Antibiotic-lock technique is an effective treatment of bacterial catheter-related sepsis during parenteral nutrition

Catheter-related sepsis is one of the most frequent and troublesome complications of parenteral nutrition. In a 2-year survey of 19 home parenteral nutrition patients, with a total of 25.2 years of cyclic nocturnal parenteral nutrition, the annual incidence of catheter-related sepsis was 1.27, of which 84% were due to bacterial catheter infection without any cutaneous focus. These 27 episodes were treated by a daily, 2 ml injection of antibiotic-saline solution, mainly amikacin, locked for 12 h per day within the infected catheter for 15 (7-20) days. On admission the parenteral nutrition was halted for 2 days and the catheter hub was changed. In 7 cases, an average of 3 days (2-5) of systemic antibiotic therapy was given in addition to the 2-week antibiotic-lock. Control of catheter-sepsis was achieved in 93% of the 27 episodes and parenteral nutrition was resumed using the same catheter with only one episode of recurrent sepsis. The present data confirm our preliminary report of the efficacy of the antibiotic-lock technique for the control of bacterial catheter-related sepsis. This treatment offers the advantage over current therapies of avoiding repeated catheter change and 2-6 weeks of systemic antibiotic therapy.     

Long-term central venous access vs other home therapies: complications in patients with acquired immunodeficiency syndrome.

One hundred and forty silicone catheters were inserted in 127 patients for long-term intravenous access with a cumulative follow-up time of 21,125 catheter-days (58 patient-years). Fifty-six patients had acquired immunodeficiency syndrome (AIDS); 44 were not AIDS patients and were receiving ambulatory home parenteral nutrition, whereas the remaining 27 did not have AIDS and were receiving home antibiotic therapy. Patients had a mean of 1.1 catheters inserted, and the rate of Hickman catheter-related sepsis was 0.18 per 100 catheter days or 0.6 septic episodes per patient year of treatment. Catheter-related sepsis was higher in AIDS patients (p < .01) and in patients receiving parenteral nutrition (p < .05) compared with those receiving antibiotic therapy. Prior catheter infection and AIDS were the most significant predictors of catheter infection (p < .01). Staphylococcus aureus was the most commonly isolated pathogen (61%) in AIDS patients. Fever (p < .001) and relative leukocytosis (p < .02) were the most common signs of infection. Only 14 infected catheters (37.8%) were salvaged by antibiotic therapy after the initial infection episode, and 6 of these catheters (42.9%) had recurrent multiple infections. In addition, inflammatory bowel disease was found to be a risk factor for venous thrombosis (p = .018). We conclude that because immunocompromised patients have a high risk of infection, catheter-related sepsis in these patients should be treated by catheter removal and antibiotics.     

Efficacy of antibiotic-lock technique with teicoplanin in staphylococcus epidermidis catheter-related sepsis during long-term parenteral nutrition

BACKGROUND: The antibiotic-lock technique has been suggested to treat catheter-related sepsis in parenteral nutrition and to avoid catheter removal. METHODS: To determine the incidence of catheter-related sepsis, the bacteria involved, and the efficacy of the antibiotic-lock technique with teicoplanin, all patients (n = 263) undergoing parenteral nutrition from January 1997 to December 1999 in one center, with patients at the hospital (n = 209) and at home (54) were retrospectively studied. The antibiotic-lock technique with teicoplanin was systematically used in all suspected infections and maintained in staphylococcus epidermidis (SE) infections. RESULTS: A total of 21 of 263 patients had 34 infections (0.11/patient per year): 12 of 209 hospitalized and 9 of 54 home patients. A total of 10 of 34 infections were due to non-SE, and the catheter was immediately removed. The other 24 of 34 infections were due to SE; in 5 of 24, the catheter was removed after 48 hours of the antibiotic-lock technique because of persistent fever or thrombosis. A total of 5 of 12 patients had 2 or more infections on the same catheter. The antibiotic-lock technique prevented short-term catheter removal in these cases, but a second infection occurred within a median of 50 days. In 4 of 5 cases, a third infection occurred in a mean delay of 90 days so that the catheter was removed. In 3 of 5 patients, bacteria was analyzed with pulsed field gel electrophoresis, which showed that recurrent infections were due to the same strain in all cases. CONCLUSIONS: In this study, the incidence of catheter-related sepsis was low and mostly related to SE. Our results do not support the use of the teicoplanin antibiotic-lock technique in SE infections.     

