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2018 HomePN Research Prize Winners
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2018 HomePN Research Prize Winners


Congratulations to the winners of the 2018 HomePN Research Prize, sponsored by Nutrishare, Inc. Prize winners Marianne Opilla, RN, BSN, CNSC, and Yannick Wouters, MD, presented their research at the Oley annual conference in Memphis in June. Their slides and presentations, which provide more information on the studies, are posted at www.oley.org/AnnualConference. Unfortunately, prize winner Siri Tribler, MD, was unable to attend.


Our thanks to Nutrishare for underwriting this important effort to highlight research affecting home parenteral nutrition consumers. Below, please find edited versions of all three research abstracts.


Central Venous Catheters for Home Parenteral Nutrition: Characteristics and Outcomes of Devices in Place for Five Years or Greater
Marianne Opilla, RN, BSN, CNSC


Purpose
: Intestinal failure patients may require home parenteral nutrition (HPN) for a lifetime. HPN is administered through a central venous catheter (CVC), and an important goal is to extend the dwell time of the CVC many years without complications leading to loss. The aim of this study was to examine a group of HPN patients and report characteristics and outcomes of CVCs in place for at least five years.
Methods: All charts of adult and pediatric patients from one home infusion pharmacy were retrospectively reviewed for CVCs in place for at least five years. Data collected included CVC type, days in place, number of lumens, material, and if removed, reason for loss. HPN regimen was also reported, including infusion days per week, cycle time, volume infused, and intravenous lipid emulsion (ILE) administration. Care routines were studied, such as use of protective alcohol cap; lock therapy; antimicrobial site patch; dressing type; lab draw method and frequency; and identification of primary caregiver. Demographic data included age, gender, diagnosis for HPN, and years on HPN.

Results: Sixty-one patients, age 13 to 91 years, were identified as having at least one CVC lasting at least five years. Sixty-two percent of these patients were female. The primary diagnosis was short bowel syndrome (70.5 percent). Total HPN years were 1495, averaging 24.5 years. HPN averaged six days per week, 2050 ml over a ten-hour cycle, and 85 percent infused ILE at least one day per week.
With fifty-one tunneled CVCs, this was the most common type. There were nine infusion ports and one PICC. Most CVCs were single lumen (95 percent) and made of silicone (87 percent). Total CVC days were 241,219, with an average of 3954 days (10.8 years).

Twenty of the sixty-one devices were still in place at the completion of the data collection. Looking at the other forty-one CVCs, catheter-related bloodstream infection (CRBSI) was the most frequent complication resulting in CVC loss (n*=20). The infection rate was 0.08 per 1000 CVC days. The second most frequent cause of CVC loss was catheter material damage (n=8), and the third was skin site failure (n=7). There were no obvious CVC losses related to infusion regimens.

The most frequently used CRBSI prevention strategy was the antimicrobial site patch (34.4 percent), followed by protective alcohol caps (18 percent), and alcohol lock (11.4 percent).** The majority of the patients did their own HPN administration and site care (self-care, 85.2 percent) and used transparent dressings (75.4 percent). Labs were drawn from the CVC 41 percent of the time, but none more frequently than once per month.

Conclusion: This cohort demonstrates that CVCs can remain in place at least five years without complications requiring removal. CRBSI was the most frequent reason for CVC loss, the CRBSI incidence was very low, and about a third of the patients used CRBSI preventative strategies. Use of transparent dressings and self-care may have impacted CRBSI incidence, but more studies would be needed to confirm this finding. The years of lived experience, education, and acquired catheter care knowledge in this unique group of HPN patients probably contributed to the low CRBSI rate. The material damage and skin site breakdown may be attributed to wear and tear as the CVC aged. HPN infusion regimens, thrombosis, occlusion, and blood draws from CVC did not appear to impact the CVC dwell time. Silicone, single-lumen tunneled CVCs provided the greatest longevity with the fewest complications, making this device the best choice for most HPN patients.

