[Catheter-related bloodstream infections in patients receiving central parenteral nutrition: prevalence, associated factors, and treatment]. / Bacteriemia en pacientes con nutrición parenteral central: prevalencia, factores asociados y tratamiento.

INTRODUCTION: Background: catheter-related infection is one of the complications of central parenteral nutrition treatment with the highest morbidity and mortality. Objectives: the primary endpoint of this study was to analyze the prevalence of bloodstream infection in patients with central parenteral nutrition. Secondary objectives included: a) an assessment of whether type of central catheter, duration of parenteral nutrition treatment, body mass index, or being admitted to the intensive care unit are factors associated with the development of bloodstream infection; b) an analysis of the therapeutic approach. Methods: this was a retrospective observational study. All patients who received central parenteral nutrition after surgery between July 2018 and March 2019 were included. The association between the different variables and the development of bloodstream infection was analyzed by logistic regression. Results: the prevalence of bloodstream infection was 7.3 % (95 % CI: 3.9-13.3) (n = 9/123 patients). The duration of central parenteral nutrition was the only variable associated with the development of bloodstream infection (OR = 1.12; 95 % CI:1.05-1.20; p = 0.001). Conclusions: the prevalence of catheter-related bloodstream infection in this study is low, and the duration of central parenteral nutrition seems to be related to its development. However, further studies are needed to identify risk factors that might help reduce this kind of complications.

INTRODUCCIÓN: Introducción: la infección relacionada con el catéter es una de las complicaciones del tratamiento con nutrición parenteral central (NPC) que generan una mayor morbimortalidad. Objetivos: el objetivo principal fue analizar la prevalencia de la bacteriemia asociada al catéter en pacientes con nutrición parenteral central. Los objetivos secundarios fueron: a) evaluar si el tipo de catéter central, la duración de la nutrición parenteral central, el índice de masa corporal o la estancia en la unidad de cuidados intensivos son factores asociados al desarrollo de bacteriemia; b) analizar el manejo terapéutico de la infección. Material y métodos: se trata de un estudio observacional retrospectivo. Se incluyeron los pacientes que recibieron nutrición parenteral central tras una intervención quirúrgica entre julio de 2018 y marzo de 2019. La asociación de las variables con el desarrollo de la bacteriemia se analizó mediante regresión logística. Resultados: el 7,3 % (IC 95 %: 3,9-13,3) (n = 9/123) de los pacientes desarrollaron bacteriemia relacionada con el catéter. El único factor asociado al desarrollo de la infección fue la duración de la nutrición parenteral central (OR = 1,12; IC 95 %: 1,05-1,20; p = 0,001). Conclusiones: la prevalencia de la bacteriemia relacionada con el catéter en este estudio es baja. La duración del tratamiento con nutrición parenteral central parece estar relacionada con el desarrollo de la bacteriemia. Sin embargo, se necesitan más estudios para identificar factores de riesgo que permitan minimizar este tipo de complicaciones.

Intravenous Iron Dosing and Infection Risk in Patients on Hemodialysis: A Prespecified Secondary Analysis of the PIVOTAL Trial.

BACKGROUND: Experimental and observational studies have raised concerns that giving intravenous (IV) iron to patients, such as individuals receiving maintenance hemodialysis, might increase the risk of infections. The Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial randomized 2141 patients undergoing maintenance hemodialysis for ESKD to a high-dose or a low-dose IV iron regimen, with a primary composite outcome of all-cause death, heart attack, stroke, or hospitalization for heart failure. Comparison of infection rates between the two groups was a prespecified secondary analysis. METHODS: Secondary end points included any infection, hospitalization for infection, and death from infection; we calculated cumulative event rates for these end points. We also interrogated the interaction between iron dose and vascular access (fistula versus catheter). RESULTS: We found no significant difference between the high-dose IV iron group compared with the lose-dose group in event rates for all infections (46.5% versus 45.5%, respectively, which represented incidences of 63.3 versus 69.4 per 100 patient years, respectively); rates of hospitalization for infection (29.6% versus 29.3%, respectively) also did not differ. We did find a significant association between risk of a first cardiovascular event and any infection in the previous 30 days. Compared with patients undergoing dialysis with an arteriovenous fistula, those doing so via a catheter had a higher incidence of having any infection, hospitalization for infection, or fatal infection, but IV iron dosing had no effect on these outcomes. CONCLUSIONS: The high-dose and low-dose IV iron groups exhibited identical infection rates. Risk of a first cardiovascular event strongly associated with a recent infection.