Pseudomonas infection of the catheter exit site successfully managed with topical acetic acid

A case of recurrent catheter exit site infection with Pseudomonas aeruginosa is presented in a patient receiving home parenteral nutrition. The past episodes were managed by elective catheter replacement following extrusion of the catheter cuff. We describe the successful use of acetic acid to the exit site which resulted in the eradication of the organism and complete resolution of all signs.     

Pseudomonas infection of the catheter exit site successfully managed with topical acetic acid

A case of recurrent catheter exit site infection with Pseudomonas aeruginosa is presented in a patient receiving home parenteral nutrition. The past episodes were managed by elective catheter replacement following extrusion of the catheter cuff. We describe the successful use of acetic acid to the exit site which resulted in the eradication of the organism and complete resolution of all signs.     

Use of Hickman right atrial catheter in pediatric oncology patients

Eighteen pediatric oncology inpatients had 21 Hickman right atrial catheters placed for total venous access; 16 patients received parenteral nutrition. Mean duration of catheterization was 43 +/- 29 (SD) days. Four catheters had to be removed for infection or clotting. The catheter-related sepsis rate was 10%. Serious catheter-related complications were no more frequent in this population than in patients receiving only parenteral nutrition via Broviac or pediatric Broviac catheters.     

肝肠联合移植术后的代谢调控治疗

目的:探讨代谢调控治疗在肝肠联合移植病人术后的应用.方法:肝肠移植术后第1天开始给予全肠外营养添加谷氨酰胺双肽和精氨酸,术后第4天开始给予肠内营养添加谷氨酰胺和精氨酸,间歇应用生长激素四个疗程.根据肠功能的恢复情况,逐渐由肠外营养向肠内营养过渡.结果:移植器官功能恢复良好,术后30天病人能够较好地耐受肠内营养.结论:应用代谢调控治疗,有利于肝肠联合移植术后移植器官的功能恢复.     

Metabolic derangements in children requiring parenteral nutrition

Intravenous alimentation is routinely used in many hospitalized pediatric patients, however, there are few reports of the nature and frequency of metabolic complications. In order to assess the frequency and nature of metabolic complications all children receiving parenteral nutrition from January 1, 1982 to December 31, 1982 were prospectively enrolled in the study. Data collection began with the institution of parenteral nutrition. Serum electrolytes, minerals, liver function tests, and renal function tests were followed weekly. A total of 201 patients received parenteral nutrition for 5378 days. Nutrition was delivered to 146 patients (4980 patient days) via a central line and 55 patients via a peripheral line (398 patient days). The sepsis rate was 3.7% in central lines used only for parenteral and 4.8% in multipurpose central lines. In general, complications were fewer in the patients supported peripherally. In patients supported centrally, hypoalbuminemia was the most commonly found abnormality followed by hypocalcemia, hypophosphatemia and hypomagnesemia, reflecting a malnourished state. One-third of the patients had abnormal liver function tests, and in half of those factors causing liver dysfunction other than parenteral nutrition were present. Abnormal renal function tests occurred in 10% of the patients. Thus, a high incidence of metabolic complications occurred in association with parenteral nutrition. Most were present during the initiation of parenteral nutrition, suggesting an abnormal metabolic state was present prior to the institution of parenteral nutrition. The frequency of low serum albumin and minerals is consistent with previous publications of the prevalence of malnutrition in hospitalized patients.     

