Increase of recurrent central line-associated bloodstream infections in children with home parenteral nutrition in a rehabilitation care facility compared to home.

BACKGROUND AND AIMS: Central line-associated bloodstream infections (CLABSIs) are the main complication in children with home parenteral nutrition (HPN) and some patients develop recurrent CLABSIs (REC-CLABSIs), defined as two or more infections within six months. Our aims were to assess the incidence and to characterize the risk factors of REC-CLABSIs in children with HPN. METHODS: We characterized 79 HPN children from 2014 to 2019 and calculated the incidence of CLABSIs. To minimize the risk of bias related to the exposure time of the septic risk, we paired the patients according to their central venous catheter (CVC) dwell time. After analyzing the whole cohort, a univariate and multivariate unconditional logistic regression was performed on the paired cohort. RESULTS: We included 75 (94.9%) children with a mean age of 7.11 years. The rate of septicemia was 1.55/1000 CVC days, mainly with Staphyloccocus sp. The patients with recurrent CLABSIs (REC group) represented 25% of the cohort, with an incidence of 2.99/1000 CVC days. In the whole cohort, a higher risk of recurrent infections was significantly associated with a longer CVC dwell time (OR = 1.04, IC 95% [1.01-1.06], p = 0.004), and with care located in rehabilitation care facilities (RCF) compared to home (OR = 6, IC 95% [1.5-26.6], p = 0.012). When children were paired according to their CVC dwell time, only in univariate analysis did the care in RCF remain significant (OR = 6.27, IC 95% [1.21-32.5], p = 0.03). CONCLUSIONS: Recurrent CLABSIs incidence was 2.99/1000 CVC days. Our study suggests that preventive measures should be implemented especially in RCFs to reduce the proportion of children with recurrent infections. A multicenter study is needed to confirm our results in a larger cohort with several RCFs.

Combined use of creatinine and cystatin C improves the detection of renal dysfunction in children undergoing home parenteral nutrition.

BACKGROUND: Renal dysfunction can complicate home parenteral nutrition (HPN). The aims were, in the context of pediatric HPN, to assess renal function using the measured glomerular filtration rate (mGFR), determine the most accurate formula(s) to estimate GFR, and identify possible underlying mechanisms of renal impairment. METHODS: A retrospective study was performed in 2 centers. Patients receiving HPN and aged 2-16 years without medical history of nephropathy were included. GFR was measured using iohexol clearance. Estimated GFR (eGFR) was calculated using creatinine, cystatin C-based, and combined (eGFRcr+cyst ) Schwartz formulas. RESULTS: A total of 36 patients (18 females) were included; they received HPN for 8 (2-16) years. The primary digestive disease was short-bowel syndrome for 16 (44%) patients, gastrointestinal motility disorder for 10 (28%), or congenital diarrhea for 10 (28%). The median (range) mGFR was 99 (33-136) ml/min/1.73 m2 ; 9 (25%) patients had mildly decreased mGFR (<90 and ≥60 ml/min/1.73 m2 ), and 2 (6%) had mildly to severely decreased mGFR (<60 ml/min/1.73 m2 ). The eGFRcr+cyst formula was the most accurate and precise to estimate GFR. A significant negative correlation between mGFR and PN duration was found for patients receiving PN for 6-7/7 days (P = .008). Activation of the renin-angiotensin system was identified in 15 of 36 (42%) patients. CONCLUSION: Renal dysfunction was frequent and correlated with the duration of PN only for patients with the most severe intestinal failure. The use of eGFRcr+cyst improves its detection in these patients. Chronic dehydration may be an underlying mechanism.

A prospective case-control pilot study to evaluate bone microarchitecture in children and teenagers on long-term parenteral nutrition using HR-pQCT.