Long-Term Management of Vascular Access Ports in Nonhuman Primates Used in Preclinical Efficacy and Tolerability Studies.

Vascular access ports (VAPs) are an essential tool for long-term vascular access in preclinical studies and disease modeling in non-human primates (NHPs). We retrospectively reviewed central (inferior vena cava, IVC) and portal VAP implantation with the maintenance at our center from 15 January 2010 to 31 January 2018. In total, 209 VAPs were implanted for long-term drug administration and sampling. Patency was >95% at 6 months and >80% at 1 year for IVC VAPs and >90% at 6 months and >85% at 1 year for portal VAPs. The majority of animals had no complications and access was generally durable with device use ranging up to 7 years. In IVC, VAPs loss of patency occurred in 13% (0.035/100 d), surgical site infection in 2.9% (0.097/100 d), port pocket infection in 2.2% (0.004/100 d), erosion in 2.9%, 0.008/100 d), and mechanical failure in 4.3% (0.012/100 d). In portal, VAPs loss of patency occurred in 11.3% (0.028/100 d) and port pocket infection in 1.4% (0.003/100 d). About 12% of VAPs were removed as a result of complications.This study confirms VAP implant and maintenance is a beneficial and safe practice in NHPs resulting in favorable outcomes. High patency rates and low complication rates are comparable to the clinical setting. In addition to enabling comprehensive data collection, VAPs increase satisfaction and well-being by minimizing interference with daily routines and fostering cooperation. VAP implantation, together with an effective maintenance regimen and co-operative handling, is a reliable and convenient refined method for drug administration and blood sampling.Keywords: Vascular access port; nonhuman primates; refinement; central vascular access; portal vascular access; surgical technique; experimental surgery; animal model.

Disperse red 15 (DR15) impedes biofilm formation of uropathogenic Escherichia coli.

Catheter associated urinary tract infection (CAUTI) is a highly prevalent hospital-acquired infection that is predominantly caused by uropathogenic Escherichia coli (UPEC). It adheres on catheter surface using type I pili as the initial step of pathogenesis that progresses to form biofilm. In this study, potential inhibitors against FimH adhesin of type I pili were screened computationally that yielded ten compounds. These were further validated in vitro against adhesion and biofilm formation. The compounds, 1-Amino-4-hydroxyanthraquinone (Disperse Red 15 or DR15) and 4-(4'-chloro-4-biphenylylsulfonylamino) benzoic acid (CB1) impaired adhesion and biofilm formation without inhibiting the planktonic growth. Also, both compounds inhibited cell assemblages like autoaggregation and swarming motility by unknown mechanisms. DR15 was further derivatised into N-(4-hydroxy-9,10-dioxo-9,10-dihydroanthracen-1-yl) undec-10-enamide that self-assembled with linseed oil, which was used as the coating material on urinary Foley catheters. The thin-film coating on the catheter did not leach when incubated in artificial urine and effectively restricted biofilm formation of UPEC. Altogether, the thin-film coating of urinary catheter with DR15 inhibited biofilm formation of UPEC and this application could potentially help to reduce CAUTI incidents in healthcare facilities.

Antibiotic prophylaxis at the time of catheter removal after radical prostatectomy: A prospective randomized clinical trial.

