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Catheter-related infections in patients receiving home parenteral nutrition (HTPN): incidence and predictive factors of catheter removal
Topic 16-METABOLIC
AND
INFECTIOUS
P.76 Catheter-related infections in patients receiving home parenteral nutrition (HTPN): incidence and predictive factors of catheter removal.
The 527 pts including 138 children were followed a total of 1154 pt yrs. The median follow-up time was 206 days (range 7-6344 days). 36 patients were followed > 10 yrs (median 12.7 yrs). 315 adults but only 4 children were never infected. A total of 427 catheter related infections occurred giving an overall infection rate of 0.37/pt.yr (0.51 /pt.yr in children and 0.28/pt.yr in pts followed > 10 yrs). 70% of the infections overall were sepsis (0.26/pt.yr), with 17% exit site (0.06/ ptyr) and 2% tunnel (0.01 /pt.yr). In children 67% of infections were sepsis (0.37/pt.yr) and 24% exit site (0.13/pt.yr). 54 different organisms were responsible and 12% of infections were polymicrobial in origin. 60% of sepsis was caused by Gram- organisms (44% catheters removed). 43% of sepsis in children was caused by Gram- organisms. 26% of sepsis was caused by Gram+ organisms (40% catheters removed). 36% of sepsis in children was caused by Gram+ organisms. 14% of sepsis was fungal in origin in both adults and children (92% catheters removed). 74% of exit site infections were caused by S. aureus (38% removed). 57% of tunnel infections were caused by S. aureus (100% removed). Chi-square analysis demonstrated that the presence of fever, leu kocytosis, bandemia, left shift organism Gram status, polymicrobial infections or organism species (except for fungi and mycobacterium) could not reliably predict the need for catheter removal in any type of catheter-related infection. Catheter infection is uncommon in HTPN pts although more common in children than in their adult counterparts, This as well as the overall incidence of catheter infection in HTPN patients may relate to the protocol and technique of catheter care.
A. L. Buchman,
A. A. Moukarzel, M. E. Ament Div. of Peds GastroenterologylNutrition, UCLA Center, Los Angeles, CA. USA
Medical
Infections related to central venous catheters are among the most common complications of HTPN. Our aim in this retrospective review was to determine the incidence and cause of infections in our group as well as what factors might allow for the prediction of the need for early catheter removal in their treatment. The inpatient and outpatient records of 527 patients (pts) who were discharged on HTPN and followed by the UCLA HTPN service for a min. of 1 wk between April, 1973 and Oct., 1991 were reviewed. Catheter-related infection was diagnosed by the exclusion of all other potential infection sources by appropriate tests. Sepsis was established by the positive identification of an organism in blood culture from the catheter and peripherally-obtained blood (if positive). Exit site infection was defined as the detection of erythema and purulent material on the skin at the catheter exit site. Tunnel infection was defined as erythema with red streaking and tenderness over the subcutaneously tunneled catheter in the absence of pos. blood cultures. Fever was defined as an oral temp. 238°C. leukocytosis, a peripheral WBC count >10.8OO/cu mm, bandemia 313% band forms and a left shift of >75% immature cells on a peripheral smear.
Topic 17-DRUG
P.77
tamicin adults.
