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Incidence of bloodstream infections was not significantly different when midline catheters (MCs) or peripherally inserted central catheters (PICCs) were used for medium- to long-term IV therapy, a randomized trial found, but MCs did have a higher overall complication rate.

Among 304 Danish adults receiving an MC or PICC for an expected 5 to 28 days, no catheter-related bloodstream infections (CRBSI) occurred in the MC group versus one in the PICC group (P>0.99), reported researchers led by Simon Thomsen, MD, of Aalborg University Hospital in Denmark.

Moreover, no symptomatic deep vein thromboses (DVTs) occurred in patients in the MC group, but two patients in the PICC group developed DVTs, according to findings of the single-center study published in .

The MC group did have a significantly higher catheter-related complication rate, at 13.2% versus 7.2% in the PICC group (incidence rate ratio [IRR] 2.37, 95% CI 1.12-5.02, P=0.02). But over 90% of these complications were classified as minor, and included pain during infusion, infiltration, accidental catheter removal, occlusion, and leaking. Complications also led to more premature removals in the MC group (13.2% vs 6.6%, respectively, P=0.045).

"Despite the MC group having a higher complication rate, our findings indicate that MCs could be considered an alternative to PICCs," the authors suggested.

Notably, researchers performed a post hoc analysis that stratified outcomes according to catheter dwell time and found that there was no significant difference between MC and PICC complication rates when catheters were used for 15 days or less (IRR 1.16, 95% CI 0.50-2.68, P=0.73). However, when catheters were used for 16 days or more, patients in the MC group had over 13 times the risk for complications and premature removals (IRR 13.18, 95% CI 1.75-99.39, P=0.01), Thomsen and colleagues found.

"I have greater confidence in using midline catheters for short durations as a result of this study," commented Vineet Chopra, MD, from the University of Colorado-Anschutz Medical Campus in Aurora, in an . "The absence of any major complications and lack of difference in rates of minor events during this period suggest that not only are midline catheters safe but likely preferred as recommended by evidence-based guidelines."

PICCs have long been the "go-to" device for both inpatient and outpatient delivery of IV therapies, Chopra noted. However, CRBSI and DVTs are known serious complications of PICCs and the devices are sometimes used inappropriately in patients, exposing them to harm. Because MCs terminate just below the axilla in the peripheral veins, they are not considered a central venous catheter and the hope has been they don't carry the same risks as PICCs, Chopra explained. However, observational data on the safety of MCs has been mixed.

Chopra noted several important study limitations. Researchers did not include the types of infusions delivered -- an important consideration because there is substantial debate about which drugs are safe for administration via peripheral veins. Also some contemporary practices, such as electrocardiography for catheter tip ascertainment in PICCs and tissue plasminogen activator for declotting, were not used in the study, he wrote. Moreover, the study data cannot be extrapolated to important settings outside the hospital, such as in the home, where MCs play an important role.

Thomsen and colleagues pointed out that not all clinicians are as familiar with MCs as with the more commonly used PICCs. In the study, the vascular access team was thoroughly trained in the insertion, use, and maintenance of MCs at the beginning of the study. However, "this proactive approach may have contributed to the low rate of complications observed with both catheters in this study," they commented.

The parallel, open-label randomized clinical trial enrolled 304 adult inpatients and outpatients at a single tertiary care center in Denmark. Patients were eligible for enrollment if they had an indication for IV medicine or fluid therapy (e.g., blood products, isotonic saline- or glucose-solutions, antibiotics, or chemotherapy) that required IV access lasting 5 to 28 days. Participants had a mean age of 65 years and 43% were women.

Study participants were randomized 1:1 to either the MC group or the PICC group. The study's primary outcome was CRBSI. Secondary outcomes included symptomatic catheter-related thrombosis and catheter failure. The most common indication for device placement was antibiotic therapy. The median dwell time was 10 days for MCs and 11 days for PICCs. Patients were followed for up to 90 days after completion of IV therapy.

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