Med Clin (Barc).

2012;139(5):185191

www.elsevier.es/medicinaclinica

Original article

Assessing the inuence of risk factors on rates and dynamics of peripheral

vein phlebitis: An observational cohort study
Gabriel Mestre Roca a,*, Cristina Berbel Bertolo a, Puricacion Tortajada Lopez a,
Gema Gallemi Samaranch b, Mari Carmen Aguilar Ramirez b, Joan Cayla` Buqueras c,
o d, Jose Antonio Martinez e
Jesus Rodrguez-Ban
a

Nosocomial Infection Control Unit, Delfos Medical Center, Barcelona, Spain

Supervisor Nursing Department, Delfos Medical Center, Barcelona, Spain
c
CIBER of Epidemiology and Public Health Service (CIBERESP), Barcelona, Spain
d
Infectious diseases and Microbiology Unit, University Hospital Virgen de Macarena, University of Seville, Spain
e
Infectious Diseases Unit, Hospital Clinic Barcelona, Barcelona, Spain
b

ARTICLE INFO

A B S T R A C T

Article history:
Received 25 July 2011
Accepted 1 December 2011
Available online 24 April 2012

Background and objectives: To assess the inuence of risk factors on the rates and kinetics of peripheral
vein phlebitis (PVP) development and its theoretical inuence in absolute PVP reduction after catheter
replacement.
Methods: All peripheral short intravenous catheters inserted during one month were included (1201
catheters and 967 patients). PVP risk factors were assessed by a Cox proportional hazard model.
Cumulative probability, conditional failure of PVP and theoretical estimation of the benet from
replacement at different intervals were performed.
Results: Female gender, catheter insertion at the emergency or medical-surgical wards, forearm site,
amoxicillinclavulamate or aminoglycosides were independent predictors of PVP with hazard ratios
(95 condence interval) of 1.46 (1.092.15), 1.94 (1.013.73), 2.51 (1.294.88), 1.93 (1.203.01), 2.15
(1.453.20) and 2.10 (1.014.63), respectively. Maximum phlebitis incidence was reached sooner in
patients with 2 risk factors (days 34) than in those with <2 (days 45). Conditional failure increased
from 0.08 phlebitis/one catheter-day for devices with 1 risk factors to 0.26 for those with 3. The greatest
benet of routine catheter exchange was obtained by replacement every 60 h. However, this benet
differed according to the number of risk factors: 24.8% reduction with 3, 13.1% with 2, and 9.2% with 1.
Conclusions: PVP dynamics is highly inuenced by identiable risk factors which may be used to rene
the strategy of catheter management. Routine replacement every 72 h seems to be strictly necessary
only in high-risk catheters.
a, S.L. All rights reserved.
2011 Elsevier Espan

Keywords:
Catheterization
Peripheral/*adverse effects/
instrumentation
Infusions
Intravenous/*adverse effects/
instrumentation
Proportional hazards models
Risk factors
Thrombophlebitis/*etiology

Evaluacion de la influencia de los factores de riesgo en la incidencia y dinamica

de aparicion de las flebitis de via periferica: Estudio de cohortes observacional
R E S U M E N

Palabras clave:
Cateterizacion
Periferica/eventos adversos/
instrumentalizacion
Terapias endovenosas/eventos adversos/
instrumentalizacion
Modelos riesgos proporcionales
Factores riesgo
Tromboebitis/*etiologa

Fundamento y objetivo: Valorar la inuencia de los factores de riesgo en la incidencia y cinetica de ebitis.
Material y metodos: Todos los cateteres cortos de insercion periferica insertados durante un mes (1201
cateteres y 967 pacientes) en un hospital medico-quirurgico general. Los factores de riesgo de ebitis se
analizaron mediante regresion de Cox. Se calcularon la probabilidad acumulada, el riesgo condicional de
ebitis y el benecio teorico del recambio en diferentes periodos.
Resultados: Fueron predictores independientes de desarrollo de ebitis el sexo femenino, la insercion de
un cateter en el servicio de urgencias o en las unidades medico-quirurgicas, la localizacion en el
antebrazo y la administracion de amoxicilina-clavulanico y aminoglucosidos con hazard ratios (intervalo
de conanza al 95%) respectivas de: 1.46 (1.092.15), 1.94 (1.013.73), 2.51(1.294.88), 1.93(1.103.01),
2.15 (1.453.20) y 2.10 (1.014.63). La maxima incidencia se alcanzo de forma mas precoz en los

