Central Venous Catheter Infections and Antibiotic Therapy During Long‐Term Home Parenteral Nutrition

Background: Catheter‐related bloodstream infections are a serious and common complication in patients receiving home parenteral nutrition (HPN). Methods: Prevalence of infections, type of agents, and effectiveness of antibiotic therapy were evaluated in 296 patients (133 males, 163 females; mean age 58.2 ± 13.5 years) receiving HPN for at least 3 months, from January 1995 to December 2006. Patients underwent 99,969 (331 ± 552; minimum 91, maximum 4353) days of catheterization, corresponding to 93,236 (311 ± 489; minimum 52, maximum 4353) days of HPN. Results: Fifty‐two patients (24 males and 28 females; 35 oncological and 17 nononcological) were diagnosed with 169 infections. The overall corresponding infection rate was 2.0 per 1000 days of catheterization, with a progressive, regular decrease with time. In 30 cases, immediate central venous catheter removal was necessary. Infections were eradicated in 103 of 139 (74%) cases. As to the most common causative agent, 86 (51%) infections were due to Staphylococcus epidermidis. Of these, 64 were treated from 1995 to 2004, 57 of them (89%) successfully; 22 were treated from 2005 onward, only 7 of them (32%) successfully. Conclusions: Although the global infection rate has progressively decreased over the years, S epidermidis has shown an alarming increase in resistance to antibiotic treatment in the last 2 years, suggesting the need for strategies to prevent central venous catheter infection.     

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.     

Peripherally Inserted Central Catheter for Use in Home Parenteral Nutrition

Background: Peripherally inserted central catheters (PICCs) are a relatively new device for home parenteral nutrition (HPN). Usually, tunneled central catheters such as the Hickman catheter are used for this purpose. However, severe complications (eg, pneumothorax) have been reported in association with the insertion of the central catheter. In contrast, PICCs may offer some advantages due to the peripheral insertion. There are only few studies on the use of PICCs for HPN. Method: A retrospective study (2008–2012) was performed in our Center for Nutrition and Bowel Disease. Patients receiving parenteral nutrition through PICCs were identified, their files examined, and indication, dwell time, cause of removal, and complications recorded. Results: Fifty‐six patients (aged 28–81 years) had a total of 94 lines. Total catheter days were 9859. Mean catheter days per patient were 179.1, and mean dwell time of each line was 104.9 days (longest, 572 days). There were no major complications in relation to the insertion of the catheters. The catheters were removed due to catheter‐related sepsis, mechanical reasons, and thrombotic complications in 1.7, 2.1, and 0.2 per 1000 catheter days, respectively. Conclusion: This study demonstrates that PICCs are appropriate for use in HPN for at least 3–4 months (a period that sometimes unexpectedly becomes long term). The complications equal those reported for tunneled central catheters. We conclude that PICCs are a relevant alternative to patients receiving HPN, especially if they cannot handle a central line. At present, the choice of catheter must be determined on an individual basis.     

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.     

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.     

American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration

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.     

Taurolidine Lock in Home Parenteral Nutrition in Adults

Background and Aim: Many techniques have been tested to reduce the incidence of catheter‐relater bloodstream infections (CRBSIs) during home parenteral nutrition (HPN). One of these methods, taurolidine lock, has shown some potential in several studies, but it has been studied primarily in patients with a relatively high CRBSI rate. Therefore, the aim of this study was to analyze the clinical value of taurolidine in patients receiving HPN who have a low infection rate. Methods: The CRBSI ratio at the Skawina HPN center has remained at 0.3–0.4 episodes/patient/y for the past 7 years. In November 2012, 30 patients (17 men, 13 women, mean age 52.3 years) were randomized to 1 of 3 groups: 2% taurolidine lock (group A), 1.35% taurolidine + citrate lock (B), and control—saline flush (C). Patients were observed for 12 consecutive months for catheter‐related complications. Blood cultures were collected in each case in which an infection was suspected. Results: The total number of catheter days reached 10,968, with the following number of days per group: group A, 3658; group B, 3650; and group C, 3660. No complications were observed in the control group, while patients in the study groups had 1 catheter infection (group A) and 1 occlusion (group B). The CRBSIs were treated successfully with antibiotics. The cost of treatment in groups A and B was significantly higher than that in group C (P < .05). Conclusion: The study did not observe any additional clinical value of taurolidine in patients receiving HPN who have a low infection rate and found low cost‐effectiveness. Taurolidine should most likely be used only in patients with a high CRBSI rate.     

