11 per cell and cannot disclose to protect patient confidentiality.

Overall 90-day any medical complication rate was 4.83% but higher for the PICC group (19.7% versus 6.7%, P < 0.01) (Table 3). Unfortunately due to a smaller sample size of the PICC group, the exact numbers of several complications were not captured (less than 11 patients per category not disclosed to protect patient confidentiality). However, all of the captured medical complications, including acute kidney injury (AKI), pneumonia, and urinary tract infection (UTI), were significantly higher in the PICC group. When looking at any 90-day and 1-year hospital admissions, the PICC group shows significantly higher rates of both compared with those without PICC (Table 4). Rate of 90-day admission of the PICC group is 28.4% compared with that of 6.3% of the no-PICC group; at 1 year, the rates remain significantly different at 35.8% and 10.9%, respectively. Interestingly, both groups showed slightly higher rates of readmission at 1 year compared with that of 90 days. Both the PICC and No-PICC groups have similar admissions per patient at 90 days (3.1 versus 2.8 admissions/patient). However, at the 1-year mark, the PICC group shows a higher rate of 4.7 admissions/patient compared with that of 3.5 of the no-PICC group.

Table 3.

90-d Medical Complications

	With PICC, N (%)	Without PICC, N (%)	P
Patients	416	24,249
Any medical complication	82 (19.7)	1615 (6.7)	<0.001
AKI	32 (7.7)	482 (2.0)	<0.001
Capsulitis	#	43
Cardiac arrest	#	13
Deep vein thrombosis	#	65 (0.3)
Disruption of wound	#	132
Hematoma	#	64
Nerve injury	#	53
Pneumonia	16 (3.8)	352 (1.5)	<0.001
Pulmonary embolism	#	67
Blood transfusion	#	78
UTI	21 (5.0)	562 (2.3)	<0.001

#, Less than 11 per cell and cannot disclose to protect patient confidentiality.

Table 4.

90-d and 1-y Hospital Admissions

	With PICC (%)	Without PICC (%)
Patients	416 (100)	24,249 (100)
Any 90-d Admissions	118 (28.4)	1539 (6.3)
Total no. admissions	365	4250
Admissions per patient	3.1	2.8
Any 1-y admission	149 (35.8)	2654 (10.9)
Total no. admissions	699	9241
Admissions per patient	4.7	3.5

The PICC group not only showed higher medical complication rate and more frequent admission rate but also longer length of stay for their treatment of hand and forearm infections. Mean length of stay for the PICC group was 7.72 compared with that of 5.14 of the no-PICC group, with more than 2 days of extra length of stay (Table 5).

Table 5.

Length of Stay

	With PICC	Without PICC
Patients	416	24,249
Length of stay (d)
Mean (range)	7.72 (1–58)	5.14 (1–78)
Median	5	3
1 QR–3 QR	(3–8)	(2–5)

DISCUSSION

Hand, wrist, and forearm infections are commonly encountered hospital problems that often require both pharmacologic and procedural interventions. While the majority of these cases do not require prolonged IV antibiotic therapy, deeper infections can require a course of broad spectrum antibiotics lasting several weeks, which often commits the patient to a PICC placement. In our present series, of the 24,665 patients who were treated for hand, wrist, and forearm infections, less than 2% of the patients (416, 1.69%) required PICC placement. Male gender and certain medical comorbidities, including CHF, CAD, CKD, DM, HTN, OA, RA, and tobacco uses, were associated with higher likelihood of PICC placement.

Previous studies have found that certain host conditions, including but not limited to the presence of an immunosuppressed state, exposure risks [ie, IV drug users (IVDUs)], and specific medical conditions, such as gout, RA, peripheral vascular disease, and CKD, are more susceptible to upper extremity infections.^6,10 Additionally, studies have shown higher risk of hand and forearm infections with IVDU population, including abscess/cellulitis, Methicillin-resistant Staphylococcus aureus infection, longer hospital stay, higher likelihood of operative treatment, and higher rate of IV antibiotics treatment.^11,12 Drug use was not a significant factor in this study; this is likely due to the fact that the present study included all illicit drug use as a category and did not specifically filter for IVDU. These data validate the concept that people with certain host characteristics and premorbid conditions are more susceptible to more severe infection, necessitating prolonged IV antimicrobial therapy.

Common CPT codes related to hand, wrist, and forearm infections were extracted for analysis. Certain procedures carried a higher likelihood of PICC placement compared with others. Procedures linked to deeper infection, such as osteomyelitis or infection in joint space/tendon sheath, led to higher rate of PICC placement as high as 9.26%. On the contrary, infections involving finger abscess I&D showed significantly lower rates of PICC placement (0.38%). It is also notable that even for some of the deeper infections, the rate of PICC placement did not exceed 10%. This likely highlights the importance of timely and definitive operative treatment, which can provide source control and ultimately decrease the need for prolonged IV antibiotic use. Certain pathology, such as osteomyelitis, septic arthritis, or infections within the tendon sheath, will more frequently require broad spectrum antibiotics, at least in the initial treatment period. Depending on the culture data and postoperative clinical progression, patients may be able to transition from IV to oral antibiotics. Given the patient burden and risks of prolonged IV antibiotic therapy with central access, clinicians should try to minimize its use when possible. Several studies have shown the effectiveness of oral antimicrobial therapy for superficial and deep infections of the hand and wrist.^13-15 However, it is important to recognize that proper and timely operative intervention must be performed with pharmacologic therapy to achieve source control, and that the transition to oral antibiotics should be monitored clinically.

