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Jahns F, Hausen A, Keller P, Stolz V, Kalff JC, Kuetting D, von Websky MW. Life on the line - Incidence and management of central venous catheter complications in intestinal failure. Clin Nutr 2024; 43:1627-1634. [PMID: 38772069 DOI: 10.1016/j.clnu.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/16/2024] [Accepted: 05/04/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Loss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. METHODS For this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDTs) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDTs were compared. RESULTS Overall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 "CVC-days"). Broviac type "B" was found to be significantly superior to type "A" regarding occlusion, CRI, and material defects (log-rank test: p = 0.05; p = 0.026; p = 0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 389 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. CONCLUSIONS Different complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.
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Affiliation(s)
- Franziska Jahns
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Annekristin Hausen
- Department of Internal Medicine, University Hospital of Bonn, Bonn, Germany
| | - Peter Keller
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Verena Stolz
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Daniel Kuetting
- Department of Radiology, University Hospital of Bonn, Bonn, Germany
| | - Martin W von Websky
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany.
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Ait Hammou Taleb MH, Mahmutovic M, Michot N, Malgras A, Nguyen-Thi PL, Quilliot D. Effectiveness of salvage catheters in home parenteral nutrition: A single-center study and systematic literature review. Clin Nutr ESPEN 2023; 56:111-119. [PMID: 37344059 DOI: 10.1016/j.clnesp.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND & AIMS There are sparse data regarding the rate of catheter salvage and long-term effectiveness of antibiotic lock treatment outcome after central line-associated bloodstream infections (CLABSI). Objectives were to analyze the effectiveness of central venous catheter (CVC) rescue strategy and its impact on catheter lifespan. Secondary objective included effectiveness of taurolidine+4% citrate in primary prevention, compared to a secondary prevention strategy, by analyzing infection incidence during two successive periods. METHOD Real-life 5-year observational study assessing CLABSI occurrence and CVC salvage outcomes in adult patients requiring Home Parenteral Nutrition (HPN) managed in a single-center Intestinal Failure Unit. RESULTS Over the 5-year period, there were 106 confirmed infections (63/143 patients (44%)). Infection incidence was 0.92/1000 catheter-days. Incidence was 1.02/1000 catheter-days during the taurolidine+4% citrate period while lower at 0.84/1000 catheter-days (p = 0.034) during the systematic taurolidine lock period. Of the total number of infections, 89 CVCs were immediately removed and 17 were salvaged. The success rate of catheter salvage with antibiotic lock was 82.4%, with 53% remaining CLABSI-free at one year. The salvage strategy extended catheter lifespan by a median 165 days (IQR 50-214). However, the rate of new infection was significantly higher in instances of salvage (71.4%) vs. removal (36%). Parenteral Nutrition (PN) ≥12 months (p = 0.002), PN (vs. hydroelectrolytic support) (p = 0.028) and self-management by patients (p = 0.049) were independent risk factors of CLABSI. CONCLUSION Catheter salvage appears to be an effective long-term strategy with >50% of CVCs remaining CLABSI-free at one year and a prolonged catheter life, although may expose to a more frequent and earlier infection recurrence. CLINICAL TRIAL REGISTRATION Cohort approved by the French CNIL (National Committee for Data Protection, authorization number CNIL 2015-25). referred to as "observational research", "non-interventional", or « non-RIPH ».
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Affiliation(s)
- Marie-Héloïse Ait Hammou Taleb
- Nutrition Support Unit, Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | - Meliha Mahmutovic
- Nutrition Support Unit, Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | - Niasha Michot
- Nutrition Support Unit, Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | - Aurélie Malgras
- Nutrition Support Unit, Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | - Phi-Linh Nguyen-Thi
- Medical Evaluation Department, Department of Clinical Research Support PARC, University of Lorraine, CHU Nancy, Nancy, France
| | - Didier Quilliot
- Nutrition Support Unit, Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France; Department of Visceral, Metabolic and Cancer Surgery (CVMC), Multidisciplinary Unit for Obesity Surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, Vandoeuvre-lès-Nancy, France; INSERM U1256, Nutrition, Genetics, Environmental Risks, Faculty of Medicine, University of Lorraine, Nancy, France.
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Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, Lichota M, Mühlebach S, Van Gossum A, Wanten G, Wheatley C, Bischoff SC. ESPEN practical guideline: Home parenteral nutrition. Clin Nutr 2023; 42:411-430. [PMID: 36796121 DOI: 10.1016/j.clnu.2022.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 01/11/2023]
Abstract
This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion catheter and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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Affiliation(s)
- Loris Pironi
- University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS AOUBO, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy.
