Environmental Risk Factors for Developing Catheter‐Related Bloodstream Infection in Home Parenteral Nutrition Patients

Background: Tunneled, cuffed, central venous catheters, including Hickman catheters and peripherally inserted central venous catheters (PICCs), are the most commonly used venous access for home parenteral nutrition (HPN) therapy. Catheter‐related bloodstream infection is the most prevalent and severe complication. This study investigated whether environmental risk factors, including smoking, catheter management by a home care nurse, colectomy with stoma, number of infusion days per week, and C‐reactive protein at catheter insertion day, influenced the time to first catheter‐related bloodstream infection (CRBSI). Materials and Methods: In this 6‐year (2008–2014) observational cohort study, adult patients with intestinal failure receiving HPN through either Hickman catheters or PICCs were included. Data were obtained by reviewing medical records, and the environmental risk factors were analyzed with the Cox proportional hazards model. Results: A total of 295 catheters (Hickman catheters: n = 169 and PICCs: n = 126) inserted into 136 patients were registered. Using the PICCs, 1 additional infusion day per week showed to significantly decrease the time to first CRBSI by a factor of 2.47. Hickman catheters managed by a home care nurse had a significantly increased mean (SD) incidence of CRBSI of 1.45 (0.68) per 1000 catheter days. Hickman catheters not managed by a home care nurse had a mean (SD) incidence of 0.56 (0.24). Conclusion: Using the PICC, 1 additional infusion day per week decreased the time to first CRBSI, while having the Hickman catheter managed by a home care nurse increased the mean CRBSI incidence. No other risk factors were found.     

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter‐Related Bloodstream Infections

Background: Catheter‐related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. Materials and Methods: All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. Results: In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase‐negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life‐threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). Conclusions: This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.     

Catheter Salvage After Catheter‐Related Bloodstream Infection During Home Parenteral Nutrition

Background: Catheter‐related bloodstream infection (CRBSI) is a common complication in patients receiving home parenteral nutrition (HPN). Data regarding catheter salvage after a CRBSI episode are limited. We aimed to determine the incidence of CRBSI and rates of catheter salvage in adult patients receiving HPN. Materials and Methods: We retrospectively searched our prospectively maintained HPN database for the records of all adult patients receiving HPN from January 1, 1990, to December 31, 2013, at our tertiary referral center. Data abstracted from the medical records included demographics, diseases, treatments, and outcomes. The incidence of CRBSI and rates of catheter salvage were determined. Results: Of 1040 patients identified, 620 (59.6%) were men. The median total duration on HPN was 124.5 days (interquartile range, 49.0–345.5 days). Mean (SD) age at HPN initiation was 53.3 (15.3) years. During the study period, 465 CRBSIs developed in 187 patients (18%). The rate of CRBSI was 0.64/1000 catheter days. Overall, 70% of catheters were salvaged (retained despite CRBSI) during the study period: 78% of infections with coagulase‐negative staphylococci, 87% with methicillin‐sensitive Staphylococcus aureus, and 27% with methicillin‐resistant S aureus. The percentage of catheters salvaged was 63% from 1990 to 1994, 63% from 1995 to 1999, 61% from 2000 to 2004, 72% from 2005 to 2009, and 76% from 2010 to 2013. Conclusion: Catheter salvage is possible after a CRBSI episode. Since most episodes of CRBSI are caused by skin commensals, effective treatment without removal of the central venous catheter is possible in most cases.     

Management of Recurrent Catheter‐Related Bloodstream Infections in an Adult Patient Receiving Home Parenteral Nutrition: Dramatic Effect of Ethanol Lock Therapy

We report the use of ethanol lock therapy to dramatically reduce the incidence of catheter‐related bloodstream infections (CRBSIs) in a long‐term adult home parenteral nutrition (HPN) patient. This case study demonstrates the efficacy of ethanol lock therapy in eliminating CRBSIs when other treatments have been unsuccessful. We suggest that ethanol lock therapy has an important role in decreasing CRBSI in HPN patients with recurrent CRBSIs.     