Total parenteral nutrition volume of distribution
AND
NUTRIENT
increases genin critically ill
C. L. Ronchera, N. V. Jime’nez, C. Tormo. J. P. Ordova’s Servicio de Farmacia, Hospital Dr Peset, Valencia, and Department of Pharmacy and Pharmaceutics, University of Valencia. Valencia, Spain Introduction: The highly water soluble aminoglycoside antibiotics distribute into the extracellular fluid compartment, and are eliminated by the kidney via glomerular filtration. Total Parenteral Nutrition (TPN) influences the fluid and electrolyte status of the patient, and causes organ changes. Therefore, it may alter the pharmacokinetics (distribution and elimination) of aminoglycoside antibiotics. Aim of the study: Does Total Parenteral Nutrition (TPN) affect gentamicin pharmacokinetics?. Patients and methods: Gentamicin pharmacokinetics were studied in 86 critically ill adult patients (mean*SD): age 60+ 14 years, weight 69.4& 10.2 kg, height 163k 10 cm;22 female/64 male. Four study groups were defined: TPN vs fluid therapy and Acute Renal Failure (ARF, CL,, < 100 mL/min/l.73 m*) vs normal renal function. The drug was administered by short IV infusion (30 min). Blood samples were drawn at steady-state, 5 min before the next dose (trough) and 30 min after the end of the infusion (peak). Serum gentamicin concentration was determined by fluorescence polarization immunoassay (TDx System, Abbott
COMPLICATIONS
INTERACTIONS
Laboratories). Gentamicin pharmacokinetic parameters (steady-state Volume of distribution (Vss) and total body clearance (CL)) were calculated by non-linear regression, based on a one-compartment model with first-order elimination Statistical analysis was performed by two-factor ANOVA. Results: TPN increased Vss (p < O.OOl), but did not affect CL (p = 0.75 NS). ARF reduced CL (p < O.OOl), but did not affect Vss (p = 0.27 NS). Consequently, TPN produced lower maximum steady-state concentrations ( <4 mcg/mL, p = 0.07), thus compromising therapeutic effectivity. ARF produced higher maximum (p < 0.001) and minimum (> 2 mgc/mL, p -X 0.0001) steady-state concentrations, thus increasing the risk of toxicity. Conclusion: TPN increases gentamicin Vss and decreases its maximum steady-state concentration, what agrees with the extracellular water expansion caused by TPN. This fact must be considered when prescribing the drug to patients under TPN, in order to attain therapeutic serum concentrations and avoid treatment failures. Gentemicin Vss (L/kg, TPN (p < 0.001)
meanfSEM) NO n = 27
Yes n=32
0.35+0.02
0.43+0.02
n=13
n=14
0.31 fO.O1
0.42*0.03
NO ARF (p = 0.27) Yes
58
AND
INFECTIOUS
P.76 Catheter-related infections in patients receiving home parenteral nutrition (HTPN): incidence and predictive factors of catheter removal.
The 527 pts including 138 children were followed a total of 1154 pt yrs. The median follow-up time was 206 days (range 7-6344 days). 36 patients were followed > 10 yrs (median 12.7 yrs). 315 adults but only 4 children were never infected. A total of 427 catheter related infections occurred giving an overall infection rate of 0.37/pt.yr (0.51 /pt.yr in children and 0.28/pt.yr in pts followed > 10 yrs). 70% of the infections overall were sepsis (0.26/pt.yr), with 17% exit site (0.06/ ptyr) and 2% tunnel (0.01 /pt.yr). In children 67% of infections were sepsis (0.37/pt.yr) and 24% exit site (0.13/pt.yr). 54 different organisms were responsible and 12% of infections were polymicrobial in origin. 60% of sepsis was caused by Gram- organisms (44% catheters removed). 43% of sepsis in children was caused by Gram- organisms. 26% of sepsis was caused by Gram+ organisms (40% catheters removed). 36% of sepsis in children was caused by Gram+ organisms. 14% of sepsis was fungal in origin in both adults and children (92% catheters removed). 74% of exit site infections were caused by S. aureus (38% removed). 57% of tunnel infections were caused by S. aureus (100% removed). Chi-square analysis demonstrated that the presence of fever, leu kocytosis, bandemia, left shift organism Gram status, polymicrobial infections or organism species (except for fungi and mycobacterium) could not reliably predict the need for catheter removal in any type of catheter-related infection. Catheter infection is uncommon in HTPN pts although more common in children than in their adult counterparts, This as well as the overall incidence of catheter infection in HTPN patients may relate to the protocol and technique of catheter care.
