Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: a systematic review. Clin Nutr. 2013;32:16-26. [PMID: 22959630 DOI: 10.1016/j.clnu.2012.08.004]

Prolonged Parenteral Nutrition Is One of the Most Significant Risk Factors for Nosocomial Infections in Adult Patients With Intestinal Failure

BACKGROUND

Intestinal failure (IF) and its management are associated with an increased likelihood of infectious complications. This study aimed to evaluate the prevalence and potential risk factors for nosocomial infections (NIs) in hospitalized adult patients with IF.

METHODS

In total, 259 eligible patients with IF admitted to a single clinical nutrition center in a tertiary referral hospital from January 1, 2012, to January 1, 2019, were retrospectively identified. NIs were defined according to the 2008 Centers for Disease Control and Prevention criteria. Univariate and multivariate analyses were performed to identify independent risk factors for NIs.

RESULTS

The mean age of the study population was 47.0 ± 17.7 years, and 158 (61.0%) were men. The mean body mass index was 16.2 ± 2.9 kg/m² , and 219 (84.6%) were diagnosed with malnutrition. The prevalence of NIs was 25.5% (113 NIs in 66 patients). The most common NIs were pneumonia (14.3%), bacteremia of unknown origin (13.5%), catheter-related bloodstream infection (5.0%), lower respiratory tract infection (5.0%), surgical site infection (3.9%), and urinary tract infection (1.9%). Multivariate analysis revealed that decreased serum albumin level (odds ratio [OR], 0.884; 95% CI, 0.883-0.978, P < .05), presence of gallbladder stones or cholestasis (OR, 3.144; 95% CI, 1.044-9.464; P < .05), and prolonged parenteral nutrition (PN) use (OR, 1.072; 95% CI, 1.039-1.105; P < .001) were independent predictors for NIs.

CONCLUSIONS

NIs remain prevalent in hospitalized adult patients with IF. Prolonged PN use was one of the most significant predictors for NIs.

Antimicrobial Locks in Patients Receiving Home Parenteral Nutrition

Catheter-related bloodstream infection (CRBSI) is one of the most common and potentially fatal complications in patients receiving home parenteral nutrition (HPN). In order to prevent permanent venous access loss, catheter locking with an antimicrobial solution has received significant interest and is often a favored approach as part of the treatment of CRBSI, but mainly for its prevention. Several agents have been used for treating and preventing CRBSI, for instance antibiotics, antiseptics (ethanol, taurolidine) and, historically, anticoagulants such as heparin. Nonetheless, current guidelines do not provide clear guidance on the use of catheter locks. Therefore, this review aims to provide a better understanding of the current use of antimicrobial locking in patients on HPN as well as reviewing the available data on novel compounds. Despite the fact that our current knowledge on catheter locking is still hampered by several gaps, taurolidine and ethanol solutions seem promising for prevention and potentially, but not proven, treatment of CRBSI. Additional studies are warranted to further characterize the efficacy and safety of these agents.

The hidden cost of catheter related blood stream infections in patients on parenteral nutrition

BACKGROUND & AIMS

Parenteral nutrition (PN) is a valuable and life-saving treatment for patients with intestinal failure. While its use is increasing, it has been demonstrated to be a risk factor for intravenous catheter-related blood stream infection (CRBSI) - a significant, serious and potentially fatal complication of PN use. CRBSI can have serious secondary consequences for patients, though, there is a paucity of literature describing these. The aim of this study is to audit the incidence of, and evaluate the consequences of, complications associated with CRBSI.

METHODS

Medical records were examined for all parenterally fed patients diagnosed with a CRBSI from 01/01/16 to 31/12/17 in a UK tertiary referral centre for patients requiring intravenous nutritional support. Patients were identified prospectively; data relating to the infection and complications was collected retrospectively.

RESULTS

114 episodes of CRBSI were recorded in 80 patients. 57 occurred during an inpatient admission, 57 occurred in the community and resulted in admission. 21 different adverse events occurred as a result of the CRBSI. The complications identified were varied with the most common being acute kidney injury, deranged electrolytes and urinary tract infections. Other significant complications included DVT, pulmonary abscess and infective endocarditis. 35% of episodes resulted in delayed discharge and 12% required escalation to a critical care bed. The financial impact is estimated at over £800,000 per annum.

CONCLUSIONS

The findings demonstrate a plethora of complications which can arise following CRBSI, which pose a significant health risk to parenterally fed patients who already have reduced physiological reserve. Moreover, these findings represent additional financial and resource burden to the health service. The adverse events resulting from CRBSIs should, therefore, be audited to improve outcomes: well-resourced specialist centres are best placed to provide this service.

Disparate Candida albicans Biofilm Formation in Clinical Lipid Emulsions Due to Capric Acid-Mediated Inhibition

Receipt of parenteral nutrition (PN) remains an independent risk factor for developing catheter-related bloodstream infections (CR-BSI) caused by fungi, including by the polymorphic fungus Candida albicans, which is notoriously adept at forming drug-resistant biofilm structures. Among a variety of macronutrients, PN solutions contain lipid emulsions to supply daily essential fats and are often delivered via central venous catheters (CVCs). Therefore, using an in vitro biofilm model system, we sought to determine whether various clinical lipid emulsions differentially impacted biofilm growth in C. albicans We observed that the lipid emulsions Intralipid and Omegaven both stimulated C. albicans biofilm formation during growth in minimal medium or a macronutrient PN solution. Conversely, Smoflipid inhibited C. albicans biofilm formation by approximately 50%. Follow-up studies revealed that while Smoflipid did not impair C. albicans growth, it did significantly inhibit hypha formation and hyphal elongation. Moreover, growth inhibition could be recapitulated in Intralipid when supplemented with capric acid-a fatty acid present in Smoflipid but absent in Intralipid. Capric acid was also found to dose dependently inhibit C. albicans biofilm formation in PN solutions. This is the first study to directly compare different clinical lipid emulsions for their capacity to affect C. albicans biofilm growth. Results derived from this study necessitate further research regarding different lipid emulsions and rates of fungus-associated CR-BSIs.