* Corresponding author.
E-mail address: mestre.ucin@centromedicodelfos.es (G. Mestre Roca).
a, S.L. All rights reserved.
0025-7753/$ see front matter 2011 Elsevier Espan
doi:10.1016/j.medcli.2011.12.021

186

G. Mestre Roca et al / Med Clin (Barc). 2012;139(5):185191

cateteres con 2 factores de riesgo (dias 3 y 4) que en los de <2 (dias 4 y 5). El riesgo condicional
aumento de 0.08 ebitis/1 cat-da para los cateteres de 1 factor de riesgo hasta 0.26 para aquellos con
3. El mayor benecio del recambio del cateter se obtuvo a las 60 horas, variando en funcion de los
factores de riesgo: 24.8% reduccion con 3, 13.1% con 2 y 9.2% con 1.
Conclusiones: La dinamica de aparicion de ebitis se halla muy inuenciada por la interaccion de los
factores de riesgo. El recambio sistematico cada 72 horas solo parece ser estrictamente necesario en
los cateteres de alto riesgo.
a, S.L. Todos los derechos reservados.
2011 Elsevier Espan

Introduction
The insertion of a peripheral vein catheter (PVC) is the most
frequently performed invasive procedure in hospitals. PVCs are
vital for delivery of hydration, medicines and nutrition. It is
estimated that in North America over 150 million peripheral
catheters are inserted annually.1 Unfortunately, this procedure is
not risk-free, and PVC-related adverse events such as peripheral
vein phlebitis (PVP) is considered the commonest complication of
intravenous catheterization, occurring in about 20% of hospitalized
patients.25 In most cases, it is a physicochemical phenomenon3,4
which requires the removal of the catheter, the insertion of a new
one in a different site, and often needs local treatment and
analgesics.
PVCs are increasingly recognized as a source of Staphylococcus
aureus bacteraemia accounting for 1250% of all catheter-related
episodes.68 Although septic or bacterial phlebitis is an uncommon
occurrence, nearly a half of the episodes of PVC-related bacteremia
are associated with PVP.3,6 Furthermore, as the administration of
intravenous therapy is steadily increasing in the hospital setting,9
PVP is in fact a PVC adverse event of utmost importance.
Although many risk factors have been reported, most of them
have not been consistently found or are even contradictory.3,4,10
Current CDC or HICPAC guidelines,11,12 recommend catheter
replacement every 72 h. However, the scientic evidence of this
approach3,13,14 is still controversial4,1520 and two recent systematic
reviews5,21 concluded that more studies are needed to clarify
whether there is an appropriate interval for PVCs replacement in
order to prevent PVP. An European multi-centre research surveillance project performed a decade ago22 observed an increase rate of
PVP from the day of insertion up to ve days, questioning the
effectiveness of a systematic catheter exchange policy. Furthermore,
recently, a Cochrane review including European and Australian
studies, concluded that clinical management could be as effective as
scheduled catheter exchange.23 Surprisingly, these repetitive
observations have not modied the recommendation of systematic
exchange and data reporting the real compliance with the universal
replacement catheter policy are lacking.
In our institution, the Nosocomial Infection Control Unit
detected in 2004 up to 25 cases of PVP per 100 inserted peripheral
catheters and up to that point no surveillance system or
monitoring of PVP had been established. As a rst corrective
action, a phlebitis working group was created with the objective
of improving nursing care and handling guidelines of PVCs
including an exchange catheter policy every 4 days. A study was
performed with three main objectives: (a) to estimate the
incidence of PVP, (b) to determine PVP risk factors and evaluate
the possible inuence in the rates and kinetics of PVP, and (c) to
estimate its theoretical inuence in absolute PVP reduction after
catheter replacement.
Methods
Setting and catheter selection
A prospective cohort study was performed in Delfos Medical
Centre, a private 200-bed hospital with teaching nursing activity.