经外周静脉置入中心静脉导管在消化系统肿瘤患者肠外营养中应用及护理进展

随着我国人口老龄化加重,生活水平提高,饮食结构调整,消化系统肿瘤的发病率逐年增高,胃肠手术及化疗变得越来越常见.同时,肠外营养作为肠内营养困难的消化系统肿瘤患者主要营养支持手段,对于患者预后有着重要意义.而目前肠外营养滴注方式主要是以静脉系统输注为主.虽然通过不同静脉入路方式如钢针、留置针、经外周静脉置入中心静脉导管(PICC)、中心静脉置管(CVC)等进行肠外营养各有优劣,但随着越来越多研究表明,PICC在消化系统肿瘤患者肠外营养中应用较其他方式具有并发症少,舒适度高,预后好等优点.文章就经外周静脉置入中心静脉导管在消化系统肿瘤患者肠外营养中应用及护理进展作一综述.     

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.     

Home Parenteral and Enteral Nutrition

While the history of nutrition support dates to the ancient world, modern home parenteral and enteral nutrition (HPEN) has been available since the 1960s. Home enteral nutrition is primarily for patients in whom there is a reduction in oral intake below the amount needed to maintain nutrition or hydration (i.e., oral failure), whereas home parenteral nutrition is used for patients when oral-enteral nutrition is temporarily or permanently impossible or absorption insufficient to maintain nutrition or hydration (i.e., intestinal failure). The development of home delivery of these therapies has revolutionized the field of clinical nutrition. The use of HPEN appears to be increasing on a global scale, and because of this, it is important for healthcare providers to understand all that HPEN entails to provide safe, efficacious, and cost-effective support to the HPEN patient. In this article, we provide a comprehensive review of the indications, patient requirements, monitoring, complications, and overall process of managing these therapies at home. Whereas some of the information in this article may be applicable to the pediatric patient, the focus is on the adult population.     

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.     

Developing and Implementing All-in-One Standard Paediatric Parenteral Nutrition

Parenteral nutrition (PN) is a feeding mode suitable for children that do not achieve requirements via the enteral route. For this intervention to be successful, healthcare professionals require: knowledge on nutrient requirements; access to an aseptic compounding facility; and a system that ensures adequate and safe delivery of PN. Previously, it was thought that individualised PN was the “gold standard” for delivering nutrients to children; however, studies have highlighted concerns regarding inadequate delivery of nutrients, prescribing and compounding errors. We, therefore, set out to develop and implement all-in-one (AIO) paediatric PN solutions. Through a systematic approach, four AIO PN solutions were developed: birth–two months of age (Ped 1); two months–10 kg (Ped 2); 11–15 kg (Ped 3); and 16–30 kg (Ped 4). We implemented them with the help of a teaching pack, over a one month time period, and reviewed usage at six months. At that time, five children initially received standard PN without electrolyte changes; but after a few days, electrolytes needed amendments, and three required individualised PN. A change to AIO PN is feasible and safe; however, some may require electrolyte changes, and there will always be those that will require individualised PN.     

Parenteral Nutrition

This article explores parenteral nutrition (PN) not only as a therapy but also as a system of care, highlighting the potential “evidence gaps” in guidelines for PN use. The importance of interdisciplinary nutrition care, error reporting, and data‐driven practice changes on improving PN therapy is emphasized. Finally, the American Society for Parenteral and Enteral Nutrition's current and future role in advancing the science, practice, and safety of PN is reviewed.