To Pull or Not to Pull: Salvaging Central Line Catheters in Home Parenteral Nutrition

PURPOSE OF REVIEW

Catheter-related blood stream infections (CRBSI) pose a significant risk to patients on home parenteral nutrition (HPN). Recurrent loss of catheters can lead to scarring and eventual loss of central access, a potentially fatal situation for patients dependent on HPN.

RECENT FINDINGS

In the past, the standard of care to treat these infections required catheter removal. More recently, several studies have indicated that many CRBSI can be treated without removal of the catheter. Successful treatment without removal can be achieved by intentionally following a catheter salvage protocol. We define this as a previously defined protocol to accurately diagnose CRBSI, identify the organism(s) involved, and effectively treat not only the blood stream infection, but also sterilize the catheter. For patients on HPN with CRBSI, consider attempting line salvage if the patient is not suffering from severe sepsis, other infection related complications, or certain specific infections. Success rates vary depending on the organism causing the infection and the risks; benefits and chance of success should be considered when deciding to attempt line salvage.

Catheter-related bloodstream infections in patients with intestinal failure receiving home parenteral support: risks related to a catheter-salvage strategy

Background

In intestinal failure (IF) patients receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) frequently result in replacement of their tunneled central venous catheters (CVCs), which may lead to future loss of central venous access.

Objective

This observational study investigated the consequences of a catheter-salvage strategy related to CRBSIs.

Design

All CRBSIs from 2002 to 2016 in the Copenhagen IF and microbiological databases were retrospectively analyzed. Catheter salvage was defined by successful antimicrobial therapy with a retained CVC at discharge. Re-occurrences of CRBSIs with the same microbial species and identical antibiogram were defined as a relapse (<30 d) or as a recurrent (30-100 d) infection. Cox regression analyses incorporated a frailty factor to account for recurrent events and overrepresentation by some patients. Cumulative incidence curves are presented with a competing risk model.

Results

There were 2006 tunneled CVCs inserted in 715 adult HPS patients covering 2014.3 CVC years, with a CRBSI incidence rate of 1.83/1000 (n = 1350) and a mortality rate of 0.007/1000 CVC days (n = 5). The mean ± SD salvage rate was 55.3% ± 5.5%, varying according to infection type [monoinfections (62.9% ± 4.4%) and polyinfections (58.6% ± 17.3%)] and causative microorganism [coagulase-negative Staphylococci (CoNS) (68.1% ± 9.4%), Staphylococcus aureus (42.6% ± 17.5%), and Enterobacteriaceae (54.3% ± 16.7%)]. The overall risk of CRBSI relapse was 7.5%, and the risk of CRBSI recurrence was 7.3%. The HR for a subsequent CRBSI was 14% lower in a replaced than in a retained CVC (95% CI: 0.74, 0.99). The HR for a new CRBSI after catheter salvage was 36% higher after polyinfections than after monoinfections (95% CI: 1.03, 1.79). Enterobacteriaceae entailed an increased risk of CRBSI recurrence compared with CoNS (2.26; 95% CI; 1.08, 4.75) and S. aureus (4.45; 95% CI: 1.28, 15.5).

Conclusions

High catheter-salvage rates related to CRBSIs were achievable and safe in HPS patients within a broad range of microorganisms but contributed to an increased risk of CRBSI relapse or recurrence.

Epidemiology of Infectious and Noninfectious Catheter Complications in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Meta-Analysis

Patients receiving parenteral nutrition (PN) as their primary source of nutrition are at high risk for both infectious and noninfectious catheter complications (catheter-related infections, catheter occlusion, and venous thrombosis). The aim of this review was to synthesize and evaluate what is known about catheter complications and prevention strategies in the PN population. Three electronic databases (Medline, Embase, and CINAHL) were screened for studies published between January 2012 and February 2019 regarding infectious and noninfectious catheter complications in patients receiving PN. Rates of infectious and noninfectious catheter complications, prevalence of causative pathogens, potential risk factors, and prevention strategies via the use of antimicrobial lock therapy (ALT) were assessed. Fifty-three catheter complication studies and 12 ALT studies were included. Studies were grouped by definition of complication: catheter-related bloodstream infections (CRBSI) or central line-associated bloodstream infections (CLABSI). Random effects summary rates per 1000 catheter days were 0.85 CRBSI episodes (95% CI 0.27-2.64) and 1.65 CLABSI episodes (95% CI 1.09-2.48). Use of taurolidine or ethanol ALT was efficacious in reducing infectious catheter complications; however, several studies had concerns for adverse mechanical complications. Potential risk factors for catheter complications were highly varied and often contradictory between studies. The rates of catheter complications were higher among catheterized patients receiving PN compared with nationally reported rates of complications in all catheterized patients. Risk factors for catheter complications need to be better understood for targeted prophylactic use of ALT. Future studies are warranted; however, they should be conducted using more standardized definitions and criteria.