All peripheral short intravenous catheters inserted in patients aged

18 years who were admitted to any ward during the study period
(November 2005) were prospectively followed from insertion to
removal. Insertion was performed by nurses according to the
following local guidelines: choice of catheter and gauge was at the
discretion of the professional inserting the catheter. Previously to
hand washing and hygienic hand-rub with alcoholic gel, the
patients skin was disinfected with a povidone iodine solution (1%
free iodine) in 70% ethanol. Using non-sterile gloves, a Teon
catheter (BD Insyte-W, Becton Dickinson S.A.) was inserted into a
peripheral vein. The catheter was xed to the skin with sterile selfadhesive gauze (Tegaderm TM, IV Reinforced, Germany). An
additional elastic bandage was applied to reduce the risk of
inadvertent withdrawal. Dressings were left on for the lifetime of
the catheter.
Collection of clinical data
A data collection form was designed by the Nosocomial
Control Infection Unit and from our nursing supervisors team.
This questionnaire was lled out on a daily basis by the
attending nurses and included reported risk factors (age; gender;
place of insertion catheter; anatomical insertion site; infusion
therapy) and selected conditions during the insertion (non
collaboration; difculties during insertion; inappropriate material) and care and handling of catheters (dressing exchange;
heparin lock). In addition, any inammatory sign or symptom
related to the insertion site was recorded. Thereafter, each
questionnaire was supervised and validated by a member of the
investigator team.
During the indwelling time, insertion sites were inspected by
ward nurses, at least once a day, and when solutions were
changed or drugs added. Observation was continued until
complications occurred or PVCs were withdrawn. Reasons for
catheter removal (discharge; end of intravenous therapy;
phlebitis; extravasations; inadvertent withdrawal; scheduled
replacement; and other reasons) were reported on a specically
designed form. Our local ethics committee approved the conduct
of the research without explicit consent from the participants
because the management of our patients was not affected by the
study.
Denitions
Phlebitis: Occurrence of at least one inammatory sign or
symptom related to the catheter insertion including persistent
pain (duration longer than 2 h after the end of a given infusion)
and/or erythema and/or swelling and/or induration (palpable cord)
and/or purulence discharge.16,20,24
Grading system: A composite from the Infusion Nurses Society
grading system and Tagers scale was used24,25 considering three
main categories: grade I (mild phlebitis): one inammatory sign or
symptom (except purulence or palpable cord); grade II (moderate
phlebitis): two inammatory signs or symptoms (except purulence or palpable cord); grade III (severe phlebitis): palpable cord
or purulence and/or three or more inammatory signs or
symptoms.

G. Mestre Roca et al / Med Clin (Barc). 2012;139(5):185191

Extravasation: Oedema in proximity to the peripheral IV

catheter, typically as a result of IV uids leaking into the tissues
without inammation of the vein itself.15
Scheduled replacement: Any replacement done for the only
reason that the catheter was in place for more than 96 h.
Idle catheter: Removal due to the catheter not being in use for a
period exceeding 24 h.
Suspected PVC-related bloodstream infections (PVC-related BI)
were dened using CDC criteria11: bacteraemia/fungemia with at
least one positive blood culture obtained from a peripheral vein,
clinical manifestations of infection and no apparent source of the
bloodstream infection except the device with or without positive
tip or entry site swab culture. In order to consider the existence of
clinical manifestations of infection, the presence of PVP was
mandatory.
Statistical analysis
Catheters inserted and not patients were the units of analysis.
Due to the purely observational nature of the study, no specic
sample size estimations were deemed necessary, besides the
assumption that a minimum of 1000 catheters would allow us to
achieve the study aims. The incidence density of phlebitis was

