Central Venous Access Device Infections and Home Parenteral Nutrition

Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN. 2011;35:67-73.       

Central venous access device (CVAD) infections are a problem in the home parenteral nutrition (HPN) patient. These infections include skin site infections and bloodstream infections. In fact, CVAD infection is one of the most common and most devastating complications of HPN. In this study, the Michigan group did a retrospective analysis of the use of the ethanol-lock therapy (locking the solution in the catheter between uses). The group used a 70% ethanol solution. The dwell time for the ethanol solution was 2 hours at a minimum. Patients had the ethanol drawn from the catheter and discarded prior to infusion. Catheter infections were diagnosed based on 2002 guidelines from the Centers for Disease Control and Prevention. Patients in the study were deemed at-risk (defined as having had 2 CVADs replaced because of infections or 2 previous infections from their current CVAD, or having limited remaining CVAD access). Fifteen patients, with an average age of 5.9 years, were followed over 16 months on average. Throughout the study period, 73% of patients remained infection-free. There was a statistically significant decrease in the number of BSIs (bloodstream infections) per 1,000 catheter days (8.0 BSIs before the ethanol lock technique was implemented, versus 1.3 BSIs afterward [p<.001]). None of the catheters was removed because of BSI. Two of the patients developed a tunnel infection. The incidence of CVAD repair for leakage or disruption was not significantly different than that noted before initiation of ethanol-lock therapy.

There has been some concern of catheter damage in CVADs composed of polyurethane and subjected to ethanol-lock or flush, although this has not been confirmed in clinical studies. Many interventions for CVAD infections have been examined over the years, including wound patches and biofilms (specialized devices to attach to catheters to maintain sterility), patient education, and antibiotic “lock,” among others. This study provides an alternative, and apparently successful, intervention for prevention of catheter infections in at-risk patients.

Study Evaluates 203 Home Enteral Nutrition (HEN) Patients

Klek S, Szybinski P, Sierzega M, et al. Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding. JPEN. 2011;3:380-385. (The authors are from Krakow, Poland. Some of the authors are employed by Nutrimed Medical Corporation.)

This was an interesting study evaluating 203 home enteral nutrition (HEN) patients. To start, the patients were fed homemade diets (pureed table foods) for tube feeding for 12 months, with oversight by the family only. Following use of the homemade diets, the patients used commercial enteral tube feeding (ETF) for 12 months, with the guidance of a nutritional support team (NST). When the patients used the ETF with the guidance of an NST, as compared to when they used a homemade tube feeding with no NST, they had significantly reduced hospital admissions (0.21/year [p<.001] vs. 1.2/year), duration of hospitalizations (3.83 days [p<.001] versus 20.84 days), and duration of ICU stay (0.50 days [p<.001] versus 2.35 days). Also, the cost of hospitalization was significantly reduced in the commercial ETF group that was followed by an NST. In addition, the incidence of pneumonia, respiratory failure, urinary tract infection, and anemia were significantly reduced in the commercial ETF/NST oversight group (p<.05).

This study used the same patients for their own controls, thus creating a very good comparison study. Often when evaluating the use of a medical product, we look at the cost of the intervention only. In this case, the use of commercial tube feeding and NST guidance was most likely more costly initially than pureed table foods and oversight only by the family. However, the use of commercial ETF and NST guidance led to significantly improved clinical outcomes and a significant reduction in the cost of hospitalization. This study shows that tube feeding at home is not an intervention that should be viewed as “secondary” to the other therapies the patient may be receiving. Proper use of HEN can significantly impact patient clinical outcomes.