Ethanol-lock technique in the treatment of bloodstream infections in pediatric oncology patients with broviac catheter

Differences in Efficacy between Antibacterial Lock Therapy and the Standard of Care for CVC-Related Infections: A Systematic Review and Meta-Analysis

Background: Central Venous Catheter (CVC)-related infections cannot always be solved by replacement, due to some vascular anomalies or an emergency status. This comprehensive, evidence-based review aimed to define the efficacy of antibacterial lock therapy (ALT) compared to the standard of care (SoC) in CVC-related infections. Methods: We performed a systematic search in PubMed, Embase, and Google Scholar, looking for randomized controlled trials (RCTs) and cohort or case-control observational studies. The eligible studies considered the subjects with a diagnosis of CVC-related infections treated with antibacterial lock therapy (ALT) compared to the standard of care (SoC). Results: Among 609 records at the end of the selection process, five articles, referring to observational studies, were included in this systematic review. In pooled analyses, including a total of 276 individuals, microbiological healing (OR 3.78; 95% CI; 2.03-7.03) showed significant differences between ALT and the SoC, with a follow-up varying from 2 weeks to 3 months. Conclusions: Our results suggested that ALT could improve the preservation of CVCs and could be considered when their replacement is not possible as a result of vascular problems. However, only observational studies were included and RCTs are needed to confirm these findings and to increase the level of evidence.

Ethanol Lock for Prevention of CVC-Related Bloodstream Infection in Pediatric Patients: A Systematic Review and Meta-Analysis

Ethanol lock therapy (ELT) can be used in patients with an indwelling central line to assist in the prevention of central venous catheter (CVC)-associated infections. However, its efficacy has not been consistently demonstrated in the pediatric population. The primary objective of this review and meta-analysis was to determine the efficacy and safety of ELT in prevention of central line-associated bloodstream infection (CLABSI) in the pediatric population. A search was conducted with the PubMed, CINAHL, PSCYInfo, Cochrane Library, and Academic Search Premier databases from inception through January 21, 2022. Studies were included if they reported incidence of CVC-related infections with ELT in pediatric patients. Meta-analyses used random-effects models according to the heterogeneity of all included studies. Of 736 studies, 25 met inclusion criteria for review and 10 for inclusion in the meta-analysis. Meta-analysis with pre- and post-ELT treatment showed that use of ELT significantly decreased mean CVC-related infections when compared with pre-treatment with no ELT with a mean difference of -5.79 (95% CI, -9.08 to -2.51; p < 0.001). The number of CVC infections also significantly decreased (OR, 0.42; 95% CI, 0.23-0.75; p = 0.004). Increased risk of thrombosis and increased frequency of catheter breakage, repair, and replacement were noted in several studies. Ethanol lock therapy is effective in preventing infection related to central venous catheter use in pediatric patients. Further study is warranted to determine the optimal protocol for, and incidence of, adverse events related to use of ELT.

Nitric Oxide-Releasing Hemodialysis Catheter Lock Solutions

In an attempt to address the significant morbidity, mortality, and economic cost associated with tunneled dialysis catheter (TDC) dysfunction, we report the development of nitric oxide-releasing dialysis catheter lock solutions. Catheter lock solutions with a range of NO payloads and release kinetics were prepared using low-molecular-weight N-diazeniumdiolate nitric oxide donors. Nitric oxide released through the catheter surface as a dissolved gas was maintained at therapeutically relevant levels for at least 72 h, supporting clinical translatability (interdialytic period). Slow, sustained NO release from the catheter surface prevented bacterial adhesion in vitro by 88.9 and 99.7% for Pseudomonas aeruginosa and Staphylococcus epidermidis, respectively, outperforming a burst NO-release profile. Furthermore, bacteria adhered to the catheter surface in vitro prior to lock solution use was reduced by 98.7 and 99.2% for P. aeruginosa and S. epidermidis, respectively, when using a slow releasing NO donor, demonstrating both preventative and treatment potential. The adhesion of proteins to the catheter surface, a process often preceding biofilm formation and thrombosis, was also lessened by 60-65% by sustained NO release. In vitro cytotoxicity of catheter extract solutions to mammalian cells was minimal, supporting the non-toxic nature of the NO-releasing lock solutions. The use of the NO-releasing lock solution in an in vivo TDC porcine model demonstrated decreased infection and thrombosis, enhanced catheter functionality, and improved outcome (i.e., likelihood of survival) as a result of catheter use.

Outcomes in Pediatric Central Line-associated Bloodstream Infections Treated With Antimicrobial Locks: A 14-year Retrospective Analysis

BACKGROUND

Central line-associated bloodstream infections (CLABSI) are the most common healthcare-associated infection in children. Antimicrobial lock therapy (ALT) is a recommended component of CLABSI treatment; however, studies characterizing pediatric ALT-based CLABSI therapy are few.

METHODS

All CLABSI treated with ALT at a single tertiary-care pediatric hospital for years 2004-2018 were identified by retrospective chart review and demographic, clinical, microbiological and pharmacy data were extracted. Three clinical outcomes were defined: CLABSI clearance, central venous catheter (CVC) removal and infection recurrence. Factors associated with these outcomes were examined and patterns in pathogen occurrence were described.

RESULTS

During the study period, 1188 CLABSI treated with ALT were identified. In all, 969 (85%) CLABSI initially cleared. In the CLABSI with initial clearance, CVCs were retained a median of 63 days after infection onset, and 20% recurred. Skin-colonizing microbes (Staphylococcus aureus, coagulase-negative Staphylococci) were more likely to produce monomicrobial infections, whereas bowel-colonizing microbes (Escherichia coli, Enterococci) were more associated with polymicrobial infections. In a multivariate model, infection history, resistant pathogens and CVC type were strongly correlated with infection recurrence, whereas bone marrow transplant status, neutrophil count and line type were correlated with CVC removal.

CONCLUSIONS

Optimal therapeutic approaches to pediatric CLABSI remain uncertain, including the utility of ALT. Prior reports of ALT use in children have been smaller in size and largely described hematology-oncology or hemodialysis populations. We describe trends in pediatric CLABSI, including efficacy among solid organ transplant recipients and children with short-gut syndrome. These data provide guidance on selecting CLABSI for optimal ALT use.