OBJECTIVE: To evaluate the role of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy in preventing urinary tract infection (UTI). MATERIALS AND METHODS: Patients undergoing radical prostatectomy were prospectively enrolled and randomized to either the antibiotic prophylaxis group (2 doses of oral ciprofloxacin prior to urinary catheter removal) or the control group (no antibiotics given prior to urinary catheter removal). Neither patients nor study providers were blinded to the group. The primary objective was to assess for development of UTI. The secondary objective was to assess for development of Clostridium difficile (C diff) enterocolitis. Continuous variables were compared using a 2-sample t test. Categorical variables were compared using Pearson's chi-squared test or Fisher's exact test. RESULTS: One hundred seventy-five patients were enrolled and randomized (90 control and 85 antibiotic prophylaxis). After randomization, 4 patients were excluded and 4 patients withdrew voluntarily. One hundred sixty-seven patients (84 control and 83 antibiotic prophylaxis) completed the study and were available for analysis. There were no significant differences in baseline characteristics, perioperative data, or complications. There was no significant difference in the rate of UTI between the control group and antibiotic prophylaxis group (5.95% vs. 6.02%, P = 1). There was also no significant difference in the rates of C diff infection between the control and the antibiotic prophylaxis groups (3.57% vs. 0%, P = 0.21). CONCLUSIONS: In this prospective, randomized, controlled trial, the use of antibiotic prophylaxis with oral ciprofloxacin prior to urinary catheter removal after radical prostatectomy did not decrease the rate of UTI, and was not associated with an increased incidence of C diff enterocolitis.

A Retrospective Sequential Comparison of Topical Application of Medicated Honey and Povidone Iodine for Preventing Peritoneal Dialysis Catheter-Related Infections.

Application of medicated honey (MH) to peritoneal dialysis (PD) catheter exit sites has been found to be as effective as intra-nasal mupirocin for preventing PD catheter-related infections (CRIs), but was associated with increased risk for CRIs in diabetics. The efficacy of topical MH as a prophylactic agent has not been compared with the exit-site application of povidone iodine (PI). This retrospective multicentre cohort study compared cumulative incidence rates of PD CRIs (peritonitis or exit-site infections) and the number of PD CRIs observed per patient over the study period with PD exit-site application of MH or PI, in both diabetic and non-diabetic patients. Outcomes were compared in incident patients in 2 eras: January 2011 - December 2012, when 147 received exit-site care with PI (PI group), and July 2013 - June 2015, when 171 patients applied MH (MH group). Patients were followed until technique failure, death, transplant, or end of study treatment era. Cumulative incidence of PD CRIs was higher in the PI group (hazard ratio [HR] = 1.7, 95% confidence interval [CI] 1.1 - 2.6, p = 0.019) and the benefit of MH was not modified by diabetic status (present/absent, interaction p = 0.723). A similar trend was observed in the cumulative incidence of peritonitis (HR = 1.6, 95% CI 0.99 - 2.6, p = 0.059). After adjusting for months of exposure, the rate ratio for PD CRIs was 1.58 for PI compared to MH (95% CI, 1.03 - 2.42, p = 0.035). We conclude that exit-site application of MH is more effective than PI in preventing PD CRIs, and this effect is not modified by the presence or absence of diabetes.

Parenteral approaches in malabsorption: Home parenteral nutrition.

Severe malabsorption of fluids and nutrients leads to intestinal failure (IF) where intravenous supplementation of nutrients and fluids is necessary to maintain health and/or growth. Long-term treatment of IF implies the start of intravenous support in the outpatient setting (home parenteral nutrition, HPN). Although HPN has proven lifesaving for many patients for more than four decades this strategy remains associated with complications that compromise the quality of life. Many problems relate to the presence of the venous access device and concern infections or vascular occlusion due to thrombosis. Patient training remains key to prevent these complications. Also metabolic problems may arise that involve liver function or composition or bone mineralization. While intestinal transplantation remains inferior to HPN as alternative treatment strategy in terms of survival, promising developments include the introduction of hormones that promote intestinal adaptation, mixed lipid emulsions that decrease liver problems and catheter lock solutions that prevent infections.

Central venous catheter related bloodstream infections in adult patients on home parenteral nutrition: Prevalence, predictive factors, therapeutic outcome.