Evidence-based prevention of catheter infection during parenteral nutrition

Parenteral nutrition is a risk factor for catheter-related bloodstream infection. Here we reviewed strategies for the prevention of catheter-related infections, which always must begin with the cornerstone of prevention: the strict adherence to aseptic techniques. Most research has been interested in coated catheters. From these results, it may be concluded that antibiotics or antiseptic-impregnated catheters, like those with minocycline-rifampicin or chlorhexidine/silver sulfadiazine, significantly reduce catheter-related blood stream infections. Antibiotics or antiseptic-impregnated central venous catheters may even result in cost saving in intensive care units. Antiseptic or antibiotic-lock techniques would also be of interest to prevent catheter-related sepsis in high-risk patients who are receiving parenteral nutrition.     

肠内营养与肠外营养对危重症临床疗效的Meta分析

目的:通过Meta分析方法系统评价肠内营养(EN)与肠外营养(PN)对危重症的临床疗效。方法:检索Pub Med、Embase、Springerlink、Medline、中国知网、万方、维普数据库(建库至2016年4月22日),纳入有关肠内营养与肠外营养治疗的随机对照试验(RCT),以总并发症发生率、总感染率、肺炎发生率、尿路感染率、脓毒症及其他感染发病率、死亡率、住院时间等为效应指标,由两名研究者独立对入选文献的质量和研究结果进行摘录,应用Review Manager 5.3进行Meta分析。结果 :Meta分析结果显示,与肠外营养相比,肠内营养显著降低了总感染发生率(OR=0.54,P=0.04)、肺炎发生率(OR=0.65,P=0.04)及脓毒症及其他感染发生率(OR=0.59,P=0.04),两者在总并发症发生率、尿路感染率、死亡率及住院时间均无显著差异。结论 :肠内营养能显著降低危重症病人感染的发生,特别是降低肺炎、脓毒症及相关性炎症反应的发生。     

Managing liver dysfunction in parenteral nutrition

Parenteral nutrition is life saving in patients with intestinal failure but liver dysfunction is commonly encountered, especially in neonates. Although abnormal liver function tests associated with short-term parenteral nutrition are usually benign and transient, liver dysfunction in both children and adults receiving long-term parenteral nutrition can progress to end-stage liver disease and liver failure. The aetiology of parenteral nutrition-associated liver disease is complex and multifactorial, with a range of patient, disease and nutrition-related factors implicated. Sepsis is of particular importance, as is the lack of enteral nutrition and overfeeding with intravenous glucose and/or lipid. Deficiencies of a number of amino acids including choline and taurine have also been implicated. Management of hepatic dysfunction in parenteral nutrition should initially focus on preventing its occurrence. Sepsis should be managed appropriately, enteral nutrition should be encouraged and maximised where possible and parenteral overfeeding should be avoided. Provision of parenteral lipid should be optimised to prevent the adverse effects of both deficiency and excess, and cyclical rather than continuous parenteral feeding should be administered. There is some evidence of benefit in neonates from oral antibiotics to prevent intestinal bacterial overgrowth and from oral ursodeoxycholic acid, but less to support their use in adults. Similarly, data to support widespread use of parenteral choline or taurine supplementation are lacking at present. Ultimately, severe parenteral nutrition-associated liver disease may necessitate referral for small intestine and/or liver transplantation.     

Catheter-related sepsis during home parenteral nutrition

Catheter-related sepsis (CRS) in patients receiving home parenteral nutrition (HPN) is the most frequent complication, with an annual incidence rate of 0.30-0.50 in investigative/approved centres. CRS is responsible for patient deaths in 2.5% of cases which represent 50% of HPN-related deaths. A detailed and strictly applied protocol is the basis of prevention; therefore a low rate of CRS can be used as a marker of quality of care. Skin and hub cultures are used to rule out CRS since their predictive negative value assessed against (semi) quantitative cultures of cannulae were reported to be almost 100%. In the absence of catheter removal, clinical assessment plus quantitative blood cultures with a threshold ratio of 4:1 in central and peripheral blood is a reasonable basis of established CRS. Removal of the infected external cannula is necessary and immediate in cases of tunnel infection, virulent bacteria (e.g. Candida, Staph aureus or pseudomonas species) and for all occurrences of CRS on implantable chambers since conventional treatment fails to sterilise such devices. Thus standard antibiotic treatment may be effective in the absence of tunnel sepsis in the majority of CRS cases due to non-virulent bacteria (mainly Staph coagulase negative species). In these cases of CRS, our experience suggests that the antibiotic-lock technique offers definite advantages over conventional systemic antibiotic treatment, since external catheters were sterilised without recurrent sepsis in more than 85% of cases.     