Contribution of Genetic and Clinical Risk Factors to Development of Candidemia in Patients Receiving Home Parenteral Nutrition

BACKGROUND

Patients receiving home parenteral nutrition (HPN) have an increased risk for central line-associated bloodstream infections (CLABSIs), including candidemia. Recently, 7 single-nucleotide polymorphisms (SNPs) in TLR1, CD58, LCE4A-Clorf68, and TAGAP have been associated with the development of candidemia. Identification of host-genetic as well as clinical risk factors may help to identify patients who have an increased susceptibility to such infections. The aim of this study was to investigate the relevance of the reported SNPs in patients receiving HPN, and to explore clinical risk factors associated with candidemia.

METHODS

We analyzed blood samples of adult patients who started HPN between 1976 and 2017 at our referral center for intestinal failure. Primary outcome was the association between TLR1, CD58, LCE4A-Clorf68, or TAGAP SNPs and candidemia. Secondary outcomes included the relation between severity of infection and these SNPs, and clinical risk factors for candidemia.

RESULTS

Of 341 included patients, 42 (12%) experienced a candidemia (range 1-6). None of the 7 SNPs were associated with candidemia or the severity of infection. The rate of non-Candida-related CLABSIs was significantly associated with candidemia (rate ratio, 1.29; 95% CI, 1.14-1.46; P < 0.001).

CONCLUSIONS

None of 7 known SNPs in TLR1, CD58, LCE4A-Clorf68, or TAGAP were associated with candidemia or severity of infection in patients receiving HPN. The rate of non-Candida-related CLABSIs was significantly associated with the development of candidemia. The latter supports the key role of aseptic catheter handling with respect to Candida susceptibility in patients receiving HPN.

TRAINING OF CHILDREN'S AND ADOLESCENTS' FAMILY MEMBERS IN HOME PARENTERAL NUTRITION CARE

Objective:

To report the experience of the training in home parenteral nutrition (PN) directed to family members of children and adolescents participating in a multidisciplinary intestinal rehabilitation program of a tertiary public hospital.

Methods:

Cross-sectional descriptive study with family caregivers of patients from the Intestinal Rehabilitation Program of Hospital de Clínicas de Porto Alegre, RS, Brazil, from July/2014 to January/2017. Inclusion criteria: family members of children aged 30 days to 17 years and estimated PN use ≥8 weeks; and family members motivated to care for the child. The training covered: hand washing and disinfection; infusion pump handling; and central venous catheter (CVC) and PN care. Outcomes assessed: catheter-related bloodstream infection (CRBSI) rate, accidental CVC exit, end of PN infusion with more than 60minutes of delay or advance compared to the time predicted, mechanical obstruction, bleeding in the CVC insertion site, and death.

Results:

Twenty-seven family members of 17 children were trained. Their median age was 28 (18-60) years, and 63% were mothers. The mean CRBSI rate was 1.7/1,000 days of CVC use, and 29.4% of patients had at least one episode of accidental CVC exit. There were no complications related to PN infusion, bleeding, or death.

Conclusions:

The training of family caregivers allowed the safe implementation of home PN, with the active participation of families, making the procedure feasible in the public health system in Brazil.

Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure

Background

Teduglutide reduces or eliminates parenteral support (PS) dependency in patients with short bowel syndrome (SBS). Recent post hoc analyses demonstrated that effects are correlated with baseline PS volume. We assessed the SBS‐related quality‐of‐life (QoL) impact of teduglutide, particularly whether improvements are greater among subgroups achieving more PS volume reduction.

Methods

Using phase 3 trial data of teduglutide in patients with SBS (NCT00798967), change in Short Bowel Syndrome–Quality of Life (SBS‐QoL) scores from baseline were compared between teduglutide vs placebo in the overall population and subgroups classified by baseline PS volume requirement, disease etiology, and bowel anatomy. Generalized estimating equation models were fitted to assess impact of teduglutide on SBS‐related QoL using data from all visits, adjusted for baseline characteristics.

Results

Of 86 patients, 43 each were randomized to teduglutide or placebo (mean age: 51 vs 50 years, respectively). In adjusted analyses, teduglutide had a nonsignificant reduction (improvement) of −8.6 points (95% CI: 2.6 to −19.8) in SBS‐QoL sum score from baseline to Week‐24 vs placebo. The impact of teduglutide varied by subgroup. Patients treated with teduglutide experienced significantly greater reductions in SBS‐QoL sum score at Week‐24 vs placebo in 2 subgroups, ie, the third (highest) tertile baseline PS volume (−27.3, 95% CI: −50.8 to −3.7) and inflammatory bowel disease (IBD; −29.6, 95% CI: −46.3 to −12.9). Results were similar for SBS‐QoL subscale and item scores.

Conclusions

The impact of teduglutide treatment on SBS‐related QoL vs placebo varied among subgroups and was significant and most pronounced among patients with highest baseline PS volume requirement or IBD.

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

BACKGROUND

The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise.

METHODS

Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach.

RESULTS

One hundred and twenty-five patients with active malignancy [mean (range) age 58 (25-80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter-related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days.

CONCLUSIONS

This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

Non-interventional, retrospective data of long-term home parenteral nutrition in patients with benign diseases: Analysis of a nurse register (SERECARE)

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of home parenteral nutrition (HPN) service in patients with benign chronic intestinal failure (CIF).

METHODS

This was a 10-y retrospective, non-interventional, multicenter study conducted with adult and pediatric patients with CIF who received HPN service. We analyzed data prospectively collected from a dedicated register by HPN nurses.

