Original articleCost-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
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.
Section snippets
Patients
Patients recruited in the study were all followed by the referral centre for HPN patients at Lille University Hospital and were aged ≥18 years.
Patients included in the study were those receiving LTTL between 1st July 2011 and 1st July 2013, following a monocentric mirror-image design. Data prospectively collected during the LTTL period was compared for each patient to data collected in a similar retrospective period before LTTL (mirror period). Patients with fewer than 60 days’ LTTL were not
Results
Among the 48 patients who received at least one taurolidine lock between July 2011 and July 2013, 11 were excluded: 7 for LTTL use <60 days, 2 for hospital stays longer than home stays and 2 for lack of data as indicated in the flow chart (Fig. 1). Among the 7 patients aged 48.5 ± 13.5 years excluded due to an LTTL duration <60 days (43.7 ± 11.6 days) with newly initiated HPN (HPN duration of 53 ± 27 days), none had suspected or proven CRBSI or hospitalisation during the LTTL period. Two
Discussion
Our study shows LTTL cost-effectiveness to prevent recurrent CRBSI, the incidence of which dramatically decreased in our HPN adult cohort of patients. The 65% cost reduction we observed can be largely accounted for as previous hospitalisation and ambulatory medication costs were superior and not balanced by LTTL incremental cost.
Little published data has concerned infection management and their costs in HPN patients. A retrospective Spanish study including 13 patients reported a lower
Statement of authorship
Damien Lannoy is the guarantor of the article.
Damien Lannoy, Alexia Janes, Xavier Lenne, Sebastien Neuville, Pascal Odou, Amélie Bruandet and David Seguy performed the research.
Damien Lannoy, Alexia Janes and Julien Bourry acquired the data.
Damien Lannoy, Alexia Janes, Xavier Lenne, Pascal Odou, Amélie Bruandet and David Seguy analysed and interpreted the data.
Damien Lannoy, Alexia Janes, Xavier Lenne and David Seguy conceived and designed the research study and wrote the article. Sebastien
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declare that they have no conflict of interest concerning this article.
Acknowledgements
The authors thank Alexandra Tavernier, M.A. (University of Glasgow U.K.), Professeur Agrégée, France, for her assistance in correcting and editing the text.
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