Prevention of Subsequent Catheter‐Related Bloodstream Infection Using Catheter Locks in High‐Risk Patients Receiving Home Parenteral Nutrition

Introduction:Catheter‐related bloodstream infection (CRBSI) is a serious complication in patients receiving home parenteral nutrition (HPN). Antibiotic lock therapy (ALT) and ethanol lock therapy (ELT) can be used to prevent CRBSI episodes in high‐risk patients. Methods: Following institutional review board approval, all patients enrolled in the Mayo Clinic HPN program from January 1, 2006, to December 31, 2013, with catheter locking were eligible to be included. Patients without research authorization and <18 years old at the initiation of HPN were excluded. Total number of infections before and after ALT or ELT were estimated in all patients. Results: A total of 63 patients were enrolled during the study period. Of 59 eligible patients, 29 (49%) were female, and 30 (51%) were male. The median duration of HPN was 3.66 (interquartile range, 0.75–8.19) years. The mean age ± SD at initiation of HPN was 49.89 ± 14.07 years. A total of 51 patients were instilled with ALT, and 8 patients were instilled with ELT during their course of HPN. A total of 313 CRBSI episodes occurred in these patients, 264 before locking and 49 after locking (P < .001). Rate of infection per 1000 catheter days was 10.97 ± 25.92 before locking and 1.09 ± 2.53 after locking (P < .001). Discussion: The major findings of the present study reveal that ALT or ELT can reduce the overall rate of infections per 1000 catheter days. ALT or ELT can be used in appropriate clinical setting for patients receiving HPN.     

Catheter‐Related Complications in Cancer Patients on Home Parenteral Nutrition

Background: Although home parenteral nutrition (HPN) is often indicated in cancer patients, many physicians are concerned about the risks potentially associated with the use of central venous access devices (VADs) in these patients. The aim of this prospective study was to investigate the actual incidence of VAD‐related complications in cancer patients on HPN. Methods: All adult cancer patient candidates for VAD insertion and HPN were enrolled. The incidence of complications associated with 4 types of VADs (peripherally inserted central catheter [PICC], Hohn catheter, tunneled Groshong catheter, and port) was investigated, as well as the most significant risk factors. Results: Two hundred eighty‐nine VADs in 254 patients were studied, for a total of 51,308 catheter‐days. The incidence of catheter‐related bloodstream infections (CRBSIs) was low (0.35/1000 catheter‐days), particularly for PICCs (0/1000; P < .01 vs Hohn and tunneled catheters) and for ports (0.19/1000; P < .01 vs Hohn and P < .05 vs tunneled catheters). Mechanical complications were uncommon (0.8/1000), as was VAD‐related venous thrombosis (0.06/1000). Ultrasound‐guided venipuncture was associated with a decreased risk of CRBSI (P < .04) and thrombosis (P < .001). VAD securement using sutureless devices reduced the risk of CRBSI and dislocation (P < .001). Hohn catheters had no advantage over PICCs (higher complication rate and shorter dwell time; P < .001). Conclusions: In cancer patients, HPN can be safely carried out with a low incidence of complications. Also, VADs are not equal in terms of complication rates, and strict adherence to meticulous insertion policies may effectively reduce catheter‐related complications.     

Catheter‐Related Bloodstream Infections in Adults Receiving Home Parenteral Nutrition: Substantial Differences in Incidence Comparing a Strict Microbiological to a Clinically Based Diagnosis

Background: A common complication in patients receiving home parenteral nutrition (HPN) is catheter‐related bloodstream infections (CRBSIs). The CRBSI incidence has been advocated as an outcome parameter assessing the quality of care. This study aimed to illustrate how the use of different CRBSI definitions affects the reported incidence. Materials and Methods: In an observational study based on the Copenhagen intestinal failure database, all clinically reported CRBSIs from 2002–2013 were compared with data from the affiliated microbiological database according to recommended CRBSI criteria. Results: Clinically, 1034 CRBSIs were observed in 548 adults receiving HPN for 1410 catheter‐years. Thus, the clinically assessed CRBSI incidence was 1.95/1000 catheter‐days. However, based on the microbiological evaluation, only 47% of our episodes fulfilled the Centers for Disease Control and Prevention (CDC) and European Society for Clinical Nutrition (ESPEN) CRBSI criteria. Employing a catheter‐salvaging strategy, 40% of the CRBSI diagnoses were supported by the paired blood culture positivity criteria and only 6% by a positive catheter tip. In 53%, CRBSIs were categorized as a clinical or “probable CRBSI” diagnosis. In 20% of all episodes, missing information/blood cultures hampered a CDC/ESPEN CRBSI diagnosis. Thereby, according to CDC/ESPEN CRBSI definitions, the incidence was 0.92/1000 days or 46% lower than clinically assessed. Conclusion: This study illustrates the practical and methodological challenges and great variability in reporting of the CRBSI incidence. Nonetheless, it is recommended as a marker of the quality of care. Consensus regarding CRBSI definitions is a prerequisite for a meaningful comparison of this important outcome parameter between HPN centers.     

