Debra S. Kovacevich

Ethanol-Lock Therapy for the Prevention of Central Venous Access Device Infections in Pediatric Patients With Intestinal Failure

BACKGROUND Central venous access device (CVAD) infections are a major complication in pediatric patients receiving long-term parenteral nutrition (PN) and are particularly prevalent in patients with intestinal failure. This study evaluated the outcomes of outpatient ethanol-lock therapy (ELT) for the prevention of CVAD infections in children with intestinal failure. METHODS In this retrospective analysis, the primary outcome measure was the rate of bloodstream infection (BSI) due to CVAD infections per 1,000 catheter days, and secondary measures included type of organisms cultured and complications of ELT. RESULTS Over the course of 2 years, 15 patients received outpatient ELT. Sixty-seven percent were male; patients had a mean ± standard deviation age at enrollment of 5.6 ± 6.9 years and body weight of 19.9 ± 15.4 kg. Mean duration of ELT was 263 ± 190 days. Mean BSI rate per 1,000 catheter days significantly decreased from 8.0 before ELT to 1.3 after ELT (P < .01). Seventy-three percent of patients remained infection free throughout the entire study period. Adverse events potentially related to ELT included thrombosis (n = 1), difficulty withdrawing blood from the CVAD, requiring thrombolytic administration (n = 3), and repair of the CVAD for leakage/tear (n = 20). The rate of CVAD repair for leakage/tear with ELT was compared to prior rates per 1,000 catheter days and was found to be elevated after initiation of ELT (6.4 ± 10.0 vs 3.1 ± 5.2; P = .20). No signs and symptoms of ethanol intoxication were observed. CONCLUSIONS ELT for the prevention of CVAD infections in pediatric intestinal failure patients significantly decreased BSI rates and may be used for extended periods of time in an outpatient setting.

Association of parenteral nutrition catheter sepsis with urinary tract infections

The infection rate (IR) of central venous catheters (CVCs) used for parenteral nutrition (PN) was prospectively evaluated over a 12-month period, with emphasis on the relationship between CVC sepsis and preexisting sites of infection. Sepsis was presumed if the CVC tip or blood culture was positive, or if defervescence followed CVC removal. Four hundred seventy-three CVCs were placed for PN for a total of 5,422 patient days, with a mean length of stay of 11.5 days. Twenty two CVCs led to sepsis for an IR of 4.65% or 4.06 infections per 1000 patient days. Twenty of the 22 septic CVCs were in patients with other sites of infection. The IR was 12.0% (20/166) when other sites of infection were present and 0.65% (2/307) in the absence of a second site. The mean length of stay was 13.2 days for CVCs with other sites of infection and 10.3 days for CVCs with no other site of infection. Fifty nine percent of septic CVCs had secondary sites of infection that included urinary tract infections (UTI). Of all septic CVCs, 22.7% had no site of infection other than UTI. The presence of UTI appears to present a high risk of CVC sepsis. Appropriate identification and treatment of UTI prior to CVC insertion is recommended.

The effects of needleless connectors on catheter-related bloodstream infections

Needleless connectors, including the standard split septum and the luer-activated mechanical valve connectors, have been introduced into clinical practice to eliminate the risk of needlestick injuries by avoiding the use of needles when accessing the intravascular catheters. Negative and positive displacement mechanical valves have been associated with increased rates of catheter-related bloodstream infections as compared with split septum connectors. Based on available data, split septum connectors should be preferentially used instead of mechanical valves. Adequate disinfection by scrubbing the access port preferably with chlorhexidine is recommended to minimize the risk of catheter microbial contamination along with proper infection control practices. Large prospective randomized clinical trials are needed to evaluate further the possible causes and effects of different types of mechanical valve needleless connectors on bloodstream infections.

A.S.P.E.N. Standards for Nutrition Support Home and Alternate Site Care

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, nurse practitioners, physician assistants, other allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality nutrition care. A.S.P.E.N.s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. These combined Standards for Nutrition Support: Home Care and Alternate Site Care are an update of the 2005 and 2006 standards.