RESULTS

From January 2002 to December 2011 a total of 794 patients (49.7% male, median age 1 y for children and 57 y for adults) were included in the analysis. Over the 10-y period, 723 central venous catheter (CVC) complications occurred, of which 394 were infectious (54.5%), 297 were mechanical (41.1%), and 32 (3.3%) were defined as CVC-related thrombosis. The complication rate was higher in children (1.11 per patient) than in adults (0.70 per patient). During the observation period, the rates of both infectious and mechanical complications showed a global declining trend and ∼75% of patients had neither infectious nor mechanical CVC complications. HPN efficacy was evaluated in 301 patients with a minimum follow-up of 36 mo. Body mass index and Karnofsky score showed that the median growth significantly increased (P < 0.001) over baseline for adults and pediatric patients in the 0 to 2 age range.

CONCLUSIONS

The use of a structured register has proved to be a key strategy for monitoring the outcomes of long-term treatment, improving time efficiency, and preventing potential malpractice. To our knowledge, this is the largest survey ever documented; the results were consistent despite the heterogeneity of the centers because of duly applied standard rules and protocols.

In vitro comparison of efficacy of catheter locks in the treatment of catheter related blood stream infection

BACKGROUND & AIMS

Venous access used for parenteral nutrition (PN) application is extremely important for patients with intestinal failure. Potential loss of venous access might be a catastrophy for the patient. Catheter infections are a serious complication of PN application. Systemic administration of antibiotics as well as local antibiotic locks into the catheter to sterilize the catheter are used to treat catheter infections. However, there is no clear recommendation applying use of antibiotic locks, that would specify the type and concentration of antimicrobial medication. Our objective were to compare the efficacy of different types of antimicrobial lock therapy (especially taurolidine) and their concentrations to eradicate infectious agents.

METHODS

Bacterial strains of microorganisms (Staphylococcus epidermidis, Staphylococcus aureus, methicillin resistant S. aureus (MRSA), Pseudomonas aeruginosa, multidrug-resistant P. aeruginosa, Candida albicans) were used. Subsequently, the catheter was exposed to the microbes and then was incubated with a specific lock for 2 or 24 h at 37 °C. We used these locks: ethanol 70%, taurolidine, gentamicine in concentrations 0,5, 1 and 10 mg/ml and vancomycine in concentrations 1, 5, and 10 mg/ml. The number of remaining CFU (colony forming units) was compared after incubation.

RESULTS

70% ethanol and taurolidine were most effective for all studied microorganisms. Gentamicine was more effective than vancomycine.

CONCLUSIONS

The most effective antimicrobial lock solutions to eradicate selected pathogenic agents were ethanol and taurolidine. Use of antibiotics is often effective after many hours of treatment and there is a risk of inadequate therapy.

Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition

Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is confirmed by qualitative and quantitative blood cultures from the catheter and peripherally. Treatment of inpatients may involve central venous catheter removal and antibiotics for patients needing short-term parenteral nutrition, but catheter salvage is generally recommended for patients needing long-term parenteral nutrition, where appropriate.

Randomised clinical trial: 2% taurolidine versus 0.9% saline locking in patients on home parenteral nutrition

BACKGROUND

The catheter lock solutions 2% taurolidine and 0.9% saline are both used to prevent catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition patients.

AIMS

To compare the effectiveness and safety of taurolidine and saline.

METHODS

This multicentre double-blinded trial randomly assigned home parenteral nutrition patients to use either 2% taurolidine or 0.9% saline for 1 year. Patients were stratified in a new catheter group and a pre-existing catheter group. Primary outcome was the rate of CRBSIs/1000 catheter days in the new catheter group and pre-existing catheter group, separately.

RESULTS

We randomised 105 patients, of which 102 were analysed as modified intention-to-treat population. In the new catheter group, rates of CRBSIs/1000 catheter days were 0.29 and 1.49 in the taurolidine and saline arm respectively (relative risk, 0.20; 95% CI, 0.04-0.71; P = 0.009). In the pre-existing catheter group, rates of CRBSIs/1000 catheter days were 0.39 and 1.32 in the taurolidine and saline arm respectively (relative risk, 0.30; 95% CI, 0.03-1.82; P = 0.25). Excluding one outlier patient in the taurolidine arm, mean costs per patient were $1865 for taurolidine and $4454 for saline (P = 0.03). Drug-related adverse events were rare and generally mild.

CONCLUSIONS

In the new catheter group, taurolidine showed a clear decrease in CRBSI rate. In the pre-existing catheter group, no superiority of taurolidine could be demonstrated, most likely due to underpowering. Overall, taurolidine reduced the risk for CRBSIs by more than four times. Given its favourable safety and cost profile, taurolidine locking should be considered as an additional strategy to prevent CRBSIs.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT01826526.

Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis

BACKGROUND

Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other.

METHODS

An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies.

RESULTS

Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity.

CONCLUSION

TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.

Direct costs of a home parenteral nutrition programme

BACKGROUND & AIMS

Home parenteral nutrition (HPN) is a lifesaving treatment for people with chronic intestinal failure and its cost has been reported to be very high. The purpose of the present paper was to study the direct healthcare and non-healthcare costs associated with the HPN programme managed by a tertiary hospital.

METHODS

Observational, retrospective study of all adult patients on HPN from 11.1.2014 to 10.31.2015 treated at Gregorio Marañón University Hospital (Madrid, Spain). An economic evaluation was undertaken to calculate the direct healthcare (HPN provision, outpatient monitoring and management of complications) and non-healthcare costs (transportation process) of the HPN programme. The variables were collected from medical records, the dispensary and the hospital's financial services. The unit costs were taken from official price lists.

RESULTS

Thirty-two patients met the inclusion criteria. Total direct healthcare and non-healthcare costs amounted to €13,363.53 per patient (€124.02 per patient per day). The direct healthcare costs accounted for 98.32% of overall costs, while the non-healthcare costs accounted for the remaining 1.68%. HPN provision accounted for the majority of the costs (74.25%), followed by management of complications (21.85%) and outpatient monitoring (2.23%).

