An evidence-based surveillance tool to identify and report catheter/cannula bloodstream infection in patients receiving parenteral nutrition.

OBJECTIVE: Catheter/cannula-bloodstream infection (CBI) has been proposed as a marker of the quality of care provided to patients receiving parenteral nutrition (PN). However, surveillance criteria for CBI are variable, inconsistent, and sometimes confusing and impractical. Surveillance criteria were developed to simply and accurately demonstrate the presence or absence of CBI. The aim of this study was to establish a simple and valid surveillance tool, with consideration of changes in vital signs, to identify CBI in patients receiving PN. METHODS: Adult (≥18 y) inpatients prescribed PN at a single large teaching hospital were recruited between October 11, 2017 and November 16, 2018. Common clinical and laboratory criteria, including blood culture, associated with 100 consecutive PN episodes associated with suspected CBI were examined for potential predictive markers of CBI. Using binary logistic regression, criteria were incorporated into an instrument that was validated against a reference classification of CBI established by an expert multidisciplinary group. RESULTS: The reference classification comprised 12 PN episodes with CBI and 88 without. Abnormal vital signs did not significantly predict CBI, but resolution of fever (≥38°C) and low systolic blood pressure (<100 mm Hg) in response to a specific treatment for CBI (line removal/antibiotics) did. Two other criteria were also significant predictors: positive blood culture; and absence of an alternative source that could explain the septic episode other than the catheter/cannula supplying PN. These two criteria together with a positive response to treatment (temperature and/or blood pressure, incorporated into a single binary variable), resulted in 100% correct CBI classification (100% sensitivity, 100% specificity, and 1.000 area under the curve in receiver operating characteristic analysis). All criteria could be retrospectively extracted from the medical records of all PN episodes. CONCLUSION: A CBI tool shows promise as a surveillance instrument for benchmarking and interinstitutional comparisons of the care received by hospitalized patients given PN.

Factors Influencing Escherichia coli and Enterococcus durans Growth in Parenteral Nutrition With and Without Lipid Emulsion to Inform Maximum Duration of Infusion Policy Decisions.

BACKGROUND: Recommendations effectively restrict the infusion duration of lipid-containing parenteral nutrition (PN) from a single bag, purportedly because it encourages growth of potential microbial contaminants more than lipid-free PN. Since other variables, including osmolarity, may independently affect microbial growth, this study examined variables affecting growth of Escherichia coli and Enterococcus durans in PN infusates. MATERIALS AND METHODS: Growth of E coli and E durans was assessed in quadruplicate in 12 different PN infusates, with and without lipid, in varying glucose concentrations. RESULTS: Results are presented as mean log10 colony-forming units (cfu)/mL ± SEM at 48 hours. The log10cfu/mL of both E coli and E durans in PN increased considerably after adjustment for baseline log10cfu/mL and pH, from 1.093 to 2.241 (P < .001) and from 0.843 to 3.451 (P < .001) respectively. Growth of each microorganism was independently increased by lipid inclusion, or increasing the proportion of nonnitrogen energy from lipid, and reduced by raising the glucose concentration or energy density. Increasing the osmolarity of lipid-PN with glucose or sodium chloride reduced growth but only significantly for sodium chloride (E coli, P = .025; E durans, P = .045). Induced changes in pH affected the growth of the 2 organisms differently. CONCLUSION: The presence of lipid and an increasing proportion of energy from lipid in PN favored the growth of E coli and E durans. Osmolarity changes and the nutrient type causing these changes independently affect the growth of these microbes. Each effect needs to be considered when establishing guidelines based on the growth of potential contaminants in different types of PN.

A comparison of the surface contaminants of handwritten recycled and printed electronic parenteral nutrition prescriptions and their transfer to bag surfaces during delivery to hospital wards.

BACKGROUND: Handwritten recycled paper prescription for parenteral nutrition (PN) may become a concentrated source of viable contaminants, including pathogens. This study examined the effect of using fresh printouts of electronic prescriptions on these contaminants. MATERIALS AND METHODS: Cellulose sponge stick swabs with neutralizing buffer were used to sample the surfaces of PN prescriptions (n = 32 handwritten recycled; n = 32 printed electronic) on arrival to the pharmacy or following printing and PN prescriptions and bags packaged together during delivery (n = 38 handwritten recycled; n = 34 printed electronic) on arrival to hospital wards. Different media plates and standard microbiological procedures identified the type and number of contaminants. RESULTS: Staphylococcus aureus, fungi, and mold were infrequent contaminants. nonspecific aerobes more frequently contaminated handwritten recycled than printed electronic prescriptions (into pharmacy, 94% vs 44%, fisher exact test P .001; onto wards, 76% vs 50%, p = .028), with greater numbers of colony-forming units (CFU) (into pharmacy, median 130 [interquartile range (IQR), 65260] VS 0 [075], Mann-Whitney U test, P .001; onto wards, median 120 [15320] vs 10 [040], P = .001). packaging with handwritten recycled prescriptions led to more frequent nonspecific aerobic bag surface contamination (63% vs 41%, fisher exact test P = .097), with greater numbers of CFU (median 40 [IQR, 080] VS 0 [040], Mann-Whitney U test, P = .036). CONCLUSION: The use of printed electronic PN prescriptions can reduce microbial loads for contamination of surfaces that compromises aseptic techniques.