Secondary Logo

Journal Logo

Prevention of catheter-related blood stream infections in children with intestinal failure

Piper, Hannah G.; Wales, Paul W.

Current Opinion in Gastroenterology: January 2013 - Volume 29 - Issue 1 - p 1–6
doi: 10.1097/MOG.0b013e328358e268
GASTROINTESTINAL INFECTIONS: Edited Mitchell B. Cohen
Free

Purpose of review Catheter-related bloodstream infections (CRBSIs) account for a major source of morbidity in children with intestinal failure. Many of these patients require long-term central venous access, placing them at significant risk for these infections. The purpose of this review is to highlight the most current strategies and interventions for minimizing CRBSIs in this population.

Recent findings Strategies for the prevention of CRBSIs continue to evolve, although most have not been specifically evaluated in children with intestinal failure. Some of the more recent interventions that are likely to be effective in this population include creating standardized protocols for catheter insertion and maintenance, ethanol lock therapy, and occasional use of antimicrobial catheters and dressings.

Summary Every effort must be made to prevent CRBSIs in infants and children with intestinal failure. Disease specific risk factors must be considered when determining the best approach for infection prevention. Because of their long-term access needs, checklists and protocols to maintain strict sterile technique at the time of catheter insertion are useful. Additionally, these children often have some degree of intestinal bacterial overgrowth secondary to dilation and dysmotility. Therefore, the use of antimicrobial locks, catheters and dressings likely provide benefit for some patients.

Group for Improvement of Intestinal Function and Treatment (GIFT), Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada

Correspondence to Paul W. Wales, BSc, MD, MSc, FRCSC, FACS, Group for Improvement of Intestinal Function and Treatment (GIFT), Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Room 1526 Hill, Toronto, ON M5G 1X8, Canada. Tel: +1 416 813 7654/1490; fax: +1 416 813 7477; e-mail: paul.wales@sickkids.ca

Back to Top | Article Outline

INTRODUCTION

Intestinal failure occurs when intestinal absorption is inadequate such that macronutrients and/or water and electrolytes supplementation is required to maintain fluid balance, growth and health [1]. Short bowel syndrome (SBS) is the most common cause of intestinal failure in children often secondary to necrotizing enterocolitis, gastroschisis, volvulus or congenital intestinal atresias [2]. A Canadian population-based study estimated the incidence of neonatal SBS to be approximately 24.5 per 100 000 live births and as high as 354 per 100 000 live births in babies born before 37 weeks gestation [3], therefore, accounting for a significant healthcare problem in the pediatric population. Children with intestinal failure are all initially dependent on central venous catheters (CVCs) for delivery of parenteral nutrition. Although approximately 62% of children with SBS eventually achieve sufficient intestinal adaptation to absorb all of their nutrients enterally [4], adaptation can take months to years during which time the patients require parenteral nutrition.

Although parenteral nutrition has allowed many patients to live healthy and productive lives, it is not without consequences. Complications from long-term parenteral nutrition are numerous and include those associated with the components of the parenteral nutrition, and those associated with its delivery, specifically CVC infections and associated venous thrombosis. Loss of long-term venous access secondary to these complications can lead to significant morbidity and ultimately mortality [5,6]. Preventing catheter-related bloodstream infections (CRBSIs) is of utmost importance for patients with intestinal failure. Not only can infections lead to catheter loss, they can also worsen intestinal failure-associated liver disease (IFALD). IFALD is often the most fatal complication in infants with intestinal failure. Healthcare providers must, therefore, be proactive in preventing CRBSI in these patients.

Box 1

Box 1

Back to Top | Article Outline

CATHETER RELATED BLOOD STREAM INFECTIONS: DEFINITION AND ETIOLOGY

A CVC is defined as any catheter with the tip located in a large central vein, namely the superior or inferior vena cava. Access can be obtained via the femoral, iliac, subclavian, jugular or more peripheral veins. CRBSIs occur when there is verification of the same pathogen on the catheter surface and in the peripheral bloodstream. It is important to confirm the pathogen in both locations because the CVC may grow organisms that have colonized the line but are not causing a bloodstream infection [7], and peripheral cultures alone cannot distinguish between a transient bacteremia and a true CRBSI [8]. CRBSIs typically arise from bacterial colonization of the internal surface of the intravascular catheter [9,10], often from migration of skin flora [11]. However, children with intestinal failure have additional sources of bacteria that can result in catheter infection including gastrostomy tubes and enterostomies [12]. These patients may also have intestinal dilation with bacterial overgrowth that can predispose to CRBSI [13]. In addition, daily access for parenteral nutrition or fluid administration increases the chance of the catheter serving as a portal for infection.