BACKGROUND: The prevalence of central venous catheter (CVC)-related blood-stream infections (CRBSI), infecting agents and the effectiveness of antibiotic therapy were evaluated in 172 adult patients on Home Parenteral Nutrition (HPN) at the Clinical Nutrition Outpatient Unit of Federico II University Hospital in Naples, Italy. MATERIALS AND METHODS: The study population consisted of 127 oncological (74%) and 45 (26%) non-oncological patients, for a total of 53,818 (median 104; range 14-1080) CVC days. RESULTS: Ninety-four CRBSIs were diagnosed on 238 CVC (infection rate 1.74/1000 CVC days). Coagulase negative (CoNs) Staphylococci were the most frequently infecting agents (52.8% as single agent) with 17.1% Staphylococcus epidermidis infections. Eighty-three percent S. epidermidis were beta-lattamase producer (BLACT), 66.6% methicillin-resistant (MR) and 55.5% had a MIC for Vancomicin ≥1. Gram-negative bacteria represented 18.6% infections, fungi 7.1%, finally 15% infections were polymicrobial. Previous catheterizations and the presence of an enterocutaneous stoma were significantly related with a higher infection risk (p < 0.0001 in both cases). CONCLUSIONS: CRBSI and antibiotic resistance of infecting agents remain an important challenge in adult patients on HPN; an active research on strategies to counteract the phenomena is required.

The efficacy of alcohol-antibiotic lock therapy for treatment of catheter related bloodstream infections in patients receiving home parenteral nutrition.

UNLABELLED: In patients with chronic gastrointestinal tract failure, requiring access to the venous system, the subsequent catheter re-insertion are leading to large veins thrombosis impeding or preventing the insertion of another catheter and exposing patients to the risk of complications. Understanding the pathophysiology of catheter-related infections, enabled to use methods allowing to eradicate the source of infection without removal and replacement of central catheter with a new one. In our center, for many years we have been using an alternative method involving implementation of the alcohol-antibiotic lock in the treatment of infections. This method is based on the assumption that the destruction of biofilm with concentrated alcohol will enable antibiotic penetration and killing other microorganisms. Treatment with alcohol-antibiotic lock lasts from 8 to 10 days and involves filling the catheter with 96% alcohol followed by a solution of the antibiotic of high concentration. The aim of the study was to evaluate the efficacy of treatment of catheter-related bloodstream infections with two methods (catheter replacement with a new one and the alcohol-antibiotic lock therapy) in patients receiving home parenteral nutrition (HPN). MATERIAL AND METHODS: 428 HPN in the period from 1 January 2005 to 31 December 2010. Among which 240 (56%) of women with an average age of 56.5 ± 16 years and 188 (44%) of men with an average age of 54 ± 17 years. The indications to HPN were as follows: short bowel syndrome in 298 (70%) patients, multilevel obstruction of the gastrointestinal tract in 52 (12%), postoperative gastrointestinal fistulas in 48 (11.2%), malabsorption syndrome in 17 (4%), motility disorders in 6, cachexia in 4 and radiation enteritis in 3 patients. RESULTS: In 247 (57.5%) from 428 patients, no episode of catheter-related bloodstream infection was found, while 181 were diagnosed with 352 episodes of catheter-related bloodstream infections. In 40 (9.4%) from 428 patients, 168 (47.8%) episodes have been found - almost a half. The mean duration of treatment of patients receiving home parenteral nutrition, starting from the first episode of catheter-related bloodstream infection, in 48 patients treated with the lock was equal to 1053+748 days, and in 133 patients treated with catheter replacement was equal to 952+709 days (t-test p = 0.62). CONCLUSIONS: The survival time of patients treated with alcohol-antibiotic lock is the same as in patients treated with the catheter removal and insertion of the new one. The use of alcohol-antibiotic lock to treat catheter-related bloodstream infections in order to eradicate selected microorganisms that colonize the lumen and cause an infection, is as effective as catheter replacement with a new one.

A comparison of two methods of treatment for catheter-related bloodstream infections in patients on home parenteral nutrition.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) enables patients who cannot eat normally to survive and function. Catheter-related bloodstream infections (CRBSIs) are the most dangerous complication, which may be fatal if left untreated or if treatment is delayed. For over 20 years CRBSIs were managed by catheter removal and implantation of a new one after completion of antibiotic treatment. However, frequent catheter replacements put the patient at risk of large vein thrombosis, which may render parenteral nutrition impossible. The management of CRBSIs evolved into antibiotic treatment without catheter removal. The effectiveness of this approach was, however, limited by the low penetration of the antibiotics into the biofilm. Filling catheters with concentrated ethanol destroys the biofilm and does not result in the emergence of drug resistance. The aim of our study was to assess the remote outcomes of CRBSI treatment using two approaches: antibiotic-ethanol lock therapy and catheter replacement. METHODS: We retrospectively analysed the treatment outcomes of CRBSI diagnosed and managed in HPN patients. During the analysed period, a total of 428 patients between 13 and 96 years of age were on HPN and a total of 181 of them suffered a total of 352 CRBSI episodes managed with one of the two approaches. RESULTS: We showed no significant differences between the two approaches in terms of survival likelihood or duration of catheter use after an episode of CRBSI caused by various bacterial species. CONCLUSION: The use of antibiotic-ethanol lock therapy in the management of CRBSI is equally effective as catheter replacement.