187

calculated in each category of the evaluated variables (phlebitis/

1000 catheter-days). The outcome of interest was the time to
phlebitis calculated from the date of insertion to the day that
phlebitis actually developed. PVCs were censored at the day of
removal if no phlebitis occurred. The Cox proportional hazard
model was used to test univariate differences in the cumulative
incidence of phlebitis, according to the selected covariates. All
variables which exhibited a p value <0.2 in the univariate analysis
were introduced in a Cox proportional hazard multivariate model.
The assumption of proportional hazards and log-linear regression
was tested using stratied analysis and the martingale residuals
graphs. To assume the proportionality requirements of the model,
age was transformed as a 3-strata categorical variable (1840;
4060; >60 years).
Actuarial life table analysis was used to estimate the cumulative
probability of phlebitis and the conditional failure (phlebitis/one
catheter-day) provided that at least >10 catheters were at risk at
the beginning of the interval. Furthermore, in order to look for the
potential inuence of signicant risk factors over time, we
conducted the same analysis stratifying the PVCs in three risk
groups dened by the number of independent covariates selected
by the Cox proportional hazard model. To estimate the theoretical
benet of replacement at different intervals, we calculated the

Table 1
Assessment of peripheral vein phlebitis risk factors in 1201 short peripheral vein catheters by multivariate Cox regression analysis.
Phlebitis (n; incidence density of/
phlebitis 1000 catheter-days)

Univariate Cox regression

(HR; 95% Cl)

Multivariate Cox regressionc

(HR; 95% Cl)

20/310; 29.32
22/326; 29.86
75/565; 47.74

Reference
0.99 (0.541.82)
1.36 (0.832.24)

1.15 (0.612.19)
1.30 (0.782.17)

56/605; 34.92
61/596; 43.20

Reference
1.36 (0.941.96)

1.46 (1.012.14)

Place of insertion catheter

Operating rooms
Medical Wards
Emergency Unit
Medical-Surgical Wards

14/486;
10/120;
53/400;
40/195;

Reference
1.54 (0.683.48)
2.41 (1.334.40)
3.69 (1.996.8)

0.85 (0.362.3)
1.94 (1.013.73)
2.50 (1.294.88)

Anatomical insertion sitea

Antecubital fossa
Hand/wrist
Forearm

25/292; 32.18
23/398; 26.75
64/421; 56.30

Reference
1.0 (0.571.78)
1.8 (1.132.85)

1.30 (0.702.40)
1.93 (1.203.01)

Conditions during insertion

Non Collaboration
Diifcult insertion
Inappropiate material

3/22; 54.54
12/68; 59.61
1/17; 30.79

1.29 (0.404.06)
1.43 (0.782.60)
1.15 (0.168.24)

Infusion therapyb
Amoxicillin-Clavulanate
Cephalosporins
Carbapenems
Quinolones
Metronidazol
Aminoglycosides
Clindamycin
Amiodarone
Fluids alone

44/167; 82.59
11/113; 32.44
1/19; 13.77
9/54; 59.31
4/14; 97.51
7/26; 83.35
2/11; 84.96
2/9; 107.87
7/196; 25.87

2.44 (1.603.60)
0.77 (0.411.42)
0.28 (0.041.99)
1.53 (0.773.1)
2.58 (0.197.01)
2.06 (0.964.44)
3.2 (0.7712.88)
3.22 (0.7913.06)
0.95 (0.442.07)

2.15 (1.463.20)

Care and handling of the catheteres

Dressing exchange
Endoscopy (Propofol)
Radiology (Contrast)
Heparine lock

15/61; 64.71
11/37; 72.15
10/50; 46.72
1/51; 10.05

1.45
1.51
0.93
0.26

1.52 (0.862.68)

Number of PVCs
First
Subsequent

75/969; 32.72
42/232; 60.23

Reference
1.66 (1.142.43)

Characteristic
Age, y
1840
4060
>60
Sex
Male
Female

a
b
c

14.77
28.63
47.32
69.77

(0.842.50)
(0.802.84)
(0.481.78)
(0.031.86)

0.27 (0.041.96)
1.91
2.13
2.77
2.34

(0.665.48)
(1.014.63)
(0.6212.42)
(0.5410.19)

0.38 (0.052.78)

1.53 (0.882.67)

88 catheters had missing data about anatomical insertion site.