*n means “number”
**The site patch is placed around the exit or insertion site of the CVC and remains in place under the dressing for up to seven days. It provides continuous release of chlorhexidine to the site as a preventive measure for site infection. CRBSI can occur when bacteria enter the CVC during manipulation at the hub with flush or infusion connections. Protective alcohol-embedded end caps cover the CVC when it is not in use to prevent skin or environmental bacteria from entering at the hub. Lock therapy sterilizes the internal CVC lumen to reduce bacterial load that may be present in biofilm.



Catheter-Related Bloodstream Infections in Patients with Intestinal Failure Dependent on Home Parenteral Nutrition: Evaluation of a Catheter-Salvage Strategy
Siri Tribler, MD


Background: In patients with intestinal failure receiving home parenteral nutrition (HPN), catheter-related bloodstream infections (CRBSIs) entail a risk of frequent need for replacements of the tunneled central venous catheters (CVCs). Implementation of a catheter-salvage strategy is important to preserve safe and long-term central venous access.

Methods: This retrospective study investigated the short- and long-term consequences of a catheter-salvage strategy in the Department of Medical Gastroenterology, University Hospital of Copenhagen (Rigshospitalet), Denmark. We evaluated all CRBSIs occurring in patients followed and treated in our tertiary intestinal failure unit from 2002 to 2016 by extracting data from the Copenhagen Intestinal Failure and Microbiological databases. Catheter salvage was defined by successful antimicrobial treatment with a retained CVC at discharge after a CRBSI episode. CRBSIs with reappearance of same microbial species and identical antibiogram (or antimicrobial resistant pattern) were defined as a relapse (<30 days) or recurrent (30–100 days) infection.

The statistical analysis was performed with the cox regression analysis, an analysis that gives a probability of experiencing an event (CRBSI) at a particular time-point. Furthermore we included a random effect. We thereby accounted for the fact that some patients are overrepresented in the dataset with repetitive CRBSIs.

Results: Seven hundred and fifteen adult HPN patients covering 2014.3 CVC years and with use of 2006 tunneled CVCs presented with a CRBSI incidence of 1.83 per 1000 (n=1350) (0.67 CRBSIs per CVC year) and a very low patient mortality rate of 0.007 per 1000 CVC days (n=5) in relation to a CRBSI episode. The mean salvage rate was 55.3% (SDF±5.5%), varying according to infection-type (mono-infections [62.9±4.4%] and poly-infections [58.6±17.3%]); and causative microorganism (coagulase-negative Staphylococcus [CoNS] [68.1±9.4%], methicillin-sensitive Staphylococcus aureus [42.6±17.5%] and Enterobacteriaceae [54.3±16.7%]). (See tables 1 and 2.)

The overall risk of CRBSI relapse was 7.5% and the risk of CRBSI recurrence was 7.3%. The probability (hazard ratio[HR]) for a subsequent CRBSI was 14% lower in a replaced (=new CVC) versus retained CVC (p=0.03). The probability (HR) of experiencing a new CRBSI after catheter salvage was 36% higher after poly-infections (more than one microorganism detected) compared to mono-infections (only a single microorganism detected) (p=0.03).

Microorganisms in the microbial group called Enterobacteriaceae demonstrated an increased risk of CRBSI recurrence compared to both the group of microorganisms called coagulase-negative Staphylococcus (which is skin commensal microorganisms) (p=0.03) and the more virulent microorganism Staphylococcus aureus (p=0.02). No significant difference in risk was observed between the coagulase-negative Staphylococcus versus Staphylococcus aureus (p=0.30).

Conclusions: In adult intestinal failure–HPN patients, high catheter salvage rates were achievable and safe in relation to CRBSIs in single-lumen tunneled CVCs within a broad range of microorganisms. However, salvage inflicts an increased risk of CRBSI relapse or recurrence.