Profilaxia com lock de etanol em cateter venoso central de longa permanência em crianças com disfunção intestinal grave: relato de seis casos

The aim of this study was to report on use of ethanol lock in long-term catheters in newborns with severe intestinal dysfunction, dependent on total and prolonged parenteral nutrition, in a Neonatal Intensive Care Center (tertiary level), between 2015 and 2020. Six infants (0.65%) out of the 914 admitted during the period met the inclusion criteria. The median age at catheter placement was 121.5 days. Two Powerpicc (PICC Power Sinergy™, São Paulo), one Groshong (Groshong™ Central Venous Catheter BD, São Paulo), and three silicone catheters were used, all tunneled, and the median dwell duration was 182.5 days. Four patients had at least one episode of infection related to the central venous catheter, and Gram-positive, Gram-negative, and fungal agents were isolated. The median length of hospital stay was 555 days and mortality was 33.3%. The ethanol lock did not cause any side effects and was relatively effective in preventing infections related to the central venous catheter.

Ethanol lock prophylaxis in long-stay central venous catheters in children with severe intestinal dysfunction: a report of six cases

Abstract The aim of this study was to report on use of ethanol lock in long-term catheters in newborns with severe intestinal dysfunction, dependent on total and prolonged parenteral nutrition, in a Neonatal Intensive Care Center (tertiary level), between 2015 and 2020. Six infants (0.65%) out of the 914 admitted during the period met the inclusion criteria. The median age at catheter placement was 121.5 days. Two Powerpicc (PICC Power Sinergy™, São Paulo), one Groshong (Groshong™ Central Venous Catheter BD, São Paulo), and three silicone catheters were used, all tunneled, and the median dwell duration was 182.5 days. Four patients had at least one episode of infection related to the central venous catheter, and Gram-positive, Gram-negative, and fungal agents were isolated. The median length of hospital stay was 555 days and mortality was 33.3%. The ethanol lock did not cause any side effects and was relatively effective in preventing infections related to the central venous catheter.

Factors predicting efficacy of ethanol lock therapy as catheter salvage strategy for pediatric catheter-related infections

AIM

Catheter-related infections are difficult to cure, and failure rates are high. We aimed to evaluate the efficacy and safety of ethanol lock therapy (ELT) as catheter salvage strategy in children with central-line-associated bloodstream infection (CLABSI), and to identify factors associated with treatment failure.

METHODS

Data were collected of all the children who received ELT for treatment of CLABSI during 2013-2018 due to failure of standard therapy or multiple catheter-related infections. Univariate and multivariate analyses of risk-factors for ELT failure were performed. Catheter salvage rates were compared to those achieved using systemic antimicrobials alone in an historical control group.

RESULTS

A total of 123 ELT episodes among 95 patients were analyzed. The majority of patients had underlying hemato-oncological disorders. Approximately half the episodes occurred in patients with implantable ports. Early and late treatment failure rates of ELT were 16% (20/123) and 7% (9/123), respectively. Overall, successful catheter salvage was achieved in 78% (96/123) of episodes, compared to 54% using systemic antimicrobials alone (P < .001), including mycobacterium, candida, and most staphylococcus aureus infections. Adverse events were reported in 9% (11/123) of episodes and were mostly mechanical. Multivariate analysis identified four risk factors for ELT failure: Gram-positive bacteria, elevated C-reactive protein, signs of tunnel infection, and low absolute neutrophil counts.

CONCLUSIONS

Our findings support the use of ELT for catheter salvage in children with CLABSI who failed standard therapy or had multiple catheter-related infections. The identified variables associated with ELT failure may help identify patients who can most benefit from ELT.

Ethanol lock therapy in pediatric patients: A multicenter prospective study

BACKGROUND

Ethanol lock therapy (ELT) has been performed for the purpose of preserving central venous catheters (CVC) in central venous catheter-related blood stream infection (CRBSI), but evidence for its effectiveness is not established. We conducted a multicenter, prospective study on the ELT protocol to ascertain its safety and effectiveness against CRBSI.

METHODS

The subjects were patients aged over 1 year with potential for developing CRBSI who had long-term indwelling silicone CVCs. After culturing the catheterized blood, a 70% ethanol lock was performed daily for 2-4 h for 7 days. The effectiveness rate of ELT for single and multiple courses, the presence or absence of relapse of CRBSI within 4 weeks of treatment, and whether the CVC could be salvaged after 4 weeks were examined.

RESULTS

From September 2014 to August 2018, 49 cases from six hospitals were enrolled in the study. Catheter blockage was seen in one case and the CVC was removed. A single course of ELT was effective in episodes 88% (42/48). In the remaining three episodes that failed after a single course of ELT, a second ELT was performed; however, all were ineffective. In episodes 93% (40/42), no CRBSI relapse was seen up to 4 weeks after the end of treatment. In episodes 84% (41/49), the catheter could be preserved for 4 weeks or more after the end of treatment. Facial flushing was seen in two cases as an adverse event; however, this was transient and soon disappeared.

CONCLUSION

ELT is effective for 88% of CRBSI and 84% of catheters can be salvaged; therefore, this protocol is considered useful.

TRIAL REGISTRATION

UMIN000013677.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital

BACKGROUND

Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010.

METHODS

Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional.

RESULTS

A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%).

CONCLUSIONS

Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.

Effect of Ethanol/Trisodium Citrate Lock on Microorganisms Causing Hemodialysis Catheter-Related Infections

Purpose

This in vitro study tested the effectiveness of a novel 30% ethanol/4% trisodium citrate (TSC) lock solution against the most common pathogens causing hemodialysis catheter-related infections.

Methods

Clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) (n=4), methicillin-sensitive S. aureus (MSSA) (n=8), methicillin-resistant Staphylococcus epidermidis (MRSE) (n=8), Pseudomonas aeruginosa (n=4) and Escherichia coli (n=4) were tested in duplicate. Bacterial suspensions of each isolate were made in a control solution of normal saline and Mueller-Hinton broth (MHB), and in a lock solution of ethanol 30%, TSC 4% and MHB. Suspensions were incubated at 37 °C for 48 h. Colony counts were determined from samples collected at t=0 h (before exposure to the ethanol/TSC lock), t=1 h (one hour after exposure to the ethanol/TSC lock), t=24 h and t=48 h. To confirm the absence of viable organisms in the lock solution, the remaining volume at 48 h was filtered through a 0.45 μm filter. The filter was rinsed with 15 mL sterile water and plated on tryptic soy agar (TSA).