| | - Kurt Boeykens
- Vitaz Hospital, Nutrition Support Team, Sint-Niklaas, Belgium
| | | | - Francisca Joly
- Beaujon Hospital, APHP, University of Paris VII, Clichy, France
| | - Stanislaw Klek
- Surgical Oncology Clinic, The Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland
| | - Simon Lal
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology and Hospital Pharmacy, University of Basel, Basel, Switzerland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), UK
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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Follow-up of Patients Receiving Home Parenteral Nutrition With a Competent Home Infusion Nurse Decreases the Prevalence of Catheter Infections. TOP CLIN NUTR 2023. [DOI: 10.1097/tin.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Crivelli A, Fabeiro M, Puga M, Dieguez N, Giunta L, Pochettino F, Balacco M, Merlo G, Garrido V, Fain H, Buncuga M, Martinuzzi A, Cascarón MF, Delgado N, Capurro G, Bernardis V, Ghiglieri C, Hassam A, Soria O, Serra D, Morando L, Flores A, Gonzalez HF, Fernandez A. Care of patients on home parenteral nutrition during the first year of the COVID-19 pandemic: Management of central line-associated bloodstream infections. Clin Nutr ESPEN 2022; 52:250-253. [PMID: 36513461 PMCID: PMC9670592 DOI: 10.1016/j.clnesp.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to analyze central line-associated bloodstream infections (CLABSI) in home parenteral nutrition (HPN) patients assisted by an interdisciplinary team during the first year of the COVID-19 pandemic in Argentina. METHODS Longitudinal, retrospective and analytical study of patients on HPN for ≥90 days during 2020. Data collection included age (adults >18 years, pediatric ≤18 years), gender, diagnosis, type of catheter, number of lumens, venous access, days on HPN, infusion modality and number of CLABSI-associated events. In COVID-19 cases, number of patients, disease progression, mortality rate and microorganisms involved were analyzed. RESULTS A total of 380 patients were included, 120 (31.6%) pediatric and 260 (68.4%) adult patients. Median age was 44.50 years (10; 62.25). Twelve patients (3.15% of the total) had COVID-19; of these, two pediatric and seven adult patients had no complications, and three adults died of COVID-19 pneumonia. The diagnoses observed were benign chronic intestinal failure (CIF, n = 311), grouped into short bowel (n = 214, 56.3%), intestinal dysmotility (n = 56, 14.7%), intestinal fistula (n = 20, 5.3%), and extensive small bowel mucosal disease (n = 21, 5.5%); malignant tumors (n = 52, 13.7%); other (n = 17, 4.4%). Total catheter days were 103,702. Median days of PN duration per patient were 366 (176.2, 366). The types of catheters used were tunneled (317 patients, 83.4%); peripherally inserted central (PICC) line (55 patients, 14.5%) and ports (8 patients; 2.1%). A total of 111 CLABSI was registered, with a prevalence of 1.09/1000 catheter days (adult, 0.86/1000 days; pediatric, 1.51/1000 days). The microorganisms identified in infectious events were Gram + bacteria (38, 34.5%); Gram-bacteria (36, 32%); mycotic (10, 9%); polymicrobial (4, 3.6%); negative culture and signs/symptoms of CLABSI (23, 20.3%). The odds ratio between pediatric and adult patients was 2.29 (1.35, 3.90). CONCLUSION The rate of CLABSI during the COVID-19 pandemic was within the ranges reported by international scientific societies. The risk of CLABSI was higher in pediatric patients, and mortality rate in COVID-19 infected patients was higher than in the general population.
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Affiliation(s)
- Adriana Crivelli
- Unidad de Soporte Nutricional y Enfermedades Malabsortivas, Hospital Interzonal General de Agudos “Gral. José de San Martín”, La Plata, Argentina,Corresponding author. Unidad de Soporte Nutricional y Enfermedades Malabsortivas, Hospital Interzonal General de Agudos “Gral. José de San Martín”, Calle 1 y 70, 1900 La Plata, Argentina
| | - Marcela Fabeiro
- Servicio de Nutrición y Dietética Del Hospital de Niños de La Plata, Argentina
| | | | | | | | | | | | | | - Verónica Garrido
- Servicio de Nutrición y Dietética Del Hospital de Niños de La Plata, Argentina
| | | | | | | | | | | | - Gabriela Capurro
- Servicio de Cuidados Intensivos Hospital Interzonal “Oscar Allende” de Mar Del Plata, Argentina
| | | | | | | | | | | | | | | | - Horacio F. Gonzalez
- Instituto de Desarrollo e Investigaciones Pediátricas (IDIP) Hospital de Niños La Plata, Argentina
| | - Adriana Fernandez
- Servicio de Nutrición y Dietética Del Hospital de Niños de La Plata, Argentina
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Koh CC, Tsai HW, Ha SC, Tsai YH, Chen Y. Efficacy of same venous route Hickman catheter replacement in patients with intestinal failure. J Formos Med Assoc 2022; 122:419-426. [PMID: 37096641 DOI: 10.1016/j.jfma.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/26/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND/PURPOSE Periodical replacement of venous Hickman catheters is required for the nutritional care of patients with intestinal failure. The conventional de novo operation (DN-OP) involves inserting the catheter into a new venous tract in each replacement; however, this could result in fast consumption of functional central vessels in patients with intestinal failure. Recently, same-route operation (SR-OP) has been adopted as an alternative approach for retaining venous access. METHODS We conducted a retrospective study to compare the efficacy of Hickman catheters and the survival of venous vessels using two different operative strategies. RESULTS Overall, 181 catheters were inserted, 109 using DN-OP and 72 using SR-OP. The mean catheter duration was 11.9 ± 8.8 months in the DN-OP group and 10.5 ± 5.6 months in the SR-OP group; the infection rate was 0.74 in the DN-OP group and 0.44 in the SR-OP group. The vein accesses used in these insertions (n = 113) were classified: the DN-vein group for veins accessed only by DN-OP (n = 75) and the SR-vein group for veins accessed by an initial DN-OP and subsequent SR-OPs (n = 38). Mean working duration per vein access was 12.3 ± 10.1 months in the DN-vein group and 28.2 ± 14.8 months in the SR-vein group (p < 0.001); mean infection-free duration was 11.4 ± 10.1 months in the DN-vein group and 27.7 ± 15.3 months in the SR-vein group (p < 0.001). CONCLUSION Application of SR-OP in Hickman catheter replacement significantly extended the working duration of venous access by re-using the same venous route without compromising catheter efficacy in patients with IF having poor venous access.
