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Mo2120 Infection Rate in Inflammatory Bowel Disease (IBD) Patients on Home Parenteral Nutrition (HPN)
Mo2119
Copenhagen HPN database by a retrospective review of all charts from patients receiving HPN at Rigshospitalet. The diagnosis of a CRBSI required clinical signs of a systemic infection, and positive blood cultures with exclusion of other causes for infection. Results: In the 40years observation period, 509 HPN patients contributed with 1806 catheter years (CY) via 2.285 catheters. In 290 patients, HPN was provided for 2 years or less, while 219 patients received HPN for more than 2 years. A total of 231 patients had no CRBSIs, while 278 IF patients were diagnosed with a total of 862 CRBSIs during the 40 years. The CRBSI incidence increased within each decade correlating with the increase in patients entering the HPN program and thereby the catheter year (CY) they contributed. The CRBSI/CY was 0.22 episodes/catheter-year in the 1970ties and increased to 0.60 in the 2000's. The overall total CRBSI/CY during the 40 years was 0.48. CRBSIs were due to bacteraemia (85 %), fungemia (9 %) or a combination of bacteremia and fungemia (6 %). The most frequent type of bacteria was Staphylococcus, whereas the most prevalent fungus was Candida Glabrata. Overall the central catheter was replaced in 42 % of the CRBSIs, while systemic antibiotic treatment salvaged 446 catheters. During the 40 years, 12 patients died in relation to a CRBSI-related sepsis. Of these deaths, 8 were related to a sepsis caused by a single bacteria strain, 1 was due to polybacteraemia and 3 died in relation to fungemia. In two patients, their first CRBSI was fatal, and in one of those patients, HPN had only been provided for 41 days. The overall annual HPN-related CRBSI mortality was 0.007 deaths/catheter year. In the 40-year period, only one patient died in relation to placement of a central catheter. Conclusion: Although livesaving in patients with IF, the need for HPN and a central line carries the risk of frequent CRBSIs. The antibiotic salvage of a catheter is recommended to preserve the patient's vascular access. Bacteraemia was the main reason for the CRBSI, while fungemia and a combination of fungemia and bacteraemia accounted for only 15 %. With the steadily increasing number of IF patients requiring HPN, we see an increase in CRBSI in the last decade. The overall total CRBSI/CY during the 40 years was 0.48 and death due to this complication was rare. Blood cultures from the 862 CRBSI according to decades for patients receiving HPN at Rigshospitalet Denmark from 1970 to 2009.
AGA Abstracts
Increased Frequency of Catheter-Related Blood Stream Infections (CRBI) With Increased HPN and Lipid Emulsion Infusion, More Catheter Lumens and Blood Drawing From Catheters in Children With Intestinal Failure Alan Buchman, Marianne Opilla, Mary Kwasny, Rod J. Okamoto, Thomas G. Diamantidis Catheter-related bloodstream infections (CRBI) are the most common potentially serious complication of long term home parenteral nutrition (HPN). In a retrospective review, we sought to determine risk factors for development of CRBI among all patients serviced through Nutrishare, a home care company, between January 1, 2006 and December 31, 2011. This group included 18 patients (67% male) aged 6-18 yrs. Diagnoses included short bowel syndrome (56%), motility disorders (28%), and other (3%). A total of 352 central catheters were placed (median 3 per patient; range 1-10). Total catheter yrs was 1148. The median yrs on HPN was 10 yrs (range 2.9-18). 94% (50) of CVCs were tunneled, 6% (3) were subcutaneous infusion ports, and type was unknown for 6. There were no PICCs. 77% (41) of catheters were single lumen, 23% (12) were double-lumen; data was missing for 6 catheters). The median CVC dwell time was 515 days (range 17-3040). Median weekly PN infusion was 7 days (range 3-7)with 83% getting HPN 7 nights/wk, 11% 3-4x/wk, and 6% 5-6x/wk, and median weekly lipid emulsion infusion was 3 days (range 0-7). 82% of patients had blood obtained routinely exclusively from the catheter for laboratory testing and 18% had blood obtained only peripherally. 