Catheter‐Related Complications in Children With Cancer Receiving Parenteral Nutrition: Change in Risk Is Moderated by Catheter Type

Background: Although central venous catheters (CVCs) are essential to pediatric cancer care, complications are common (eg, occlusion, central line–associated bloodstream infection [CLABSI]). Parenteral nutrition (PN) and external CVCs are associated with an increased complication risk, but their interaction is unknown. Methods: A retrospective matched cohort study of pediatric oncology patients who received PN through subcutaneous ports or external CVCs. Complication rates were compared between CVC types during PN and non‐PN periods (log‐negative binomial model). Results: Risk of CLABSI was higher during PN for children with ports (relative risk [RR] = 39.6; 95% confidence interval, 5.0–309) or external CVCs (RR = 2.9; 95% confidence interval, 1.1–7.4). This increased risk during PN was greater for ports than for external CVCs (ratio of relative risks = 13.6). Occlusion risk was higher during PN in both groups (RR = 10.0 for ports; RR = 2.0 for external CVCs), and the increase was significantly greater in ports (ratio of relative risks, 4.9). Overall, complication rates for ports were much lower than for external CVCs during the non‐PN period but similar during the PN period. Conclusion: Children with cancer who receive PN have increased risk of CLABSI and occlusion. The risk increase is greatest in children with ports: a 40‐ and 10‐fold increase in infection risk and occlusion, respectively, resulting in similar complication rates during PN regardless of CVC type and negating the usual benefits of ports. Children with cancer who will require PN should have primary insertion of external CVCs where possible.     

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter‐Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center

Background/Aims: Catheter‐related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk. Methods: All patients with IF discharged with HPN from 1970–2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days. Results: The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter‐related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter‐related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018). Conclusion: Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.     

Epidemiology and Risk Factors for Bloodstream Infections in a Home Parenteral Nutrition Program

Background: An increasing number of patients with intestinal failure are receiving home parenteral nutrition (HPN). Associated complications include bloodstream infections (BSIs), but data on rates and risk factors for HPN‐related BSIs are scarce. Methods: A retrospective review was conducted of patients enrolled in the regional HPN program between 2001 and 2008. Demographic information and data on indication for HPN, duration of PN therapy, type and date of insertion of central venous access device, and blood culture results were recorded. Results: In total, 155 patients (165 courses of HPN) were included for a total of 45,876 catheter days. The mean patient age was 49 years, and 105 (64%) patients were female. A total of 105 organisms were cultured from 93 distinct episodes of BSIs. The rate of BSI was found to be 2.0 per 1000 catheter days, but excluding BSIs with a single positive culture of coagulase‐negative staphylococcus and diphtheroid bacilli, the rate of infection was 1.4 per 1000 catheter days. Male sex and underlying malignancy were significant predictors of BSI, with hazard ratios of 1.69 (95% confidence interval [CI], 1.14–2.60; P = .009) and 2.38 (95% CI, 1.53–3.50; P < .001). Conclusion: In a large heterogeneous group of HPN patients, the BSI rate ranged between 1.4 and 2.0 infections per 1000 catheter days. Isolated organisms were similar to those found in hospitalized patients. Male sex and underlying malignancy were significant risk factors for BSI. These high‐risk patients are likely to benefit from interventions aimed at reducing BSIs.     

Epidemiology of Infectious and Noninfectious Catheter Complications in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Meta‐Analysis

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.     