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Graungaard S, Geisler L, Andersen JR, Rasmussen HH, Vinter-Jensen L, Holst M. Personalized exercise intervention in HPN patients - A feasibility study. Clin Nutr ESPEN 2021; 45:420-425. [PMID: 34620349 DOI: 10.1016/j.clnesp.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Physical health status may be predictive of readmissions, psychological health and mortality in patients with short bowel syndrome. AIMS This study aimed to investigate the feasibility and effect of an individualized exercise intervention and secondary, oral nutrition intake counseling on Timed-Up-and-Go (TUG) and 30 s Chair Stand Test (CST) as well as body-composition and EuroQol (EQ)-5D-5L, in patients with chronic intestinal failure (IF) type III receiving HPN and/or fluid therapy. METHODS A 12-week individualized exercise intervention consisting on three weekly home based sessions, and nutrition counselling focusing on protein intake and reducing high stoma output, was performed. Weekly follow-up by phone was done on motivation to exercise. RESULTS The study invited 71 patients, 44 accepted the invitation (62%), 37(52%) were included, and 31 (84%) completed the intervention. The exercise intervention was well tolerated. TUG improved from 8.9(SD 5.5) to 7.7(SD 3.8) (p = 0.033). CST improved by four repetitions (<0.001∗). A statistical, however not clinically relevant improvement was seen in muscle mass. No improvement was seen in (EQ)-5D-5L total, but insignificantly (p = 0.055) for physical function only. Protein intake improved by 10.6 g/day (p = 0.008). CONCLUSIONS A 12 weeks individualized exercise intervention showed very feasible and beneficial in HPN patients. Physical function improved statistically and clinically, and oral protein intake improved. QoL overall did not improve, however COVID-19 was an uninvited partner throughout the study period, which may have influenced general QoL. As only 62% accepted the invitation to participate, home based exercise intervention may not apply to all patients.
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Affiliation(s)
- Signe Graungaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, DK-1958 FC, Copenhagen, Denmark.
| | - Lea Geisler
- Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Jens R Andersen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, DK-1958 FC, Copenhagen, Denmark.
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Lars Vinter-Jensen
- Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Mette Holst
- Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Tirumandas M, Gendlina I, Figueredo J, Shiloh A, Trachuk P, Jain R, Corpuz M, Spund B, Maity A, Shmunko D, Garcia M, Barthelemy D, Weston G, Madaline T. Analysis of catheter utilization, central line associated bloodstream infections, and costs associated with an inpatient critical care-driven vascular access model. Am J Infect Control 2021; 49:582-585. [PMID: 33080360 DOI: 10.1016/j.ajic.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) carry serious risks for patients and financial consequences for hospitals. Avoiding unnecessary temporary central venous catheters (CVC) can reduce CLABSI. Critical Care Medicine (CCM) is often consulted to insert CVC when alternatives are unavailable. We aim to describe clinical and financial implications of a CCM-driven vascular access model. METHODS In this retrospective, observational cohort study, all CLABSI and a sample of CCM consults for CVC insertion on adult medical-surgical inpatient units were reviewed in 2019. Assessment of CVC appropriateness and financial analysis of labor, reimbursement, and attributable CLABSI cost was conducted. RESULTS Of 554 CCM consult requests, 75 (13.5%) were for CVC and 36 (48.0%) resulted in CVC insertion; 6 (16.7%) CVC were avoidable. Three CLABSI occurred in avoidable CVC with estimated annual attributable cost of $165,099. Estimated annual CCM consultant cost for CVC was $78,094 generating $110,733 in reimbursement. Overall estimated annual loss was $132,460. DISCUSSION Reliance on CCM for intravenous access resulted in avoidable CVC, CLABSI, inefficient physician effort, and financial losses; nurse-driven vascular access models offer potential cost savings and risk reduction. CONCLUSIONS CCM-driven vascular access models may not be cost-effective; alternatives should be considered for utilization reduction, CLABSI prevention, and financial viability.