Vancomycin, chemotherapy, vasoactive drugs and peripheral parenteral nutrition are not included in the table, because less than 5 cases were reported.
An overall of 13 variables were included in the multivariate analysis and six risk factors showed independent association with peripheral vein phlebitis.

188

G. Mestre Roca et al / Med Clin (Barc). 2012;139(5):185191

difference in cumulative probability of phlebitis from a catheter in

place during a given T time, assuming that the probability of two
consecutive catheters each one in place for half T time should
be the probability of phlebitis of a catheter in place half T time
elevated to the square, as described previously3,26. Finally, the
reasons for censoring data were evaluated as a control quality of
the study. Statistical analysis was done using Microsoft Windows
SPSS (Statistical Package for the Social Sciences, 15.0).
Results
A total of 1201 PVC inserted in 967 patients (2290 catheterdays) were included. The median (SD) age of the patients was 55
years (20) and 54% were female. The median number (interquartile range) of catheterizations per patient was one (IQR: 12
catheters) with a median length of catheterization of 1.5 days
(IQR: 1.53.5 days). The vast majority of catheters (986/1201,
82%) were in place less than 96 h, being uncommon an indwelling
time of more than 120 h (94/1201, 7.8%). The phlebitis rate was
9.7 cases per 100 catheters (95% CI: 8.111.4) or 39.3 per 1000
catheter-days (95% CI: 32.146.2). The majority of phlebitis were
mild (77, 66%), being erythema the most frequently inammatory sign reported (47%), while 26 (22%) were moderate and only
14 (12%) severe. Notably, fever and purulence were very
uncommon, accounting for less than 2% and 1%, respectively.
The incidence of moderate or severe phlebitis was 3.3 per 100
catheters (95% CI: 2.54.3) or 17.4 per 1000 catheter-days (95%
CI: 11.922.8). The main reason for catheter removal was
hospital discharge (50%) followed by end of IV therapy (18.6%)
and phlebitis (9.7%). Nearly 8% of the catheters were removed
because of scheduled replacement or idleness. Less common
causes were extravasations (5.2%), inadvertent withdrawal (4.7%)

and other reasons (3.9%). No PVC-related BI was reported

during the study period.
The incidence density of phlebitis according to risk factors and
the results of the unvaried and multivariate Cox proportional
hazard model analysis are shown in Table 1. The multivariate
analysis was performed including 1113 catheters (88 catheters
were excluded due to missing data about the anatomical insertion
site). A total of six risk factors were independently associated with
phlebitis (see Table 1): female gender, insertion in the emergency
department or in medical-surgical wards, forearm insertion site,
and IV antibiotic therapy (amoxicillinclavulamate and/or aminoglycosides). According to these signicant risk factors (range
from 0 to 5 because two were mutually exclusive), 175 cases had
no risk factors; 367 presented one risk factor; 378 two and 193
three or more risk factors. Overall (see Table 2 and Fig. 1) between
the fourth and fth day of insertion, 28% of catheters caused
phlebitis and the rate of appearance reached a peak between the
third and fth day of insertion (range: 0.120.13 phlebitis/
one catheter-day), maintaining high rates of phlebitis over time
(range: 0.070.09 phlebitis/one catheter-day). The same approach
in the stratied groups (see Table 2 and Fig. 1) clearly showed the
inuence of the number of risk factors on the kinetics of the
development of phlebitis. Thus, if none or one risk factor was
present (low-risk catheters group) the incidence of phlebitis was
15% between the fourth and fth day of insertion, and achieved the
highest incidence at this point (0.08 phlebitis/one catheter-day).
When two risk factors were present (moderate-risk catheters
group) 26% of catheters developed phlebitis between the fourth
and fth day of insertion (twice as compared to the low risk group)
with a peak between the third and fourth day (0.11 phlebitis/one
catheter-day). Lastly, in the highest-risk catheters group (35) as
many as 47% of catheters caused phlebitis (thrice compared to the

