Some Candida spp., in the presence of dextrose-containing fluids, produce slime similar to that of their bacterial counterparts, potentially explaining the increased proportion of BSIs caused by fungal pathogens among patients receiving parenteral nutrition fluids [1].

A study done by Nassaji-Zavareh and Ghorbani [1] with the aim to investigate the incidence of phlebitis and to evaluate some important related factors in 300 patients admitted to medical and surgical wards of hospitals in Semnan, Iran concluded that phlebitis is still an important and ongoing problem in medical practice. In patients with diabetes mellitus and infectious diseases, more attention is needed. The incidence of phlebitis was 26%. One of the most striking findings of this study was the relationship between diabetes mellitus and phlebitis. In diabetic patients, phlebitis was 7.8 times more common than in non-diabetics [2].

In a prospective study conducted by Abolfotouh et al. [1] on 359 patients admitted at King Abdulaziz Medical City, Saudi Arabia incidence of catheter related complications was found to be 39.3%. The catheter related complications were: phlebitis (17.6%), pain (7.6%), catheter leak (3.9%) and catheter dislodgement (2.4%). Females were found to have significantly higher risk of PIC related complications than males. They also found that patients on IV medications were at higher risk of developing complications than patients on hydration alone [3].

Study conducted by Maki and Mermel [8] concluded that multiple factors, including the infusate and the duration of cannulation, contribute to the development of infusion-related phlebitis. Infuscate characteristics also influence the occurrence of peripheral vein Infusion thrombophlebitis. Both low pH and high osmolality intravenous solutions, such as hypertonic glucose, confer a higher risk. In addition, intravenously administered medications, such as potassium chloride, barbiturates, phenytoin and many cancers chemotherapeutic agents, have been implicated. Intravenous antibiotics, such as vancomycin, amphotericin B and most beta-lactams, have been associated with a twofold increased risk, which may be attributable to the presence of microparticulates in the antibiotic solutions.

The use of peripheral intravenous catheters made of PEU-Vialon appears to pose the same risk for catheter-related infection as the use of catheters made of FEP-Teflon and PEU-Vialon can permit longer cannulation with less risk for phlebitis. The risk for catheter-related bacteremia with FEP-Teflon and PEU-Vialon catheters is sufficiently low that it no longer seems justifiable to recommend the use of small steel needles for most peripheral intravenous therapy [4]. 

In a data analysis done by Miliani et al. [5] on the MEDLINE database ranging over a period of 35 years from 1966 to 2001, incidence of thrombophlebitis was found to be between 25% and 35%. In a prospective study of 90 hospitalized patients with peripheral intravenous catheters, (26%) developed peripheral vein infusion thrombophlebitis, among whom one third had complications   that   resulted   in   a   delay    in   intravenous therapy, additional intravenous therapy or an extended hospital stay of 2 to 5 days. Several medical complications are associated with peripheral vein infusion thrombophlebitis. Occlusion of the vein by thrombus may lead to extravasation of fluid into surrounding tissues, which may limit venous access in the affected limb [6].

Arnow and colleagues studied 94 patients with 102 episodes of sepsis due to percutaneously inserted catheters and found that 44 (43%) of these episodes occurred with peripheral venous catheters; the remaining episodes were due to central vein and peripheral arterial catheters. Of the 44 episodes, 16 were accompanied by peripheral vein infusion thrombophlebitis, cellulitis or superficial abscess and 7 were complicated by suppurative thrombophlebitis [7,8]. 

Variations of the grading system for peripheral thrombophlebitis have evolved during the past 20 years, including the Maddox scale and the Baxter scale as discussed in Table 1 [9].

A prospective observational study conducted by Jisal et al. [6] in 82 patients, the incidence of peripheral catheter related thrombophlebitis is found to be 50%. In this study only grade 1 and grade 2 thrombophlebitis were observed [5]. A prospective cohort Study conducted by Miliani et al. [5] on behalf of the CATHEVAL Study Group Showed that an average of 1.4 PVCAEs per PVC were observed. The incidence rate of at least one PVCAE (peripheral venous catheter related adverse events) was 52.3 per 100 PVCS; 95% CI: 48.8±55.7. 

Clinical PVCAEs were significantly more frequent than mechanical ones (p<0.001). The most frequent clinical PVCAEs were phlebitis, followed by haematoma and fluid/blood leaking whereas obstruction/occlusion of PVC was the most frequent 

mechanical PVCAEs. According to the five levels of phlebitis grading scale, there were 35 (21.3%) graded 1; 95 (57.9%) graded 2; 19 (11.6%) graded 3; 14 (8.6%) graded 4; 1 (0.6%) graded 5. Suspected phlebitis cases (grade 1 or 2) were more frequent than manifest phlebitis (grade 3 or greater). Most PVCAEs occurred before the second day after PIVC insertion.