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Noguchi K, Ochiai R, Imazu Y, Tokunaga-Nakawatase Y, Watabe S. Incidence and Prevalence of Infectious Diseases and Their Risk Factors among Patients Who Use Visiting Nursing Services in Japan. J Community Health Nurs 2021; 37:115-128. [PMID: 32820980 DOI: 10.1080/07370016.2020.1780047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study aimed to clarify the incidence of infectious diseases and the associated risk factors among patients who use visiting nursing services in Japan. We conducted a one-year follow up cohort study with 419 participants. The incidence and period prevalence rate of infectious diseases were 0.63 and 15.0%, respectively. In the multiple logistic regression analysis, the presence of chronic respiratory failure, Parkinson's disease, dermatosis other than pressure ulcers, and the inability to perform oral self-care were significantly related to the contraction of an infectious disease.
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Affiliation(s)
- Kyoko Noguchi
- Infection Control Nursing, Department of Nursing, Graduate School of Medicine, Yokohama City University , Yokohama, Japan
| | - Ryota Ochiai
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
| | - Yoko Imazu
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
| | | | - Setsuko Watabe
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
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Hoxha A, Duysburgh E, Mortgat L. Healthcare-associated infections in home healthcare: an extensive assessment, 2019. Euro Surveill 2021; 26:1900646. [PMID: 33541482 PMCID: PMC7863228 DOI: 10.2807/1560-7917.es.2021.26.5.1900646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/01/2020] [Indexed: 11/20/2022] Open
Abstract
IntroductionThe number of patients and clinical conditions treated in home healthcare (HHC) is increasing. Care in home settings presents many challenges, including healthcare-associated infections (HAI). Currently, in Belgium, data and guidelines on the topic are lacking.AimTo develop a definition of HAI in HHC and investigate associated risk factors and recommendations for infection prevention and control (IPC).MethodsThe study included three components: a scoping literature review, in-depth interviews with individuals involved in HHC and a two-round Delphi survey to reach consensus among key informants on the previous steps' results.ResultsThe literature review included 47 publications. We conducted 21 in-depth interviews. The Delphi survey's two rounds had 21 and 23 participants, respectively. No standard definition was broadly accepted or known. Evidence on associated risk factors was impacted by methodological limitations and recommendations were inconsistent. Agreement was reached on defining HAI in HHC as any infection specifically linked with providing care that develops in a patient receiving HHC from a professional healthcare worker and occurs ≥ 48 hours after starting HHC. Risk factors were hand hygiene, untrained patients and caregivers, patients' hygiene and presence and management of invasive devices. Agreed recommendations were to adapt and standardise existing IPC guidelines to HHC and to perform a national point prevalence study to measure the burden of HAI in HHC.ConclusionsThis study offers an overview of available evidence and field knowledge of HAI in HHC. It provides a framework for a prevalence study, future monitoring policies and guidelines on IPC in Belgium.
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Affiliation(s)
- Ana Hoxha
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Els Duysburgh
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Laure Mortgat
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
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Schedin A, Goodrose-Flores C, Bonn S, Björkhem-Bergman L. Catheter-related bloodstream infections in palliative care patients receiving parenteral nutrition by medical home care. BMJ Support Palliat Care 2020:bmjspcare-2020-002331. [PMID: 32943471 DOI: 10.1136/bmjspcare-2020-002331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/30/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Catheter-related bloodstream infections (CRBSIs) constitute a major complication associated with the use of central venous lines (CVL). The aim of this study was to investigate the incidence proportion and risk factors of CRSBI in palliative care patients with CVL receiving home parenteral nutrition (HPN). METHODS Medical records from patients admitted to a medical home care unit in stockholm, Sweden, during 2017 were reviewed (n=1022) and 454 palliative care patients with a CVL were identified. Data on CRBSI cases, HPN exposure time, type of parenteral nutrition (PN), age, diagnosis and type of CVL were collected. RESULTS Twenty-nine of 143 patients receiving HPN through a CVL were diagnosed with a CRBSI (20%). Nine of 311 patients with CVL without exposure for HPN developed CRBSI (3%). The risk of a CRBSI was significantly higher in patients receiving HPN compared with those not receiving HPN, OR 8.5 (95% CI 4.0 to 18.7). For those receiving HPN six to seven times a week the risk was even higher, OR 13 (95% CI 5.1 to 30.3). The highest incidence proportion of CRBSI (31%) was found in a home care team where patients had been trained to disconnect themselves from the PN drip. Sex, cancer versus non-cancer, type of CVL or protein content in the PN, did not differ between patients that developed CRBSI versus those that did not develop the outcome. CONCLUSION HPN entails a high risk of CRBSI. A high frequency of PN and incautious handling of the disconnection of the drip, seem to be the most important risk factors.
