Diagnosis of catheter-related bloodstream infection in a total parenteral nutrition population: inclusion of sepsis defervescence after removal of culture-positive central venous catheter

Comparison of catheter-related bloodstream infection rates in pediatric patients receiving parenteral nutrition with soybean oil-based intravenous fat emulsion versus a mixed oil fat emulsion

STUDY OBJECTIVE

To compare rates of catheter-related bloodstream infections (CR-BSI) in pediatric patients who received parenteral nutrition (PN) with either soybean oil-based intravenous fat emulsion (SO-IFE) or mixed oil-IFE (MO-IFE). We hypothesized that the use of MO-IFE would be independently associated with reduced infection rates compared with SO-IFE.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral children's hospital and its associated gastrointestinal rehabilitation clinic (01 January, 2015-31 July, 2019).

PATIENTS

Days of IFE exposure were counted for patients aged <18 years on IFE initiated during the review period, who had a central venous catheter (CVC) placed for PN administration, received IFE at least three times weekly, and for at least 7 days.

MEASUREMENTS

The primary outcome included total and categorical CR-BSI rates expressed as the average with standard error (SE) number of infections per 1000 fat emulsion days. The following categories were specified: Candida albicans, non-albicans Candida spp., coagulase-negative Staphylococcus (CoNS), Enterobacterales, methicillin-resistant S. aureus, methicillin-susceptible S. aureus, and Pseudomonadales. Average infection rate comparisons were quantified as incidence rate ratios (IRR) using generalized linear mixed modeling with a Poisson distribution.

MAIN RESULTS

Seven hundred and forty-three SO-IFE and 450 MO-IFE exposures were reviewed from 1131 patients, totaling 37,599 and 19,796 days of therapy, respectively. From those found significantly different, the average rate of infections with CoNS was 3.58 (SE 0.5)/1000 days of SO-IFE and 1.39 (SE 0.45)/1000 days of MO-IFE (IRR [95% confidence interval, CI]: 0.27 [0.16-0.46]; p < 0.01). Total average rates of infection were 7.33 (SE 0.76)/1000 days of SO-IFE and 4.52 (SE 0.75)/1000 days of MO-IFE (IRR [95% CI]: 0.60 [0.44-0.81]; p < 0.01). Other factors associated with higher infection rates include female gender, neonatal age, and inpatient-only IFE exposure.

CONCLUSIONS

Receipt of MO-IFE was associated with lower rates of CoNS and total CR-BSIs compared with SO-IFE in pediatric patients. These findings could have major implications on IFE selection for pediatric patients receiving PN.

Cost-effectiveness of taurolidine locks to prevent recurrent catheter-related blood stream infections in adult patients receiving home parenteral nutrition: a 2-year mirror-image study

BACKGROUND & AIMS

The use of long-term taurolidine locks (LTTL) seems to be effective in preventing catheter-related blood stream infections (CRBSI), especially in patients on home parenteral nutrition (HPN). This work targets the cost-effectiveness of LTTL in a cohort of adult HPN patients.

METHODS

A monocentric mirror-image design study was conducted in our referral centre among long-term HPN patients experiencing recurrent CRBSI. From 7th January 2011, LTTL were started after the third CRBSI episode within 12 months. CRBSI data was prospectively collected until 7th January 2013, in the same way as it had retrospectively been done before initiating LTTL. A cost-effective analysis was conducted to estimate the incremental costs and effects on CRBSI with LTTL. The efficacy of LTTL on CRBSI rate was assessed over 1000 days of catheter use.

RESULTS

A total of 31,100 catheter days were analysed in 37 patients (median [interquartile range (IQR)]) aged 58 [42-68] years. The mean ± SD proven CRBSI rate was 3.18 ± 3.51 per 1000 catheter days before the introduction of LTTL and 0.39 ± 1.50 per 1000 catheter days after its introduction (p < 0.0001). Considering both proven and probable CRBSI requiring hospital management, LTTL reduced by (mean [bootstrap CI 95%]) -2.63 [-3.26 to -2.06] infections per patient (from 2.89 [2.31 to 3.49] before to 0.26 [0.13 to 0.41] after) as well as incremental costs by -7 258 [-10 450 to -4 016] € (from 11 176 [8 004 to 14 968] € before to 3 918 [2 390 to 5 445] € after).

CONCLUSION

Implementing LTTL to prevent recurrent CRBSI is cost-effective by dramatically decreasing their incidence.

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.