Taurolidine locks significantly reduce the incidence of catheter-related blood stream infections in high-risk patients on home parenteral nutrition.

Emerging evidence suggests taurolidine reduces the risk of repeated episodes of catheter related blood stream infections (CRBSI) in a subgroup of patients receiving home parenteral nutrition (HPN). We defined 3 indications where taurolidine could be considered and retrospectively analysed data from patients who were treated over a 10 year period to examine the validity of these criteria. Twenty-two patients were identified from a total HPN population of 81, representing 33.2 years of experience. The overall CRBSI rate pre- and post-taurolidine usage was reduced from 5.71 to 0.99 infections per 1000 patient parenteral nutrition days (P-value <0.0001), with reductions identified in each smaller subgroup, confirming previous reports of a significant reduction in infections when taurolidine is used as secondary prophylaxis and providing initial data suggesting the benefit of its use as primary prophylaxis.

[Emergency vascular access conversion to native arterio veinous fistula: a prospective study of 37 hemodialysis patients in Rwanda]. / Conversion des abords vasculaires d'urgence pour hémodialyse en fistules natives au Rwanda : à propos de 37 cas.

UNLABELLED: Chronic hemodialysis in Rwanda is relatively recent and most of patients are treated with catheters. SUMMARY: Thirty-seven patients who require chronic hemodialysis with catheters were evaluated during a 3-years period in order to facilitate the creation of a permanent vascular access for hemodialysis (AVF). Patient selection were made during a multi-disciplinary consultation. The sex-ratio was 1.5 and the main cause of the nephropathy was arterial hypertension. RESULTS: Thirty-one patients benefited from the creation of an arterioveinous fistula. All of the interventions were performed using local or loco-regional anesthesia. Sixty percent of these AVF were radio-cephalic, 35.4% were humero-cephalic. Sixty-four percent of the operations were performed on ambulatory patients, with a primary function for 90% of them. CONCLUSION: This work proves the feasibility of the creation of AVF in Rwanda, thus allowing to preclude the various complications that arise with the prolonged use of a catheter. This experience was made possible by the pooling of the resources of 4 of Rwanda's leading hospitals. In an early future, the development of vascular surgery will assure the permanence of this care.

Comparative short-term safety of bolus versus maintenance iron dosing in hemodialysis patients: a replication study.

BACKGROUND: Recent research has reported that patients receiving bolus (frequent large doses to achieve iron repletion) versus maintenance dosing of iron have an increased short-term risk of infection, but a similar risk of cardiovascular events. We sought to determine whether these findings could be replicated using the same methods and a different data source. METHODS: Clinical data from 6,605 patients of a small U.S. dialysis provider merged with Medicare claims data were examined. Iron dosing patterns (bolus, maintenance, no iron) were identified during 1-month exposure periods and cardiovascular and infection-related outcomes were assessed during 3-month follow-up periods. The effects of bolus versus maintenance dosing were assessed using Cox proportional hazards regression analyses to estimate hazard ratios and semiparametric additive risk models to estimate hazard rate differences, controlling for demographic and clinical characteristics, laboratory values and medications, and comorbidities. RESULTS: 48,050 exposure/follow-up periods were examined. 13.9 percent of the exposure periods were bolus dosing, 49.3 percent were maintenance dosing, and the remainder were no iron use. All of the adjusted hazard ratios were >1.00 for the infection-related outcomes, suggesting that bolus dosing increases the risk of these events. The effects were greatest for hospitalized for infection of any major organ system (hazard ratio 1.13 (1.03, 1.24)) and use of intravenous antibiotics (hazard ratio 1.08 (1.02, 1.15). When examining the subgroup of individuals with catheters, the hazard ratios for the infection-related outcomes were generally greater than in the overall sample. There was little association between type of dosing practice and cardiovascular outcomes. CONCLUSIONS: Results of this study provide further evidence of the association between bolus dosing and increased infection risk, particularly in the subgroup of patients with a catheter, and of the lack of an association between dosing practices and cardiovascular outcomes.