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Affiliation(s)
- Anna Schedin
- Palliative Home Care and Hospice Ward, ASIH Stockholm Södra, Älvsjö, Sweden
| | - Charlotte Goodrose-Flores
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Stephanie Bonn
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Linda Björkhem-Bergman
- Palliative Home Care and Hospice Ward, Stockholms Sjukhem, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Huddinge, Sweden
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Keller S, Salinas A, Williams D, McGoldrick M, Gorski L, Alexander M, Norris A, Charron J, Stienecker RS, Passaretti C, Maragakis L, Cosgrove SE. Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach. Am J Infect Control 2020; 48:993-1000. [PMID: 31982215 DOI: 10.1016/j.ajic.2019.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives METHODS: Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition. RESULTS The numerator criterion was identified by participants as involving one of the 2 following: (1) recognized pathogen isolated from blood culture and pathogen is not related to infection at another site, or (2) one of the following signs or symptoms: fever of 38°C (100.4°F), chills, or hypotension (systolic blood pressure ≤90 mm Hg), and one of the 2 following: (A) common skin contaminant isolated from 2 blood cultures drawn on separate occasions and organism is not related to infection at another site, or (B) common skin contaminant isolated from blood culture from patient with intravascular access device and provider institutes appropriate antimicrobial therapy. The criteria for a denominator included days from the day of admission with a central venous catheter to day of removal of central venous catheter. In addition, 11 inclusion criteria and 4 exclusion criteria were included. DISCUSSION Home infusion therapy and healthcare epidemiology experts developed candidate criteria for a home infusion CLABSI surveillance definition. CONCLUSIONS Home care and home infusion agencies can use this definition to monitor their own CLABSI rates and implement preventative strategies.
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13
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Cotogni P, Mussa B, Degiorgis C, De Francesco A, Pittiruti M. Comparative Complication Rates of 854 Central Venous Access Devices for Home Parenteral Nutrition in Cancer Patients: A Prospective Study of Over 169,000 Catheter-Days. JPEN J Parenter Enteral Nutr 2020; 45:768-776. [PMID: 32511768 DOI: 10.1002/jpen.1939] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/17/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Whether peripherally inserted central catheters (PICCs) are appropriate as safe and durable venous access devices (VADs) is still controversial. The aim of this 7-year, prospective cohort study was to compare the incidence rate differences of catheter-related complications (CRCs) among 4 types of central VADs in cancer patients receiving home parenteral nutrition (HPN). METHODS We enrolled all adult cancer outpatients who were candidates for HPN and who had a central VAD inserted during the study period, focusing on the incidence rate of CRCs. RESULTS We evaluated 854 central VADs (401 PICCs, 137 nontunneled centrally inserted central catheters [CICCs], 118 tunneled-cuffed CICCs, and 198 ports) in 761 patients, for a total of 169,116 catheter-days. Overall, the rate of total CRCs was 1.08/1000 catheter-days. The incidence of catheter-related bloodstream infections was low (0.29/1000), particularly for PICCs (0.08/1000; P < .001 vs tunneled-cuffed CICCs) and for ports (0.21/1000; P < .019 vs tunneled-cuffed CICCs). The rates of mechanical complications (0.58/1000) and of catheter-related symptomatic thrombosis (0.09/1000) were low and similar for PICCs, tunneled-cuffed CICCs, and ports. In terms of duration and removal rate due to complications, PICCs were like tunneled-cuffed CICCs and ports. Altogether, PICCs had fewer total complications than tunneled-cuffed CICCs (P < .001), there was no difference in total complications between PICCs and ports. CONCLUSION PICCs had significantly better outcomes than tunneled-cuffed CICCs and were safe and durable as ports. Our extensive, long-term study suggests that PICCs can be successfully used as safe and long-lasting VADs for HPN in cancer patients.
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Affiliation(s)
- Paolo Cotogni
- Unit of Parenteral Nutrition in Oncology, Department of Internal Medicine, Molinette Hospital, Turin, Italy
| | - Baudolino Mussa
- Central Venous, Access Team, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Claudia Degiorgis
- Central Venous, Access Team, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | | | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital, Rome, Italy
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14
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Xue Z, Coughlin R, Amorosa V, Quinn R, Schiavone P, Stoner N, Kinosian B, Compher C. Factors Associated With Central Line-Associated Bloodstream Infections in a Cohort of Adult Home Parenteral Nutrition Patients. JPEN J Parenter Enteral Nutr 2020; 44:1388-1396. [PMID: 32386254 DOI: 10.1002/jpen.1876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/04/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Central line-associated bloodstream infection (CLABSI) is a potentially life-threatening complication in home parenteral nutrition (HPN) patients. We investigated potential predictors of CLABSI in a cohort of adult HPN patients METHODS: Patients managed by the HPN service at the Hospital of University of Pennsylvania on January 1, 2018, were included and followed through June 30, 2019, using existing medical records to collect demographic and clinical data. CLABSIs were adjudicated prospectively by infectious disease experts. Variables with P ≤ .2, when comparing patients with CLABSIs and those without, were included in logistic regression models. RESULTS Among 114 patients, mean age was 54 ± 16 years, 78/114 were female, and BMI was 25 ± 5.6. Median experience with HPN was 516 days (range, 15-10,281), and 30 had prior CLABSI. Catheter types were peripherally inserted central catheters (83/114), tunneled (27), and implanted (4). The incidence of CLABSI was 0.89 per 1000 catheter days. One multivariate model identified ostomy/wound (odds ratio [OR], 22.0; 95% CI, 4.8-101.7), tunneled/implanted catheter (OR, 4.4; 95% CI, 1.4-13.9), and BMI < 18.5 (OR, 5.9; 95% CI, 1.4-24.2) as predictors of CLABSI. A second model identified patients with 2 potential predictors (OR, 22.9; 95% CI, 5.6-93.5) and tunneled/implanted catheter (OR, 6.7; 95% CI, 2.1-21.8) at high risk of CLABSI. Whether CLABSIrates might be reduced by more intense training in wound or catheter care (especially for those with multiple predictors), different types of catheters, or rapid treatment of malnutrition will require further study.