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 nutrition with standard solutions: not the best solution for everyone? A retrospective audit of 300 patients

An observational retrospective study audited the incidence of adverse events in 300 consecutive inpatients receiving a single, premade total nutrient admixture. No patient experienced critically high triglycerides; 16% of patients had a metabolic adverse event, including raised bilirubin, urea, creatinine, or liver enzymes. Line sepsis occurred on 30 occasions representing 0.67 infections per 1000 catheter days. Mortality was significantly higher in dialysis, nonsurgical, and intensive care unit patients. The use of a standard formulation for all parenterally nourished patients does not lead to an unacceptable incidence or severity of metabolic complications; however, it did not meet the protein requirements of surgical or critically ill patients.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Comparison of complications associated with peripherally inserted central catheters and Hickman™ catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study

BACKGROUND & AIM

Patients with intestinal failure (IF) are dependent on parenteral nutrition delivered through central access such as Hickman™ catheters. The peripherally inserted central catheter (PICC) is becoming increasingly popular for the purpose. The aim of the present study was to compare complication rates between the two types of catheters.

PATIENTS AND METHODS

Over a six-year period (2008-2014), we included 136 patients with IF receiving home parenteral nutrition (HPN). These patients had a total of 295 catheters (169 Hickman™ catheters and 126 PICCs). Data were collected by reviewing their medical records. Incidences are given per 1000 catheter days. Data are given as means ± standard deviation (SD) and compared using independent student's t-tests, Mann-Whitney-Wilcoxon, and X(2)-tests. A survival analysis for time to the first infection was conducted using Cox regression.

RESULTS

The total number of catheter days was 54,912 days for Hickman™ catheters (mean dwell time 325 ± 402) and 15,974 days for PICCs (mean dwell time 127 ± 121), respectively. The incidence of catheter-related blood stream infection (CRBSI) per 1000 catheter days was significantly lower for Hickman™ catheters compared to PICCs (0.56 vs. 1.63, p < 0.05). The mean time to first CRBSI was significantly shorter for PICCs compared to Hickman™ catheters (84 ± 94 days vs. 297 ± 387 days, p < 0.05), which was confirmed with a cox analysis corrected for age and gender. A total of 75 catheters were removed due to CRBSI, 49 Hickman™ catheters and 26 PICCs respectively. In addition, PICCs were more often removed due to local infection/phlebitis and mechanical causes (p < 0.001).

CONCLUSION

We found a higher risk and shorter time to first CRBSI in PICCs compared to Hickman catheters supporting that PICCs should mainly be chosen for planned HPN up to 3-6 months. We therefore conclude that the choice of catheter must still be determined on an individual basis.

Three-in-one parenteral nutrition in neonates and pediatric patients: risks and benefits

Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.

Diagnosis of central venous catheter-related bloodstream infection without catheter removal: A prospective observational study

BACKGROUND

Catheter-related bloodstream infections (CRBSI) resulting from bacterial colonisation of an intravascular catheter are the leading cause of nosocomially acquired sepsis contributing significantly towards in-hospital morbidity and mortality. Suspicion of central venous CRBSI leads frequently to catheter withdrawal but not all infection requires the catheter to be withdrawn; therefore, diagnosis of central venous CRBSI without catheter withdrawal is a necessity.

METHODS

The study was prospectively performed in a cohort of adult patients who had short term central venous catheter use. The samples collected from each patients included, skin swab from insertion site, swab from catheter hub, paired blood samples from catheter and from the peripheral vein for quantitative blood culture collected within 15 min of each other and catheter-tip sample by cutting off the tip (distal 5-cm segment). All samples were processed immediately.

RESULTS

50 episodes of clinical sepsis involving 100 patients occurred in the study population. 28 of the episodes were confirmed as CR-BSI (56%). Blood culture from the central venous catheter had the highest sensitivity (71.43%) and the greatest negative predictive value (86.67%). However, the peripheral blood culture was most specific and had the highest positive predictive value (specificity75%; positive predictive value 50%). The most accurate technique was differential quantitative blood cultures (accuracy 72%), followed by semiquantitative superficial cultures (accuracy 68%), although there were no statistically significant differences between values.

CONCLUSION

We recommend combining semiquantitative cultures and peripheral blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique.

Catheter-related infection in Irish intensive care units diagnosed with HELICS criteria: a multi-centre surveillance study

BACKGROUND

Catheter-related infection (CRI) surveillance is advocated as a healthcare quality indicator. However, there is no national CRI surveillance programme or standardized CRI definitions in Irish intensive care units (ICUs).