A review of the pediatric literature reports the incidence of CRBSI to be between 1.1 and 14 infections per 1000 catheter days, depending on patient and catheter variables [4,8,14–19]. In children with intestinal failure the range is very similar (0.9–11 per 1000 catheter days) [20▪,21,22,23▪]. Despite several novel therapies proposed to reduce CRBSI, it continues to be a significant problem for patients with intestinal failure [24], as well as, a financial burden on the healthcare system [14]. Prevention is essential and begins with basic principles.

Back to Top | Article Outline

CATHETER INSERTION AND MAINTENANCE

One of the most basic, yet crucial factors in preventing CRBSI is meticulous sterile technique during catheter insertion. The most current guidelines from the Centers for Disease Control and Prevention published in 2011 [25▪▪] outline the following steps for central catheter insertion: proper hand hygiene, the use of a mask, cap, sterile gown, sterile gloves, full body drape and cleansing the patient's skin with at least 0.5% chlorhexidine. With the guidelines in mind, many institutions have implemented care ‘bundles’ for CVC insertion. These bundles include a sterile pack containing the necessary equipment for line insertion and/or maintenance, as well as, a checklist for inserting or accessing the line. They may also include routine education sessions and posters for teaching proper sterile technique. A recent multi-institutional collaborative study implemented care bundles in 26 pediatric ICUs. The rate of CRBSIs decreased from 6.3 to 4.3 per 1000 catheter days [26] and most sites sustained the reduced rate over the following 12 months [27▪▪]. Several additional studies in adult ICUs demonstrated similar reductions in CRBSIs with the implementation of CVC bundles [28–30]. Although there is nothing particularly novel about these interventions, the fact that many hospitals have seen a reduction in the incidence of infections emphasizes the importance of these details. The bundles are probably most valuable when there is a high baseline CRBSI rate. For children with intestinal failure, having protocols for both line insertion and maintenance is ideal considering the prolonged duration of therapy, the high likelihood of multiple care providers, and the importance of preserving venous access.

Back to Top | Article Outline

CATHETER LOCATION AND CATHETER TYPE

There are no recent studies investigating the impact of catheter location on CRBSI rates. Previously published reports demonstrated a higher infection rate with femoral catheters compared to other sites in adults [31–34]. This relationship has not been shown in children, even when considering high-risk patients such as burn victims and neonates [19,35]. Children with intestinal failure, however, frequently have chronic stomas with high outputs predisposing to bag leakage and spillage. A CVC in close proximity, therefore, has a higher likelihood of becoming infected. For these reasons, it is preferential to avoid the femoral veins as initial sites in children with intestinal failure.

Similarly, there are no recent data comparing the incidence of CRBSIs among different types of catheters including nontunneled central catheters, tunneled central catheters and peripherally inserted central catheters (PICCs). Most children with intestinal failure require long-term central access and are, therefore, best served by a tunneled CVC or a PICC. Risk factors associated with an increased rate of CRBSI include prematurity, previous abdominal surgery, presence of an enterostomy and using the catheter for parenteral nutrition, but not the specific type of catheter [36,37,38▪,39,40].

Back to Top | Article Outline

CATHETER LOCK SOLUTIONS

Traditionally, a catheter lock solution is used to prevent a thrombus from forming within the catheter when not in use. Heparin, because of its anticoagulant properties, is the standard lock solution; however, there is recent interest in broadening the function of the lock to include infection prevention. Multiple antibiotics have been used, but the more common agents include vancomycin and or gentamicin combined with heparin or citrate. The majority of studies have been conducted in adult patients on hemodialysis or receiving chemotherapy. It is difficult to draw clear conclusions from these trials because of variability among studies including the lock solution, the patient population, the baseline incidence of CRBSI, the type of central catheter and the duration of therapy. However, a recent meta-analysis summarized 16 randomized controlled trials and found a small overall benefit to using an antibiotic lock solution [41]. Nine of the studies were conducted in patients on hemodialysis and seven of the nine demonstrated a statistically significant reduction in infections when an antibiotic was added to the lock. Six of the trials were in patients receiving chemotherapy, and five of these were in children. The pooled results from all six studies showed a slight benefit with the antibiotic lock. Finally, there was one study in critically ill neonates. This study showed a significant reduction in CRBSI from 15.4 to 13.1 per 1000 catheter days with the use of vancomycin and heparin compared to heparin alone [42].

