High Parenteral Support Volume Is Associated With Reduced Quality of Life Determined by the Short-Bowel Syndrome Quality of Life Scale in Nonmalignant Intestinal Failure Patients.

BACKGROUND: Aim was to investigate the association between quality of life (QoL), bowel anatomy, and the need for home parenteral support (HPS) volume in patients with nonmalignant short-bowel syndrome (SBS) and intestinal failure (IF). METHODS: The SBS-QoL scale was used in a cross-sectional study of 95 nonmalignant SBS-IF patients. Sum QoL scores (0: best, 170: worst) were calculated. Patients were defined as having a small bowel (≤200 cm), and patients with jejunostomy or ileostomy were subclassified based on functional small-bowel length (cm) into 4 anatomy subgroups: 1a-1d (0-49, 50-99, 100-149, 150-200 cm, respectively). Multiple linear regression analyses explored associations between QoL, patient groups, and HPS volume, adjusting for age, sex, body mass index, and education. RESULTS: Complete data were obtained from 60 patients. HPS volume was associated with a worse SBS-QoL score (L/d, ß = 7.91; SE = 3.90; P = .048), but male sex associated with improvement (ß = -26.28; SE = 11.06; P = .021). No differences in sum QoL were seen between the benign SBS-IF subgroups 1a-d (P = .210). Multivariate regression analyses showed that patients with a small-bowel stoma, a small-bowel length <50 cm was associated with a significantly worse/higher SBS-QoL score compared with a length >50 cm. CONCLUSION: In patients with benign SBS-IF, high HPS volume was associated with poor QoL. Also, jejunostomy or ileostomy with small-bowel length <50 cm was associated with impaired QoL. These findings support rehabilitation strategies that reduce fecal losses and decrease HPS needs.

Catheter-related bloodstream infections in patients with intestinal failure receiving home parenteral support: risks related to a catheter-salvage strategy.

Background: In intestinal failure (IF) patients receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) frequently result in replacement of their tunneled central venous catheters (CVCs), which may lead to future loss of central venous access. Objective: This observational study investigated the consequences of a catheter-salvage strategy related to CRBSIs. Design: All CRBSIs from 2002 to 2016 in the Copenhagen IF and microbiological databases were retrospectively analyzed. Catheter salvage was defined by successful antimicrobial therapy with a retained CVC at discharge. Re-occurrences of CRBSIs with the same microbial species and identical antibiogram were defined as a relapse (<30 d) or as a recurrent (30-100 d) infection. Cox regression analyses incorporated a frailty factor to account for recurrent events and overrepresentation by some patients. Cumulative incidence curves are presented with a competing risk model. Results: There were 2006 tunneled CVCs inserted in 715 adult HPS patients covering 2014.3 CVC years, with a CRBSI incidence rate of 1.83/1000 (n = 1350) and a mortality rate of 0.007/1000 CVC days (n = 5). The mean ± SD salvage rate was 55.3% ± 5.5%, varying according to infection type [monoinfections (62.9% ± 4.4%) and polyinfections (58.6% ± 17.3%)] and causative microorganism [coagulase-negative Staphylococci (CoNS) (68.1% ± 9.4%), Staphylococcus aureus (42.6% ± 17.5%), and Enterobacteriaceae (54.3% ± 16.7%)]. The overall risk of CRBSI relapse was 7.5%, and the risk of CRBSI recurrence was 7.3%. The HR for a subsequent CRBSI was 14% lower in a replaced than in a retained CVC (95% CI: 0.74, 0.99). The HR for a new CRBSI after catheter salvage was 36% higher after polyinfections than after monoinfections (95% CI: 1.03, 1.79). Enterobacteriaceae entailed an increased risk of CRBSI recurrence compared with CoNS (2.26; 95% CI; 1.08, 4.75) and S. aureus (4.45; 95% CI: 1.28, 15.5). Conclusions: High catheter-salvage rates related to CRBSIs were achievable and safe in HPS patients within a broad range of microorganisms but contributed to an increased risk of CRBSI relapse or recurrence.

Catheter-Related Bloodstream Infections in Adults Receiving Home Parenteral Nutrition: Substantial Differences in Incidence Comparing a Strict Microbiological to a Clinically Based Diagnosis.