44% of patients used IPA/chlorhexidine and 66% used IPA/povidone-iodine for a catheter hub disinfectant. 6 patients had no CRBSI. There were 166 CRBI's for a rate of 0.4 per yr. 56% of patients (10) had no IV medications other than their HPN while 7 (44%) had one or two additional medication daily. 37% of patients experienced a single CRBI, 4% had 2 and 1% had 3 infections. Generalized Estimating Equations (proc GENMOD in SASv9.2) were used to assess single predictors of any CRBI, adjusted for subject effect of the patient. Type 3 Chi Square analysis showed increased frequency of lipid emulsion infusion (p=0.02) and obtaining blood samples from the PN catheter (p=0.01) were the only risk factors identified for CRBI. CRBSI frequency was greater in patients that received lipid emulsion . twice weekly (p=0.01). Frequency of weekly HPN and type of hub disinfectant were not predictive of CRBI risk. Trends towards more frequent CRBI were observed with non-HPN catheter use and increased number of catheter lumens. In conclusion, blood samples should not be obtained from PN catheters and consideration should be given to decrease lipid emulsion infusion, perhaps only to provide essential fatty acids (one or twice weekly). Mo2120 Infection Rate in Inflammatory Bowel Disease (IBD) Patients on Home Parenteral Nutrition (HPN) Jithinraj Edakkanambeth Varayil, Ryan T. Hurt, Felicity Enders, Darlene G. Kelly Background: Nutritional intervention is an important in the treatment of patients with IBD. Even though total parenteral nutrition is no longer felt to have a primary therapeutic role in IBD, patients with IBD and severe malabsorption often require HPN as a temporary or permanent measure to maintain nutrition. There is a substantial lack of information about the goals of HPN as a short term and long term therapy in this patient cohort. There is also little information about HPN complications specific to this sub-group of severely malnourished IBD patients. This study was aimed at identifying short-term and long-term HPN-related infectious complications in IBD patients. Methods: Following IRB approval, data were collected prospectively from 1990-2011 when patients were enrolled in the HPN Program at the Mayo Clinic. All patients receiving HPN for the primary diagnosis of IBD who gave research authorization (% of total) were included. Comparison of infections rates (occurrences/1000 HPN days) was made among those with and without IBD. In addition, infections rates within the first 6 months of HPN time were compared to after the first 6 months of HPN in the same cohort. Student's t test was used to compare data. Results: A total of 923 patients were enrolled during the study period; 136 patients received HPN for IBD as the primary diagnosis. There were 55 (40.4%) males in the IBD group and, 312 males (39.6%) in the non-IBD group. Mean age at start of HPN was 46.8+15.7 years in IBD group and 55.2+14.8 years in the non-IBD group. Of patients with IBD 27% developed at least one infection in the first 6 months of therapy, and 47% after 6 months (p = 0.35). In the non- IBD group, 28% developed at least 1 infection in the first 6 months and 34% were infected after 6 months (p ,0.001). Gram negative infections averaged 0.78/1000 HPN days in the IBD group which had a higher trend than in the non-IBD group (0.54/1000 days, p=0.067). However total infections (1.68 vs 1.84 / 1000 days respectively), gram positive infection (0.84 vs. 0.78 per 1000 HPN days) and fungal infection (0.04 vs. 0.20 per 1000 days) were not significantly different by the two groups. Conclusions: HPN has a role in short term and long term treatment of patients with IBD and marked malabsorption or malnutrition. Infections are the most common complication in adults on HPN, and this is true in patients with IBD. In both IBD and non-IBD patients, the most common source of infection was gram positive organisms, but in those with IBD there was a trend for gram negative bacteremias to be more common than in others. This is not surprising since many of those with IBD have stomas favoring cross contamination of central lines or active disease which may favor translocation of bacteria. Care should be taken in training all patients on HPN to avoid central venous catheter infections.
