February 2012 Issue

Prevent Catheter Sepsis in Home PN Care — RDs Can Help Nip This Serious Complication in the Bud
By Mandy L. Corrigan, MPH, RD, LD, CNSC
Today’s Dietitian
Vol. 14 No. 2 P. 60

In 2002, nearly 40,000 patients received home parenteral nutrition (HPN).1 PN is reserved for patients with a nonfunctioning gastrointestinal (GI) track who are unable to adequately consume or absorb nutrients enterally. Indications for PN include peritonitis, intestinal obstruction or prolonged ileus, bowel ischemia, radiation enteritis, intestinal malabsorption due to short-bowel syndrome, GI fistulae, or severe persistent GI bleeding.2-4

The use of PN doesn’t come without risk. Patients can potentially develop many different types of complications, including metabolic (eg, electrolyte imbalances, hydration status alterations, nutrient deficiencies, metabolic bone disease); hepatobiliary (eg, hepatosteatosis, cirrhosis), and those that are catheter related (eg, mechanical, noninfectious, infectious). The infectious complication considered to be one of the most serious and life threatening in patients receiving long-term PN is catheter-related bloodstream infection (CRBSI).

This article will discuss CRBSI; the research supporting ethanol lock therapy (ELT), a successful method of CRBSI prevention; and the role RDs can play in caring for long-term PN patients in the home setting.

Signs and Symptoms
The typical presentation of CRBSI includes a fever greater than 101˚F accompanied by shaking chills during the PN infusion, increased white blood cell count, and positive blood cultures. Frequent episodes of CRBSI can lead to the loss of access sites to place IV catheters, which is an indication for small-bowel transplantation in patients requiring lifelong PN. Steps taken to prevent CRBSI, based on 2011 Centers for Disease Control and Prevention guidelines, include proper hand hygiene, maximal barrier precautions during catheter placement, chlorhexidine skin antisepsis, prompt removal of catheters that are no longer needed, and educating the patient on proper catheter care.5

Methods of Prevention
Recent research has focused on more effective ways of preventing CRBSI that involve locking solutions with either an antibiotic or ethanol. The antibiotic or ethanol is instilled into the lumen of the catheter as a “lock” (while the PN is not infusing) to prevent undesirable bacterial entry and growth within the catheter. Antibiotic therapy or ELT has been studied in multiple populations, including hemodiaysis, oncology, and pediatric and adult PN patients, as a tool to prevent CRBSI. ELT has emerged as a means to prevent the main drawback in using an antibiotic lock, which is the potential for antibiotic resistance over time. Ethanol is inexpensive, bactericidal, and fungicidal, and there’s less concern about resistance since alcohol denatures proteins.6

Eligible Candidates
Patients receiving HPN through tunneled silicone catheters (eg, Hickman, Broviac, Groshong) or implanted ports are eligible to receive ELT. Some patients who are identified as being at high risk for developing CRBSI begin receiving ELT empirically, whereas others are administered ELT only after their first episode of CRBSI. Many physicians caring for HPN patients instill a 70% ethanol lock during the longest window of time when the catheter isn’t in use (eg, when the patient isn’t receiving cycled PN infusions or other IV preparations). Before the patient starts the next PN infusion, the ELT is flushed through the catheter with a saline flush.

The optimal concentration of ethanol and dwell time in the catheter is unknown, but research in this area continues.

Best Time to Begin ELT
Probably the ideal time to start ELT is immediately after a new catheter is placed in a patient on discharge from the hospital to home since biofilm begins to form on the internal surface of the catheter soon after placement. ELT is less likely to be as effective in older catheters with existing biofilm growth, but it still may play a role in preventing CRBSI.

In an acute care inpatient hospital setting, ELT isn’t used routinely since catheters are accessed more frequently for IV medications and infusions during an acute illness, plus there wouldn’t be enough time for the ELT to dwell to achieve its benefits. Nonetheless, ELT can be used after hospital discharge in the home setting or long-term care facilities.

Currently, ELT isn’t an approved therapy, but it’s showing promising results in clinical practice with HPN patients in the prevention of CRBSI.

Current Research
Since ELT isn’t an approved therapy, no commercially available product exists, so a pharmacy must compound it and provide it to patients in a prefilled syringe for daily use. Stability of the compounded ethanol lock within the syringe has been studied and well documented.7,8  

Many published reports have shown a decreased incidence of CRBSI in patients after the initiation of ELT. A small retrospective study of 31 HPN patients (serving as their own controls) used a 70% ethanol lock daily between cycled PN infusions through tunneled silicone catheters and implanted ports. There was a significant reduction in hospital admissions for CRBSI: 10 per 1,000 catheter-days pre-ELT compared with 6.5 per 1,000 catheter-days post ELT.9

ELT was found to be efficacious in reducing CRBSI and indicates a potential healthcare cost savings based on a decreased number of hospital admissions.9 Opilla and colleagues6 studied nine HPN patients with a crossover design using ELT. The patients had 81 CRBSIs before ELT and nine CRBSIs after ELT (8.3 per 1,000 catheter-days pre-ELT vs. 2.7 per 1,000 catheter-days post ELT).6