The effects of needleless connectors on catheter-related thrombotic occlusions

Needleless connectors have been introduced into clinical practice to prevent accidental needlestick injuries and associated bloodborne infections. Needleless connectors include the split-septum devices and the mechanical valves that are classified as neutral-, negative-, and positive-displacement types on the basis of their internal membrane or valve function. Some studies have reported that mechanical valves, especially positive-displacement valves, may decrease thrombotic catheter occlusions based on their valve function that prevents blood reflux into the intravascular catheter. This article describes the types of needleless connectors and reviews the evidence related to their effects on thrombotic catheter occlusions.

Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care

BACKGROUND Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutritions National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients. OBJECTIVE To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014. METHODS Descriptive, χ2, and t tests were used to analyze data from the Sustain registry. RESULTS Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type. CONCLUSIONS Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.

Guidelines for the prevention of intravascular catheter-related infections: Centers for Disease Control and Prevention.

MMWR 51:1–30, 2002 Debra S. Kovacevich, RN, MPH*; and Lorelei F. Papke, RN, MSN, CRNI† *Department of Home Care Services, College of Pharmacy, and †Vascular Access Service, Department of Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor Since 1983, the Centers for Disease Control and Prevention have been providing healthcare practitioners with guidelines based on evidence for the prevention of catheter-related infection. This latest report was developed by a working group representing various organizations and disciplines from the fields of infection control, critical care medicine, infectious disease, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. As per the previous guidelines published in 1983 and 1996, each recommendation is categorized based on existing scientific data, theoretical rationale, applicability, and economic impact. The categories are listed as follows: Category IA—strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies; Category IB—strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies, and a strong theoretical rationale; Category IC—required by state or federal regulations, rules, or standards; Category II—suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale; and Unresolved Issue—an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. In the past, the guidelines were intended for use in hospitals and acute care with the recommendation of adapting them for use in home care and outpatient areas. They are now recommended to be used across the health continuum. Overall, the guidelines are much easier to read. The working group placed catheter types into their respective categories instead of listing them separately. For instance, peripheral venous catheter recommendations incorporate midline catheter information, and central venous catheter recommendations include peripherally inserted central catheters (PICC), hemodialysis, and pulmonary artery catheters. The paper also has two appendices for reference purposes. One contains examples of clinical and surveillance definitions for primary bloodstream infection (BSI), and the second is a summary of the recommended frequency for the replacement of catheters, dressings, administration sets, and fluids. There are major areas that have been included into the paper. These include the following: (1) suggestions for performance indicators that organizations can monitor to reduce the incidence of catheter-related bloodstream infection (Category IA); (2) the use of maximal sterile barrier precautions inclusive of mask, cap, sterile gown, sterile gloves, and large sterile sheet for the insertion and guidewire changes of central venous catheters (CVCs), including PICCs (Category IA); (3) preference of a 2% chlorhexidinebased preparation for insertion and catheter site care, although tincture of iodine and iodophor or 70% alcohol may be used (Category IA); (4) the use of antimicrobialor antiseptic-impregnated catheters should be used in adults whose catheters are to remain in place for 5 days if the institution’s BSI rate is greater than benchmark rates and if other infection control measures have failed (Category IB); (5) central catheters and midline catheters should not be routinely replaced to decrease the risk of infection (Category IB); and (6) the importance of educational programs and competency testing for clinicians responsible for the insertion and care of venous catheters (Category IA). Evidence-based documentation in refereed journals and clinical competencies has demonstrated that specially trained personnel decrease the potential for catheter-related bloodstream infections (CRBSI). In the guidelines there is a lengthy discussion concerning the morbidity and mortality of patients requiring central venous access and the substantial financial burden CRBSI places on the healthcare system. Numerous studies have demonCorrespondence: Debra S. Kovacevich, RN, MPH, University of Michigan, Homemed, 2850 S. Industrial Hwy Ste 50, Ann Arbor, MI 48104-9821. Electronic mail may be sent to debbiek@ umich.edu.

American Society for Parenteral and Enteral Nutrition Guidelines for the Selection and Care of Central Venous Access Devices for Adult Home Parenteral Nutrition Administration

This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non-English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non-MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline-related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.