In a prospective observational study done by Singh et al. [10] on 230 patients admitted in the Intensive Care Unit (ICU), medical, surgical, obstetrics and gynecology wards of Dhulikhel Hospital, the incidence of incidence of phlebitis was found to be 59.1%. The chance of having phlebitis was also found to be 4.13 and 3.06 times more for age 21-30 and 31-40 than age 60 and over. This study found the highest incidence of phlebitis in the ICU (81.82%), followed by medical ward (61.48%), OBGYN wards (54.54%) and Surgical ward (52.83%) [1].

A prospective, observational study conducted by Mandal and Raghu [9] on 150 patients who were admitted to the medical and surgical division of the hospital, the incidence of phlebitis was 31.4% [11]. Thirty percent (30%) of male patients and 32% of female patients had phlebitis during the stay in hospital. Thirty‑five percent (35%) phlebitis occurred in the age group less than 60 years and 26% in more than 60 years. Phlebitis was more in the catheter inserted in lower limb (56.66%) when compared to upper limb (16.6%). Incidence of phlebitis was found to be higher in patients who had an18 G catheter (37.97%) when compared to patients with 20 G (23.94%).

In a prospective observational study conducted by Salma et al. [11] at Dhaka National Medical College Institute Hospital, in medicine department among 300 hospitalized patients from 15th March to 20th June 2018, 420 I/V catheters were observed from 1st to last day of hospitalization with a range of 1-7 days. In this study, 28.57% patients developed PIVC related complications. Out of 420 observed PIVC, 120 (28.57%) developed complication. Phlebitis ranked first among complications (18.09%) followed by extravasation (9%), cannula obstruction (7.86%) and dislodge (2%) subsequently. Among the 76 phlebitis cases 42 (55.26%) develop grade II, 17 (22.37%) patient developed grade III phlebitis. Frequency of phlebitis is higher among the patients received hypertonic fluid 11.4% than those received isotonic fluid 5.19% (p-value<0.05). Phlebitis is observed more in patient group received KCI injection 26.31% than those not received the KCI. Among the patients received antibiotics injection frequency of phlebitis more with Flucloxacillin (60%), Amikacin (50%), Meropenem (50%), Amoxicillin+clavulanic acid (34.78%). Less frequently with Ceftazidime (16.67%), Cefuroxime (11.86%) and Ceftriaxone (11.25%) [10].

1. Nassaji-Zavareh, M. and R. Ghorbani. "Peripheral intravenous catheter-related phlebitis and related risk factors." Singapore Medical Journal, vol. 48, no. 8, 2007, pp. 733–736.

2. Abolfotouh et al. "Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications." Therapeutics and Clinical Risk Management, vol. 10, 2014.

3. Arnow, P., E. Quimosing and M. Beach. "Consequences of intravascular catheter sepsis." American Journal of Infection Control, vol. 22, no. 4, 1994, pp. 242–243.

4. Brezenger, T. et al. "Is routine replacement of peripheral intravenous catheters necessary?" Archives of Internal Medicine, vol. 158, 1998, pp. 151–156.

5. Miliani, K. et al. "Peripheral venous catheter-related adverse events: evaluation from a multicentre epidemiological study in France (The CATHEVAL Project)." PLOS ONE, vol. 12, no. 1, 2017, e0168637.

6. Jisal, S. et al. "The incidence of thrombophlebitis following the use of peripheral intravenous cannula in post-operative patients: a prospective observational study." IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 14, no. 6, 2015, pp. 1–4.

7. Maddox, R. R. and D. R. Rush. "Double-blind study to investigate methods to prevent cephalothin-induced phlebitis." American Journal of Hospital Pharmacy, vol. 34, 1977, pp. 29–34.

8. Maki, D. G. and L. A. Mermel. "Infections due to infusion therapy." Hospital Infections, edited by J. V. Bennett and P. S. Brachman, 4th ed., Lippincott-Raven Publishers, 1998, pp. 689–724.

9. Mandal, A. and K. Raghu. "Study on incidence of phlebitis following the use of peripheral intravenous catheter." Journal of Family Medicine and Primary Care, vol. 8, 2019, pp. 2827–2831.

10. Singh, R. et al. "Peripheral intravenous catheter-related phlebitis and its contributing factors among adult population at KU Teaching Hospital." Kathmandu University Medical Journal, vol. 6, no. 4, 1970, pp. 443–447.

11. Salma, U. et al. "Frequency of peripheral intravenous catheter-related phlebitis and related risk factors: a prospective study." Journal of Medicine, vol. 20, no. 1, 2019, pp. 29–33.