BACKGROUND: A common complication in patients receiving home parenteral nutrition (HPN) is catheter-related bloodstream infections (CRBSIs). The CRBSI incidence has been advocated as an outcome parameter assessing the quality of care. This study aimed to illustrate how the use of different CRBSI definitions affects the reported incidence. MATERIALS AND METHODS: In an observational study based on the Copenhagen intestinal failure database, all clinically reported CRBSIs from 2002-2013 were compared with data from the affiliated microbiological database according to recommended CRBSI criteria. RESULTS: Clinically, 1034 CRBSIs were observed in 548 adults receiving HPN for 1410 catheter-years. Thus, the clinically assessed CRBSI incidence was 1.95/1000 catheter-days. However, based on the microbiological evaluation, only 47% of our episodes fulfilled the Centers for Disease Control and Prevention (CDC) and European Society for Clinical Nutrition (ESPEN) CRBSI criteria. Employing a catheter-salvaging strategy, 40% of the CRBSI diagnoses were supported by the paired blood culture positivity criteria and only 6% by a positive catheter tip. In 53%, CRBSIs were categorized as a clinical or "probable CRBSI" diagnosis. In 20% of all episodes, missing information/blood cultures hampered a CDC/ESPEN CRBSI diagnosis. Thereby, according to CDC/ESPEN CRBSI definitions, the incidence was 0.92/1000 days or 46% lower than clinically assessed. CONCLUSION: This study illustrates the practical and methodological challenges and great variability in reporting of the CRBSI incidence. Nonetheless, it is recommended as a marker of the quality of care. Consensus regarding CRBSI definitions is a prerequisite for a meaningful comparison of this important outcome parameter between HPN centers.

Taurolidine-citrate-heparin lock reduces catheter-related bloodstream infections in intestinal failure patients dependent on home parenteral support: a randomized, placebo-controlled trial.

Background: In patients with intestinal failure who are receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) inflict health impairment and high costs.Objective: This study investigates the efficacy and safety of the antimicrobial catheter lock solution, taurolidine-citrate-heparin, compared with heparin 100 IE/mL on CRBSI occurrence.Design: Forty-one high-risk patients receiving HPS followed in a tertiary HPS unit were randomly assigned in a double-blinded, placebo-controlled trial. External, stratified randomization was performed according to age, sex, and prior CRBSI incidence. The prior CRBSI incidence in the study population was 2.4 episodes/1000 central venous catheter (CVC) days [95% Poisson confidence limits (CLs): 2.12, 2.71 episodes/1000 CVC days]. The maximum treatment period was 2 y or until occurrence of a CRBSI or right-censoring because of CVC removal. The exact permutation tests were used to calculate P values for the log-rank tests.Results: Twenty patients received the taurolidine-citrate-heparin lock and 21 received the heparin lock, with 9622 and 6956 treatment days, respectively. In the taurolidine-citrate-heparin arm, no CRBSIs occurred, whereas 7 CRBSIs occurred in the heparin arm, with an incidence of 1.0/1000 CVC days (95% Poisson CLs: 0.4, 2.07/1000 CVC days; P = 0.005). The CVC removal rates were 0.52/1000 CVC days (95% Poisson CLs: 0.17, 1.21/1000 CVC days) and 1.72/1000 CVC days (95% Poisson CLs: 0.89, 3.0/1000 CVC days) in the taurolidine-citrate-heparin and heparin arm, respectively, tending to prolong CVC survival in the taurolidine arm (P = 0.06). Costs per treatment year were lower in the taurolidine arm (€2348) than in the heparin arm (€6744) owing to fewer admission days related to treating CVC-related complications (P = 0.02).Conclusions: In patients with intestinal failure who are life dependent on HPS, the taurolidine-citrate-heparin catheter lock demonstrates a clinically substantial and cost-beneficial reduction of CRBSI occurrence in a high-risk population compared with heparin. This trial was registered at clinicaltrials.gov as NCT01948245.

The use of metabolic balance studies in the objective discrimination between intestinal insufficiency and intestinal failure.

Background: In research settings that use metabolic balance studies (MBSs) of stable adult patients with short bowel syndrome, intestinal failure (IF) and dependence on parenteral support (PS) have been defined objectively as energy absorption <84% of calculated basal metabolic rate (BMR), wet weight (WW) absorption <23 g · kg body weight-1 · d-1, or both. Objective: This study aimed to explore and validate these borderlines in the clinical setting.Design: Intestinal absorption was measured from April 2003 to March 2015 in 175 consecutive patients with intestinal insufficiency (INS) in 96-h MBSs. They had not received PS 3 mo before referral.Results: To avoid the need for PS, the minimum absorptive requirements were energy absorption of ≥81% of BMR and WW absorption of ≥21 g · kg body weight-1 · d-1, which were equivalent to findings in research settings (differences of 3.6% and 8.7%; P = 0.65 and 0.60, respectively). Oral failure defined as energy intake <130% of calculated BMR or WW intake <40 g · kg body weight-1 · d-1 was seen in 71% and 82% of the 10% of patients with the lowest energy absorption and WW absorption, respectively.Conclusions: In clinical settings, the borderlines between INS and IF were not significantly different from those in research settings, even in an unselected patient population in which oral failure was also a predominant cause of nutritional dyshomeostasis. MBSs may be recommended to identify the individual patient in the spectrum from INS to IF, to objectivize the cause of nutritional dyshomeostasis (oral failure, malabsorption, or both), and to quantify the effects of treatment.