Efficacy of Teicoplanin Lock Therapy in the Treatment of Port-related Coagulase-negative Staphylococci Bacteremia in Pediatric Oncology Patients

The number of studies evaluating teicoplanin lock therapy in coagulase-negative staphylococcus-associated catheter infection in pediatric malignancies is limited. The aim of this study was to evaluate the efficacy of teicoplanin lock therapy in pediatric cancer cases. Twenty-two patients with coagulase-negative staphylococcus-associated totally implantable venous access device infection, who had undergone teicoplanin closure treatment, were included in the study. Demographic data, number of lock treatment days, and treatment success data were obtained from the medical files of the patients. Fourteen of the patients (63.6%) had acute lymphocytic leukemia, 3 (13.6%) had acute myelocytic leukemia, and 5 (22.7%) had solid cancer. The median neutrophil count was 240×10 3 /μL (interquartile range: 0 to 1195×10 3 /μL). Between patients with and without catheter removal, no statistically significant difference was found in terms of baseline C-reactive protein, absolute neutrophil count, and the day of starting systemic teicoplanin treatment ( P >0.05). The overall port survival rate of teicoplanin lock therapy was 72.7%. Within an average of 4 days, negative cultures of 16 (72.7%) patients whose catheters had not been removed were obtained. In conclusion, we suggest that teicoplanin lock therapy is an effective and safe treatment for catheter-related infections, caused by methicillin-resistant coagulase-negative staphylococcus.

An Ounce of Prevention Saves Tons of Lives: Infection in Burns

BACKGROUND

Modern day burn care continues to wage an uphill battle against an enemy that evolves faster than we can develop weapons. Bacteria (bioburden) are everywhere and can infiltrate anywhere within our susceptible population of burn patients. This is why prevention of infection is key to improving their survival and outcome.

PURPOSE

To reduce the incidence of infection in the burn patient population.

MATERIALS

Review of pertinent recent literature regarding infection prevention and control in the intensive care unit setting.

RESULTS

We propose that bioburden is one of the central elements in the infectious cycle that is ever-present in burn units. The mechanism of bacterial entry into the unit and subsequent transmission and infection are delineated. Recommendations for mitigating this risk are provided to guide future clinicians in their care of burn patients.

CONCLUSIONS

The treatment of infection and sepsis against highly adaptable bacteria is often insurmountable by ill patients. In this process, bioburden needs to be corralled to have any success. Thus, preventing organisms from entering the unit and transferring onto other patients, and eliminating the bacteria dwelling in the unit are all necessary actions in this battle. Ultimately, maintaining a culture that is constantly wary of this risk only can achieve this goal.

Antibiotic lock therapy: review of technique and logistical challenges

Antibiotic lock therapy (ALT) for the prevention and treatment of catheter-related bloodstream infections is a simple strategy in theory, yet its real-world application may be delayed or avoided due to technical questions and/or logistical challenges. This review focuses on these latter aspects of ALT, including preparation information for a variety of antibiotic lock solutions (ie, aminoglycosides, beta-lactams, fluoroquinolones, folate antagonists, glycopeptides, glycylcyclines, lipopeptides, oxazolidinones, polymyxins, and tetracyclines) and common clinical issues surrounding ALT administration. Detailed data regarding concentrations, additives, stability/compatibility, and dwell times are summarized. Logistical challenges such as lock preparation procedures, use of additives (eg, heparin, citrate, or ethylenediaminetetraacetic acid), timing of initiation and therapy duration, optimal dwell time and catheter accessibility, and risks of ALT are also described. Development of local protocols is recommended in order to avoid these potential barriers and encourage utilization of ALT where appropriate.

No evidence of benefit from antibiotic lock therapy in pediatric oncology patients with central line-related bloodstream infection: results of a retrospective matched cohort study and review of the literature

BACKGROUND

Long-term central venous catheters (CVCs) are essential to modern pediatric oncology practice, but central line-related bloodstream infection (CRBSI) is a frequent and important complication. CVC salvage is often attempted but treatment failure is common due to persistent infection, delayed catheter removal, or subsequent relapse of infection, which can be associated with significant morbidity and cost. Adjunctive antibiotic lock therapy (ALT) has been proposed to reduce the risk of treatment failure, but insufficient data are available to confirm efficacy of this intervention.