Given that deep infections of the hand‚ forearm‚ and wrist may require serial operative interventions and clinical evaluation to determine therapeutic efficacy, hospitalization length of stay was also analyzed. Despite the fact that PICC placement itself only takes a few minutes, those requiring a PICC had significantly longer hospital stay by 2 days. Given that an average inpatient stay in the US has direct costs of up to $5326 for some for-profit hospitals, 2 days of additional inpatient stay may translate to a significant increase in health care cost.¹⁶

Various medical complications within 90 days of hand infection were analyzed. The PICC group had higher rates of medical complications compared with those without PICC, with 19.7% of the patients developing some form of medical complication, compared with the 6.7% of the no-PICC group. Unfortunately, the exact numbers of many of these complications within the PICC group were not available given their small numbers‚ to protect patient confidentiality. However, AKI, pneumonia, and UTI were all significantly higher in the PICC group. The causes of such significantly higher complication rates are likely multifactorial, including increased medical comorbidity burden and possible complications linked to prolonged central access and broad spectrum antibiotics use in the PICC group. For example, many of the broad-spectrum antibiotics such as vancomycin and aminoglycosides are known to be nephrotoxic, which can lead to AKI. Notably, the rate of deep vein thrombosis (DVT) among the PICC group did not exceed 2.4%. PICC-related DVT is a well-described and studied topic, and studies have shown that the incidence of DVT can range from 2.4% to 15%.^17,18 This lower rate of DVT in PICC patients may be secondary to patient factors (unlikely to have malignancy, average age in early 1950s, and most likely to be ambulatory) as well as mechanical factors (PICC for antibiotic use typically utilizes single lumen catheter; the duration is usually in the order of weeks). Unfortunately due to the limitations of the mechanism by which we can extract the data based on CPT code, we were unable to identify which complications were truly secondary to PICC placement. However, this would be interesting and meaningful data to further analyze in future studies.

Along with complications, 90-day and 1-year hospital admission data were analyzed. Again, the PICC group had a significantly higher rate of hospitalization at both 90 days and 1 year than the no-PICC group (Table 4). Interestingly, admissions per patient for the PICC group are significantly higher at 1 year with almost five admissions per patient, representing that there is a certain group of patients with repeated hospital admissions. Although the data do not track the indication for admission, it is likely secondary to baseline patient comorbidities. However, the possibility of complications secondary to having deeper infection, PICC placement, and prolonged broad-spectrum antibiotic use cannot be excluded. Placement of a PICC itself also poses a risk for specific complications, including line infection (both local and systemic), thrombosis, occlusion, and other mechanical complications that may require emergency department visits, hospitalization, and line removal.^19,20 Overall, this study shows that while a small portion of patients with hand and wrist infections require a PICC, it has significant clinical implications, including increased length of stay in the hospital by 2 days and higher rates of complication and hospital admission. Based on these data, surgeons should utilize PICC and prolonged IV antibiotics therapy judiciously and counsel the patients appropriately on their expected course of treatment, as well as possible complications relating to it.

Both the strength and limitations of the study arises from the fact that this is a study based on national registry. PearlDiver contains more than 122 million distinct patient records from all US states and territories and can extract data from various clinical settings, including inpatient, outpatient, and pharmacy settings with all types of payers. Unfortunately, national registry comes with its own set of limitations, including primarily the quality of the data and the accuracy of the procedural reporting. The database cannot provide specific information on the bacterial culture data or antimicrobial susceptibility testing results. The antimicrobial agents utilized were not specifically queried. The indications for subsequent hospital admission were not specifically identified. Procedural or diagnosis coding is subject to inaccuracies; however, the size of the database and the number of patients allow accurate reporting of trends in treatment across the nation, lending to the generalizability of the results.

CONCLUSIONS

Hand and wrist infection is a commonly encountered problem in the hospital setting that can require not only procedural treatment but also long-term antibiotic therapy utilizing a PICC. While less than 2% of this patient population require a PICC placement, they tend to be male with pre-existing medical comorbidities. Importantly, patients who require a PICC will have a longer hospital stay by 2 days and be more likely to develop both medical complications and require more frequent hospital readmission. Clinicians should use this information to appropriately counsel their patients and minimize unnecessary prolonged broad spectrum antibiotics use requiring a PICC.

Supplementary Material

gox-10-e4657-s001.pdf ^{(18.2KB, pdf)}