Results

All controls demonstrated significant growth over 48 h. In the lock solutions, initial inocula were reduced to 0 viable colonies by t=1 h (6-log kill), and there was no growth at t=24 and 48 h. Filtering of lock solutions also showed no growth. These results were consistent among duplicates of all isolates.

Conclusions

The 30% ethanol/4% TSC lock solution consistently eradicated MRSA, MSSA, MRSE, P. aeruginosa and E. coli within 1 h of exposure. Experiments are currently underway to test this novel lock solution on preventing biofilm production by these pathogens.

Intravascular Catheters and Biofilm Control

Intravascular catheters are the most common cause of nosocomially acquired bloodstream infections. Bacteria found adhering to the intraluminal surfaces of catheters are the principal source and cause of these infections. Adherent bacteria overtime are known to form multicellular communities which become encased within a three dimensional matrix of extracellular polymeric material known as biofilms, which are thought to be responsible for persistent infections. Consequently, a number of technologies have been developed to help prevent and control biofilms in intravascular catheters. One such approach involves impregnating catheter material with antimicrobial agents. Unfortunately these methods are not universally effective in preventing catheter-related biofilm infections. Technologies that utilise antimicrobials, as catheter locks have been shown to have more potential for preventing biofilm formation and reducing the incidences of catheter related bloodstream infections (CRBSI). This article discusses the significance of biofilms in intravascular catheters and determines whether the treatments available today are proving to be effective for controlling biofilms and draws attention to future avenues which are being investigated to control biofilms and therefore CRBSI.

Preemptive Ethanol Lock Therapy in Pediatric Hematology/Oncology Patients With Catheter-Associated Bloodstream Infection: Impact on Length of Stay, Cost, and Catheter Salvage

BACKGROUND

Ethanol lock therapy (ELT) with systemic antimicrobial therapy is a promising therapy for catheter-related infection (CRI). The impact of ELT timing on treatment efficacy and costs is unknown.

PROCEDURES

A prospective study was conducted in the Hematology/Oncology Unit at the Children's Hospital of Michigan. Patients with suspected CRI were randomized to Preemptive ELT arm or Rescue ELT arm after positive culture.

RESULTS

Five cases in Preemptive arm and 9 in Rescue arm had a confirmed CRI. All cases cleared infection with line salvage with no adverse events due to ELT or recurrence within 14 days. Our data showed a trend toward 36% reduction in average hospital costs and 40% reduction in average length of stay in Preemptive arm over Rescue arm.

CONCLUSION

Although a small study, our data on preemptive ELT with systemic antimicrobial therapy suggest a potentially important treatment strategy in reducing length of stay as well as hospital costs.

Clinical Application of Prophylactic Ethanol Lock Therapy in Pediatric Patients With Intestinal Failure

Patients with intestinal failure have an increased risk for catheter-related bloodstream infections that can necessitate central venous line replacement and result in morbidity, prolonged hospitalization, or mortality. For pediatric patients with intestinal failure, the severe loss of intestinal absorptive ability leads to reliance on parenteral nutrition to meet minimal needs required for growth and development. Reliance on parenteral nutrition, in turn, forces dependency on central venous lines. Recent research concentrating on the pediatric population with intestinal failure indicates that prophylactic ethanol lock therapy can reduce the rate of catheter-related bloodstream infections and decrease central venous line removal rates in this high-risk population. Prevention of catheter-related bloodstream infections is critical for patients with intestinal failure. Ethanol lock therapy policies and protocols are increasingly being developed in healthcare institutions. Despite these efforts, no standard guidelines currently exist for ethanol lock therapy, and research in this area, specifically involving the pediatric population, is limited. This article presents the evidence to date as a means for assisting nursing professionals to make informed clinical decisions regarding the use of ethanol lock therapy for pediatric patients with intestinal failure.

Central venous catheters and biofilms: where do we stand in 2017?

The use of central venous catheters (CVC) is associated with a risk of microbial colonization and subsequent potentially severe infection. Microbial contamination of the catheter leads to the development of a microbial consortia associated with the CVC surface and embedded in an extracellular matrix, named biofilm. This biofilm provides bacterial cells the ability to survive antimicrobial agents and the host immune system and to disseminate to other sites of the body. The best preventive strategy is to avoid any unnecessary catheterization or to reduce indwelling duration when a CVC is required. Beside aseptic care and antibiotic-impregnated catheters (like minocycline/rifampin), preventive locks can be proposed in some cases, whereas non-biocidal approaches are under active research like anti-adhesive or competitive interactions strategies. When the diagnosis of catheter-related bloodstream infection (CRBSI) is suspected on clinical symptoms, it requires a microbiological confirmation by paired blood cultures in order to avoid unnecessary catheter removal. The treatment of CRBSI relies on catheter removal and systemic antimicrobials. However, antibiotic lock technique (ALT) can be used as an attempt to eradicate biofilm formed on the inside lumen of the catheter in case of uncomplicated long-term catheter-related BSI caused by coagulase-negative staphylococci (CoNS) or Enterobacteriaceae. Recently, promising strategies have been developed to improve biofilm eradication; they rely on matrix degradation or destabilization or the development of anti-persister compounds, targeting the most tolerant bacterial cells inside the biofilm. Understanding biofilm formation at the molecular level may help us to develop new approaches to prevent or treat these frequent infections.

Redefining short bowel syndrome in the 21st century

In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.

Ethanol Lock Therapy for the Treatment of Intravenous Catheter Infections That Have Failed Standard Treatment

This study used ethanol lock therapy (ELT) to treat intravenous catheter infections that had failed standard intravenous antimicrobial treatment. Of 15 patients enrolled, 13 were successfully treated with ELT. Twenty-one organisms were identified: 12 bacteria, 9 fungi. Eight of the 9 fungi were eradicated, and no patient became hemodynamically unstable on treatment.

Use of Ethanol Lock Therapy to Reduce the Incidence of Catheter-Related Bloodstream Infections in Home Parenteral Nutrition Patients

BACKGROUND

Catheter-related bloodstream infection (CRBSI) is a serious complication for home parenteral nutrition (HPN) patients. To reduce the incidence of infection in frequently infected HPN patients, prophylactic ethanol lock therapy (ELT) was initiated.