Consequences of catheter-related infections in patients with intestinal failure 1970-2009
Mo2122 Inpatient Need for Total Parenteral Nutrition in Inflammatory Bowel Disease Is Associated With Higher Mortality - A Study Using National Inpatient Sample Over the Last Decade 2000-2008 Nilay Kumar, Shahryar Ahmad, Muhammad Ali, Gagan Kumar, Nanda Venu Introduction Patients with Inflammatory Bowel Disease (IBD) are at a high risk of nutritional deficiencies. Total parenteral nutrition (TPN) is frequently utilized in these patients if enteral nutrition is not tolerated or to optimize the nutritional status prior to surgery. But TPN itself is complicated by more frequent infections and other systemic side effects. The impact of TPN utilization on the mortality related to hospitalization for IBD has not been studied. Methods We utilized the Nationwide Inpatient Sample (NIS) database 2000-2008 for this study. NIS is the largest all payer inpatient database in the USA. All patients older than 18 years discharged with any diagnosis of IBD (Crohn's and Ulcerative Colitis) and requiring TPN were identified using appropriate international classification of diseases (ICD-9-CM) diagnosis and procedure codes. Outcome variables included in-hospital mortality, length of stay (LOS) and discharge disposition of IBD patients with or without TPN. Using the Stata software multivariate logistic regression was done to adjust for age, sex, race and Elixhauser co-morbidity index. Appropriate survey commands allowed weighting of the stratified data to give a national estimate. Results Between 2000-2008 there were 386,380 discharges related to IBD nationwide. TPN was utilized in 14,869 (4%) of these patients. IBD patients requiring TPN had a significantly higher mortality 4% vs. 1.2% (p ,0.001). The Odd's Ratio (OR) for mortality related to TPN in IBD was 3.1 (95% Confidence Interval [C.I] : 3-3.21). Although the overall mortality related to TPN in hospitalized patients with IBD has remained
Mo2121 Catheter-Related Bloodstream Infections (CRBSIs) in Adults Intestinal Failure (IF) Patients Depending on Home Parenteral Nutrition (HPN) in a Referral Centre Christopher F. Brandt, Louise Bangsgaard, Michael Staun, Lone Tjellesen, Kent V. Haderslev, Klavs Holtug, Per B. Mortensen, Palle B. Jeppesen Catheter-related bloodstream infections (CRBSI) is a serious and common complication to home aprenteral nutrition (HPN). Through the Copenhagen HPN database we looked at the incidence, infectious agents and consequences of CRBSI in our population from January 1st, 1970 to December 31st, 2009. Methods: Data was entered systematically into the
AGA Abstracts
S-748
Copenhagen HPN database by a retrospective review of all charts from patients receiving HPN at Rigshospitalet. The diagnosis of a CRBSI required clinical signs of a systemic infection, and positive blood cultures with exclusion of other causes for infection. Results: In the 40years observation period, 509 HPN patients contributed with 1806 catheter years (CY) via 2.285 catheters. In 290 patients, HPN was provided for 2 years or less, while 219 patients received HPN for more than 2 years. A total of 231 patients had no CRBSIs, while 278 IF patients were diagnosed with a total of 862 CRBSIs during the 40 years. The CRBSI incidence increased within each decade correlating with the increase in patients entering the HPN program and thereby the catheter year (CY) they contributed. The CRBSI/CY was 0.22 episodes/catheter-year in the 1970ties and increased to 0.60 in the 2000's. The overall total CRBSI/CY during the 40 years was 0.48. CRBSIs were due to bacteraemia (85 %), fungemia (9 %) or a combination of bacteremia and fungemia (6 %). The most frequent type of bacteria was Staphylococcus, whereas the most prevalent fungus was Candida Glabrata. Overall the central catheter was replaced in 42 % of the CRBSIs, while systemic antibiotic treatment salvaged 446 catheters. During the 40 years, 12 patients died in relation to a CRBSI-related sepsis. Of these deaths, 8 were related to a sepsis caused by a single bacteria strain, 1 was due to polybacteraemia and 3 died in relation to fungemia. In two patients, their first CRBSI was fatal, and in one of those patients, HPN had only been provided for 41 days. The overall annual HPN-related CRBSI mortality was 0.007 deaths/catheter year. In the 40-year period, only one patient died in relation to placement of a central catheter. Conclusion: Although livesaving in patients with IF, the need for HPN and a central line carries the risk of frequent CRBSIs. The antibiotic salvage of a catheter is recommended to preserve the patient's vascular access. Bacteraemia was the main reason for the CRBSI, while fungemia and a combination of fungemia and bacteraemia accounted for only 15 %. With the steadily increasing number of IF patients requiring HPN, we see an increase in CRBSI in the last decade. The overall total CRBSI/CY during the 40 years was 0.48 and death due to this complication was rare. Blood cultures from the 862 CRBSI according to decades for patients receiving HPN at Rigshospitalet Denmark from 1970 to 2009.