Table 2
Cumulative probability and conditional failure of peripheral vein phlebitis related to indwelling time (interval days) assessed in 1113 short peripheral vein catheters by
actuarial method, overall and grouped by risk factors (05).
Catheter indwelling time
(intervals days)

Catheters
at risk (n)

Cumulative probability
of phlebitis (SE)a

Conditional failure (SE)b

All catheters
[01]
[12]
[23]
[34]
[45]
[56]

1028
759
469
296
152
69

0.01
0.04
0.08
0.18
0.28
0.33

(0.00)
(0.01)
(0.01)
(0.02)
(0.03)
(0.03)

0.01
0.03
0.06
0.12
0.13
0.08

(0.00)
(0.01)
(0.01)
(0.02)
(0.03)
(0.03)

Low risk catheters (01 risk factors)

[01]
[12]
[23]
[34]
[45]
[56]

503
351
185
101
50
22

0.00
0.01
0.04
0.08
0.15
0.19

(0.00)
(0.01)
(0.01)
(0.02)
(0.04)
(0.05)

0.00
0.01
0.03
0.04
0.08
0.05

(0.00)
(0.01)
(0.01)
(0.02)
(0.04)
(0.05)

Moderate risk catheters (2 risk factors)

[01]
[12]
[23]
[34]
[45]
[56]

342
250
167
119
66
29

0.02
0.05
0.08
0.17
0.26
0.31

(0.01)
(0.01)
(0.02)
(0.03)
(0.04)
(0.05)

0.02
0.04
0.03
0.11
0.11
0.07

(0.01)
(0.01)
(0.01)
(0.03)
(0.04)
(0.05)

High risk catheters (>3 risk factors)

[01]
[12]
[23]
[34]
[45]
[56]

184
158
116
75
36
17

0.01
0.06
0.15
0.34
0.47
0.58

(0.01)
(0.02)
(0.03)
(0.05)
(0.06)
(0.08)

0.01
0.06
0.10
0.26
0.22
0.12

(0.01)
(0.02)
(0.03)
(0.06)
(0.08)
(0.09)

a
Indicates the probability of peripheral vein phlebitis of a catheter inserted from the beginning of the interval day to just before the end of the interval. In actuarial method
it is assumed that the value is referred to the middle of the interval.
b
Indicates the risk of development of peripheral vein phlebitis per day of insertion (phlebitis/one catheter-day).

Conditional failure for Phlebitis

0,30

0,25
0,20
0,15
0,10
0,05
0,00
0

Phlebitis per 1 catheter day (Incidence density)

Phlebitis per 1 catheter day (Incidence density)

G. Mestre Roca et al / Med Clin (Barc). 2012;139(5):185191

Conditional failure for Phlebitis
0,30

0,25
0,20
0,15
0,10
0,05
0,00
0

Days catheter in place

0,20
0,15
0,10
0,05
0,00
2

Days catheter in place

C-Conditional failure (phlebitis/one catheter-day) in
moderate risk catheters

Phlebitis per 1 catheter day (Incidence density)

Phlebitis per 1 catheter day (Incidence density)

0,25

B-Conditional failure (phlebitis/one catheter-day) in

low risk catheters

Conditional failure for Phlebitis

Days catheter in place

A-Conditional failure (phlebitis/one catheter-day)

in all catheters

0,30

189

Conditional failure for Phlebitis

0,30

0,25
0,20
0,15
0,10
0,05
0,00
0

Days catheter in place

D-Conditional failure (phlebitis/one catheter-day) in
high risk catheters

Fig. 1. Conditional failure of peripheral vein phlebitis (Incidence Density).