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Affiliation(s)
- Zhigang Xue
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Valerianna Amorosa
- Penn Home Infusion Therapy, Philadelphia, Pennsylvania, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ryan Quinn
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phyllis Schiavone
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy Stoner
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bruce Kinosian
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Charlene Compher
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, Lichota M, Mühlebach S, Van Gossum A, Wanten G, Wheatley C, Bischoff SC. ESPEN guideline on home parenteral nutrition. Clin Nutr 2020; 39:1645-1666. [PMID: 32359933 DOI: 10.1016/j.clnu.2020.03.005] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 02/07/2023]
Abstract
This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Kurt Boeykens
- AZ Nikolaas Hospital, Nutrition Support Team, Sint-Niklaas, Belgium
| | | | - Francisca Joly
- Beaujon Hospital, APHP, Clichy, University of Paris VII, France
| | | | - Simon Lal
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology and Hospital Pharmacy, University of Basel, Basel, Switzerland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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16
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Yang J, Sun H, Wan S, Mamtawla G, Gao X, Zhang L, Wang X. Prolonged Parenteral Nutrition Is One of the Most Significant Risk Factors for Nosocomial Infections in Adult Patients With Intestinal Failure. Nutr Clin Pract 2020; 35:903-910. [PMID: 32166772 DOI: 10.1002/ncp.10483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intestinal failure (IF) and its management are associated with an increased likelihood of infectious complications. This study aimed to evaluate the prevalence and potential risk factors for nosocomial infections (NIs) in hospitalized adult patients with IF. METHODS In total, 259 eligible patients with IF admitted to a single clinical nutrition center in a tertiary referral hospital from January 1, 2012, to January 1, 2019, were retrospectively identified. NIs were defined according to the 2008 Centers for Disease Control and Prevention criteria. Univariate and multivariate analyses were performed to identify independent risk factors for NIs. RESULTS The mean age of the study population was 47.0 ± 17.7 years, and 158 (61.0%) were men. The mean body mass index was 16.2 ± 2.9 kg/m2 , and 219 (84.6%) were diagnosed with malnutrition. The prevalence of NIs was 25.5% (113 NIs in 66 patients). The most common NIs were pneumonia (14.3%), bacteremia of unknown origin (13.5%), catheter-related bloodstream infection (5.0%), lower respiratory tract infection (5.0%), surgical site infection (3.9%), and urinary tract infection (1.9%). Multivariate analysis revealed that decreased serum albumin level (odds ratio [OR], 0.884; 95% CI, 0.883-0.978, P < .05), presence of gallbladder stones or cholestasis (OR, 3.144; 95% CI, 1.044-9.464; P < .05), and prolonged parenteral nutrition (PN) use (OR, 1.072; 95% CI, 1.039-1.105; P < .001) were independent predictors for NIs. CONCLUSIONS NIs remain prevalent in hospitalized adult patients with IF. Prolonged PN use was one of the most significant predictors for NIs.
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Affiliation(s)
- Jianbo Yang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Haifeng Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Songlin Wan
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Gulsudum Mamtawla
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Xuejin Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Li Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Xinying Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
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17
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Wouters Y, Roosenboom B, Causevic E, Kievit W, Groenewoud H, Wanten GJ. Clinical outcomes of home parenteral nutrition patients using taurolidine as catheter lock: A long-term cohort study. Clin Nutr 2019; 38:2210-2218. [DOI: 10.1016/j.clnu.2018.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 12/18/2022]
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18
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Infectious Complications in Home Parenteral Nutrition: A Systematic Review and Meta-Analysis Comparing Peripherally-Inserted Central Catheters with Other Central Catheters. Nutrients 2019; 11:nu11092083. [PMID: 31487777 PMCID: PMC6770172 DOI: 10.3390/nu11092083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/24/2019] [Accepted: 08/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Home parenteral nutrition (HPN) has become a common therapy. There is still controversy regarding the possibility that peripherally inserted central catheters (PICCs) may diminish catheter-related blood stream infection (CRBSI) rates. Methods: We searched the PubMed database for studies reporting the rates of CRBSI with HPN. Study selection was performed independently by three investigators. Disagreements were discussed and resolved by consensus or by arbitration by an author not involved in the search. The National Institutes of Health Quality Assessment Tools was used to assess the methodological quality of the studies. Meta-analyses were performed using MetaXL 5.3 with the quality effects model. Results: Screening of the article titles and abstracts yielded 134 full text articles for evaluation. Only three prospective studies that included appropriate data were considered for the final analysis. The relative risk of the CRBSI rate was 0.41 (0.14–1.17) for PICC vs. tunneled catheters. The relative risk of the CRBSI rate was 0.16 (0.04–0.64) for PICC vs. ports. The relative risk of the thrombosis rate was 3.16 (0.20–49.67) for PICCs vs. tunneled. Conclusions: There is insufficient evidence to show a difference in CRBSI rates between PICCs and tunneled catheters. On the other hand, PICCs showed lower CRBSI rates than ports. There was also no difference in the rate of catheter-related thrombosis and mechanical complications.
