Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience

doi:10.1016/j.jpedsurg.2011.02.036

Journal of Pediatric Surgery

Volume 46, Issue 5, May 2011, Pages 951-956

https://doi.org/10.1016/j.jpedsurg.2011.02.036 Get rights and content

Abstract

Background

Catheter-related bloodstream infections (CRBSI) cause morbidity and mortality in patients with intestinal failure dependent on parenteral nutrition. Ethanol lock of central venous catheters may decrease CRBSI, but limited pediatric data are available.

Methods

Home parenteral nutrition patients with at least one previous CRBSI were initiated on a 70% ethanol lock protocol for a minimum of 4 hours. Infection rates (per 1000 catheter days) before and after initiation of ethanol locks were compared using a paired t test.

Results

Ten patients (4 girls; median age, 44 months [range, 31-129 months]) began ethanol lock therapy after a total of 91 CRBSIs (37 gram-positive, 30 gram-negative, and 24 fungal) with a mean of 10.2 ± 6.2 per 1000 catheter days. Patients received ethanol lock for an average of 227 ± 64 days with only 3 CRBSI occurring (CRBSI rate of 0.9 ± 1.8 per 1000 catheter days [P = .005]). Central venous catheter replacements decreased from 5.6 per 1000 days to 0.3 per 1000 days posttherapy (P = .038). Ethanol lock was discontinued in 2 of 10 patients because of catheter thrombosis.

Conclusion

Preliminary results demonstrate a significant decrease in CRBSI with a 70% ethanol lock protocol. Catheter thrombosis may be a limitation that needs to be addressed. With such a dramatic therapeutic effect, a randomized trial is feasible and should be performed.

Section snippets

Methods

All pediatric patients with IF and home PN are managed by our multidisciplinary intestinal rehabilitation team, the Group for Improvement of Intestinal Function and Treatment (GIFT) at the Hospital for Sick Children [4]. An ethanol lock protocol for prevention of recurrent CRBSI was initiated June 1, 2009, for home PN patients, and this retrospective cohort study includes follow-up through May 30, 2010. Inclusion criteria for ethanol lock therapy included the following: (1) patients managed by

Results

The GIFT program has managed 149 patients since its inception in November 2002. Typically, our home PN program consists of 20 to 30 patients. Since June 1, 2009, 10 patients met the inclusion criteria for ethanol lock therapy. There were 4 girls and 6 boys with a median age of 44 months (range, 31-129 months) at the start of therapy. Five patients had SBS, 3 from a primary motility disorder, and 2 from mucosal enteropathy (microvillus inclusion disease). The median residual small bowel length

Discussion

Catheter-related bloodstream infections are a major source of morbidity and mortality in pediatric patients with IF dependent on PN [4], [5], [7]. Catheter-related bloodstream infections are an independent predictor of IFALD in the IF population and result in CVC removal and replacement in children with IF who have limited venous access sites [6]. The most common cause of mortality in pediatric SBS is related to IFALD and sepsis [2]. A recent multivariable analysis of SBS neonates managed by

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Cited by (120)

