Discussion

We detected no statistically significant difference in the rate of CLABSI based on lumen number in patients with acute leukemia. The combination of a prolonged duration of neutropenia, mucositis, and barrier disruption due to lines and invasive procedures puts this population at the highest risk among cancer patients for bacteremia. ^{Reference Nørgaard, Larsson, Pedersen, Schønheyder and Sørensen7} Accordingly, our analysis demonstrated a 22.7% rate of CLABSI overall, similar to prior studies in leukemia patients, and significantly higher than the rates in general hospitalized patients (∼6%). ^{Reference Lee, Kim and Shim3,Reference Chopra, Ratz, Kuhn, Lopus, Chenoweth and Krein4,Reference Nørgaard, Larsson, Pedersen, Schønheyder and Sørensen7}

Although patients were statistically older in the double-lumen group, the absolute difference was small (61 vs 57 years) and was not likely to have affected the rate of CLABSI. Notably, significantly more patients received FLAG chemotherapy in the double-lumen group, a non–anthracycline-containing AML regimen with a shorter duration of neutropenia and less toxicity compared to standard AML induction chemotherapy regimens (eg, 3+7). ^{Reference Vulaj, Perissinotti and Uebel8} Despite these differences in baseline characteristics, according to multivariable logistic regression, there was no association between CLABSI incidence and number of PICC lumens.

Importantly, more than half of all CLABSI events were MBI-LCBIs. This finding suggests that a significant proportion of bacteremias in this population may be a function of mucosal barrier injury due to mucositis-inducing chemotherapy, rather than related to the presence of a PICC. The microbiologic data are concordant with this premise: most of the organisms isolated were of enteric origin, consistent with prior studies of hematology patients. ^{Reference Nørgaard, Larsson, Pedersen, Schønheyder and Sørensen7}

Notably, the incidence of PICC-associated DVT was low and did not differ between groups (3.2% vs 4.4%). Given the low incidence, we were not powered to detect any possible difference in the rate of DVT; however, this may be significantly affected by differences in the thrombotic potential of leukemia subtypes (eg, APL), as well as therapies that significantly increase the risk of thrombosis in this population (eg, asparaginase). ^{Reference Del Principe, Del Principe and Venditti9}

Although rates of CLABSI and DVT did not differ, the need for additional PIVs was more than twice as high in patients with double-lumen PICCs and occurred in 34% of patients. This finding may represent a significant quality of life (QOL) burden in acute leukemia patients already at high risk for bleeding complications because PIVs are typically replaced every 72–96 hours. ¹⁰ The impact the requirement for additional PIV placement has on delays in medication administration and other care remains unknown.

This study had several limitations. First, it was a single-center study of hospitalized patients with acute leukemia. These results should not be extrapolated to outpatient hematology and oncology patients, including those with a lower rate of bacteremia and other complications. Such patients may not require central venous access nor multiple-lumen PICCs. As such, when choosing a PICC, a risk-guided approach should be considered, weighing the complexity of care with the aim to avoid central venous access when not necessary (Supplementary Fig. S2 online). Such an approach created by our center in response to these results is shown in Supplementary Figure S3 (online). Second, despite our multivariable analysis, we cannot exclude selection bias in the choice of lumen number. However, we would expect higher-risk patients to have more lumens placed in anticipation of a higher complexity of care; thus, a similar CLABSI rate in the triple-lumen group is reassuring. Finally, without prospective data, we cannot confirm any possible adverse impact of more frequent PIV access on patient satisfaction and broader QOL outcomes.

In conclusion, we detected no relationship between the number of PICC lumens and the incidence of CLABSI or DVT in patients with acute leukemia undergoing intensive chemotherapy. The use of a double-lumen PICC was associated with a >2-fold increase in the rate of requiring additional venous access, which may affect QOL.