Long-term parenteral nutrition (PN) may induce bone complications. Tridimensional bone imaging techniques such as high-resolution peripheral quantitative computed tomography (HR-pQCT) allow the assessment of both compartmental volumetric densities and microarchitecture. Our aim was to evaluate these parameters in children and teenagers receiving long-term PN. This cross-sectional, case-control study included children older than 9 years undergoing PN for at least 2 years. They were age-, gender- and puberty-matched with healthy controls (1:2). Evaluation included biological assessment of bone metabolism (serum calcium, phosphate, and albumin; urinary calcium and creatinine; 25-OH vitamin D, osteocalcin and PTH), dual X-ray absorptiometry (DXA) and HR-pQCT at the ultradistal tibia and radius. Results are presented as median [range]. Eleven patients (3 girls) with a median age of 16 [9-19] years were included. Bone parameters assessed by HR-pQCT at the ultradistal radius and tibia were similar in patients and controls. Parathyroid hormone (PTH) levels were higher (14 [7-115] vs 16 [12-27]) and osteocalcin levels were lower (44 [15-65] vs 65 [38-142]) in patients than in controls, although within the normal range. Conclusions: there were no differences for compartmental bone densities and microarchitecture in patients undergoing chronic PN. Further longitudinal studies are required to confirm these quite reassuring preliminary results.

Longitudinal Bone Mineralization Assessment in Children Treated With Long-Term Parenteral Nutrition for Severe Intestinal Failure.

BACKGROUND: Metabolic bone disease is common in children receiving home parenteral nutrition (HPN) for intestinal failure (IF). Long-term evolution of bone mass in pediatric IF is poorly documented. The aims of this study were (1) to determine the prevalence of low bone mass (LBM) in children receiving HPN for IF, (2) to evaluate the evolution of total bone mineral content (TBMC) during HPN with dual-energy x-ray absorptiometry (DXA), and (3) to identify related factors. METHODS: All children referred in our HPN center from 2004 to 2014 were eligible. Inclusion criteria were HPN dependence due to noninflammatory IF, at least 2 TBMC assessments, and HPN duration of at least 2 years at last DXA. TBMC was expressed in z score for ideal weight for height (WFH). LBM was defined by a TBMC WFH z score ≤-2 standard deviations (SD). RESULTS: A total of 175 DXAs for 31 children were performed, mean of 5.6 ± 2.9 assessments per child. The median time between first and last DXA recorded was 6.2 years (0.7-16.6). At the first DXA, 14 children (45%) had a LBM. TBMC increased by +0.1 ± 0.04 SD per year of HPN (P = .012). The risk of LBM decreased with an odds ratio of 0.9 per year of HPN (95% confidence interval, 0.92-0.99; P = .018). Lean mass z score and calcium parenteral intakes were related to the TBMC improvement. CONCLUSION: LBM is common in pediatric IF, but bone status could improve during HPN in these children.

Dramatic increase of central venous catheter-related infections associated with a high turnover of the nursing team.

BACKGROUND & AIMS: This retrospective study evaluated the impact of new organization during the moving to a new university pediatric hospital on the incidence of central catheter-related blood stream infections (CRBSIs) among children on long-term parenteral nutrition. METHODS: The study ran from April 2007 to March 2014, starting a year prior to reorganisation of the department of pediatric Hepato-Gastroenterology and Nutrition associated to moving the children to a new hospital in April 2008, and continuing for 6 years following the move. During this time, data from all children hospitalized in this department who received parenteral nutrition (PN) for more than 15 days were analysed. RESULTS: During this 7-years study, 183 children aged 4.6 ± 0.5 years received prolonged PN. Intestinal diseases were the main aetiologies (89%), primarily short bowel syndrome (18.4%), Hirschsprung disease and CIPO (13.5%) and inflammatory bowel disease (13.8%). The mean durations of hospitalization and of PN during hospitalization were, respectively, 70 ± 2.1 and 55.7 ± 3.6 days. During the study period, 151 CRBSIs occurred in 77 children (42% of all patients), i.e. 14.8 septic episodes/1000 PN days and 12.0 septic episodes/1000 CVC days. No patient died of a central venous catheter-related infection. However, following the move from the older hospital to the newer one, the rate of CRBSIs significantly doubled, from 3.9/1000 to 8.8/1000 CVC days (p = 0.02). During the following 4 years, the incidence of CRBSIs tended to increase between the 2nd and the 5th year after the move: 11.3 (p = NS); 21.4 (p = 0.01); 17.3 (p = NS), 20.3/1000 (p = NS) CVC days. We also observed that after evaluations by the Department of Infection Control, nurse training and stabilization of the nursing team, the incidence decreased significantly from 20.3 to 11.1/1000 CVC days during the 6th year after the move (p = 0.01). CONCLUSION: Our results reveal the deleterious impact of the reorganization during the hospital moving on the CRBSI incidence rate, and the possible implication of inexperienced team of nurses.