METHODS

Nine patients were selected as candidates for ELT because of their history of recurrent CRBSI. Diagnosis of CRBSI was determined by symptoms correlating with positive peripheral and access device blood cultures. Medical-grade ethyl alcohol 25%-70% was instilled into the central venous access device and allowed to dwell for 2-4 hours. The incidence of CRBSI and catheter changes was compared before and after initiation of ELT.

RESULTS

Nine patients experienced 81 CRBSIs (8.3 per 1,000 catheter-days) before starting ELT vs 9 infections (2.7 per 1,000 catheter-days: relative risk [RR], 0.325; confidence interval [CI] 95%, 0.17-0.64) after ELT. Catheter changes were also reduced from 69 (7.0 per 1000 days) before ELT to 1 (0.3 per 1,000 days: RR, 0.043; CI 95%, 0.01-0.25) after ELT. No significant adverse effects were noted, although some patients complained of transient dizziness and nausea.

CONCLUSIONS

ELT shows promise in reducing the incidence of CRBSI in the frequently infected HPN population. Further studies are warranted.

Twenty-five Years of Advances in Vascular Access: Bridging Research to Clinical Practice

Vascular access has become a key component for a multitude of IV therapies, including parenteral nutrition. Access of the central venous system has been long recognized for its associated complications of infection, thrombosis, and occlusion. Over the past 25 years, clinical practice based on research and innovation has attempted to decrease complication rates and therefore improve the safety of vascular access. This article highlights the research and its influence on catheter care procedures, technology, and education that has led to advances in vascular access. An improved understanding of the pathophysiology associated with catheter-related complications and an ongoing evaluation of new treatment modalities has provided clinicians today with new options for improved patient care and the ability to preserve vascular access options for patients.

Efficacy of ethanol locks to reduce the incidence of catheter-related bloodstream infections for home parenteral nutrition pediatric patients: comparison of therapeutic treatment with prophylactic treatment

PURPOSE

Children with intestinal failure (IF) requiring central venous catheters (CVCs) often experience frequent catheter-related bloodstream infections (CRBSIs), which is a serious and life-threatening complication. To reduce the incidence of CRBSI, prophylactic ethanol lock therapy (ELT) was initiated.

METHODS

Patients with IF received home parenteral nutrition via a silicone tunneled CVC. All of them had received therapeutic ELT from January 2009 (first period) and prophylactic ELT from December 2012 (second period). Prophylactic ELT refers to ethanol lock for 2 h during the monthly hospital visit. We compared the CRBSI rate and number of CVC replacements between both periods.

RESULTS

Four patients received 19 CVCs for a total of 5623 catheter days. In the first period, there were 12 CRBSIs in 1823 catheter days (rate 6.77 per 1000 catheter days). In the second period, there were 9 CRBSIs in 3800 catheter days (rate 3.13 per 1000 catheter days). Overall, the rate of CVC replacement decreased from 4.92 to 1.72 per 1000 catheter days (p = 0.04). No adverse reactions were experienced during ethanol instillation.

CONCLUSION

Monthly prophylactic ELT for IF patients is considered to be a safe and effective modality for reducing the replacement of CVCs due to CRBSIs.

Stability of a heparin-free 50% ethanol lock solution for central venous catheters

Objectives. To determine the stability of a compounded 50% ethanol solution (v/v) in syringes used for ethanol locks for central venous catheters. Design. Syringes were compounded with 50% ethanol solution (v/v) and were tested for ethanol concentration over a 28 day period. Syringes were stored at room temperature not protected from light and assayed on days 0, 1, 2, 3, 6, 7, 10, 15, 17, 21, and 28. Ethanolic content was determined using gas chromatography/flame ionization detection (GC/ FID) Varian CP-WAX58 (FFAP) CB capillary column. Setting. University of Wisconsin Comprehensive Cancer Center. Results. The mean value for all samples over 28 days was found to be 47.08% with a standard deviation of 2.72. Mean ethanol concentrations ranged from 43 to 52% over the 28 day period and did not vary with time. Conclusions. Ethanol is an effective disinfectant against a broad range of micro-organisms, including bacteria and fungi. Retrospective trials have suggested that the efficacy of an ethanol lock solution is superior to systemic antibiotics to treat and/or prevent central line venous infections; however, there is not a commercially available pharmaceutical product and ethanol 50% solutions are currently compounded. These findings suggest that a 50% (v/v) ethanol solution stored in a syringe at room temperature, not protected from light is stable over a 28 day period. J Oncol Pharm Practice (2007) 13: 33–37.

The Effects of Prolonged Ethanol Exposure on the Mechanical Properties of Polyurethane and Silicone Catheters Used for Intravascular Access

Background:

Products containing alcohol are commonly used with intravascular devices at insertion, to remove lipids from occluded intravascular devices used during parenteral nutrition, and increasingly for the prevention and treatment of intravascular device-related bloodstream infection. The effects of alcohol on the integrity of intravascular devices remain unknown.

Methods:

Two types of widely used commercial peripherally inserted central catheters, one made of polyether-urethane and one made of silicone, were exposed to a 70% etha-nol lock solution for up to 10 weeks. Mechanical testing was performed to identify force-at-break, stress, strain, modulus of elasticity, modulus of toughness, and wall area of ethanol-exposed and control catheters.

Results:

No significant differences between exposed and unexposed catheters were identified for any of the mechanical parameters tested except for a marginal reduction in the modulus of elasticity for both polyetherurethane and silicone catheters and minor increases in the wall area of polyetherurethane catheters.

Conclusions:

These data indicate that exposure to a 70% ethanol lock solution does not appreciably alter the integrity of selected commercial polyetherurethane and silicone catheters. Given the greatly expanded use of alcoholic solutions with intravascular devices of all types, we believe that manufacturers would be well advised to subject their catheters and other intravascular devices to formal testing of the type employed in this study.

Cholestasis in Preterm Infants

Cholestasis in preterm infants has a multifactorial etiology. Risk factors include degree of prematurity, lack of enteral feeding, intestinal injury, prolonged use of parenteral nutrition (PN), and sepsis. Soy-based parenteral lipid emulsions have been implicated in the pathophysiology of PN-associated liver injury. Inflammation plays an important role. Medical therapies are used; however, their effects have not consistently proven effective. Evaluation of cholestasis involves laboratory work; direct bilirubin levels are used for diagnosis and trending. Adverse outcomes include risk for hepatobiliary dysfunction, irreversible liver failure, and death. Early enteral feedings as tolerated is the best way to prevent and manage cholestasis.