Reorganization of nutritional therapy can markedly reduce the rate of catheter-related blood stream infections in pediatric patients receiving parenteral nutrition - a 7-year prospective follow-up study.

BACKGROUND: Implementation of hygienic measures and simple changes in the structure of medical team may considerably reduce the rate of catheter-related bloodstream infections (CRBSIs) in parenterally nourished patients. AIM: To analyze the effects of organizational changes in parenteral nutrition services on the CRBSI rates in pediatric patients. METHODS: We compared the CRBSI rates documented prior to, during and after the implementation of the organizational changes (introduction of a nutritional support team and related procedures, medical staff training). FINDINGS: A total of 260 courses of parenteral nutrition were offered to 141 pediatric patients during the analyzed period. Thirty CRBSIs were documented during this period. The most frequent etiological factors were staphylococci (21/30), followed by Klebsiella pneumoniae, Escherichia coli and Candida albicans (2/30 each). The reorganization was reflected by more than 8-fold reduction of the CRBSI incidence rate: from the initial value of 10.14 to 6.89 per 1000 catheter days and 1.17 per 1000 catheter days during and after the reorganization, respectively. CONCLUSION: Introduction of a nutritional support team, accompanied by extensive training of medical staff, can result in a marked reduction of CRBSI rate in pediatric patients nourished parenterally in a hospital setting.

Antecedentes: La implementación de medidas higiénicas y cambios sencillos en la estructura del personal médico puede reducir considerablemente la tasa de bacteriemia asociada al catéter (BAC) en pacientes que reciben nutrición parenteral. Objetivo: Analizar el impacto de los cambios organizacionales dentro de los servicios de nutrición parenteral sobre las tasas de BAC en pacientes pediátricos. Métodos: Hemos comparado las tasas de BAC documentadas antes, durante y después de la implementación de los cambios organizacionales (introducción de un grupo de apoyo nutricional y los procedimientos relacionados, formación del personal médico). Descubrimientos: Un total de 260 series de nutrición parenteral fueron ofrecidos a 141 pacientes pediátricos durante el periodo analizado. Se documentaron treinta BAC durante este periodo. Los factores etiológicos más frecuentes eran staphylococci (21/30), seguidos por Klebsiella pneumoniae, Escherichia coli y Candida albicans (2/30 cada uno). Los cambios organizacionales fueron reflejados en una reducción de la incidencia de BAC en más de 8 veces: el valor inicial disminuyó desde 10.14 hasta 6.89 por 1000 días-catéter y hasta 1.17 por 1000 días-catéter durante y después de la reorganización, respectivamente. Conclusión: La introducción de un grupo de apoyo nutricional, acompañada de una extensa formación del personal médico puede resultar en una reducción considera ble de la tasa de BAC en pacientes pediátricos que reciben nutrición parenteral en en un entorno hospitalario.

Applying mindful evidence-based practice at the bedside: using catheter-associated urinary tract infection as a model.

We introduce a mindful evidence-based practice model to operationalize mindfulness to improve bedside infection prevention practices. Using catheter-associated urinary tract infection prevention as an example, we illustrate how clinicians can be more mindful about appropriate catheter indications and timely catheter removal.

Efficacy of taurolidine on the prevention of catheter-related bloodstream infections in patients on home parenteral nutrition.