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19
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Reitzel RA, Rosenblatt J, Chaftari AM, Raad II. Epidemiology of Infectious and Noninfectious Catheter Complications in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Meta-Analysis. JPEN J Parenter Enteral Nutr 2019; 43:832-851. [PMID: 31172542 DOI: 10.1002/jpen.1609] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 05/03/2019] [Indexed: 12/14/2022]
Abstract
Patients receiving parenteral nutrition (PN) as their primary source of nutrition are at high risk for both infectious and noninfectious catheter complications (catheter-related infections, catheter occlusion, and venous thrombosis). The aim of this review was to synthesize and evaluate what is known about catheter complications and prevention strategies in the PN population. Three electronic databases (Medline, Embase, and CINAHL) were screened for studies published between January 2012 and February 2019 regarding infectious and noninfectious catheter complications in patients receiving PN. Rates of infectious and noninfectious catheter complications, prevalence of causative pathogens, potential risk factors, and prevention strategies via the use of antimicrobial lock therapy (ALT) were assessed. Fifty-three catheter complication studies and 12 ALT studies were included. Studies were grouped by definition of complication: catheter-related bloodstream infections (CRBSI) or central line-associated bloodstream infections (CLABSI). Random effects summary rates per 1000 catheter days were 0.85 CRBSI episodes (95% CI 0.27-2.64) and 1.65 CLABSI episodes (95% CI 1.09-2.48). Use of taurolidine or ethanol ALT was efficacious in reducing infectious catheter complications; however, several studies had concerns for adverse mechanical complications. Potential risk factors for catheter complications were highly varied and often contradictory between studies. The rates of catheter complications were higher among catheterized patients receiving PN compared with nationally reported rates of complications in all catheterized patients. Risk factors for catheter complications need to be better understood for targeted prophylactic use of ALT. Future studies are warranted; however, they should be conducted using more standardized definitions and criteria.
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Affiliation(s)
- Ruth A Reitzel
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joel Rosenblatt
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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20
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Bond A, Teubner A, Taylor M, Willbraham L, Gillespie L, Farrer K, McMahon M, Leahy G, Abraham A, Soop M, Clamp AR, Hasan J, Mitchell C, Jayson GC, Lal S. A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition. J Hum Nutr Diet 2019; 32:492-500. [PMID: 31006921 DOI: 10.1111/jhn.12650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise. METHODS Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach. RESULTS One hundred and twenty-five patients with active malignancy [mean (range) age 58 (25-80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter-related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days. CONCLUSIONS This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.
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Affiliation(s)
- A Bond
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - A Teubner
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - M Taylor
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - L Willbraham
- The Christie NHS Foundation Trust, Manchester, UK
| | - L Gillespie
- The Christie NHS Foundation Trust, Manchester, UK
| | - K Farrer
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - M McMahon
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - G Leahy
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - A Abraham
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - M Soop
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - A R Clamp
- The Christie NHS Foundation Trust, Manchester, UK
| | - J Hasan
- The Christie NHS Foundation Trust, Manchester, UK
| | - C Mitchell
- The Christie NHS Foundation Trust, Manchester, UK
| | - G C Jayson
- The Christie NHS Foundation Trust, Manchester, UK.,The University of Manchester, Manchester, UK
| | - S Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK.,The University of Manchester, Manchester, UK
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21
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Bond A, Chadwick P, Smith TR, Nightingale JMD, Lal S. Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition. Frontline Gastroenterol 2019; 11:48-54. [PMID: 31885840 PMCID: PMC6914297 DOI: 10.1136/flgastro-2018-101094] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 02/04/2023] Open
Abstract
Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is confirmed by qualitative and quantitative blood cultures from the catheter and peripherally. Treatment of inpatients may involve central venous catheter removal and antibiotics for patients needing short-term parenteral nutrition, but catheter salvage is generally recommended for patients needing long-term parenteral nutrition, where appropriate.
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Affiliation(s)
- Ashley Bond
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Paul Chadwick
- Microbiology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Trevor R Smith
- Gastroenterology, University Hospital Southampton NHS Foundation Trusts, Southampton, UK
| | | | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
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22
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Kovacevich DS, Corrigan M, Ross VM, McKeever L, Hall AM, Braunschweig C. American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration. JPEN J Parenter Enteral Nutr 2019; 43:15-31. [PMID: 30339287 DOI: 10.1002/jpen.1455] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 11/07/2022]
Abstract
This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non-English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non-MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline-related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.