Staphylococcal biofilms: quest for the magic bullet

The biofilm phenotype has been recognized only relatively recently in medical history but it has rapidly become clear that the development of many, if not the majority of bacterial infections depends upon the formation of a biofilm. Medical device-related infections are one of the clearest examples of biofilm-dependent infections. Bacteria proficiently adhere to and establish biofilms on synthetic surfaces, and to date, no material has proven to completely preclude bacterial adherence. Any inserted device can be colonized but intravenous catheters, due to their widespread use, are the most commonly colonized devices. As many as half a million catheter-related infections occur each year in the United States and the staphylococci, in particular, Staphylococcus aureus and Staphylococcus epidermidis, are the leading cause. Biofilms exhibit tolerance to biocides, chemotherapeutic agents, and host-immune defenses and subsequently, biofilm-associated infections are extremely difficult to treat, frequently chronic, and often recurrent, making them a confounding clinical problem. Development of an effective strategy for preventing and/or treating these infections is of paramount importance and consequently, the search for novel approaches to target the biofilm phenotype has exploded in recent years. Because the biofilm phenotype is complex, targets for antibiofilm approaches are numerous and this line of research is significantly expanding our knowledge about the biofilm mode of growth and its role in disease. This review highlights a number of antibiofilm approaches that are currently under investigation as novel interventions for staphylococcal infections.

Comparative effectiveness of catheter salvage strategies for pediatric catheter-related bloodstream infections

BACKGROUND

Intravascular catheter salvage may be attempted in clinically suitable cases in pediatric patients with catheter-related bloodstream infections. The purpose of this study was to assess the effectiveness of ethanol and hydrochloric acid (HCl) locks in achieving catheter salvage through decision-analysis modeling.

METHODS

A Markov decision model was created to simulate catheter salvage using three management strategies: systemic antibiotics alone, antibiotics plus HCl lock, and antibiotics plus ethanol lock. One-way and two-way sensitivity analyses were performed for all model variables. Infection control rates and recurrence rates for each strategy were derived from prospective institutional data and existing pediatric literature. Costs were derived from institutional charges.

RESULTS

With antibiotics alone, 73% of patients would require line replacement within 100days, compared to only 31% and 19% of patients treated with HCl and ethanol lock, respectively. Incremental cost per additional catheter salvaged is $89 for HCl lock and $456 for ethanol lock. Superior efficacy of adjunct lock therapy is insensitive to changes in the anticipated duration of central access requirement and to clinically relevant variations in all model input variables.

CONCLUSION

HCl or ethanol locks are cost-effective adjuncts to systemic antibiotics for attempted catheter salvage in the setting of catheter-related bloodstream infections.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.

Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks.

Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).

Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Update on infection control challenges in special pediatric populations

PURPOSE OF REVIEW

Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children.

RECENT FINDINGS

Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients.

SUMMARY

Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.

Antimicrobial lock therapy in central-line associated bloodstream infections: a systematic review

PURPOSE

Antimicrobial lock therapy (ALT) seems a promising approach for treatment of central line associated bloodstream infections (CLABSI). The recent introduction of molecules such as daptomycin and tigecycline, alone or in combination with other molecules, improved chances of efficacy of ALT, due to their activity on the bacterial biofilm. Our aim was to review the literature concerning ALT for CLABSI, including data concerning novel molecules.

METHODS

We included case-control studies evaluating two or more molecules as ALT in central venous catheter infections extracted from the Medline database. Among 221 available articles in Pubmed, 54 were selected for their particular interest concerning ALT.

RESULTS

Incidence of CLABSI is high worldwide. Mechanisms of catheter infection include contamination by skin bacteria, hand contamination and hematogenous diffusion. Catheter-infection is associated with biofilm formation, which reduces the efficacy of ALT. The most promising situation for ALT to succeed in salvaging a catheter appears to be coagulase-negative Staphylococcus infection, which is the main causative agent of CLABSI. Daptomycin, Tigecycline, Ethanol and Taurolidine appear as the best options for treating CLABSI; data are mostly available for Daptomycin, which showed, alone or associated with Rifampin, good in vitro potency on biofilm, but few in vivo data exist on efficacy.

CONCLUSIONS

The introduction of novel molecules has increased chances of catheter salvage with ALT in case of CLABSI, but further in vivo studies are needed.

Effects of Prolonged Ethanol Lock Exposure to Carbothane- and Silicone-based Hemodialysis Catheters: A 26-week Study

Purpose

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related bloodstream infections (CRBSIs), but may be associated with the development of resistant bacteria. Ethanol-based catheter locks may provide a better alternative; however, there are limited data on the long-term integrity of dialysis catheters exposed to ethanol.

Methods

We performed in vitro testing of two types of hemodialysis catheters—silicone (SLC) and carbothane (CBT) based—with a 70% ethanol lock (EL) versus heparin lock (HL) for 26 weeks. Lock solutions were changed thrice weekly to mimic a conventional hemodialysis schedule. We tested mechanical properties of the catheters at 0, 13 and 26 weeks by examining stress/strain relationships (SS400%) and modulus of elasticity (ME). Electron microscopy was performed to examine catheter ultrastructure at 0 and 26 weeks.

Results

Catheter integrity for HL versus EL in SLC (SS400%: 4.5 vs. 4.5 MPa, p = NS; ME: 4.6 vs. 4.7 MPa, p = NS) or CBT-based catheters (SS400%: 7.6 vs. 8.9 MPa, p = NS; ME: 9.6 vs. 12.2 MPa, p = NS) were all similar at 13 and 26 weeks. Scanning electron microscopy revealed no structural changes in the central and luminal wall internal surfaces of EL- versus HL-treated catheters.

Conclusions

There were no significant differences in catheter integrity between SLC or CBT catheters exposed to a 70% EL for 26 weeks. Given its low cost, potential to avoid antibiotic resistance and structural integrity after 6 months of high-dose ethanol, ELs should be studied prospectively against antibiotic locks to assess the efficacy and safety in hemodialysis patients.