A. L. Buchman,
A. A. Moukarzel, M. E. Ament Div. of Peds GastroenterologylNutrition, UCLA Center, Los Angeles, CA. USA
Medical
Infections related to central venous catheters are among the most common complications of HTPN. Our aim in this retrospective review was to determine the incidence and cause of infections in our group as well as what factors might allow for the prediction of the need for early catheter removal in their treatment. The inpatient and outpatient records of 527 patients (pts) who were discharged on HTPN and followed by the UCLA HTPN service for a min. of 1 wk between April, 1973 and Oct., 1991 were reviewed. Catheter-related infection was diagnosed by the exclusion of all other potential infection sources by appropriate tests. Sepsis was established by the positive identification of an organism in blood culture from the catheter and peripherally-obtained blood (if positive). Exit site infection was defined as the detection of erythema and purulent material on the skin at the catheter exit site. Tunnel infection was defined as erythema with red streaking and tenderness over the subcutaneously tunneled catheter in the absence of pos. blood cultures. Fever was defined as an oral temp. 238°C. leukocytosis, a peripheral WBC count >10.8OO/cu mm, bandemia 313% band forms and a left shift of >75% immature cells on a peripheral smear.
Topic 17-DRUG
P.77
tamicin adults.
Total parenteral nutrition volume of distribution
AND
NUTRIENT
increases genin critically ill
C. L. Ronchera, N. V. Jime’nez, C. Tormo. J. P. Ordova’s Servicio de Farmacia, Hospital Dr Peset, Valencia, and Department of Pharmacy and Pharmaceutics, University of Valencia. Valencia, Spain Introduction: The highly water soluble aminoglycoside antibiotics distribute into the extracellular fluid compartment, and are eliminated by the kidney via glomerular filtration. Total Parenteral Nutrition (TPN) influences the fluid and electrolyte status of the patient, and causes organ changes. Therefore, it may alter the pharmacokinetics (distribution and elimination) of aminoglycoside antibiotics. Aim of the study: Does Total Parenteral Nutrition (TPN) affect gentamicin pharmacokinetics?. Patients and methods: Gentamicin pharmacokinetics were studied in 86 critically ill adult patients (mean*SD): age 60+ 14 years, weight 69.4& 10.2 kg, height 163k 10 cm;22 female/64 male. Four study groups were defined: TPN vs fluid therapy and Acute Renal Failure (ARF, CL,, < 100 mL/min/l.73 m*) vs normal renal function. The drug was administered by short IV infusion (30 min). Blood samples were drawn at steady-state, 5 min before the next dose (trough) and 30 min after the end of the infusion (peak). Serum gentamicin concentration was determined by fluorescence polarization immunoassay (TDx System, Abbott
COMPLICATIONS
INTERACTIONS
Laboratories). Gentamicin pharmacokinetic parameters (steady-state Volume of distribution (Vss) and total body clearance (CL)) were calculated by non-linear regression, based on a one-compartment model with first-order elimination Statistical analysis was performed by two-factor ANOVA. Results: TPN increased Vss (p < O.OOl), but did not affect CL (p = 0.75 NS). ARF reduced CL (p < O.OOl), but did not affect Vss (p = 0.27 NS). Consequently, TPN produced lower maximum steady-state concentrations ( <4 mcg/mL, p = 0.07), thus compromising therapeutic effectivity. ARF produced higher maximum (p < 0.001) and minimum (> 2 mgc/mL, p -X 0.0001) steady-state concentrations, thus increasing the risk of toxicity. Conclusion: TPN increases gentamicin Vss and decreases its maximum steady-state concentration, what agrees with the extracellular water expansion caused by TPN. This fact must be considered when prescribing the drug to patients under TPN, in order to attain therapeutic serum concentrations and avoid treatment failures. Gentemicin Vss (L/kg, TPN (p < 0.001)
meanfSEM) NO n = 27
Yes n=32
0.35+0.02
0.43+0.02
n=13
n=14
0.31 fO.O1
0.42*0.03
NO ARF (p = 0.27) Yes
58