PROCEDURE

We undertook a retrospective matched cohort study of ALT use for treatment of CRBSI in pediatric hematology/oncology patients at St. Jude Children's Research Hospital between 2006 and 2012.

RESULTS

Thirty-eight eligible episodes of CRBSI treated with adjunctive ALT were identified and compared to 73 episodes treated with standard therapy (ST) alone, matched by catheter-type and organism. Overall, treatment failure was similar between ALT and ST groups (50.0 vs. 38.4%; P = 0.24), but the timing was different; in the ALT cohort, immediate CVC removal was less common (0.0 vs. 12.3%; P = 0.03) but delayed removal (4-13 days) and relapse of infection was more common (50.0 vs. 24.7%; P = 0.01).

CONCLUSIONS

This retrospective study was unable to identify any benefit of adjunctive ALT in pediatric oncology patients with CRBSI. The available evidence does not support routine ALT use, and well-conducted prospective studies are needed.

Stability and compatibility of antimicrobial lock solutions

PURPOSE

Published stability and compatibility data on a growing array of solutions used for antimicrobial lock therapy (ALT) are reviewed.

SUMMARY

ALT involves the instillation of a highly concentrated antimicrobial, often in combination with an anticoagulant, into a central venous catheter (CVC) lumen; this technique is often used for prophylaxis after CVC insertion or as an adjunctive treatment in cases of central line-associated bloodstream infection (CLABSI) if catheter removal is not feasible. Optimal selection of stable and compatible antimicrobials and additives can maximize catheter dwell times, streamline pharmacy compounding practices, and help ensure patient safety. Of 98 articles on ALT solutions identified in a literature search, 17 met the prespecified criteria for the use of validated stability and compatibility methodology. Antimicrobials active against common CLABSI pathogens that may be appropriate for ALT include cefazolin, cefotaxime, ceftazidime, ciprofloxacin, daptomycin, gentamicin, linezolid, telavancin, ticarcillin-clavulanic acid, and vancomycin; validated data demonstrate the stability of these agents in solution with heparin or nonheparin anticoagulants over 72-96 hours or longer. Other antifungal agents and antiinfectives (e.g., ethyl alcohol) have been used in specific patients and ALT situations. The prolonged stability of several antimicrobial-additive combinations may allow for extended dwell times and less frequent lock solution exchanges.

CONCLUSION

Pharmacists' knowledge of diverse combinations of antimicrobial agents and additives in lock solutions, including several shown to be stable and compatible for extended periods, can help expand and optimize the use of ALT in both treatment and prophylactic modalities.

Long-term catheterization: current approaches in the diagnosis and treatment of port-related infections

Since the first description in 1982, totally implanted venous access ports have progressively improved patients' quality of life and medical assistance when a medical condition requires the use of long-term venous access. Currently, they are part of the standard medical care for oncohematologic patients. However, apart from mechanical and thrombotic complications, there are also complications associated with biofilm development inside the catheters. These biofilms increase the cost of medical assistance and extend hospitalization. The most frequently involved micro-organisms in these infections are gram-positive cocci. Many efforts have been made to understand biofilm formation within the lumen catheters, and to resolve catheter-related infection once it has been established. Apart from systemic antibiotic treatment, the use of local catheter treatment (ie, antibiotic lock technique) is widely employed. Many different antimicrobial options have been tested, with different outcomes, in clinical and in in vitro assays. The stability of antibiotic concentration in the lock solution once instilled inside the catheter lumen remains unresolved. To prevent infection, it is mandatory to perform hand hygiene before catheter insertion and manipulation, and to disinfect catheter hubs, connectors, and injection ports before accessing the catheter. At present, there are still unresolved questions regarding the best antimicrobial agent for catheter-related bloodstream infection treatment and the duration of concentration stability of the antibiotic solution within the lumen of the port.