When specifically considering children with intestinal failure, there is only one recent retrospective study in this population. The study evaluated five children with intestinal failure, who had undergone multivisceral transplantation and were then treated prophylactically with tobramycin-tissue plasminogen activator locks [43]. The lines were locked 4 h each day, for 6 weeks and each patient served as his or her own control. They found significantly fewer bloodstream infections during the study period compared to the control period (46 vs. 74%, P < 0.05). The most recent guidelines published in 2011 by the Centers for Disease Control and Prevention [25▪▪] recommend the use of antibiotic locks in patients with long-term catheters who have multiple line infections despite adherence to basic principles of infection prevention. There is no recommendation regarding what type of antibiotic or the duration of therapy. As a general rule the antibiotic should be chosen to cover the most common organisms cultured from bloodstream infections within the particular institution.

One of the main concerns with the routine use of antibiotic locks is the development of resistant strains of bacteria. Although this has not yet been reported, there are few data available. However, alternative antimicrobial locks are becoming more popular in pediatric patients with CVCs. A randomized controlled trial was conducted in pediatric patients in the last year comparing taurolidine citrate to heparin locks in children receiving chemotherapy [44▪▪]. Taurolidine is derived from the amino acid taurine and is effective against a wide range of microorganisms. A total of 71 patients were included in the study (35 in the intervention group and 36 in the control group) and the incidence of CRBSI was 1.3 per 1000 catheter days in the heparin group compared to 0.3 per 1000 catheter days in the taurolidine/citrate group, which was a statistically significant difference.

A more readily available alternative is ethanol. The bactericidal properties of ethanol have been demonstrated in several in-vitro studies [9,45]. The mechanism of action includes nonspecific protein denaturation and diffusion through the polysaccharide matrix of the bacterial biofilm [10,24,46,47]. Biofilms form on implanted medical devices and can result in persistent infection because they are 10–1000 times more resistant to antibiotic therapy [10]. Ethanol lock therapy (ELT) has been utilized for both prevention and treatment of CRBSI at a standard concentration of 70% [14,22,24,47–50]. There have been several studies evaluating ELT for the prevention of CRBSI in children with intestinal failure. A retrospective study by Mouw et al.[22] reviewed 10 children with SBS on home parenteral nutrition. Each child's CVC was treated with 70% ethanol daily for 4–14 h. The infection rate decreased from 11.1 to 2.1 per 1000 catheter days after initiating ethanol lock. A retrospective study by Jones et al.[21] reviewed 23 children with intestinal failure. Each patient received 70% ethanol lock for 3 days each week, 4 h per day, and was compared to his or herself prior to the use of the ethanol lock. The infection rate dropped from 9.9 to 2.1 per 1000 catheter days after initiating ELT. Finally, a recently published study [23▪] reviewed 10 patients with intestinal failure on parenteral nutrition. The patients were treated with ELT daily for at least 4 h per day and the catheter infection rate decreased from 10.2 to 0.9 per 1000 catheter days. The same group published a meta-analysis of four studies comparing the rate of CRBSI in children with intestinal failure who received either ethanol or heparin CVC locks. The analysis found that the use of ethanol significantly reduced the risk of CRBSI by 81% [51▪▪]. The theoretical downside to routinely using ethanol as a lock solution is the potentially increased risk of catheter thrombosis, with published studies reporting a catheter thrombosis rate ranging from 0 to 50% [21,22,23▪,52]. An alternate day ethanol/heparin lock schedule may be superior and is worthy of investigation. In addition, it is becoming more difficult to obtain 95% ethanol, from which 70% ethanol lock is derived, and, therefore, the efficacy of ethanol at a lower concentration is being investigated. Ethanol may prove to be an effective lock solution for children with intestinal failure.

Back to Top | Article Outline

ANTIBIOTIC IMPREGNATED CATHETERS AND DRESSINGS

In addition to antimicrobial lock solutions, there are also catheters impregnated with antibiotics. In theory this could reduce the likelihood of a biofilm forming on the inside surface of the catheter, thereby decreasing the incidence of CRBSI. The majority of the studies have been conducted in adults with short-term catheters impregnated with chlorhexidine/silver sulfadiazine or minocycline/rifampin. Initially, catheters were coated with antibiotic on the outside surface but newer catheters are coated on both external and internal surfaces. The most recent randomized controlled trials in adults using second-generation catheters demonstrated a reduction in catheter colonization, but did not show a reduction in the rate of CRBSI [53–55].

