Recurrent Sepsis in Home Parenteral Nutrition Patients: An Analysis of Risk Factors

Abstract

Septicemia is the major cause of morbidity in home parenteral nutrition patients, accounting for approximately 70% of rehospitalizations. To identify risk factors, the incidence of infection was examined in 41 current home parenteral nutrition patients, 30 with short-bowel syndrome (including 16 with inflammatory bowel disease and 11 with bowel infarction) and 11 with chronic obstructive disorders. Management, which was followed for a mean duration of 78.6 months (range, 1 to 15 1/2 years), was standardized by protocol. Ten patients never experienced infection during the average follow-up of 61 months (range, 14 to 174 months), whereas seven patients experienced frequent infections during the mean follow-up of 77 months (range, 24 to 180 months). Significant distinguishing features in the frequent-infection group were younger age (45 ± 12 vs 66.9 ± 14.3 years, P < .05), Crohn's disease (in five of seven vs zero of 10 subjects, P < .05), jejunostomies (in seven of seven vs one of 10 subjects, p < .0005), and central vein thrombosis (in five of seven vs zero of 10 subjects, P < .05). A greater proportion of the frequent-infection group had poor catheter-care technique and more were smokers. One hundred fifty septicemias were confirmed by blood culture, giving an average infection rate of one every 31 months, 52% caused by Gram-positive organisms (chiefly coagulase-negative staphylococci and Staphylococcus aureus), 30% caused by Gram-negative organisms, and 16% caused by fungus (chiefly Candida albicans). In conclusion, these results indicate that catheter sepsis is not invariably associated with long-term intravenous feeding but that a combination of host factors (Crohn's disease, jejunostomy, and central vein thrombosis) and environmental factors (catheter management technique) increase the risk of recurrent sepsis. The results suggest that early preventative measures, such as maintenance of hydration, long-term anticoagulation, and decontamination of catheter hub and locking solution, should be considered in patients with the combination of Crohn's disease and jejunostomies to decrease the risk of frequent septicemias. (Journal of Parenteral and Enteral Nutrition 18:256-263, 1994)

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References

Burnes JU , O'Keefe SJD , Fleming CR , et al: Home parenteral nutrition: a 3 year analysis of clinical and laboratory monitoring. JPEN 16:327-332, 1992

Howard L. , Heaphey L. , Fleming CR , et al: Four years of the North American registry home parenteral nutrition outcome data and their implications for patient management. JPEN 15:384-393, 1991

Fleming CR , Berkener S (eds): Home Parenteral Nutrition: A Handbook for Patients. JB Lippincott Co, Philadelphia, 1987

American Heart Association : Prevention of bacterial endocarditis: Recommendations of the American Heart Association. JAMA 264: 2919-2922, 1990

Henry NK , McLimans CA , Wright AJ , et al: Microbiological and clinical evaluation of the isolator lysis-centrifugation blood culture tube. J Clin Microbiol 17:864-869, 1993

O'Keefe SJD , Ogden J. , Rund J. , et al: Steroids and bowel rest versus elemental diet with Crohn's disease: The effects on protein metabolism and immune function . JPEN 13:455-460, 1989

Stillman R. , Soleman F. , Carcia L. , et al: Etiology of catheter associated sepsis: Correlation with thrombogenicity . Arch Surg 112:1497-1499, 1977

Brismar B. , Hardstedt C. , Jacobson S. : Diagnosis of thrombosis by catheter phlebography after prolonged central venous catheterization. Ann Surg 194:779-783, 1981

Strinden WD , Helgerson RB , Maki DG : Candida septic thrombosis of the great central veins associated with central catheters. Ann Surg 202:653-658, 1985

10.

Bern MN , Lokich JJ , Wallach SR , et al: Very low doses of Warfarin can prevent thrombosis in central venous catheters: A randomized prospective trial. Ann Intern Med 112:423-428, 1990

11.

O'Keefe SJD. Peterson ME Fleming CR : Octreotide as an adjunct to home parenteral nutrition in the management of permanent end-jejunostomy syndrome. JPEN 18:26-34

12.

Yao JDC , Arkin CF , Karchmer AW : Vancomycin stability in heparin and total parenteral nutrition solution: Novel approach to therapy of central venous catheter related infections. JPEN 16:268-274. 1992

13.

O'Keefe SJD , Kelly DG : Nutrition and gastroenterology. IN Current Gastroenterology, vol 12, Gitnick G (ed). Times Mirror Co, St. Louis, 351-381, 1992

14.

Maki DG , Band JD : A comparative study of poly antibiotic and iodophore ointments in prevention of vascular catheter-related infections. Am J Med 70: 739-744, 1981

15.

Sitges-Serra A. , Linares J. , Garau J. : Catheter sepsis: The clue is the hub. Surgery 97:355-357, 1985

16.

Flowers RH , Schwenzer KJ , Copple RP , et al: Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter infection: A randomized controlled trial. JAMA 261:878-883, 1989

17.

Maki DG , Wheeler SJ , Stolz SM , et al: Clinical trial of a novel antiseptic-coated central venous catheter . Proceedings of the 31st ICAAC Clinical Infections , Washington, DC, 1991

18.

Maki DG , Cobb L. , Garman JK , et al: An attachable silver-impregnated cap for prevention of infection with central venous catheters: A prospective randomized multi-centered trial . Am J Med 85:307-314, 1988

19.

Messing B. , Pietra-Cohen S. , Debure A. , et al: Antibiotic-lock techniques: A new approach for optimal therapy for catheter related sepsis in home parenteral nutrition patients. JPEN 12:185-189, 1988