A comparison of two methods of treatment for central catheter tunnel phlegmon in home parenteral nutrition patients.

INTRODUCTION: The ESPEN guidelines on long-term (> 3 months) parenteral nutrition recommend the use of tunnelled central venous catheters (CVCs) to minimise the risk of insertion site infection. A developed symptomatic infection of the soft tissue tunnel surrounding a CVC may rapidly become directly life threatening if the infection progresses along the catheter tunnel towards its end inserted into the venous system. This requires immediate management to eliminate infection and limit its effects. AIM: To compare two surgical techniques for the treatment of suppurative inflammation of a CVC tunnel: conventional drainage of the infected tissues (surgical technique A) vs. radical en bloc excision of the infected tissues together with the infected central catheter (surgical technique B). MATERIAL AND METHODS: Seventy-three patients hospitalised due to CVC tunnel phlegmon between April 2004 and May 2014 were included in the retrospective study. Thirty-four (46.5%) patients underwent surgical procedure A and another 39 (53.5%) underwent procedure B. RESULTS: The mean duration of antibiotic therapy following procedure A was 8 ±3 days, whereas procedure B required 7 ±2 days of antibiotic therapy (NS). The mean hospitalisation period following procedure B was over 8 days shorter in comparison to that following procedure A (16.54 ±7.59 vs. 24.87 ±10.19, p = 0.009, respectively). CONCLUSIONS: The surgical treatment of CVC tunnel phlegmon involving radical en bloc excision of suppurated tissues along with the infected CVC shortens hospitalisation, expedites the insertion of a new CVC, and potentially reduces treatment costs.

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.

Method of nutrition of patients after major oral and craniofacial surgery and its effects on BMI changes during a half-year period of observation.

UNLABELLED: Injuries, deformations and tumours of the facial part of skull, oral cavity or neck often hamper or prevent normal food consumption. After surgery of these structures food intake may be decreased due to postoperative wounds, pain, swelling and trismus. The aim of the study was to evaluate nutritional state of patients treated surgically in the craniomaxillo- facial surgery department and determination of factors affecting body weight changes after surgery. MATERIAL AND METHODS: The study included 83 patients operated between 2008 and 2010 in the department of cranio-maxillo-facial surgery, due to: maxillo-facial defects (30 individuals), malignant tumours (23 individuals), injuries (19 individuals), benign tumours (11 individuals). The study was prospective. A method of nutrition during the observation period and BMI (Body Mass Index) value on the first day of hospitalization and after 10, 60, 180 days after hospital admission were considered. For statistical analysis of results a general regression analysis was used. RESULTS: Significant reduction of BMI was observed in all patients after 10 and 60 days from the start of hospitalization. A significant increase of this parameter was observed between Day 60 and Day 180 of observation, however the BMI values after 180 days were still significantly lower than the baseline. A dependency between these changes and a cause of hospitalization as well as nutrition during and after the stay at hospital has been shown. CONCLUSIONS: There is a distinct relationship between the worsening of nutritional state after craniofacial surgery and nutrition during and after hospitalization, and therefore special attention should be paid to the issue of nutrition during this period.

Cholelithiasis in home parenteral nutrition (Hpn) patients--complications of the clinical nutrition: diagnosis, treatment, prevention.

UNLABELLED: Long-term home parenteral nutrition (HPN) is an important factor for cholelithiasis. An individualized nutrition program, trophic enteral nutrition and ultrasound bile ducts monitoring is a necessity in those patients. The aim of the study was to evaluate the usefulness of prophylactic cholecystectomy in patients with asymptomatic cholelithiasis requiring HPN. MATERIAL AND METHODS: 292 chronic HPN patients were analyzed in the period from 2005 to 2012. Patients were divided into four groups: A - without cholelithiasis, B - with asymptomatic cholelithiasis, C - urgent cholecystectomy because of cholecystisis caused by gallstones, D - cholecystectomy in patients without cholelithiasis performed during an operation to restore the continuity of the digestive tract. The patients were additionally divided depending on the extent of resection of the small intestine and colon. RESULTS: 36.9% of chronic HPN patients had cholelithiasis confirmed using ultrasonographic examination. Cholecystectomy due to acute cholecystitis symptoms was performed in 14.4% of the patients. The remaining 22.6% patients had asymptomatic cholelithiasis. Prophylactic cholecystectomy was performed in 5.5% patients with no signs of cholelcystisis during the planned operation to restore the continuity of the digestive tract. CONCLUSIONS: Cholelithiasis in chronic HPN patients is a frequent phenomenon. It seems useful to perform prophylactic cholecystectomy during primary subtotal resection of the small intestine, because the risk of cholelithiasis in this group of patients is very high.