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Adjunctive management of central line-associated bloodstream infections with 70% ethanol-lock therapy.

ABSTRACT: Ethanol is bactericidal against most pathogens implicated in central line-associated bloodstream infections (CLABSIs) and biofilms. Current Infectious Diseases Society of America guidelines cite insufficient evidence to support adjunctive ethanol-lock therapy (ELT) for central venous catheter (CVC) salvage in patients with CLABSI in combination with systemic antimicrobial treatment. We evaluated the safety and potential efficacy of 70% ELT for CLABSI at our institution after implementation of a hospital ELT protocol.We collected data on all patients treated with adjunctive 70% ELT for catheter salvage from September 2009 to September 2011 and assessed clinical outcomes and adverse events associated with ELT.Sixty-eight hospitalized patients received 70% ELT for CVC salvage: 45 (66%) met the criteria for CLABSI. Five (11%) had persistent or recurrent bacteraemia triggering CVC removal; 28 (62%) preserved their CVC long term. There were no documented adverse events associated with ELT.Adjunctive 70% ELT is an inexpensive, well-tolerated option for CVC salvage in patients with CLABSI and warrants further investigation.

SUBMITTER: Kubiak DW

PROVIDER: S-EPMC4019330 | biostudies-literature | 2014 Jun

REPOSITORIES: biostudies-literature

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Adjunctive management of central line-associated bloodstream infections with 70% ethanol-lock therapy.

Kubiak David W DW Gilmore Erin T ET Buckley Mary W MW Lynch Robert R Marty Francisco M FM Koo Sophia S

The Journal of antimicrobial chemotherapy 20140212 6

<h4>Objectives</h4>Ethanol is bactericidal against most pathogens implicated in central line-associated bloodstream infections (CLABSIs) and biofilms. Current Infectious Diseases Society of America guidelines cite insufficient evidence to support adjunctive ethanol-lock therapy (ELT) for central venous catheter (CVC) salvage in patients with CLABSI in combination with systemic antimicrobial treatment. We evaluated the safety and potential efficacy of 70% ELT for CLABSI at our institution after i ...[more]

PMID: 24526514

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Project description:Abstract Background Central line-associated bloodstream infection (CLABSI) commonly affects children with cancer and hematological disorders, with significant attributable costs and morbidity. Treatment failure, comprising persistent infection, infection relapse or new infection, occurs in ~50% of cases. Adjunctive ethanol lock therapy (ELT) has been proposed to prevent failure, but has never been tested in a prospective controlled study. Methods A prospective, dual-center, double-blind, block-randomized, placebo-controlled trial of ELT (70% ethanol in water) for CLABSI, given as treatment (2 hours per lumen per day) for 5 days, followed by secondary prophylaxis (2 hours per lumen up to 3 days per week) for 24 weeks, in children with oncologic or hematologic disorders (NCT01472965). Risk of treatment failure was compared between intervention and control groups according to proportional and cumulative incidence models, using intention-to-treat and per-protocol analyses. The study was discontinued at a pre-specified futility analysis. Results Of 94 evaluable participants, 48 were randomized to ELT and 46 to placebo; groups were similar at baseline for all measured variables. Forty-one (43.6%) participants had treatment failure (11 early failure, 9 relapse, and 21 reinfection). There was no difference between patients receiving ELT or placebo for risk of treatment failure (43.8% vs. 43.5%; P = 0.9) or for cumulative incidence of treatment failure in intention to treat (Figure 1) and per-protocol analyses (Figure 2). Catheter occlusion was significantly more common in participants receiving ethanol (58.3% vs. 32.6%, P = 0.01) but other adverse events, including LFT elevations (14.6% vs. 26.1%) and infusion reactions (18.8% vs. 8.7%), were not significantly different between groups. Conclusion Although observational studies suggested ELT might be effective for treatment of CLABSI in pediatric oncology, we found no benefit in treatment outcome and an increase in adverse effects. These results may not apply to patients receiving dialysis or with fungal CLABSI as these were not well-represented. Routine use of ELT for CLABSI in children with oncologic or hematologic disorders is not recommended. Disclosures All authors: No reported disclosures.

Project description:Importance:National Healthcare Safety Network methods for central line-associated bloodstream infection (CLABSI) surveillance do not account for potential additive risk for CLABSI associated with use of 2 central venous catheters (CVCs) at the same time (concurrent CVCs); facilities that serve patients requiring high acuity care with medically indicated concurrent CVC use likely disproportionally incur Centers for Medicare & Medicaid Services payment penalties for higher CLABSI rates. Objective:To quantify the risk for CLABSI associated with concurrent use of a second CVC. Design, Setting, and Participants:This retrospective cohort study included adult patients with 2 or more days with a CVC at 4 geographically separated general acute care hospitals in the Atlanta, Georgia, area that varied in size from 110 to 580 beds, from January 1, 2012, to December 31, 2017. Variables included clinical conditions, central line-days, and concurrent CVC use. Patients were propensity score-matched for likelihood of concurrence (limited to 2 CVCs), and conditional logistic regression modeling was performed to estimate the risk of CLABSI associated with concurrence. Episodes of CVC were categorized as low or high risk and single vs concurrent use to evaluate time to CLABSI with Cox proportional hazards regression models. Data were analyzed from January to June 2019. Exposures:Two CVCs present at the same time. Main Outcomes and Measures:Hospitalizations in which a patient developed a CLABSI, allowing estimation of patient risk for CLABSI and daily hazard for a CVC episode ending in CLABSI. Results:Among a total of 50?254 patients (median [interquartile range] age, 59 [45-69] years; 26?661 [53.1%] women), 64?575 CVCs were used and 647 CLABSIs were recorded. Concurrent CVC use was recorded in 6877 patients (13.7%); the most frequent indications for concurrent CVC use were nutrition (554 patients [14.1%]) or hemodialysis (1706 patients [43.4%]). In the propensity score-matched cohort, 74 of 3932 patients with concurrent CVC use (1.9%) developed CLABSI, compared with 81 of 7864 patients with single CVC use (1.0%). Having 2 CVCs for longer than two-thirds of a patient's CVC use duration was associated with increased likelihood of developing a CLABSI, adjusting for central line-days and comorbidities (adjusted risk ratio, 1.62; 95% CI, 1.10-2.33; P?=?.001). In survival analysis adjusting for sex, receipt of chemotherapy or total parenteral nutrition, and facility, compared with a single CVC, the daily hazard for 2 low-risk CVCs was 1.78 (95% CI, 1.35-2.34; P?<?.001), while the daily hazard for 1 low-risk and 1 high-risk CVC was 1.80 (95% CI, 1.42-2.28; P?<?.001), and the daily hazard for 2 high-risk CVCs was 1.78 (95% CI, 1.14-2.77; P?=?.01). Conclusions and Relevance:These findings suggest that concurrent CVC use is associated with nearly 2-fold the risk of CLABSI compared with use of a single low-risk CVC. Performance metrics for CLABSI should change to account for variations of this intrinsic patient risk among facilities to reduce biased comparisons and resultant penalties applied to facilities that are caring for more patients with medically indicated concurrent CVC use.

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Adjunctive management of central line-associated bloodstream infections with 70% ethanol-lock therapy.

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Adjunctive management of central line-associated bloodstream infections with 70% ethanol-lock therapy.

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