Parenteral approaches in malabsorption: Home parenteral nutrition

Candida catheter-related bloodstream infection in patients on home parenteral nutrition - Rates, risk factors, outcomes, and management

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are life-threatening complications for home parenteral nutrition (HPN) patients. This review clarifies Candida CRBSI rates by species, risk factors, outcomes, and management to improve effectiveness of HPN programs.

METHODS

A review of Candida CRBSIs in HPN patients was conducted around the following questions: 1. How often do adult and paediatric HPN patients contract Candida CRBSIs? 2. What is the proportion of different Candida species? 3. What are the risk factors? 4. How are outcomes in Candida versus other CRBSIs? 5. What are current guidelines to manage Candida CRBSIs? Specifically, should catheters be removed? What antimicrobial therapy is indicated? Are catheter lock techniques effective?

RESULTS

20 studies were included - six paediatric and 14 adult. Candida represented 9.8% of paediatric CRBSIs and 11.7% of adult CRBSIs. Paediatric candidal CRBSIs featured these species: C. albicans (46.2%), C. parapsilosis (34.6%), Candida guilliermondii (11.5%), Candida tropicalis (3.8%), and mixed or other types of Candida (3.8%). Adult candidal CRBSIs featured these species: C. albicans (37.3%), C. glabrata (33.3%), C. parapsilosis (22.4%), mixed or other types of Candida (5.7%), and C. tropicalis (1.3%). Risk factors for paediatric HPN CRBSIs include underlying haematological disease and previous fungaemia. Candida infection is associated with mortality rates around 30%. In Candida CRBSIs, major guidelines advocate catheter removal prior to systemic antifungal treatment (fluconazole, amphotericin B, echinocandins), ideally until 14 days after the first negative blood culture; some studies suggest the possibility of systemic therapy while catheters remain in-situ to preserve crucial line access. Various catheter lock solutions are effective as treatment and prophylaxis, but are not yet firmly established.

CONCLUSIONS

Candida CRBSI is a significant danger to HPN patients causing high mortality; gold standard treatment is catheter removal and antifungal treatment, although treatments with catheters in-situ and catheter locks as prophylaxis appear to be gaining traction.

Anesthesia for Intestinal Transplantation

The diagnosis of irreversible intestinal failure confers significant morbidity, mortality, and decreased quality of life. Patients with irreversible intestinal failure may be treated with intestinal transplantation. Intestinal transplantation may include intestine only, liver-intestine, or other visceral elements. Intestinal transplantation candidates present with systemic manifestations of intestinal failure requiring multidisciplinary evaluation at an intestinal transplantation center. Central access may be difficult in intestinal transplantation candidates. Intestinal transplantation is a complex operation with potential for hemodynamic and metabolic instability. Patient and graft survival are improving, but graft failure remains the most common postoperative complication.

Acute mesenteric ischemia (Part II) - Vascular and endovascular surgical approaches

The modern treatment of acute mesenteric ischemia (AMI) requires seamless collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. The treatment strategy is straightforward aiming at rapid restoration of blood flow to the intestine. Bowel resection is performed on demand. The first thing to consider is the patient's clinical condition at presentation, whether there are signs of peritonitis or not, and whether the patient is hemodynamically stable or not. Second, there are four etiologies of AMI that need to be distinguished as they differ in treatment: superior mesenteric artery embolism, mesenteric arterial occlusive disease, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. In this review, we describe the basic vascular and endovascular treatment modalities accompanied by a simple algorithm for the various situations in AMI. Furthermore, the indications for damage control and primary definitive surgery are discussed.