Risk Factors for the Development of Catheter‐Related Bloodstream Infections in Patients Receiving Home Parenteral Nutrition

Background: Risk factors for development of catheter‐related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). Methods: Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006‐December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. Results: In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non‐PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone‐iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine‐containing regimens. Conclusion: Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

Expediting Transition to Home Parenteral Nutrition With Fast‐Track Cycling

Background. Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long‐term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN‐related AEs. Methods. Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1‐step “fast‐track” protocol or 2‐step “standard” protocol. AEs were defined as hypoglycemia or hyperglycemia, new‐onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. Results. In the 63 patients studied, the most prevalent PN‐related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast‐track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN‐related minor AEs between fast‐track and standard groups (33.3% and 53.3%, P = .5). No major PN‐related AEs occurred in the fast‐track group, while 1 major PN‐related AE (pulmonary edema) occurred in the standard group. Conclusions. Fast‐track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long‐term PN. Fast‐track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.     

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.     

The Association Between Home Parenteral Nutrition and Patients With FAP‐Associated Intra‐Abdominal Desmoids

Background: Intra‐abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life‐saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP‐IADTs. Methods: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP‐IADTs and 6‐month follow up at CC. Exclusion criteria were <6‐month follow‐up, lack of 3‐dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan‐Meier curves were analyzed for HPN and non‐HPN groups. Results: One hundred fifty‐four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non‐HPN (n = 113, 73.4%). The HPN group was more likely to have advanced‐stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5‐year survival HPN = 72% vs non‐HPN = 95%), but duration of HPN did not affect mortality. Conclusion: HPN, although a life‐saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.     

Influence of Age and Type of Underlying Disease on Complications Related to Home Enteral Nutrition

Background: No data about the influence of age and underlying diseases on home enteral nutrition (HEN)–related complications are reported in the literature. Herein, we retrospectively investigated this issue by analyzing HEN‐related complications in a cohort of consecutive patients grouped according to the underlying disease and age. Material and Methods: We reviewed the medical records of 101 patients referring to our team in 2007–2010 to obtain patients’ demographic data, age, nutrition status, duration of HEN treatment, and type of HEN‐related complications. They were divided in cancer and neurologic patients and subgrouped on the basis of their age. HEN‐related complications were expressed as complication rates. Results: Patients with neurological diseases suffered a significantly higher number of complications as compared with cancer patients (P = .04). Age did not significantly influence complication rates. The mechanical complications were the most frequent. The majority of HEN‐related complications were resolved at home. Conclusion: Our data strongly suggest that HEN‐related complications are influenced by underlying diseases and not by age. In neurologic patients, dementia, loss of autonomy, and the different therapies administered by PEG probably play an important role in increasing the number of HEN‐related complications as compared with cancer patients. The most frequent complications can be managed at home, reducing the costs of hospitalizations and discomfort for the patient.     

Home Parenteral Nutrition Tutorial

The nutrition support practitioner may be called upon to help coordinate care at home for a patient who requires prolonged intravenous nutrition after he or she becomes stable enough to leave the hospital. This tutorial reviews the many concepts that must be considered to manage this type of care successfully.     

Anemia and Leukopenia in a Long‐Term Parenteral Nutrition Patient During a Shortage of Parenteral Trace Element Products in the United States

Recently, drug shortages in the United States have affected multiple components of the parenteral nutrition (PN) solution. A 62‐year‐old patient with systemic sclerosis who was dependent on home PN due to intestinal dysmotility developed anemia and leukopenia approximately 4 months after parenteral copper was withheld from her PN solution due to drug shortages. The patient was not able to tolerate a sufficient amount of oral multivitamins with trace elements due to severe dysphagia. Her serum copper and ceruloplasmin concentrations were undetectable, confirming the diagnosis of severe copper deficiency. The hematological abnormalities promptly resolved with copper supplementation. This report emphasizes the importance of close monitoring for nutrient deficiencies during drug shortages and supplementing with oral or enteral nutrition when feasible, particularly in high‐risk patients such as those with intestinal malabsorption or short bowel syndrome who are dependent on long‐term PN.     

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.