Management of pediatric intestinal failure related to short bowel syndrome
2022, Seminars in Pediatric Surgery
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring.
The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure
2020, Journal of Pediatrics
To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based.
A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges.
Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission.
A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.
Reporting on outcome measures in pediatric chronic intestinal failure: A systematic review
2020, Clinical Nutrition
Chronic intestinal failure (IF) in children is a rare and heterogeneous disease requiring treatment with parenteral nutrition. A uniform definition for chronic IF and standardized outcome measures to compare therapeutic trials in these children are lacking. Therefore, the aim of this study is to systematically assess how definitions and outcome measures are defined in therapeutic trials of children with chronic IF.
MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till August 2018. No language restriction was used.
A total of 1766 articles was found of which 70 studies fulfilled our inclusion criteria. 54 studies (76%) did not report any definition of IF. Of the 16 studies (23%) which reported a definition of IF, 7 different definitions were found. The two most frequently used definitions were: (1) the inability to absorb adequate nutrients to maintain body weight or normal growth and development (n = 5), and (2) the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development (n = 5). A total of 117 different outcomes were reported. The three most reported outcome measures were: mortality (n = 27), liver enzymes (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyl trans peptidase) (n = 27), and growth (n = 23). Quality of reporting was considered fair to poor in most studies.
There is a lack of reported definitions in studies concerning pediatric IF. Heterogeneity exists in outcome reporting in research concerning pediatric chronic IF. Therefore, we recommend the development of a core outcome set.
Intestinal Failure: A Description of the Problem and Recent Therapeutic Advances
2020, Clinics in Perinatology
Comparative efficacy and safety of lock solutions for the prevention of catheter-related complications including infectious and bleeding events in adult haemodialysis patients: a systematic review and network meta-analysis
2020, Clinical Microbiology and Infection
Central venous catheters are used extensively as temporary or permanent vascular access for haemodialysis patients. Catheter-related bloodstream infections are the main complication of central venous catheters and increase morbidity and mortality in haemodialysis patients.
The aim was to assess the most appropriate lock solution for central venous catheters to prevent catheter-related bloodstream infections and other complications.
Medline, Embase and the Cochrane Central Register of Controlled Trials from the date of their inception to August 2018 were used as data sources. The reference lists of eligible studies and relevant reviews were also checked.
Randomized controlled trials (RCTs) comparing different lock solutions for the prevention of central venous catheter-related infectious and bleeding complications for adult dialysis patients were included.
Interventions were lock solutions for haemodialysis catheters.
The primary outcomes were catheter-related bloodstream infections and bleeding events. The secondary outcomes were catheter malfunction, exit-site infection, and all-cause mortality. We estimated summary risk ratios (RRs) using pairwise and network meta-analysis. We assessed the risk of bias of individual studies with the Cochrane risk of bias tool.
Forty-nine trials (7020 patients) were included for this study. Compared with heparin 5000 U/mL, antibiotic locks (antibiotics with trisodium citrate (TSC), ethylenediamine tetraacetic acid (EDTA), heparin 5000 U/mL, low-dose heparin or urokinase) and ethanol locks were more effective in preventing catheter-related bloodstream infections. Antimicrobial agents plus low-dose heparin (500–2500 U/mL), TSC and low-dose heparin locks had lower risk of bleeding events than heparin 5000 U/mL. None of the lock solutions reduced rates of catheter malfunction and all-cause mortality compared with heparin 5000 U/mL. In summary, antibiotics plus low-dose heparin was ranked as the best lock solution. The overall results were not materially changed in sensitivity analyses.
Taking into account both efficacy and safety, antibiotics plus low-dose heparin (500–2500 U/mL) may be the preferred lock solution.
Parenteral Nutrition
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Parenteral nutrition (PN) is the intravenous administration of nutrients necessary for the maintenance of life. The nutrient components of PN include dextrose, amino acids, fat, electrolytes, multivitamins, and trace elements. Clinicians who are caring for infants and children should pay close attention to the changing nutrient requirements with age, specialized needs of children, vascular access, and the sometimes-limited ability of infants, children, and the critically ill to handle large amounts of fluid, protein, fat, and carbohydrates.¹ In the 1960s, Dudrick et al. showed that beagle puppies and, subsequently, an infant could be successfully nourished with the use of PN solutions and central venous access. Since that time, research has promoted substantial advancement in the fields of intravenous access and PN solution components, as well as an improved understanding of the needs of patients with various illnesses to provide individualized care across the spectrum of life. Normal growth and development have been shown in patients exclusively fed by PN.

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^☆: No Conflict of Interest to disclose.

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CAPS papersEthanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience☆

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Infect

J Pediatr Surg

J Pediatr

J Hosp Infect

Arch Oral Biol

Clin Nutr

J Vasc Interv Radiol

J Vasc Interv Radiol

J Pediatr Surg

Collaborative strategies to reduce mortality and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation

Transplantation

Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation

Pediatr Transplant

10-year review of pediatric intestinal failure: clinical factors associated with outcome

Nutr Clin Pract

CAPS papers
Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience☆