In pediatric patients, Mouw and colleagues showed a reduction in CRBSI in 10 pediatric patients with short-bowel syndrome using 70% ELT (11.15 per 1,000 catheter-days pre-ELT compared with 2.06 per 1,000 catheter-days post ELT).10 A retrospective review of pediatric patients requiring PN due to intestinal failure showed a decreased rate of CRBSI from 9.9 per 1,000 catheter-days to 2.1 per 1,000 catheter-days after using 70% ELT as preventative therapy.11  

One case study report addressed the concern that ELT could affect blood alcohol concentrations (BACs). A 98% ethanol lock was used once daily with a two-hour dwell time. Researchers measured BAC once and then performed follow-up breath testing. Interestingly, the BAC was undetectable 10 to 20 minutes after the ELT was flushed through the catheter into the bloodstream.12 Breath tests 20 seconds after flushing the ethanol showed a maximum BAC of 0.002%.12 The BAC further decreased after 15 minutes to 0.001% after the ethanol was flushed into the bloodstream, and after 20 minutes it was undetectable.12

Although this is only a single case report, studies using ELT in the HPN patient population are valuable and offer opportunities for clinicians to learn and pose new research questions.

More studies are needed in this area to address many unanswered questions regarding ELT: the optimal ethanol concentration, optimal dwell time in the catheter, cost-savings analysis, and if quality of life is positively impacted (decreased morbidity and hospital admissions for CRBSI) for HPN patients.  

What Dietitians Can Do
RDs can’t prescribe or compound ELT, but they can play an instrumental role in recommending ELT and advocating for patients who may benefit from this promising therapy.7,8 Dietitians can do the following:

Screen patients who may be eligible ELT candidates (patients on HPN therapy and with a history of frequent episodes of CRBSI).

Evaluate the type of catheters that have been used in patients experiencing repeated bouts of CRBSI. If a patient regularly develops CRBSI and has a temporary catheter that’s not tunneled or cuffed (eg, peripherally inserted central catheters), dietitians can recommend a tunneled catheter. Tunneled catheters have the potential to lower infection risk and can be used for ELT if they’re made from silicone. RDs also can work with physicians and nursing staff to ensure patients receive more education about how to use the proper technique to care for their catheters.

Discuss ELT with physicians and recommend it for patients who may benefit from it in the home or long-term care setting.

Work with home care or skilled nursing pharmacies to provide information on ELT to pharmacists, physicians, and nurses who may be unfamiliar with the therapy.  

Keep abreast of ELT research findings and contribute to this area of study.

 — Mandy L. Corrigan, MPH, RD, LD, CNSC, is a nutrition support clinician at the Cleveland Clinic specializing in home parenteral nutrition patient care.

 

Side Effects of ELT
• Potential side effects of ethanol lock therapy (ELT) include a warm flush after flushing the ELT into the catheter, dizziness, or a metallic taste. Suggest the patient eat a small piece of candy to remove the taste.

• If patients experience lightheadedness, RDs can suggest reducing the ethanol concentration from 70% to either 50% or 25%. Before reducing the concentration, however, ensure the patient or nurse flushes the ethanol very slowly.

• Consider discontinuing ELT while a patient is receiving oral metronidazole and vomiting occurs as a result. This reaction is similar to the antabuselike side effect of an alcohol and metronidazole combination.

— MLC

 

References
1. Ireton-Jones C, DeLegge MH, Epperson LA, Alexander J. Management of the home parenteral nutrition patient. Nutr Clin Pract. 2003;18(4):310-317. 

2. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(1 Suppl):1SA-138SA.

3. Skipper A. Principles of parenteral nutrition. In: Matarese LE, Gottschlich MM, eds. Contemporary Nutrition Support Practice. 2nd ed. St Louis, MO: W. B. Saunders Company; 2003:227-262.

4. Mirtallo JM. Overview of parenteral nutrition. In: Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach — The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007:264-275.

5. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.

6. Opilla MT, Kirby DF, Edmond MB. Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients. JPEN J Parenter Enteral Nutr. 2007;31(4):302-305.

7. Cober MP, Johnson CE. Stability of 70% alcohol solutions in polypropylene syringes for use in ethanol-lock therapy.  Am J Health Syst Pharm. 2007;64(23):2480-2482.

8. Pomplun M, Johnson JJ, Johnston S, Kolesar JM. Stability of a heparin-free 50% ethanol lock solution for central venous catheters. J Oncol Pharm Pract. 2007;13(1):33-37.

9. John BK, Khan MA, Speerhas R, et al. Ethanol lock therapy in reducing catheter related blood stream infections (CRBSI) in home parenteral nutrition patients. Gastroenterology. 2010;138(5 Suppl 1):S39.

10. Mouw E, Chessman K, Lesher A, Tagge E. Use of an ethanol lock to prevent catheter-related infections in children with short bowel syndrome. J Pediatr Surg. 2008;43(6):1025-1029.

11. Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg. 2010;45(6):1287-1293.

12. Robertson I, Diamantidis T, Okamoto R. Blood alcohol concentration during ethanol lock therapy for catheter-related blood stream infection. Abstract presented at: American Society of Parenteral and Enteral Nutrition Clinical Nutrition Week; January 29 – February 1, 2011; Vancouver, British Columbia, Canada.

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