CONCLUSIONS

The direct healthcare costs accounted for the majority of HPN expenditure, specifically HPN provision was the category with the highest percentage.

Long-term Staphylococcus aureus decolonization in patients on home parenteral nutrition: study protocol for a randomized multicenter trial

Background

Patients with long-term intestinal failure are usually treated by means of home parenteral nutrition (HPN) where they administer their nutritional formulation intravenously via a central venous access device (mostly a catheter). This implies that such patients are exposed to a lifelong risk of developing Staphylococcus aureus bacteremia (SAB). SAB poses a threat to both catheter and patient survival and may lead to frequent hospitalization and a permanent loss of vascular access. In other clinical settings, S. aureus carriage eradication has been proven effective in the prevention of S. aureus infections. Unfortunately, there is a complete lack of evidence in HPN support on the most effective and safe S. aureus decolonization strategy in S. aureus carriers. We hypothesized that long-term S. aureus decolonization in HPN patients can only be effective if it is aimed at the whole body (nasal and extra-nasal) and is given chronically or repeatedly on indication. Besides this, we believe that S. aureus carriage among caregivers, who are in close contact with the patient, are of great importance in the S. aureus transmission routes.

Methods/design

The CARRIER trial is a randomized, open-label, multicenter clinical trial in Dutch and Danish hospitals that treat patients on HPN. A total of 138 adult HPN patients carrying S. aureus will be randomly assigned to a search and destroy (SD) strategy, a quick and short, systemic antibiotic treatment, or a continuous suppression (CS) strategy, a repeated chronic topical antibiotic treatment. The primary outcome measure is the proportion of patients in whom S. aureus is totally eradicated during a 1-year period. Secondary outcomes are time to successful eradication, long-term antimicrobial resistance, adverse events, patient compliance, incidence of (S. aureus) infections, catheter removals, mortality rates, S. aureus transmission routes, quality of life, and health care costs.

Discussion

The CARRIER trial is designed to identify the most safe and effective long-term S. aureus carriage decolonization strategy in HPN patients. This will eventually lead to a better understanding of long-term S. aureus decolonization treatments in general. The results of this study will have a great impact on our daily clinical practice, which eventually may result in less S. aureus-related infections.

Trial registration

ClinicalTrials.gov; NCT03173053. Registered on 1 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2732-2) contains supplementary material, which is available to authorized users.

Parenteral Nutrition: Indications, Access, and Complications

Parenteral nutrition (PN) is a life-sustaining therapy in patients with intestinal failure who are unable to tolerate enteral feedings. Patient selection should be based on a thorough assessment to identify those at high nutrition risk based on both disease severity and nutritional status. This article reviews both the acute and chronic indications for PN as well as special formulation consideration in specific disease states, vascular access, and complications of both short-term and long-term PN.

Epidemiology and Risk Factors for Outpatient-Acquired Catheter-Related Bloodstream Infections in Children Receiving Home Parenteral Nutrition

BACKGROUND

Few studies have examined the epidemiology and risk factors for the development of outpatient-acquired catheter-related bloodstream infections (CRBSIs) in children receiving home parenteral nutrition. This study aimed to (1) characterize the incidence, clinical presentation, and epidemiology of CRBSIs and (2) identify risk factors for CRBSIs in children receiving home parenteral nutrition.

METHODS

A longitudinal database approved by our Institutional Review Board was created to prospectively track CRBSIs in the UCLA pediatric population from January to December 2012. Eligible patients included those < 18 years old receiving home parenteral nutrition.

RESULTS

Thirty of 60 patients (50%) were diagnosed with 66 CRBSIs, for an overall CRBSI rate of 3.6 per 1000 catheter days. Of the CRBSIs, 73% were due to single microorganisms and 27% were polymicrobial. There was a significant difference in median (range) time for blood cultures to turn positive depending on type of CRBSIs (p = 0.03), with polymicrobial infections detected at 13.4 (8.7-24.3) hours, gram-negative infections at 16.5 (9-30.8) hours, and gram-positive infections at 18.9 (8.4-37.1) hours. The most common presenting symptom was fever (82%), followed by gastrointestinal symptoms (42%) and chills (29%). The only significant multivariate risk factor for CRBSIs was presence of a feeding tube (2.3-fold increase in CRBSI risk, p = 0.04).

DISCUSSION

Outpatient-acquired CRBSIs are common in children receiving home parenteral nutrition. CRBSIs typically present with fever, but are also associated with gastrointestinal and/or respiratory symptoms. The presence of feeding tubes may predispose children on home parenteral nutrition to developing CRBSIs.

Strategies to Reduce Catheter-Related Bloodstream Infections in Pediatric Patients Receiving Home Parenteral Nutrition: The Efficacy of Taurolidine-Citrate Prophylactic-Locking

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) remain a major issue in patients who are receiving home parenteral nutrition (HPN). The aim of this interventional study was to assess the impact of a new strategy using taurolidine-citrate (T-C) prophylactic locks on the CRBSI rate in children with intestinal failure who are receiving HPN.

METHODS

The rate of CRBSIs was monitored every calendar year in a prospective cohort of 195 children with intestinal failure. T-C locks were initiated from October 2011 in children with recurring CRBSIs (≥2 episodes per year).