F CI, confidence interval; n, number; SD, standard deviation



Repair of Damaged Central Venous Catheters Is Safe and Substantially Prolongs Catheter Survival in Patients on Home Parenteral Nutrition
Yannick Wouters, MD


Background: Repeated central venous catheter (CVC) loss due to complications, including material breakage, compromises the options to obtain adequate vascular access in home parenteral nutrition (HPN) patients. On average, per patient, there is one damaged CVC every ten years. The most frequent reasons for damage include natural wear of material; rupture due to flushing occluded catheters; damage from sharp objects; repeated clamping maneuvers; and frequent bending.

It remains unclear whether repair of damaged catheters is an effective strategy to extend catheter survival, avoid surgical replacement, and maintain venous access. The aim of this study was to evaluate the efficacy and safety of catheter repair in our cohort of intestinal failure patients.

Methods: We performed a retrospective analysis of all catheter repairs that were performed between 2006 and 2017 at our tertiary referral center for intestinal failure. Primary endpoint was the additional median catheter survival after catheter repair, as calculated with Kaplan-Meier analysis. Survival of repaired catheters was compared with undamaged catheters. Secondary outcomes included risk for catheter-related bloodstream infections (CRBSIs) after repair (thirty days or whole catheter period, pre- versus post-repair), and risk factors for catheter damage, as calculated with Poisson regression analysis.†

Results: A total of fifty-eight repairs in forty-one CVCs of thirty-five HPN patients were included in the analysis (see figure 1). The median time to first repair was 452 days (interquartile range [IQR] 206–1134). After repair, catheter survival increased by 316 days (IQR 96–804). Incidence rates were 1.23 and 1.26 CRBSIs per 1000 catheter days for the 30 days pre- and post-repair periods, respectively (relative risk, 1.03; 95%CI, 0.11–9.88; P>0.99). For the whole pre- and post-repair catheter period, incidence rates were 0.12 and 0.59 CRBSIs per 1000 catheter days, respectively (relative risk, 4.73; 95%CI, 1.46–19.98; P=0.006). The overall CRBSI incidence rates in undamaged versus repaired catheters were 0.84 and 0.31 CRBSIs per 1000 catheter days, respectively (relative risk, 0.37; 95%CI, 0.22–0.61; P<0.001). Both a younger age at catheter start and femoral catheterization were independently associated with an increased risk for catheter damage.

Conclusion: Repair of damaged catheters is often successful, and an effective and safe strategy to prolong venous access in HPN patients.†† Both physicians and patients should be aware of this relatively low-cost strategy to maintain venous access. Identification of risk factors may help educate patients, especially during catheter training, to prevent future catheter damage.†††

† A Poisson regression analysis compares groups, but corrects for events that occur multiple times. For example, catheters were used multiple times per patient, and CRBSIs occurred multiple times per patient and even per catheter.

††To clarify, we conclude that repairs are safe (short-term, and overall) because:

  • The risk for CRBSIs on the short-term (thirty days) after a repair was not increased and thus safe
  • On the long-term (whole catheter period after repair) we observed an increase in CRBSIs. We think that the problem here is that catheters mostly at the end have a complication such as a CRBSI (that’s why they are removed). However, we officially cannot exclude the possibility that the repair itself also played a role for the increase in CRBSI rate.

When we compared repaired catheters with undamaged catheters, we found that repaired catheters (although there was an increase in CRBSI risk, see bullet 2 above) still had a lower risk of CRBSIs compared with undamaged catheters.


†††Physicians should be extra alert for younger patients and warn them to be careful with their catheters. Note that we included only adult patients in this study, and therefore you should, for example, interpret the data as a twenty-five-year-old patient having a higher risk for damage than a fifty-year-old patient.


July/August LifelineLetter, 2018

more Calendar

6/21/2019 » 6/24/2019
2019 Oley/UI Health Combined Conference

6/22/2019 » 6/23/2019
Virtual 2019 Oley Conference

This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

 

Updated in 2015 with a generous grant from Shire, Inc. 

 

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.
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