Key Publication

Reviewer: Arsalan Khan, MD, Nutrition Support Service UICOMP/St. Francis Medical Center Peoria, Illinois

Reference: Xue Z, Coughlin R, Amorosa V, Quinn R, Schiavone P, Stoner N, et al. Factors Associated With Central Line-Associated Bloodstream Infections in a Cohort of Adult Home Parenteral Nutrition Patients. Journal of Parenteral and Enteral Nutrition. 2020 Nov;44(8):1388–96.

Why is this paper important? Infectious complications of parenteral nutrition (PN) are amongst the most frequent causes of morbidity and rehospitalization in home parenteral nutrition patients. The exact cost of catheter related blood stream infections (CLABSI) in dollars terms is challenging to quantify but could be upwards of 30,000 dollars per admission depending on severity and length of stay. Given the frequency of infections in PN patients, the cost can quickly add up to significant sums over the course of therapy.1 Despite how common CLABSIs are, there remains no accurate way to predict risk. The heterogeneous nature of the HPN population has led to conflicting data, even for the most fundamental issue, such as the type of catheter used. This study, in particular, reports a unique observation: patients with low BMI (<18.5) may have up to six times greater risk of CLABSI.

Summary: This study is an observational study attempting to identify patient factors/characteristics in home parenteral nutrition patients that predispose them to CLABSI. The patient population consists of patients under the care of the HPN service at the University of Pennsylvania Hospital from January 1, 2018, to June 30, 2019. The authors reviewed all medical records for basic demographics, diagnosis, experience with TPN, type of catheter (including the number of lumens), prior CLABSI, history of ostomy or wound, immunosuppression, and depression/anxiety. Bivariate associations between predictors and CLABSI outcome were assessed using chi-square or Fisher exact tests/t-test depending whether the predictor was categorical or continuous. The authors found presence of ostomy, tunneled/implanted catheter, and BMI less than 18 was associated with an increased risk of CLABSI.  

Commentary: While many studies have been conducted to assess risk factors predisposing patients to CLABSIs, this seems to be the first to describe BMI as an independent predictor of it. The authors also found tunneled/implanted ports to be associated with more infections than PICC lines. This, however, remains a point of contention, with various studies reporting either increased or decreased incidence of CLABSI associated with PICC lines. As per the ASPEN 2019 catheter selection guidelines, there remains mostly weak evidence regarding the risk of infection and mechanical complications based on catheter type. The situation is made even more confusing when comparing valved with non-valved central venous catheters, with one study reporting higher rates of CLABSI with valved Groshong catheters.2 In the absence of strong evidence to guide decision-making, the best course of action is to individualize therapy to a patients' unique circumstances.  

References:

  1. Analysis of Healthcare Institutional Costs of Pediatric Home Parenteral Nutrition Central Line Infections Raphael, Bram P.∗; Hazekamp, Christina∗,‡; Samnaliev, Mihail†; Ozonoff, Al‡,§ Author Information Journal of Pediatric Gastroenterology and Nutrition: October 2018 - Volume 67 - Issue 4 - p e77-e81 doi: 10.1097/MPG.0000000000002058
  2. Gleeson NC, Fiorica JV, Mark JE, Pinelli DM, Hoffman MS, Roberts WS, et al. Externalized Groshong Catheters and Hickman Ports for Central Venous Access in Gynecologic Oncology Patients. Gynecologic Oncology. 1993 Dec;51(3):372–6.

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