RESULTS

In the whole cohort, the median annual CRBSI rate per 1000 catheter days decreased significantly from 2.07 in 2008 to 2010 to 1.23 in 2012 to 2014 (P < .05). T-C locks were used in 40 patients. No adverse events were reported. In taurolidine-treated patients, the CRBSI rate per 1000 catheter days decreased from 4.16 to 0.25 (P < .0001). The cumulative percentage of patients free of CRBSI at 18 months was 92% (95% confidence interval [CI]: 71-98) on T-C lock vs 61% (95% CI: 49-72) in controls (P = .01). In multivariate analysis, factors associated with CRBSI were immune deficiency (adjusted hazard ratio 3.49; 95% CI: 1.01-12.17) and the young age of the parents (adjusted hazard ratio 4.79, 95% CI: 2.16-10.62), whereas T-C locks were protective (adjusted hazard ratio 0.22, 95% CI: 0.06-0.74).

CONCLUSION

This study confirms the efficacy of T-C catheter locks in decreasing the incidence of CRBSIs in children with intestinal failure who are receiving HPN.

Intestinal failure: a review

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter-Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center

BACKGROUND/AIMS

Catheter-related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk.

METHODS

All patients with IF discharged with HPN from 1970-2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days.

RESULTS

The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter-related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter-related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018).

CONCLUSION

Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.

Catheter-Related Bloodstream Infections in Adults Receiving Home Parenteral Nutrition: Substantial Differences in Incidence Comparing a Strict Microbiological to a Clinically Based Diagnosis

BACKGROUND

A common complication in patients receiving home parenteral nutrition (HPN) is catheter-related bloodstream infections (CRBSIs). The CRBSI incidence has been advocated as an outcome parameter assessing the quality of care. This study aimed to illustrate how the use of different CRBSI definitions affects the reported incidence.

MATERIALS AND METHODS

In an observational study based on the Copenhagen intestinal failure database, all clinically reported CRBSIs from 2002-2013 were compared with data from the affiliated microbiological database according to recommended CRBSI criteria.

RESULTS

Clinically, 1034 CRBSIs were observed in 548 adults receiving HPN for 1410 catheter-years. Thus, the clinically assessed CRBSI incidence was 1.95/1000 catheter-days. However, based on the microbiological evaluation, only 47% of our episodes fulfilled the Centers for Disease Control and Prevention (CDC) and European Society for Clinical Nutrition (ESPEN) CRBSI criteria. Employing a catheter-salvaging strategy, 40% of the CRBSI diagnoses were supported by the paired blood culture positivity criteria and only 6% by a positive catheter tip. In 53%, CRBSIs were categorized as a clinical or "probable CRBSI" diagnosis. In 20% of all episodes, missing information/blood cultures hampered a CDC/ESPEN CRBSI diagnosis. Thereby, according to CDC/ESPEN CRBSI definitions, the incidence was 0.92/1000 days or 46% lower than clinically assessed.

CONCLUSION

This study illustrates the practical and methodological challenges and great variability in reporting of the CRBSI incidence. Nonetheless, it is recommended as a marker of the quality of care. Consensus regarding CRBSI definitions is a prerequisite for a meaningful comparison of this important outcome parameter between HPN centers.

Parenteral therapy and complications in patients with intestinal failure in a regional unit

OBJECTIVE

To describe a cohort of patients with intestinal failure (IF) and tunnelled catheters in a regional IF unit, treatment and catheter-related complication rates, and to compare the quality of care with previously published results from specialised IF centres in Denmark.

METHODS

A retrospective chart review of an adult IF patient cohort receiving parenteral therapy through tunnelled catheters in a regional IF unit from 2005 to 2014. Demographics, indication, type and frequency of parenteral therapy, dwell time, cause of removal and complications were recorded.

RESULTS

Parenteral therapy was provided to 78 patients with a median age of 64 (25-86) years. Numbers increased from seven patients in 2005 to 40 in 2014. The cause of IF was surgical complications (33%), cancer (28%), inflammatory bowel disease (IBD, 15%) and other causes (24%). The median duration of parenteral therapy was 453 days (range: 16-3651 days). One hundred and forty-two tunnelled catheters were inserted. The incidence of catheter-related blood stream infection (CRBSI) was 1.51/1000 days (95% CI: 1.20-1.90) and the incidence of thrombosis was 0.10/1000 days (0.04-0.25). Seventy-two episodes of CRBSI occurred with 89 microorganisms cultured, the most common being coagulase-negative Staphylococcus (n = 25, 28%).

CONCLUSION

The rate of CRBSI did not differ from larger centres in Denmark but the rate of thrombotic events was higher than expected. Parenteral therapy can safely and effectively be offered to patients with IF in smaller centres.

Telemedicine Support Groups for Home Parenteral Nutrition Users

Patients receiving home parenteral nutrition (HPN), a life-sustaining intravenous (IV) infusion that provides nourishment and hydration to patients with short gut or inflammatory bowel diseases, are often isolated and not in visual contact with peers or health providers. One completed clinical trial (Clinical Trials.gov NCT0190028) and 1 ongoing clinical trial (Clinical Trials.gov NCT02987569) are evaluating a mobile videoconferencing-delivered support group intervention for patients on HPN and their caregivers. This home-based telemedicine intervention uses encrypted tablet-based videoconferencing to connect multiple families in real time. The twice-daily IV regimen is challenging for patients who may experience infusion catheter-related bloodstream infections, difficulties with fatigue, loss of sleep, depressive disorders, and worry over the potential life-threatening side effects and the expenses of this therapy. Using secure telemedicine, the facilitated support group intervention aims to enhance HPN home care, daily functioning, and quality of life. The authors provide the rationale for the telemedicine approach with HPN users and caregivers. They provide "how-to" information about the content and process of the facilitated support group sessions via secure videoconferencing. They share lessons learned from the ongoing evaluation of the telemedicine approach.