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Affiliation(s)
- Debra S Kovacevich
- Home Care Services, Michigan Medicine, University of Michigan School of Nursing and College of Pharmacy, Ann Arbor, Michigan
| | - Mandy Corrigan
- Center for Human Nutrition, Home Nutrition Support & Center for Gut Rehabilitation and Transplant, Cleveland, Ohio
| | - Vicki M Ross
- Nutrition Support Nurse Consultant, Shawnee Mission, Kansas
| | - Liam McKeever
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago Illinois
| | - Amber M Hall
- University of North Carolina Chapel Hill, Raleigh Durham, North Carolina
| | - Carol Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago Illinois
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23
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Bond A, Teubner A, Taylor M, Cawley C, Abraham A, Dibb M, Chadwick P, Soop M, Carlson G, Lal S. Assessing the impact of quality improvement measures on catheter related blood stream infections and catheter salvage: Experience from a national intestinal failure unit. Clin Nutr 2018; 37:2097-2101. [DOI: 10.1016/j.clnu.2017.10.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/21/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
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24
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Obling SR, Wilson BV, Kjeldsen J. Home parenteral support in patients with incurable cancer. Patient characteristics of importance for catheter related complications and overall survival. Clin Nutr ESPEN 2018; 28:88-95. [DOI: 10.1016/j.clnesp.2018.09.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 08/29/2018] [Accepted: 09/24/2018] [Indexed: 02/08/2023]
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25
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Hon K, Bihari S, Holt A, Bersten A, Kulkarni H. Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis. JPEN J Parenter Enteral Nutr 2018; 43:41-53. [PMID: 30035806 DOI: 10.1002/jpen.1421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/05/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other. METHODS An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies. RESULTS Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity. CONCLUSION TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.
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Affiliation(s)
- Kay Hon
- College of Medicine, Flinders University, South Australia, Australia
| | - Shailesh Bihari
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia
| | - Andrew Holt
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia.,South Australia Home Parenteral Nutrition Unit, Flinders Medical Centre, South Australia, Australia
| | - Andrew Bersten
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia
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Abstract
Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.
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Affiliation(s)
- Philip Allan
- Translational Gastroenterology Department, University Hospitals Oxford NHS Foundation Trust, Oxford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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Lorentsen R, Munck LK, Wildt S. Parenteral therapy and complications in patients with intestinal failure in a regional unit. Scand J Gastroenterol 2017; 52:1326-1330. [PMID: 28936879 DOI: 10.1080/00365521.2017.1380840] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe a cohort of patients with intestinal failure (IF) and tunnelled catheters in a regional IF unit, treatment and catheter-related complication rates, and to compare the quality of care with previously published results from specialised IF centres in Denmark. METHODS A retrospective chart review of an adult IF patient cohort receiving parenteral therapy through tunnelled catheters in a regional IF unit from 2005 to 2014. Demographics, indication, type and frequency of parenteral therapy, dwell time, cause of removal and complications were recorded. RESULTS Parenteral therapy was provided to 78 patients with a median age of 64 (25-86) years. Numbers increased from seven patients in 2005 to 40 in 2014. The cause of IF was surgical complications (33%), cancer (28%), inflammatory bowel disease (IBD, 15%) and other causes (24%). The median duration of parenteral therapy was 453 days (range: 16-3651 days). One hundred and forty-two tunnelled catheters were inserted. The incidence of catheter-related blood stream infection (CRBSI) was 1.51/1000 days (95% CI: 1.20-1.90) and the incidence of thrombosis was 0.10/1000 days (0.04-0.25). Seventy-two episodes of CRBSI occurred with 89 microorganisms cultured, the most common being coagulase-negative Staphylococcus (n = 25, 28%). CONCLUSION The rate of CRBSI did not differ from larger centres in Denmark but the rate of thrombotic events was higher than expected. Parenteral therapy can safely and effectively be offered to patients with IF in smaller centres.
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Affiliation(s)
- Ruben Lorentsen
- a Section of Gastroenterology, Medical Department , Zealand University Hospital , Koege , Denmark
| | - Lars Kristian Munck
- a Section of Gastroenterology, Medical Department , Zealand University Hospital , Koege , Denmark.,b Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Signe Wildt
- a Section of Gastroenterology, Medical Department , Zealand University Hospital , Koege , Denmark.,b Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
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Ross VM, Guenter P, Corrigan ML, Kovacevich D, Winkler MF, Resnick HE, Norris TL, Robinson L, Steiger E. Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care. Am J Infect Control 2016; 44:1462-1468. [PMID: 27908433 DOI: 10.1016/j.ajic.2016.06.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients. OBJECTIVE To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014. METHODS Descriptive, χ2, and t tests were used to analyze data from the Sustain registry. RESULTS Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type. CONCLUSIONS Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.
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