Midlines vs PICCs in the Hospital: Helping the patient or just gaming the system?

Reviewed by S. Shaefer Spires, MD, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC

There has been increased discussion about whether use of midlines in the hospital is an effective way to reduce harm from catheter-related bloodstream infections (CRBSIs), and a recent study has highlighted the relative risks of midline and peripherally inserted central catheters (PICCs). In a multihospital registry of over 10,000 inpatients who had a midline catheter or PICC placed for the indication of difficult venous access or IV antibiotic therapy, the authors found that patients with PICCs had a greater risk of catheter occlusions and bloodstream infections (BSI). However, when examining the time to event models there was a lower hazard of deep venous thrombosis (DVT) in those with PICCs (HR 0.53). There were some relevant differences in the groups prior to catheter placement including the indication of difficult venous access cited more frequently for midlines (72% vs 40%) and patients with midlines were more likely to have had a history of DVT.  Consequently, while they found lower BSI and occlusion risk in midline, the occurrence of DVT was similar and a higher daily hazard. Therefore, while there is likely a niche for midlines in this population, we cannot dismiss the risk of thrombosis associated with midlines especially in those patients with hypercoagulability or predisposing factors (e.g. cancer, COVID-19).

Swaminathan L, Flanders S, Horowitz J, Zhang Q, O’Malley M, Chopra V. Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients with Short-term Indications. JAMA Internal Medicine. 2022;182(1):50-58. doi:10.1001/jamainternmed.2021.6844

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