The prevention, diagnosis and management of central venous line infections in children

With advancing paediatric healthcare, the use of central venous lines has become a fundamental part of management of neonates and children. Uses include haemodynamic monitoring and the delivery of lifesaving treatments such as intravenous fluids, blood products, antibiotics, chemotherapy, haemodialysis and total parenteral nutrition (TPN). Despite preventative measures, central venous catheter-related infections are common, with rates of 0.5-2.8/1000 catheter days in children and 0.6-2.5/1000 catheter days in neonates. Central line infections in children are associated with increased mortality, increased length of hospital and intensive care unit stay, treatment interruptions, and increased complications. Prevention is paramount, using a variety of measures including tunnelling of long-term devices, chlorhexidine antisepsis, maximum sterile barriers, aseptic non-touch technique, minimal line accessing, and evidence-based care bundles. Diagnosis of central line infections in children is challenging. Available samples are often limited to a single central line blood culture, as clinicians are reluctant to perform painful venepuncture on children with a central, pain-free, access device. With the advancing evidence basis for antibiotic lock therapy for treatment, paediatricians are pushing the boundaries of line retention if safe to do so, due to among other reasons, often limited venous access sites. This review evaluates the available paediatric studies on management of central venous line infections and refers to consensus guidelines such as those of the Infectious Diseases Society of America (IDSA).

Inhibition of heparin precipitation, bacterial growth, and fungal growth with a combined isopropanol-ethanol locking solution for vascular access devices

BACKGROUND

Clinical reports of ethanol-lock use for the prevention of catheter-related bloodstream infections have been marked by the occurrence of serious catheter occlusions, particularly among children with mediports. We hypothesized that precipitate forms when ethanol mixes with heparin at the concentrations relevant for vascular access devices, but that the use of a combination of two alcohols, ethanol and isopropanol, would diminish heparin-related precipitation, while retaining anti-bacterial and anti-fungal effects.

METHODS

Heparin (0-100units/mL) was incubated in ethanol-water solutions (30%-70% vol/vol) or in an aqueous solution containing equal parts (35% and 35% vol/vol) of isopropanol and ethanol. Precipitation at temperatures from 4 to 40°C was measured in nephelometric turbidity units using a benchtop turbidimeter. Growth of Escherichia coli, Staphylococcus aureus, and Candida albicans colonies were measured following exposure to solutions of ethanol or isopropanol-ethanol. Groupwise comparisons were performed using analysis of variance with Bonferroni-corrected, post-hoc T-testing.

RESULTS

Seventy percent ethanol and heparin exhibit dose-dependent precipitation that is pronounced and significant at the concentrations typically used in mediports (p<0.05). Precipitate is significantly reduced by use of a combined 35% isopropanol-35% ethanol solution rather than 70% ethanol (p<0.05), while maintaining the solution's anti-bacterial and anti-fungal properties. On the other hand, although ethanol solutions under 70% form less precipitate with heparin, such concentrations are also less effective at bacterial colony inhibition than solutions of either 70% ethanol or 35% isopropanol-35% ethanol (p<0.05).

CONCLUSIONS

A combined 35% isopropanol-35% ethanol locking solution inhibits bacterial and fungal growth similarly to 70% ethanol, but results in less precipitate than 70% ethanol when exposed to heparin. Further study of a combined isopropanol-ethanol locking solution for the prevention of catheter-related bloodstream infections should focus on the determination as to whether such a locking solution may reduce the rate of precipitation-related catheter occlusion, and whether it may be administered with low systemic toxicity.

Ethanol Lock Efficacy and Associated Complications in Children With Intestinal Failure

BACKGROUND

Prophylactic ethanol lock therapy (ELT) reduces central line-associated bloodstream infections (CLA-BSIs) in children with intestinal failure (IF). However, the risk of associated complications is unclear. We aim to describe our experience with prophylactic ethanol locks in a cohort of patients with IF.

MATERIALS AND METHODS

Thirty patients on ELT from 2010-2013 were identified by review of our intestinal rehabilitation registry. Patient demographics, CLA-BSI events, and line complications were extracted. Comparisons in infection and complication rates when on and off ELT were made using a Poisson mixed-effect regression model.

RESULTS

CLA-BSIs when on and off ELT were 3.1 and 5.5 per 1000 catheter days, respectively (P <015). Overall complication rates were similar in both groups. In those patients who experienced a complication, the complication rates on ELT compared with time off ELT were significantly lower (P <003). Line perforation or breakage rates declined significantly when on ELT, from 1.8 to 1.53 per 1000 catheter days (P <006). Line occlusion rates also decreased on ELT, from 0.6 to 0.3 per 1000 catheter days (P =056). Infecting organisms were not different on and off ELT, and patients experienced a similar number of polymicrobial infections on or off therapy. Klebsiella pneumoniae was the most common infecting organism in both groups.

CONCLUSIONS

Ethanol lock therapy use reduces both CLA-BSI and central line complication rates in children with IF. These results underscore the safety and efficacy of ELT use in this population.

Ethanol lock therapy: a pilot infusion study in infants

BACKGROUND

Ethanol lock therapy (ELT) has emerged as an effective method for the prevention and treatment of central line-associated bloodstream infections (CLABSIs), but the safety of ELT in infants has not been established.

OBJECTIVE

The objective of this study was to determine blood alcohol concentration (BAC) and evidence of hepatic injury in infants after infusing a small one-time dose of ethanol, equivalent to the volume that would be flushed through the central venous catheter (CVC) after ELT is completed.

METHODS

This was a prospective pilot study in infants weighing ≤6 kg with and without liver dysfunction who had a CVC. The primary end points were 5-minute and 1-hour BACs after a 0.4-mL dose of 70% ethanol was flushed through the CVC. Acceptable BACs were defined as <0.025% at 5 minutes and <0.01% at 1 hour. The secondary end point was evidence of hepatic injury, defined as a change of greater than 2 times the upper limit of normal of any component in the hepatic panel in patients with a normal baseline panel or doubling of any component in the hepatic panel in patients with an abnormal baseline panel (aspartate aminotransferase, alanine transaminase, total or direct bilirubin, gamma-glutamyl transferase, or alkaline phosphatase).