AGA Abstracts
Increased Frequency of Catheter-Related Blood Stream Infections (CRBI) With Increased HPN and Lipid Emulsion Infusion, More Catheter Lumens and Blood Drawing From Catheters in Children With Intestinal Failure Alan Buchman, Marianne Opilla, Mary Kwasny, Rod J. Okamoto, Thomas G. Diamantidis Catheter-related bloodstream infections (CRBI) are the most common potentially serious complication of long term home parenteral nutrition (HPN). In a retrospective review, we sought to determine risk factors for development of CRBI among all patients serviced through Nutrishare, a home care company, between January 1, 2006 and December 31, 2011. This group included 18 patients (67% male) aged 6-18 yrs. Diagnoses included short bowel syndrome (56%), motility disorders (28%), and other (3%). A total of 352 central catheters were placed (median 3 per patient; range 1-10). Total catheter yrs was 1148. The median yrs on HPN was 10 yrs (range 2.9-18). 94% (50) of CVCs were tunneled, 6% (3) were subcutaneous infusion ports, and type was unknown for 6. There were no PICCs. 77% (41) of catheters were single lumen, 23% (12) were double-lumen; data was missing for 6 catheters). The median CVC dwell time was 515 days (range 17-3040). Median weekly PN infusion was 7 days (range 3-7)with 83% getting HPN 7 nights/wk, 11% 3-4x/wk, and 6% 5-6x/wk, and median weekly lipid emulsion infusion was 3 days (range 0-7). 82% of patients had blood obtained routinely exclusively from the catheter for laboratory testing and 18% had blood obtained only peripherally. 44% of patients used IPA/chlorhexidine and 66% used IPA/povidone-iodine for a catheter hub disinfectant. 6 patients had no CRBSI. There were 166 CRBI's for a rate of 0.4 per yr. 56% of patients (10) had no IV medications other than their HPN while 7 (44%) had one or two additional medication daily. 37% of patients experienced a single CRBI, 4% had 2 and 1% had 3 infections. Generalized Estimating Equations (proc GENMOD in SASv9.2) were used to assess single predictors of any CRBI, adjusted for subject effect of the patient. Type 3 Chi Square analysis showed increased frequency of lipid emulsion infusion (p=0.02) and obtaining blood samples from the PN catheter (p=0.01) were the only risk factors identified for CRBI. CRBSI frequency was greater in patients that received lipid emulsion . twice weekly (p=0.01). Frequency of weekly HPN and type of hub disinfectant were not predictive of CRBI risk. Trends towards more frequent CRBI were observed with non-HPN catheter use and increased number of catheter lumens. In conclusion, blood samples should not be obtained from PN catheters and consideration should be given to decrease lipid emulsion infusion, perhaps only to provide essential fatty acids (one or twice weekly). Mo2120 Infection Rate in Inflammatory Bowel Disease (IBD) Patients on Home Parenteral Nutrition (HPN) Jithinraj Edakkanambeth Varayil, Ryan T. Hurt, Felicity Enders, Darlene G. Kelly Background: Nutritional intervention is an important in the treatment of patients with IBD. Even though total parenteral nutrition is no longer felt to have a primary therapeutic role in IBD, patients with IBD and severe malabsorption often require HPN as a temporary or permanent measure to maintain nutrition. There is a substantial lack of information about the goals of HPN as a short term and long term therapy in this patient cohort. There is also little information about HPN complications specific to this sub-group of severely malnourished IBD patients. This study was aimed at identifying short-term and long-term HPN-related infectious complications in IBD patients. Methods: Following IRB approval, data were collected prospectively from 1990-2011 when patients were enrolled in the HPN Program at the Mayo Clinic. All patients receiving HPN for the primary diagnosis of IBD who gave research authorization (% of total) were included. Comparison of infections rates (occurrences/1000 HPN days) was made among those with and without IBD. In addition, infections rates within the first 6 months of HPN time were compared to after the first 6 months of HPN in the same cohort. Student's t test was used to compare data. Results: A total of 923 patients were enrolled during the