Differentiating subtypes (hypoalbuminemic vs marasmic) of protein-calorie malnutrition: incidence and clinical significance in a university hospital setting.

Clinical nutrition assessment has identified two types of protein-calorie malnutrition (PCM), a stress-induced hypoalbuminemic form (HAF-PCM) and a marasmic form (MF-PCM) generated by adaptation to starvation. This study evaluated the differences between these two patterns of PCM with regard to precipitating factors and the clinical sequelae of mortality, cost of total parenteral nutrition, length of hospitalization, and rate of sepsis and nosocomial infection. Of 220 patients receiving total parenteral nutrition over a 12-month period (0.7% of 30, 127 admissions), 180 were included in this study. HAF-PCM was diagnosed in 45% and MF-PCM in 25% of study patients. HAF-PCM was more common in older age groups. Women had PCM less often than did men (57% vs 83%), but whereas men developed both forms of PCM equally, women were more likely to develop HAF-PCM. Prolonged mechanical ventilation increased the likelihood of both patterns, whereas the presence of malignancy, concomitant organ failure, trauma, burns, or surgery did not increase the likelihood of developing either pattern of PCM. HAF-PCM increased the length of hospitalization by 29% and the cost of total parenteral nutrition by 42%. The presence of HAF-PCM increased four-fold the odds of dying, and the odds of developing nosocomial infection and sepsis almost 2.5 times above that seen in its absence. MF-PCM had no clinical effect of its own on any of the outcome parameters, but instead exerted only an interactive synergistic effect with HAF-PCM on length of hospitalization and cost of total parenteral nutrition.     

Monoclonal gammopathy associated with Crohn's disease during treatment with total parenteral nutrition

A patient with Crohn's disease developed monoclonal gammopathy while receiving total parenteral nutrition. There was no evidence of worsening of the primary disorder or presence of infection or malignancy.     

Prise en charge à long terme du grêle court : spécificités de l'enfant

Short bowel syndrome is defined as the malabsorptive state that follows massive resection of the small intestine (remaining intestinal length < 80 cm). This definition implies that a significant malabsorption of nutrients, water and electrolytes is present, leading to long-term dependence on parenteral nutrition. The management goals in short bowel syndrome are to maintain growth and development, promote intestinal adaptation, prevent complications, ensure a good quality of life, and establish enteral nutrition. Children treated with long-term parenteral nutrition require the expertise of a multi-disciplinary nutritional care team in order to reach the best balance between the constraints of parenteral nutrition and a normal social and familial lifestyle. All the aspects of the disease (medical, social, educational and psychological) have to be taken into account to achieve weaning from parenteral nutrition. Intestinal transplantation is indicated in patients who are likely to die because of irreversible TPN-induced liver disease (associated with liver transplantation), recurrent sepsis or difficult vascular access.     

Osteomyelitis of the clavicle secondary to infected Hickman catheter

A patient receiving home parenteral nutrition developed osteomyelitis of the clavicle associated with a Hickman catheter which had been functioning for 14 months. The infection was treated with bone curettage, parenteral antibiotics, and catheter removal. Although this has been a reported complication of subclavian vein catheters, this is the first reported case associated with a Hickman catheter.     

Priapism--a complication of home parenteral nutrition?

A case of priapism in a patient receiving home parenteral nutrition is reported. To our knowledge this is the first such case to occur in a patient receiving home parenteral nutrition. The literature is reviewed and the possible aetiology discussed.     