RESULTS

A total of 10 patients were included for analysis, with a mean age and weight of 3.5 ± 2.4 months and 4.5 ± 0.9 kg, respectively. All patients had acceptable BACs and no evidence of hepatic injury. In 8 patients, 5-minute BACs were undetectable; BACs of the other 2 patients were 0.011%. One-hour BACs in all patients were undetectable.

CONCLUSIONS

Flushing ELT resulted in acceptable BACs and no evidence of hepatic injury in this patient cohort. Further studies are needed to investigate the long-term safety and efficacy of ethanol infusion after ELT in this patient population for the prevention and treatment of CLABSIs.

Ethanol Lock Technique: Review of the Literature

Central venous catheters (CVCs) are commonly used among adult and pediatric patients for administration of fluids, medications, and nutrition. Central line–associated (CLA) bloodstream infection (BSI) is a serious complication following CVC insertion. The aim of this review is to summarize available data regarding the ethanol lock technique, which is a proposed method for sterilizing the lumen of the catheter by instilling an ethanol solution and allowing it to dwell in the catheter for a certain amount of time. Studies on ethanol lock technique differ in ethanol concentrations, luminal dwell times, catheter types, inclusion of anticoagulants, use of systemic antibiotics, and use of the technique for prevention or for treatment of CLA BSI. In vitro studies demonstrate the efficacy of ethanol in the eradication of various pathogens. Definitive catheter integrity data are limited. Clinical trials report tolerable adverse events with ethanol locks, as well as encouraging results for prevention and treatment of CLA BSI.

Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population

BACKGROUND

Although several studies have estimated the attributable cost and length of stay (LOS) of central line-associated bloodstream infections (CLABSIs) in the pediatric intensive care unit setting, little is known about the attributable costs and LOS of CLABSIs in the vulnerable pediatric hematology/oncology population.

METHODS

We studied a total of 1562 inpatient admissions for 291 pediatric hematology/oncology patients at a single tertiary care children's hospital in the mid-Atlantic region between January 2008 and May 2011. Costs were normalized to year 2011 dollars. Propensity score matching was used to estimate the effect of CLABSIs on total cost and LOS while controlling for other covariates.

RESULTS

Sixty CLABSIs occurred during the 1562 admissions. Compared with the patients without a CLABSI, those who developed a CLABSI tended to be older (9.0 years vs 7.5 years; P = .026) and to have a tunneled catheter (46.7% vs 27.0%) and a peripherally inserted central catheter (20.0% vs 11.2%) as opposed to other types of catheters (P < .0001). Propensity score matching yielded matched groups without significant differences in patient characteristics. In the propensity score analysis, the attributable LOS of a CLABSI was 21.2 days (P < .0001), and the attributable cost of a CLABSI was $69,332 (P < .0001).

CONCLUSIONS

Among pediatric hematology/oncology patients, CLABSI was associated with an additional LOS of 21 days and increased costs of nearly $70,000. These findings may inform decisions regarding the value of investing in efforts to prevent CLABSIs in this vulnerable population.

The impact of ethanol lock therapy on length of stay and catheter salvage in pediatric catheter-associated bloodstream infection

BACKGROUND

Ethanol lock therapy (ELT) with systemic antimicrobial therapy (SAT) is a treatment for catheter-associated bloodstream infections (CABSI). However, its impact on hospital length of stay (LOS) is unknown.

OBJECTIVES

Assess the impact of ELT on LOS, LOS attributable to CABSI (ALOS), and catheter salvage in pediatric hematology, oncology, stem cell transplant (HOSCT) CABSI.

METHODS

Retrospective review of HOSCT CABSI from January 2009 to July 2011.

RESULTS

A total of 124 CABSI episodes were reviewed in 66 patients. Mean LOS with ELT after 1 positive blood culture (BC) was 7.1 versus 12.3 days after ≥2 positive BC (P = .014). Mean ALOS was 1.6 days with ELT versus 2.9 days without ELT (P = .018). Mean ALOS with ELT after 1 positive BC was 3.75 days versus 5.8 days after ≥2 positive BC (P = .022). Catheter salvage rate: 41 of 48 (85%) with ELT versus 49 of 68 (72%) without ELT (P = .169).

CONCLUSION

Earlier initiation of ELT may decrease ALOS.

Ethanol Locks in the Prevention and Treatment of Catheter-Related Bloodstream Infections

Objective: To evaluate the evidence regarding the use of ethanol lock therapy (ELT) for catheter-related bloodstream infection (CRBSI) prophylaxis and treatment. Data Sources: A literature search was conducted using PubMed (August 2003-January 2013) with search terms: ethanol lock, ethanol locks, ethanol lock therapy, prophylaxis, prevention, catheter-related bloodstream infection, and catheter-related infection. Additional sources were identified through a subsequent review of relevant articles. Study Selection and Data Extraction: All English-language studies with >1 patient and a primary outcome of rates of infection, clinical cure, catheter removal or line salvage were evaluated. Studies where ELT was not used for CRBSI prophylaxis or treatment, review articles, and in vitro studies were excluded. Data were abstracted through an independent review of all articles by 2 authors. Discrepancies were discussed and resolved. Data Synthesis: 13 prophylaxis studies evaluated 617 patients; all studies reported decreased rates of infection and catheter removal with ELT. The ELT regimen associated with the most consistent benefit was 70% ethanol, a 2- to 4-hour dwell time, and daily exchange for ≥1 month. 9 treatment studies evaluated 213 catheters, with 90% (192/213) cure and 84% (179/213) line salvage. ELT was always used in combination with systemic antibiotics. The most common ELT treatment regimen was 70% ethanol, a 12- to 24-hour dwell time, and a duration of 1-5 days. No serious adverse events were reported. Conclusion: The current literature suggests that prophylactic ELT decreases the rates of infection and catheter removal, and ELT treatment appears efficacious in combination with systemic antibiotics.

Adjunctive management of central line-associated bloodstream infections with 70% ethanol-lock therapy

OBJECTIVES

Ethanol is bactericidal against most pathogens implicated in central line-associated bloodstream infections (CLABSIs) and biofilms. Current Infectious Diseases Society of America guidelines cite insufficient evidence to support adjunctive ethanol-lock therapy (ELT) for central venous catheter (CVC) salvage in patients with CLABSI in combination with systemic antimicrobial treatment. We evaluated the safety and potential efficacy of 70% ELT for CLABSI at our institution after implementation of a hospital ELT protocol.