low risk group) by the fth day of insertion, reaching the highest
incidence between the third and fourth day (0.26 phlebitis/one
catheter-day).
Overall, all groups showed a low phlebitis risk during the rst
day of insertion (2% or 0.02 phlebitis/one catheter-day as the
highest value) with a slight increase between the rst and second
day (6% of phlebitis or 0.06 phlebitis/one catheter-day as the
highest value). It is of note that the highest rate of phlebitis was
reached sooner in the moderate or high risk group (between the
third and fourth day) than in the low risk group (between the
fourth and fth day).
In regards to the theoretical absolute reduction of phlebitis (see
Table 3) we estimated that the greatest benet could be achieved
by exchanging catheters between the second and third day (60 h)
with an estimated global phlebitis reduction of 14.6%. In this
regard, the greatest benet of exchanging catheter (see Table 3)
would be achieved in patients with high risk catheters (phlebitis
rate reduction up to 24.8%) in comparison with those with
moderate (13.1% reduction) or low risk (9.2% reduction).
Finally, to ascertain the absence of potential correlations
between the risk of phlebitis associated with different episodes
of catheterization in the same individual, we analyzed the cohort of
patients in which a second catheterization was performed
(n = 146). The development of phlebitis was not more likely in
patients who had a previous episode than in those who had not
[17% (17/100) of patients without a previous PVP developed
phlebitis vs 19.6% (9/46) of those with a previous PVP, p = 0.8].
Discussion
The main nding of this study is the ascertainment that the
conditional risk of phlebitis over time depends on the number of a
limited set of easily assessable risk factors. The conditional risk of

phlebitis increases faster and reaches higher values as the number

of risk factors increases. According to our estimations, per 100
scheduled replacements performed on day 3 instead of maintaining the catheter in situ (6 days), phlebitis would be prevented in 9,
13, and 25 cases for catheters of low, moderate and high risk
groups, respectively. Therefore, when contemplating the preventive effect of scheduled catheter exchanges, our data suggest that
current American guidelines11,12 should be appropriate for highrisk episodes while a clinical management should be considered
for catheters with a lower risk prole.
Our study has several limitations. First of all, it is a single centre
study; hence the results may not be applicable to other settings.
However, the large cohort of patients and risk factors evaluated as
well as the nding that risk conditions were similar to those found
in other studies, suggest that our population may be representative
of that admitted to most acute-care facilities. Secondly, the study
was conducted during a limited period of time after an
intervention aimed to improve the insertion and maintenance of
PVC. Although this circumstance may have inuenced the rate of
catheter complications or their severity, we believe it could hardly
be inuential on the observed relationship between the catheter
risk prole and dynamics of phlebitis development. Conversely,
the relatively large sample size, the probable consistency of the
observations due to their systematic validation by a small and
compact team and a detailed analysis based on time to event
outcomes could be considered potential strengths of the study.
Our incidence of phlebitis (9.7% or 39.3 per 1000 catheter-days
and 3.3% or 17.4 per 1000 catheter-days for moderate or severe
phlebitis) was in the low range in comparison to that reported in
the literature.3,16,20 Furthermore, 70% of phlebitis was mild,
suggesting that the preventive measures in our centre are effective
and most PVCs are removed before serious complications
developed.27 These data agree with those reported by Curran

190

G. Mestre Roca et al / Med Clin (Barc). 2012;139(5):185191

Table 3
Theoretical benet of catheter replacement according to the indwelling time and catheter risk factors selected by the Cox regression analysis.
Cumulative probability of phlebitis (%)
Indwelling time (T time; h)
24 h

48 h

All catheters
One catheter T time in placea
Two catheters 1/2 T time in placeb
Theoretical benet of replacementc

72 h

96 h

120 h

2.5
2
0.5

6
4.9
1.1

13
7.8
5.2

23
11.6
11.4

30
15.4
14.6

Low risk catheters (01 risk factors)

One catheter T time in placea
Two catheters 1/2 T time in placeb
Theoretical benet of replacementc

0.5
0
0

2.5
1
1.5

3
2
1

11.5
4.9
6.6

17
7.8
9.2

Moderate risk catheters (2 risk factors)

One catheter T time in placea
Two catheters 1/2 T time in placeb
Theoretical benet of replacementc

3.5
4
+0.5

6.5
6.9
+0.5

12.5
9.8
2.7

21.5
12.6
8.9

28.5
15.4
13.1

High risk catheters (>3 risk factors)

One catheter T time in placea
Two catheters 1/2 T time in placeb
Theoretical benet of replacementc