Nutritional Factors Associated with Late-Onset Sepsis in Very Low Birth Weight Newborns

Background: Delayed onset of minimal enteral nutrition compromises the immune response of preterm infants, increasing the risk of colonization and clinical complications (e.g., late-onset sepsis). This study aimed to analyze associations between late-onset sepsis in very low birth weight infants (<1500 g) and days of parenteral nutrition, days to reach full enteral nutrition, and maternal and nutritional factors. Methods: A cross-sectional study was carried out with very low birth weight infants admitted to a neonatal intensive care unit (NICU) of a reference maternity hospital of high-risk deliveries. Data regarding days of parenteral nutrition, days to reach full enteral nutrition, fasting days, extrauterine growth restriction, and NICU length of stay were extracted from online medical records. Late-onset sepsis was diagnosed (clinical or laboratory) after 48 h of life. Chi-squared, Mann–Whitney tests, and binary logistic regression were applied. Results: A total of 97 preterm infants were included. Of those, 75 presented late-onset sepsis with clinical (n = 40) or laboratory (n = 35) diagnosis. Maternal urinary tract infection, prolonged parenteral nutrition (>14 days), and extrauterine growth restriction presented 4.24-fold, 4.86-fold, and 4.90-fold higher chance of late-onset sepsis, respectively. Conclusion: Very low birth weight infants with late-onset sepsis had prolonged parenteral nutrition and took longer to reach full enteral nutrition. They also presented a higher prevalence of extrauterine growth restriction than infants without late-onset sepsis.     

Antibiotic therapy of catheter infections in patients receiving home parenteral nutrition

Fifty-eight episodes of catheter-related sepsis in 21 patients receiving home parenteral nutrition were retrospectively studied. Of 81 organisms isolated from the blood, 59% were Gram-positive cocci, 25% were Gram-negative bacilli, and 16% were yeast. Attempts to treat bacterial infections at home with antibiotic therapy while the catheter remained in place were made; fungal isolation resulted in immediate hospitalization and catheter removal. Gram-negative infections more often resulted in eventual hospitalization (92%) and catheter removal (50%) than Gram-positive infections (57% hospitalization and 23% catheter removal). Empiric therapy with 1 g of cefazolin intravenously every 12 hr was successful in only 33% of episodes caused by coagulase-negative staphylococci, whereas vancomycin was successful in 62%. Sensitivity testing was not a reliable guide for antibiotic choice for treatment of these infections. Cefazolin, 1 g, intravenously every 12 hr was successful in only 25% of Gram-negative episodes treated empirically with this regimen. We conclude that our home parenteral nutrition patients should be hospitalized for a few days upon presentation with a catheter infection for clinical evaluation and aggressive antibiotic therapy. Vancomycin is the preferred drug for treatment of catheter-related infections caused by coagulase-negative staphylococcus.     

Randomized clinical trial of intra-operative antimicrobial prophylaxis of infection after neurosurgical procedures

A randomized, placebo-controlled, double-blind and sequentially analysed clinical trial to determine the efficacy of intra-operative parenteral gentamicin and vancomycin (with streptomycin in the irrigating solution) in preventing infection at the operative site following neurosurgical procedures is described. Patients receiving prophylaxis had a significantly (P = 0.046) lower operative site infection rate (2/71 = 2.8%) than those receiving placebo (9/77 = 11.7%). This difference was most apparent during an epidemic, the source of which was not evident. Moreover, a total of 13 infections (two operative site, five pneumonia and six urinary tract) occurred among 12 patients receiving prophylaxis, whereas there was a total of 31 infections (nine operative site, nine pneumonia, 10 urinary tract and three septicaemia) among 24 patients receiving placebo. A smaller quantity of antimicrobial drugs was administered postoperatively to patients receiving prophylaxis (3.96 'antibiotic-days' per patient) than to those receiving placebo (6.87 'antibiotic-days' per patient).