PURPOSE: To assess the efficacy of taurolidine (TauroLockTM) line locks on the prevention of catheter-related bloodstream infections (CRBSI) in patients on home parenteral nutrition (HPN). METHODS: In our unit, any patient with ≥2 CRBSIs in six months is considered for TauroLockTM (2% taurolidine and 4% citrate) line locks. All such patients from May 2007 until January 2012 were identified, along with associated CRBSI rates. CRBSI was defined by differential time to positivity for positive blood cultures. CRBSIs were grouped into pre-taurolidine use and post-taurolidine commencement for each patient and the infection rate per 1000 catheter days calculated. Results were analyzed using Wilcoxon two-sided test. RESULTS: A total of nine patients were included (two men and seven women) with a median age of 51 (range 43-82) years. Infection rates after commencing taurolidine decreased markedly in all patients studied. The median CRBSI rate prior to taurolidine use was 6.39 per 1000 catheter days. This decreased to a median CRBSI rate of 0 per 1000 catheter days after commencing taurolidine. CONCLUSIONS: Taurolidine is no substitute for careful aseptic technique. However, it is clearly effective at preventing CRBSIs and should be used in patients with recurrent infections to reduce morbidity.

Prevention of recurrent urinary tract infections.

Urinary tract infections (UTI) are among the most frequent bacterial infections in the community and health care setting. Mostly young and, to some extent, postmenopausal women are affected by recurrent UTI (rUTI) defined as ≥3 UTI/year or ≥2 UTI/half year. In contrast, rUTI is rare in healthy men. On the other hand, rUTI are frequently found in female and male patients with complicating urological factors, e.g. urinary catheters, infection stones. Remediable predisposing factors in uncomplicated rUTI in women are rare. In complicated rUTI the success depends mainly on the possibility to eliminate or at leastimprove the complicating risk factors. Continuous antibiotic prophylaxis or postcoital prophylaxis, if there is close correlation with sexual intercourse, are most effective to prevent rUTI. Nitrofurantoin, trimethoprim (or cotrimoxazole), and fosfomycin trometamol are available as first-line drugs. Oral cephalosporins and quinolones should be restricted to specific indications. Antibiotic prophylaxis reduces the number of uropathogens in the gut and/or vaginal flora and reduces bacterial "fitness". Given the correct indication, the recurrence rate of rUTI can be reduced by about 90%. Due to possible adverse events and the concern of selecting resistant pathogens, according to the guidelines of the European Association of Urology antimicrobial prophylaxis should be considered only after counselling, behavioural modification and non-antimicrobial measures have been attempted. In postmenopausal patients vaginal substitution of oestriol should be started first. Oral or parenteral immunoprophylaxis is another option in patients with rUTI. Other possibilities with varying scientific evidence are prophylaxis with cranberry products, specific plant combinations or probiotics. The prophylaxis of catheter-associated UTI should employ strategies which result in a reduction of frequency and duration of catheter drainage of the urinary tract. The currently available catheter materials have only little influence on reducing catheter-associated rUTI.

Hospital readmissions for catheter-related bloodstream infection and use of ethanol lock therapy: comparison of patients receiving parenteral nutrition or intravenous fluids in the home vs a skilled nursing facility.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is the most serious long-term infectious complication of long-term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. METHODS: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. RESULTS: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). CONCLUSION: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.

Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience.

BACKGROUND: Catheter-related bloodstream infections (CRBSI) cause morbidity and mortality in patients with intestinal failure dependent on parenteral nutrition. Ethanol lock of central venous catheters may decrease CRBSI, but limited pediatric data are available. METHODS: Home parenteral nutrition patients with at least one previous CRBSI were initiated on a 70% ethanol lock protocol for a minimum of 4 hours. Infection rates (per 1000 catheter days) before and after initiation of ethanol locks were compared using a paired t test. RESULTS: Ten patients (4 girls; median age, 44 months [range, 31-129 months]) began ethanol lock therapy after a total of 91 CRBSIs (37 gram-positive, 30 gram-negative, and 24 fungal) with a mean of 10.2 ± 6.2 per 1000 catheter days. Patients received ethanol lock for an average of 227 ± 64 days with only 3 CRBSI occurring (CRBSI rate of 0.9 ± 1.8 per 1000 catheter days [P = .005]). Central venous catheter replacements decreased from 5.6 per 1000 days to 0.3 per 1000 days posttherapy (P = .038). Ethanol lock was discontinued in 2 of 10 patients because of catheter thrombosis. CONCLUSION: Preliminary results demonstrate a significant decrease in CRBSI with a 70% ethanol lock protocol. Catheter thrombosis may be a limitation that needs to be addressed. With such a dramatic therapeutic effect, a randomized trial is feasible and should be performed.