A Descriptive Study of the Risk Factors Associated With Catheter‐Related Bloodstream Infections in the Home Parenteral Nutrition Population

Background: Home parenteral nutrition (HPN) is increasingly used for nutrition support after patients are discharged from the hospital. Catheter‐related bloodstream infections (CR‐BSI) are a common and potentially fatal complication of HPN. The risk factors for development of CR‐BSI in the outpatient setting are poorly understood. Methods: We conducted an observational, retrospective study of 225 patients discharged from Barnes‐Jewish Hospital on HPN between January 1, 2007, and December 31, 2009. HPN complications were defined as any cause that led to either premature discontinuation of HPN therapy or catheter replacement. CR‐BSI events were identified by provider documentation. We calculated the overall complication rate and the complication rate specifically due to CR‐BSI. Backward stepwise Cox regression analyses were used to assess for independent predictors of catheter‐related complications. Results: In total, 111 of 225 patients (49%) developed complications while receiving HPN (incidence = 5.06 episodes/1000 catheter days). Sixty‐eight of 225 patients (30%) required catheter removal for CR‐BSI (incidence = 3.10 episodes/1000 catheter days). Independent predictors of line removal specifically due to infection included anticoagulant use, ulcer or open wound, and Medicare or Medicaid insurance. The following risk factors were associated with catheter‐associated complications and/or CR‐BSI: the presence of ulcers, the use of systemic anticoagulants, public insurance (Medicare or Medicaid), and patient age. Independent predictors of line removal for any complication included age and anticoagulant use. Conclusion: Catheter‐related complications were extremely common in patients receiving HPN. Healthcare providers caring for individuals who require HPN should be aware of risk factors for complications.     

Role of Peripherally Inserted Central Catheters in Home Parenteral Nutrition

Background: Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVCs) being preferred for its administration. Peripherally inserted central catheters (PICCs) are not currently recommended for long‐term HPN, although evidence to support this statement is scarce. The authors aimed to evaluate the outcomes of HPN, focusing on CVC‐related complications. Materials and Methods: All patients attended at the authors’ center for HPN from 2007–2011 were prospectively included. HPN composition aimed at 20–35 kcal/kg/d, 3–6 g/kg/d of glucose, 1.0 g/kg/d of amino acids, and <1 g/kg/d of lipids. HPN was infused in an intermittent schedule, mostly at night. Catheter‐related bloodstream infections (CRBSIs) were confirmed with positive semi‐quantitative or quantitative culture of the catheter or simultaneous differential blood cultures drawn through the CVC and peripheral vein. Results: Seventy‐two patients received HPN, with 79 implanted CVCs (48 PICCs, 10 Hickman, and 21 ports). Mean catheter‐days were 129.1 for PICCs, 98.5 for Hickman, and 67.7 for ports (P = .685). When analyzing CRBSIs, ports had 44, Hickman had 20, and PICC had 0 episodes per 1000 catheter‐days (P = .078). Only PICCs showed less incidence of CRBSIs vs ports (P = .043). Multivariate logistic regression, correcting by catheter‐days, patients’ age and sex, underlying disease, and type of catheter, showed that only catheter‐days (P = .031) was a predictor for CRBSIs (P = .007, Nagelkerke R= = 0.246). Conclusion: PICCs are similar in terms of catheter‐related complications to other CVCs for the administration of HPN, especially for oncology patients with HPN lasting <6 months.     

Outcome Indicators for Home Parenteral Nutrition Care

Background and Aims: Patients receiving home parenteral nutrition (HPN) deserve a high‐quality and patient‐centered care. Patient‐centered care can be delivered only if the patient's priorities and concerns are known. Therefore, the aim is to identify the top 3 most important outcome indicators according to patients' perspectives and the differences between several centers, HPN regimen, and HPN experience. Methods: A questionnaire, based on previously developed outcome indicators, was translated into the mother tongue using forward‐backward translation and distributed to adult HPN patients with benign disease in March 2013. To identify differences, a Kruskal‐Wallis or Mann‐Whitney test was performed with GraphPad Prism (significance level <.05) when applicable. Results: Nine centers over 8 countries (300 patients) participated. The top 3 outcome indicators for patients were (1) incidence of catheter‐related infection (CRI), (2) survival, and (3) quality of life (QoL). Between the participating centers, significant differences on rating were found for 5 outcome indicators (catheter obstruction, .015; weight, .002; energy, .010; fear, <.001; and independence, .010). The independence outcome indicator (.050) was considered less important for experienced (>2 years HPN) vs less experienced patients. For this outcome indicator, patients' view also differed significantly based on number of HPN days per week (.0103). Conclusion: A cohort of HPN patients identified incidence of CRI, survival, and QoL as the most important outcome indicators for their care; however, there were significant differences between the participating centers. For one outcome indicator (independence), there were significant differences based on experience and regimen.