METHODS

We collected data on all patients treated with adjunctive 70% ELT for catheter salvage from September 2009 to September 2011 and assessed clinical outcomes and adverse events associated with ELT.

RESULTS

Sixty-eight hospitalized patients received 70% ELT for CVC salvage: 45 (66%) met the criteria for CLABSI. Five (11%) had persistent or recurrent bacteraemia triggering CVC removal; 28 (62%) preserved their CVC long term. There were no documented adverse events associated with ELT.

DISCUSSION

Adjunctive 70% ELT is an inexpensive, well-tolerated option for CVC salvage in patients with CLABSI and warrants further investigation.

Ethanol causes protein precipitation--new safety issues for catheter locking techniques

OBJECTIVE

The ethanol lock technique has shown great potential to eradicate organisms in biofilms and to treat or prevent central venous catheter related infections. Following instillation of ethanol lock solution, however, the inherent density gradient between blood and ethanol causes gravity induced seepage of ethanol out of the catheter and blood influx into the catheter. Plasma proteins so are exposed to highly concentrated ethanol, which is a classic agent for protein precipitation. We aimed to investigate the precipitating effect of ethanol locks on plasma proteins as a possible cause for reported catheter occlusions.

METHODS

Plasma samples were exposed in-vitro to ethanol (concentrations ranging from 7 to 70 v/v%) and heparin lock solutions. In catheter studies designed to mimic different in-vivo situations, the catheter tip was placed in a plasma reservoir and the material contained within the catheter was analyzed after ethanol lock instillation. The samples underwent standardized investigation for protein precipitation.

RESULTS

Protein precipitation was observed in plasma samples containing ethanol solutions above a concentration of 28%, as well as in material retrieved from vertically positioned femoral catheters and jugular (subclavian) catheters simulating recumbent or head down tilt body positions. Precipitates could not be re-dissolved by dilution with plasma, urokinase or alteplase. Plasma samples containing heparin lock solutions showed no signs of precipitation.

CONCLUSIONS

Our in-vitro results demonstrate that ethanol locks may be associated with plasma protein precipitation in central venous catheters. This phenomenon could be related to occlusion of vascular access devices locked with ethanol, as has been reported. Concerns should be raised regarding possible complications upon injection or spontaneous gravity induced leakage of such irreversibly precipitated protein particles into the systemic circulation. We suggest limiting the maximum advisable concentration of ethanol to 28 v/v% in catheter lock solutions.

Complementary mass spectrometric approaches and scanning electron microscopy to study the structural stability of polyurethane tunneled dialysis catheters after exposure to ethanol solutions

RATIONALE

Ethanol lock is an emerging therapeutic option for preventing and/or controlling catheter-associated infection. A previous study of silicone catheters showed they underwent no polymer degradation when kept in 60% ethanol for 15 days at 37 °C. The stability of the more widely used polyurethane catheters was studied here in the same way.

METHODS

A qualitative and quantitative study of the stability of Carbothane® catheters was performed following their immersion at 37 °C in different solvents (0.9% sodium chloride as control medium and 40%, 60%, 95% ethanol solutions) for different periods of time (from 5 min to 15 days) using scanning electron microscopy and complementary mass spectrometry techniques.

RESULTS

Electron ionization analysis of the 95% ethanol storage solutions revealed the release of about 45 products (8 of which were major) subdivided into two groups according to their fragmentation patterns. Combining all the mass spectrometric data made it possible to propose structures. Group I (major) originated from the polycarbonate diol component (soft segment) and group II (minor) from the dicyclohexylmethane-4,4'-diisocyanate component (rigid segment). Semi-quantitative gas chromatography/mass spectrometry (GC/MS) analysis showed that no significantly higher release was observed after immersion for 30 min at 37 °C in 40% ethanol (mean ratio = 0.677 ± 0.068) than after immersion in reference 0.9% sodium chloride solution for 15 days (0.837 ± 0.127).

CONCLUSIONS

A 30 min-40% (v/v) ethanol solution can be considered as safe for preventing the infectious complications of Carbothane® dialysis catheters, and a 30 min-60% (v/v) ethanol treatment can be occasionally used to eradicate established biofilm.

Reduction of central line-associated bloodstream infections in a pediatric hematology/oncology population

This study reports the results of an initiative to reduce central line-associated bloodstream infections (CLABSIs) among pediatric hematology/oncology patients, a population at increased risk for CLABSI. The study design was a pre-post comparison of a series of specific interventions over 40 months. Logistic regression was used to determine if the risk of developing CLABSI decreased in the postintervention period, after controlling for covariates. The overall CLABSI rate fell from 9 infections per 1000 line days at the beginning of the study to zero in a cohort of 291 patients encompassing 2107 admissions. Admissions during the intervention period had an 86% reduction in odds of developing a CLABSI, controlling for other factors. At the study team's institution, an initiative that standardized blood culturing techniques, lab draw times, line care techniques, and provided physician and nurse education was able to eliminate CLABSI among pediatric hematology/oncology patients.

Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors

BACKGROUND

To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs.

PROCEDURE

We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs.

RESULTS

We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17).

CONCLUSIONS

In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts.

Bench-to-bedside review: Challenges of diagnosis, care and prevention of central catheter-related bloodstream infections in children

Central venous catheters (CVCs) are indispensable in modern pediatric medicine. CVCs provide secure vascular access, but are associated with a risk of severe complications, in particular bloodstream infection. We provide a review of the recent literature about the diagnostic and therapeutic challenges of catheter-related bloodstream infection (CRBSI) in children and its prevention. Variations in blood sampling and limitations in blood culturing interfere with accurate and timely diagnosis of CRBSI. Although novel molecular testing methods appear promising in overcoming some of the present diagnostic limitations of conventional blood sampling in children, they still need to solidly prove their accuracy and reliability in clinical practice. Standardized practices of catheter insertion and care remain the cornerstone of CRBSI prevention although their implementation in daily practice may be difficult. Technology such as CVC impregnation or catheter locking with antimicrobial substances has been shown less effective than anticipated. Despite encouraging results in CRBSI prevention among adults, the goal of zero infection in children is still not in range. More high-quality research is needed in the field of prevention, accurate and reliable diagnostic measures and effective treatment of CRBSI in children.