Taurolidine-citrate-heparin lock reduces catheter-related bloodstream infections in intestinal failure patients dependent on home parenteral support: a randomized, placebo-controlled trial

Background: In patients with intestinal failure who are receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) inflict health impairment and high costs.Objective: This study investigates the efficacy and safety of the antimicrobial catheter lock solution, taurolidine-citrate-heparin, compared with heparin 100 IE/mL on CRBSI occurrence.Design: Forty-one high-risk patients receiving HPS followed in a tertiary HPS unit were randomly assigned in a double-blinded, placebo-controlled trial. External, stratified randomization was performed according to age, sex, and prior CRBSI incidence. The prior CRBSI incidence in the study population was 2.4 episodes/1000 central venous catheter (CVC) days [95% Poisson confidence limits (CLs): 2.12, 2.71 episodes/1000 CVC days]. The maximum treatment period was 2 y or until occurrence of a CRBSI or right-censoring because of CVC removal. The exact permutation tests were used to calculate P values for the log-rank tests.Results: Twenty patients received the taurolidine-citrate-heparin lock and 21 received the heparin lock, with 9622 and 6956 treatment days, respectively. In the taurolidine-citrate-heparin arm, no CRBSIs occurred, whereas 7 CRBSIs occurred in the heparin arm, with an incidence of 1.0/1000 CVC days (95% Poisson CLs: 0.4, 2.07/1000 CVC days; P = 0.005). The CVC removal rates were 0.52/1000 CVC days (95% Poisson CLs: 0.17, 1.21/1000 CVC days) and 1.72/1000 CVC days (95% Poisson CLs: 0.89, 3.0/1000 CVC days) in the taurolidine-citrate-heparin and heparin arm, respectively, tending to prolong CVC survival in the taurolidine arm (P = 0.06). Costs per treatment year were lower in the taurolidine arm (€2348) than in the heparin arm (€6744) owing to fewer admission days related to treating CVC-related complications (P = 0.02).Conclusions: In patients with intestinal failure who are life dependent on HPS, the taurolidine-citrate-heparin catheter lock demonstrates a clinically substantial and cost-beneficial reduction of CRBSI occurrence in a high-risk population compared with heparin. This trial was registered at clinicaltrials.gov as NCT01948245.

Sarcopenia in gastric cancer: when the loss costs too much

Sarcopenia is a complex syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Malignancy is a major determinant of sarcopenia, and gastric cancer (GC) is among the most common causes of this phenomenon. As sarcopenia is a well-recognized poor prognostic feature in GC and has been associated with worse tolerance of surgical and medical treatments, members of the multidisciplinary team should be aware of the clinical relevance, pathogenic mechanisms, and potential treatments for this syndrome. The importance of sarcopenia is often underestimated in everyday practice and clinical trials, particularly among elderly or fragile patients. As treatment options are improving in all disease stages, deeper knowledge and greater attention to the metabolic balance in GC patients could further increase the benefit of novel therapeutic strategies and dramatically impact on quality of life. In this review, we describe the role of sarcopenia in different phases of GC progression. Our aim is to provide oncologists and surgeons dealing with GC patients with a useful tool for comprehensive assessment and timely management of this potentially life-threatening condition.

Incidence of and factors associated with catheter-related bloodstream infection in patients with advanced solid tumors on home parenteral nutrition managed using a standardized catheter care protocol

Background

Catheter-related bloodstream infections (CRBSIs) are associated with high morbidity and mortality as well as increased medical costs. Cancer patients, who are often immunocompromised, are susceptible to CRBSI while receiving home parenteral nutrition (HPN). We evaluated the incidence of and factors associated with CRBSIs in cancer patients undergoing HPN managed using a standardized catheter care protocol.

Methods

This is a retrospective cohort study of 335 cancer patients receiving HPN between January 2012 and July 2015. The primary outcome of interest was the incidence of CRBSI expressed as events per 1000 HPN days. HPN days were calculated from the start date with the home infusion provider until the discontinuation of HPN, or the removal of the venous access device (VAD), or the death of the patient. The VADs used were either peripherally inserted central catheters (PICCs) or a subcutaneous implanted port or tunneled central catheters (TCCs). Univariate Poisson regression analyses were used to determine the variables associated with CRBSIs.

Results

Of 335 patients, 193 were females and 142 were males. The most common cancer types were colorectal, pancreatic, ovarian and stomach. A total of 408 VADs in 335 patients were studied, covering a total of 29,403 HPN days. Of 408 VADs, 206 (50.5%) were ports, 191 (46.8%) were PICCs, and 7 (2.7%) were TCCs. The median duration of HPN was 54 days. A total of 16 CRBSI episodes were recorded (8 in ports, 7 in PICCs and 1 in TCCs). The median duration from the start of HPN to the development of CRBSI episodes was 43.5 days. The overall incidence of CRBSI per 1000 HPN days was 0.54 (95% confidence interval: 0.32–0.86). Upon univariate analysis, no variables were found to be statistically significantly associated with CRBSI incidence.

Conclusions

We found a low rate of CRBSI following a standardized catheter maintenance protocol in a high-risk oncology population undergoing HPN.

A prospective double blind randomized controlled study on the use of ethanol locks in HPN patients

BACKGROUND & AIMS

Ethanol lock therapy (ELT) has been shown to reduce the rate of catheter-related bloodstream infection (CRBSI) in high-risk home parenteral nutrition (HPN) patients. The aim of this study was to determine whether ELT therapy for all patients newly started on HPN would reduce the incidence of CRBSI.