study period; 136 patients received HPN for IBD as the primary diagnosis. There were 55 (40.4%) males in the IBD group and, 312 males (39.6%) in the non-IBD group. Mean age at start of HPN was 46.8+15.7 years in IBD group and 55.2+14.8 years in the non-IBD group. Of patients with IBD 27% developed at least one infection in the first 6 months of therapy, and 47% after 6 months (p = 0.35). In the non- IBD group, 28% developed at least 1 infection in the first 6 months and 34% were infected after 6 months (p ,0.001). Gram negative infections averaged 0.78/1000 HPN days in the IBD group which had a higher trend than in the non-IBD group (0.54/1000 days, p=0.067). However total infections (1.68 vs 1.84 / 1000 days respectively), gram positive infection (0.84 vs. 0.78 per 1000 HPN days) and fungal infection (0.04 vs. 0.20 per 1000 days) were not significantly different by the two groups. Conclusions: HPN has a role in short term and long term treatment of patients with IBD and marked malabsorption or malnutrition. Infections are the most common complication in adults on HPN, and this is true in patients with IBD. In both IBD and non-IBD patients, the most common source of infection was gram positive organisms, but in those with IBD there was a trend for gram negative bacteremias to be more common than in others. This is not surprising since many of those with IBD have stomas favoring cross contamination of central lines or active disease which may favor translocation of bacteria. Care should be taken in training all patients on HPN to avoid central venous catheter infections.
Consequences of catheter-related infections in patients with intestinal failure 1970-2009
Mo2122 Inpatient Need for Total Parenteral Nutrition in Inflammatory Bowel Disease Is Associated With Higher Mortality - A Study Using National Inpatient Sample Over the Last Decade 2000-2008 Nilay Kumar, Shahryar Ahmad, Muhammad Ali, Gagan Kumar, Nanda Venu Introduction Patients with Inflammatory Bowel Disease (IBD) are at a high risk of nutritional deficiencies. Total parenteral nutrition (TPN) is frequently utilized in these patients if enteral nutrition is not tolerated or to optimize the nutritional status prior to surgery. But TPN itself is complicated by more frequent infections and other systemic side effects. The impact of TPN utilization on the mortality related to hospitalization for IBD has not been studied. Methods We utilized the Nationwide Inpatient Sample (NIS) database 2000-2008 for this study. NIS is the largest all payer inpatient database in the USA. All patients older than 18 years discharged with any diagnosis of IBD (Crohn's and Ulcerative Colitis) and requiring TPN were identified using appropriate international classification of diseases (ICD-9-CM) diagnosis and procedure codes. Outcome variables included in-hospital mortality, length of stay (LOS) and discharge disposition of IBD patients with or without TPN. Using the Stata software multivariate logistic regression was done to adjust for age, sex, race and Elixhauser co-morbidity index. Appropriate survey commands allowed weighting of the stratified data to give a national estimate. Results Between 2000-2008 there were 386,380 discharges related to IBD nationwide. TPN was utilized in 14,869 (4%) of these patients. IBD patients requiring TPN had a significantly higher mortality 4% vs. 1.2% (p ,0.001). The Odd's Ratio (OR) for mortality related to TPN in IBD was 3.1 (95% Confidence Interval [C.I] : 3-3.21). Although the overall mortality related to TPN in hospitalized patients with IBD has remained
Mo2121 Catheter-Related Bloodstream Infections (CRBSIs) in Adults Intestinal Failure (IF) Patients Depending on Home Parenteral Nutrition (HPN) in a Referral Centre Christopher F. Brandt, Louise Bangsgaard, Michael Staun, Lone Tjellesen, Kent V. Haderslev, Klavs Holtug, Per B. Mortensen, Palle B. Jeppesen Catheter-related bloodstream infections (CRBSI) is a serious and common complication to home aprenteral nutrition (HPN). Through the Copenhagen HPN database we looked at the incidence, infectious agents and consequences of CRBSI in our population from January 1st, 1970 to December 31st, 2009. Methods: Data was entered systematically into the
AGA Abstracts
S-748