AIM

To examine the feasibility of multi-centre CRI surveillance in nine Irish ICUs, using Hospitals in Europe Link for Infection Control through Surveillance (HELICS) definitions (CRI 1, CRI 2 and CRI 3).

METHODS

All non-tunnelled central venous catheters (CVCs) inserted in patients aged >18 years with an ICU stay ≥48 h were included over a three-month study period.

FINDINGS

Feasibility was demonstrated by the 99.5% return rate for study forms. Data on 1209 CVCs in 614 patients over 7587 CVC-days showed 17 episodes of CRI, representing a national rate of 2.2 per 1000 CVC-days [95% confidence interval (CI) 1.2-3.3]. Rates of CRI 1, CRI 2 and CRI 3 were 0.13 (95% CI 0.00-0.39), 0.79 (95% CI 0.16-1.42) and 1.39 (95% CI 0.60-2.17) per 1000 CVC-days, respectively. CRI was associated with length of ICU stay (P < 0.001), number of CVCs inserted (P < 0.001) and total number of CVC-days per patient (P < 0.001). CRI was higher in CVCs inserted in operating theatres (incident rate ratio 3.9, 95% CI 1.3-11.5; P = 0.02) compared with CVCs inserted in ICUs. Participant feedback reported minimal difficulty with surveillance implementation, and data collection required approximately 1 h per patient per week.

CONCLUSION

The study demonstrated that multi-centre ICU surveillance using HELICS CRI definitions was practical, feasible and provided clinically relevant information. CRI surveillance in ICUs, although labour intensive, is recommended to reduce CRI and allow ongoing evaluation of processes aimed at CRI reduction.

Significant reduction in central venous catheter-related bloodstream infections in children on HPN after starting treatment with taurolidine line lock

OBJECTIVE

The aim of this study was to review the incidence and type of central venous catheter-related bloodstream infection in children on treatment with home parenteral nutrition (PN) before and after the introduction of taurolidine. Taurolidine is a catheter lock solution that prevents biofilm formation and has broad-spectrum bactericidal and antifungal action. Its use in pediatric patients on PN has only been reported in case studies.

METHODS

A total of 19 children were reviewed, with the diagnoses of enteropathy (8 cases), short bowel syndrome (7 cases), and gastrointestinal dysmotility (4 cases). Incidence and type of sepsis were reviewed for 8 to 12 months pre- (when heparin was used) and 2 to 33 months postintroduction of the taurolidine catheter lock.

RESULTS

There were 8.6 episodes of catheter-related bloodstream infections per 1000 catheter days with heparin and 1.1 episodes per 1000 catheter days with taurolidine (P=0.002). A total of 14 of the 19 patients (74%) had no infections for up to 33 months after changing to taurolidine. No reports of multiresistant organisms or adverse effects with taurolidine were found.

CONCLUSIONS

Taurolidine line lock was associated with a decreased incidence of catheter-related bloodstream infections. This finding supports its use in patients with a history of septicemia on treatment with cyclical PN.

Culture Positivity of CVCs Used for TPN: Investigation of an Association with Catheter-Related Infection and Comparison of Causative Organisms between ICU and Non-ICU CVCs

A relationship between central venous catheter (CVC) tip colonisation and catheter-related blood-stream infection (CRBSI) has been suggested. We examined culture positivity of CVC tips (colonised and infected CVCs) in a total parenteral nutrition (TPN) population. Our aims were to define the relationship between culture positivity and CRBSI, and to compare causative organisms between culture positive and CRBSI CVCS, and between ward and ICU CVCs. All patients receiving TPN via non-tunnelled CVCs during the study (1997–2009) were included. All CVC tips were analysed. Data were collated contemporaneously. A TPN audit committee determined whether CVC tip culture positivity reflected colonisation/CRBSI using CDC criteria. 1,392 patients received TPN via 2,565 CVCs over 15,397 CVC days. 25.4% of CVCs tips were culture positive, of these 32% developed CRBSI. There was a nonsignificant trend of higher Gram negative Bacilli isolation in ICU CVCs (P = 0.1), ward CVCs were associated with higher rates of staphylococcal isolation (P = 0.01). A similar pattern of organisms were cultured from CRBSI and culture positive CVCs. The consistent relationship between CRBSI and culture positive CVCs, and similar pattern of causative organisms further supports an aetiological relationship between culture positive CVC tips and CRBSI, supporting the contention that CVC culture-positivity may be a useful surrogate marker for CRBSI rates.