METHODS

This study was a prospective, double-blind, randomized controlled trial that was carried out from July 2014 to April 2016. The study participants were patients newly started on HPN, and they were randomly assigned to either treatment with ELT or our current standard of care with saline heparin locks. The primary outcome was occurrence of CRBSI.

RESULTS

Thirty eight patients that were newly started on HPN were randomized to either treatment with ELT (n = 18) or to our current standard of care with heparin locks (n = 20). Four patients in the ELT group and one patient in the control arm had a CRBSI (p = 0.17). No significant adverse side effects were noted during the study.

CONCLUSIONS

This study did not show improvement in the rate of CRBSI with ELT in all patients started on HPN. ELT therapy may be most helpful to reduce in CRBSI in high-risk HPN patients, but further studies with a randomized control trial design of high-risk patients are needed to further clarify this important issue in HPN patients. The study was registered at clinicaltrials.gov prior to patient enrollment (NCT02227329).

Parenteral Nutrition and Intestinal Failure

Severe short bowel syndrome (SBS) is a major cause of chronic (Type 3) intestinal failure (IF) where structural and functional changes contribute to malabsorption and risk of micronutrient deficiencies. Chronic IF may be reversible, depending on anatomy and intestinal adaptation, but most patients require long-term nutritional support, generally in the form of parenteral nutrition (PN). SBS management begins with dietary changes and pharmacologic therapies taking into account individual anatomy and physiology, but these are rarely sufficient to avoid PN. New hormonal therapies targeting intestinal adaptation hold promise. Surgical options for SBS including intestinal transplant are available, but have significant limitations. Home PN (HPN) is therefore the mainstay of treatment for severe SBS. HPN involves chronic administration of macronutrients, micronutrients, fluid, and electrolytes via central venous access in the patient's home. HPN requires careful clinical and biochemical monitoring. Main complications of HPN are related to venous access (infection, thrombosis) and metabolic complications including intestinal failure associated liver disease (IFALD). Although HPN significantly impacts quality of life, outcomes are generally good and survival is mostly determined by the underlying disease. As chronic intestinal failure is a rare disease, registries are a promising strategy for studying HPN patients to improve outcomes.

Identification of Depressive Signs in Patients and Their Family Members During iPad-based Audiovisual Sessions

Home parenteral nutrition requires a daily life-sustaining intravenous infusion over 12 hours. The daily intravenous infusion home care procedures are stringent, time-consuming tasks for patients and family caregivers who often experience depression. The purposes of this study were (1) to assess home parenteral nutrition patients and caregivers for depression and (2) to assess whether depressive signs can be seen during audiovisual discussion sessions using an Apple iPad Mini. In a clinical trial (N = 126), a subsample of 21 participants (16.7%) had depressive symptoms. Of those with depression, 13 participants were home parenteral nutrition patients and eight were family caregivers; ages ranged from 20 to 79 years (with 48.9 [standard deviation, 17.37] years); 76.2% were female. Individual assessments by the mental health nurse found factors related to depressive symptoms across all 21 participants. A different nurse observed participants for signs of depression when viewing the videotapes of the discussion sessions on audiovisual technology. Conclusions are that depression questionnaires, individual assessment, and observation using audiovisual technology can identify depressive symptoms. Considering the growing provision of healthcare at a distance, via technology, recommendations are to observe and assess for known signs and symptoms of depression during all audiovisual interactions.

Peripherally Inserted Central Catheter Experience in Long-Term Home Parenteral Nutrition Patients

Parenteral nutrition is administered through a central venous catheter(CVC). Peripherally inserted central catheters (PICC) are appropriate for home parenteral nutrition (HPN). The objective of this study was to examine a group of HPN patients with a PICC in place for more than six months, and the complications associated with PICC removal. Medical records from one home infusion pharmacy were retrospectively reviewed for PICC characteristics and complications leading to removal. Nineteen adult HPN patients had 26 PICC placements. Total PICC days were 22,262 with a mean of 856 (265–2500) days. Seven PICCs were in place for 3 to greater than 5 years. The overall complication rate was 0.58/1000 CVC days. Catheter related bloodstream infection (CRBSI) was the main cause of PICC removal. There was no evidence of symptomatic thrombosis. Patients experienced no infusion related complications. The PICCs were 88% polyurethane, 65% double lumen, and 54% were 5 Fr. No patient received alcohol or antibiotic lock therapy, and 8 patients had successful alteplase administered at least one time. All patients needed caregiver assistance for site care and dressing changes, but were independent in HPN infusion and flushing. This group of patients demonstrated that PICCs are a viable option HPN administration. The PICC overall complication rate was very low, and the most frequent complication leading to removal was CRBSI. The infection rate of 0.36/1000 CVC days is considered very low in an HPN population. This is the only HPN infusion study to date reporting 7 PICCs lasting 3 or more years, with 2 lasting greater than 5 years without complications resulting in removal. Patients received their prescribed therapy reliably and without interruption with this device. Larger studies are needed to confirm the efficacy of maintaining a PICC for very long-term HPN administration.

Taurolidine in Pediatric Home Parenteral Nutrition Patients

To reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients, the use of taurolidine was introduced in the Sophia Children's Hospital in 2011. This introduction led to a reduction in catheter-related bloodstream infections: 12.7/1000 catheter days before the use of taurolidine, compared with 4.3/1000 catheter days afterwards (n = 7) [relative risk = 0.36, 95% confidence interval: 0.20-0.65 (P = 0.018)].

Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care

BACKGROUND

Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients.

OBJECTIVE

To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014.

METHODS

Descriptive, χ², and t tests were used to analyze data from the Sustain registry.

RESULTS

Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type.

CONCLUSIONS

Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.