The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used to conduct this systematic review and meta-analysis (15). The study protocol was registered on INPLASY (Registration number: INPLASY2025120072). A systematic literature search was conducted in PubMed, Embase, and the Cochrane Library databases from their inception to 3 June 2025. The search terms included combinations of the following keywords and Medical Subject Headings (MeSH): “peripherally inserted central catheter,” “PICCs,” “central venous catheter,” “CVCs,” and “home parenteral nutrition.” The detailed search strategy was described in Supplementary Table S1. The search was restricted to studies published in English. Reference lists of relevant articles and reviews were also manually screened to identify additional eligible studies.

Studies that met the following criteria according to the PICOS guidelines were included: Patients: adult patients (≥18 years) receiving home parenteral nutrition; Intervention and comparison: peripherally inserted central catheters versus tunneled central venous catheters; Outcomes: the incidence of CRBSI; and Study design: cohort or case–control studies. Articles were excluded if they lacked eligible data or were case reports, reviews, or conference abstracts.

All eligible data were independently extracted by two investigators using a standardized data extraction form. Any discrepancies were resolved through discussion, and if consensus could not be reached, a third investigator was consulted. Data extracted included the first author, year of publication, country, study design, treatment regimen, outcome measures, and definition of CRBSI. The methodological quality of the included studies was independently assessed by two reviewers using the Newcastle–Ottawa Scale (NOS) (16). Studies with an accumulated score of ≥6 points were considered high quality. The certainty of evidence and strength of recommendations were evaluated using the GRADE approach (17), which rates confidence in summary effect estimates across four levels: very low, low, moderate, and high.

Stata 12.0 (STATA Corp, College Station, TX, USA) was used for the meta-analysis. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated to estimate the incidence of CRBSI using either the fixed-effects model or random-effects model, depending on the degree of heterogeneity. Heterogeneity was assessed using Cochran’s Q test and quantified with the I² statistic, with I² > 50% considered substantial. Sensitivity analysis was conducted by sequentially removing individual studies to assess the robustness of the results. Subgroup analyses were conducted based on available variables. Publication bias was evaluated using funnel plots, Egger’s regression test, and Begg’s test.

A total of 323 studies were initially retrieved from the databases. After removal of duplicates and screening titles and abstracts, 13 articles were retained for full-text review. Of these, three studies were excluded due to unavailable or insufficient data. Finally, 10 studies (11–15, 18–22) met the inclusion criteria for the meta-analysis. The study selection process is presented in the PRISMA flow diagram (Figure 1). The included 10 studies, published between 2013 and 2021, involved a total of 1,139 patients receiving PICCs, with sample sizes ranging from 48 to 202 participants. The studies were conducted between 2013 and 2021 across multiple countries, including the USA, Spain, Canada, France, Italy, Denmark, and Poland. Both prospective and retrospective cohort designs were represented, with patient populations including both cancer and non-cancer patients. CRBSI definitions varied among studies: the Infectious Diseases Society of America (IDSA) criteria were used in two studies, the CDC criteria in five studies, and no standard criteria were reported in three studies. CRBSI was generally diagnosed based on blood cultures or catheter lumen cultures, with slight differences depending on the study protocol. Catheter types included PICCs and tunneled CVCs. The number of lumens, catheter-days, and CRBSI rates per 1,000 catheter-days were reported when available (Table 1). The microorganisms responsible for catheter-associated infections are primarily Gram-positive bacteria, Gram-negative pathogens, and fungi (Table 2). The quality of the included literature was scored 6–7 (Supplementary Table 2).

Ten studies reported the effects of PICCs and tunneled CVCs on the incidence of CRBSI based on per-patient risk. Moderate heterogeneity was observed among the included studies (I² = 33.1%, p = 0.14). Therefore, both fixed-effects and random-effects models were applied. Under both models, PICC use was associated with a significantly lower risk of CRBSI compared with tunneled CVCs (fixed-effects model: RR = 0.40, 95% CI 0.33–0.49; random-effects model: RR = 0.38, 95% CI 0.29–0.50; both p < 0.001) (Figure 2). According to GRADE, the quality of evidence was very low (Supplementary Table 3). In addition, seven studies reported CRBSI incidence based on per 1,000 catheter-days. The mean CRBSI rate was 0.77 per 1,000 PICC-days (range: 0.00–1.96 per 1,000 PICC-days) and 1.01 per 1,000 tunneled CVC-days (range: 0.41–1.93 per 1,000 tunneled CVC-days), indicating a consistently lower incidence associated with PICCs.

Subgroup analysis by country showed consistent results across most regions, including the USA, Spain, Canada, France, and Denmark, with no significant differences between PICCs and tunneled CVCs. In contrast, Italy and Poland did not demonstrate a statistically significant difference between the two catheter types. Subgroup analyses stratified by study design demonstrated that both prospective cohort and retrospective cohort studies found a significant difference between PICCs and tunneled CVCs, with PICC use being associated with a lower risk of CRBSI. When stratified by patient population, the association between catheter type and CRBSI risk remained consistent in both cancer and non-cancer populations. Moreover, subgroup analyses stratified by CRBSI definition demonstrated that studies using IDSA criteria, CDC criteria, and those applying non-standard clinical definitions all showed a statistically significant difference between PICCs and tunneled CVCs, with PICC use consistently associated with a lower risk of CRBSI (Table 3).

Sensitivity analysis was performed by sequentially excluding each study (Figure 3). After excluding the study by Christensen et al., heterogeneity was eliminated (I² decreased from 33.1 to 0%). The pooled effect estimate remained stable, with PICCs still associated with a significantly lower risk of CRBSI compared with tunneled CVCs (RR = 0.33, 95% CI 0.26–0.41), indicating the robustness of the overall findings (Figure 4).

Publication bias was evaluated using funnel plots and Begg’s test. Visual inspection of the funnel plot revealed no significant asymmetry (Figure 5). Both Egger’s test (p = 0.138) and Begg’s test (p = 0.421) indicated no significant publication bias.