Cost-effectiveness of taurolidine locks to prevent recurrent catheter-related blood stream infections in adult patients receiving home parenteral nutrition: a 2-year mirror-image study

Summary

Background & aims

The use of long-term taurolidine locks (LTTL) seems to be effective in preventing catheter-related blood stream infections (CRBSI), especially in patients on home parenteral nutrition (HPN). This work targets the cost-effectiveness of LTTL in a cohort of adult HPN patients.

Methods

A monocentric mirror-image design study was conducted in our referral centre among long-term HPN patients experiencing recurrent CRBSI. From 7th January 2011, LTTL were started after the third CRBSI episode within 12 months. CRBSI data was prospectively collected until 7th January 2013, in the same way as it had retrospectively been done before initiating LTTL. A cost-effective analysis was conducted to estimate the incremental costs and effects on CRBSI with LTTL. The efficacy of LTTL on CRBSI rate was assessed over 1000 days of catheter use.

Results

A total of 31,100 catheter days were analysed in 37 patients (median [interquartile range (IQR)]) aged 58 [42–68] years. The mean ± SD proven CRBSI rate was 3.18 ± 3.51 per 1000 catheter days before the introduction of LTTL and 0.39 ± 1.50 per 1000 catheter days after its introduction (p < 0.0001). Considering both proven and probable CRBSI requiring hospital management, LTTL reduced by (mean [bootstrap CI 95%]) -2.63 [-3.26 to -2.06] infections per patient (from 2.89 [2.31 to 3.49] before to 0.26 [0.13 to 0.41] after) as well as incremental costs by -7 258 [-10 450 to -4 016] € (from 11 176 [8 004 to 14 968] € before to 3 918 [2 390 to 5 445] € after).

Conclusion

Implementing LTTL to prevent recurrent CRBSI is cost-effective by dramatically decreasing their incidence.

Introduction

Catheter-related blood stream infections (CRBSI) are the main complication in patients on long-term home parenteral nutrition (HPN) [1]. According to the systematic review by Dreesen et al., the incidence of CRBSI (where is defined as isolation of the same organism in paired blood cultures from peripheral vein and catheter lumen associated with clinical symptoms) varies from 0.38 to 4.58 episodes per 1000 catheter days in adults and reaches 10.6 in the retrospective Walshe et al. study [2,3]. CRBSI require hospitalisation and treatment with intravenous (IV) antibiotics combined or not with catheter locks; they complicate or limit the venous access and occasionally justify the replacement of the central venous access (CVA). Iterative replacements may lead to suspending HPN and making intestinal transplantation surgery necessary for patients at greater risk of death [4]. HPN patients fear CRBSI because they are aware of the impact on their quality of life [5].

While patient and nurse awareness is an essential aspect of CRBSI prevention, there is currently no consensus about the type and use of CVA locks for prophylaxis or treatment. Transient antibiotic locks should be adequate to salvage the CVA in uncomplicated infections, but this strategy has to be challenged, because of the induced risk of resistance and the limited effect on the biofilm that shelters bacteria [[6], [7], [8]]. Ethanol lock therapy, assessed in various adult cohorts has also been proposed to reduce CRBSI rate, but no licensed and ready-to-use product is available in Europe [[9], [10], [11]]. Currently, the ESPEN does not recommend locking with 70% ethanol because of the risk of systemic toxicity and catheter damage leading to reaspiration which increases the number of catheter manipulations [8].

Among the different types of locks tried, taurolidine, whose efficacy was first shown in hemodialysis, appears to be a promising candidate [8,12]. Taurolidine is an antiseptic agent with bactericidal and fungicidal properties which attacks irreversibly the cell wall of both Gram positive and negative bacteria, as well as fungi via the methylol taurinamide, its hydrolysed form. Thanks to its action mechanism, it could also be effective on biofilm eradication [13]. To date, no resistance has been described with taurolidine [14]. Different studies have shown its efficacy in preventing both CRBSI and their recurrences and in improving catheter salvage [[14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]]. Unfortunately, there is little data about the cost-effectiveness of this strategy.

The aim of this work was to evaluate the cost-effectiveness of long-term taurolidine locks (LTTL) in preventing recurrent CRBSI in a cohort of adult patients receiving HPN.