3.5
2
1.5

10.5
6.9
3.6

24.5
11.7
12.8

40.5
19.9
20.6

52.5
27.7
24.8

Based on actuarial life estimates of the cumulative probability of events at the indicated hours in place.
Calculated by the formula: 1 [(1 probability of event at day x)2], using the actuarial life estimates at 12 h, 24 h, 36 h, 48 h, 60 h and 72 h of catheterization for 24 h, 48 h,
72 h, 96 h, 120 h and 144 h estimations, respectively.
c
Calculated by the difference between the estimated cumulative risk for two catheters Vfe T time in place and the cumulative probability for one catheter T time in place
(actuarial risk). If the sign is negative means a theoretical benet from the replacement (reduction of phlebitis).
b

et al.22 on the potential value of surveillance itself in the

improvement strategy of catheter management.
In the present study, the probability of developing phlebitis was
higher if a PVC was inserted in females, if the procedure was done
at the emergency department or at medical-surgical wards instead
of an operating room, if located at forearm instead of antecubital
fosse and if used for IV antibiotics (amoxicillinclavulamate or
aminoglycosides). All these factors have been previously reported
as associated with development of phlebitis.3,4,10,28 During the
study period we did not observe any bacteraemia, and these results
are in agreement with other studies3,4,28 reporting it as inexistent
or as a very uncommon event (00.3%).
Descriptive analysis have shown as a universal rule that the
cumulative proportion of phlebitis increases over time4 but few
studies have used life table analysis to explore the kinetics of
phlebitis development.3,4,15,16,28,29 These studies have usually
reported a sharp increase in phlebitis incidence at some point
during follow up, ranging from the rst to the fourth day of
catheterization. Overall, we observed a low risk of phlebitis until
the second day of insertion, with a hazard function that achieved
the highest rates between the third and fth day. Notably, this
pattern differed markedly depending on the number of risk factors.
While low-risk catheters (nearly half) reached the peak between
the fourth and fth day of insertion, the moderate or high risk
catheters reached this peak earlier (between the third and fourth
day of insertion). Although there are no studies specically
addressing the dynamics of phlebitis taking into account risk
factors, there are some indirect data available14,28,29 indicating
that, in the absence of specic predisposing conditions (infusion of
blood, interleukins, parenteral nutrition or antibiotics), catheter
survival is often longer than three days and the specic daily risk
after the fourth day of insertion may remain below 10%.
The question of routine replacement of catheters not showing
signs of inammation or discomfort is subject to discussion.5,21,23
Overall, we have estimated that the greatest benet (reduction of
14.6% in the cumulative incidence of phlebitis) would be achieved
by exchanging catheters every 60 h. However, the same approach
considering risk factors showed clearly that this benet is nearly
thrice for high-risk catheters (24.8% reduction) in comparison with
low-risk ones (9.2% reduction). These data point out a key concept:

PVP development depends on the interaction of risk factors with

length of insertion. This may explain the great variability observed
in PVP rates in multi-centre surveillance systems. Most probably,
such variability depended on what was the catheter used for.22
In conclusion, when establishing a policy of catheter replacement, both cost and discomfort of the patients must be taken into
account and catheters management without considering the
catheter risk prole may expose a signicant number of patients to
uncomfortable replacements for a small clinic absolute benet.
The denitive answer to the question of whether routine catheter
exchange is better than replacement on a clinical basis can only be
obtained from a carefully designed, well conducted randomized
clinical trial comparing both strategies, particularly in high-risk
catheters.
Financial support
o receives funding for research from Ministerio
J. Rodriguez-Ban
de Sanidad y Consumo, Instituto de Salud Carlos III-FEDER, Spanish
Network for the Research in infectious Diseases (REIPI RD006/
0008). The sponsoring institution had no role in the design and
conduct of the study; the collection, analysis and interpretation of
the data; or the preparation, review or approval of the manuscript.
Conict of interest
The authors declare that they have no competing interests.
Acknowledgements
We appreciate MSc Silvia Gonzalez, Irene Garca, Encarna
Figueras, Margarita Alarcia and Roser Coca contribution to
monitoring the quality of data recorded in this study.
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