Although there are no randomized pediatric trials, there are two recent studies in critically ill children. Chelliah et al.[56] compared the incidence of CRBSI in children in the ICU with minocycline–rifampin catheters compared to standard noncoated catheters. A total of 225 catheters were included in the analysis (69 coated and 156 noncoated). The overall incidence of CRBSI did not differ significantly between groups (7.53 vs. 8.64 per 1000 catheter days). The second study [57] looked at a stepwise approach to reducing CRBSIs in children in the ICU. One of the interventions included using minocycline–rifampin catheters. They found that the coated catheters decreased the infection rate from 6.4 to 4.2 per 1000 catheter days, without an increase in antibiotic-resistant organisms. Given that the majority of the available antibiotic impregnated catheters are designed for short-term use, are large (7F and larger) and are not cuffed, these catheters should not be routinely used for infants and children with intestinal failure. However, there is a relatively new minocycline–rifampin coated PICC (Cook Spectrum Turbo-Ject) that could be considered for patients with difficult-to-manage or recurrent infections.

The catheter dressing is another potential mechanism for preventing CRBSIs. Sterile dressings act as the initial barrier to the environment. The chlorhexidine sponge dressing has been the most popular choice due to the effectiveness of chlorhexidine as a skin preparation [11,25▪▪,27▪▪]. A randomized controlled trial by Timsit et al.[58] found that by using chlorhexidine sponge dressings for CVCs in adult patients in the ICU, the incidence of CRBSIs was reduced from 1.3 to 0.3 per 1000 catheter days. Catheters were in situ for a mean of 6 days and there was no evidence of antibiotic resistance in the bacteria found in skin samples when the catheters were removed. The current guidelines recommend the use of chlorhexidine sponge dressings for short-term catheters in patients older than 2 months of age when the CRBSI rate remains elevated despite best efforts [25▪▪]. Applicability to patients with intestinal failure must be approached with caution because many of the patients are neonates and may not tolerate chlorhexidine exposure and most patients require long-term CVCs.

Back to Top | Article Outline

CONCLUSION

Minimizing CRBSIs in infants and children with intestinal failure is of utmost importance to prevent worsening liver dysfunction and maintain the ability to administer parenteral nutrition. Current strategies for CRBSI prevention in these patients include implementing protocols and checklists for line insertion and maintenance, avoiding femoral veins in patients with enterostomies, considering an antibiotic or ethanol lock and using a chlorhexidine dressing in patients with recurrent infections.

Back to Top | Article Outline

Acknowledgements

None.

Back to Top | Article Outline

Conflicts of interest

The authors have no conflicts of interest to disclose.

Back to Top | Article Outline

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 92).

Back to Top | Article Outline

REFERENCES

1. Beath S, Pironi L, Gabe S, et al. Collaborative strategies to reduce mortality and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation. Transplantation 2008; 85:1378–1384.
2. Vanderhoof JA, Langnas AN. Short-bowel syndrome in children and adults. Gastroenterology 1997; 113:1767–1778.
3. Wales PW, de Silva N, Kim J, et al. Neonatal short bowel syndrome: population-based estimates of incidence and mortality rates. J Pediatr Surg 2004; 39:690–695.
4. Wales PW, de Silva N, Kim J, et al. Neonatal short bowel syndrome: a cohort study. J Pediatr Surg 2005; 40:755–762.
5. Diamanti A, Basso MS, Castro M, et al. Prevalence of life-threatening complications in pediatric patients affected by intestinal failure. Transplant Proc 2007; 39:1632–1633.
6. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant 2001; 5:80–87.
7. Fatkenheuer G, Cornely O, Seifert H. Clinical management of catheter-related infections. Clin Microbiol Infect 2002; 8:545–550.
8. Segarra-Newnham M, Martin-Cooper EM. Antibiotic lock technique: a review of the literature. Ann Pharmacother 2005; 39:311–318.
9. Chambers ST, Peddie B, Pithie A. Ethanol disinfection of plastic-adherent micro-organisms. J Hosp Infect 2006; 63:193–196.
10. Sanders J, Pithie A, Ganly P, et al. A prospective double-blind randomized trial comparing intraluminal ethanol with heparinized saline for the prevention of catheter-associated bloodstream infection in immunosuppressed haematology patients. J Antimicrob Chemother 2008; 62:809–815.
11. Kline AM. Pediatric catheter-related bloodstream infections: latest strategies to decrease risk. AACN Clin Issues 2005; 16:185–198.quiz 272–274.
12. Drews BB, Sanghavi R, Siegel JD, et al. Characteristics of catheter-related bloodstream infections in children with intestinal failure: implications for clinical management. Gastroenterol Nurs 2009; 32:385–390.quiz 391–392.
13. Terra RM, Plopper C, Waitzberg DL, et al. Remaining small bowel length: association with catheter sepsis in patients receiving home total parenteral nutrition: evidence of bacterial translocation. World J Surg 2000; 24:1537–1541.
14. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U. S. Pediatrics 2002; 110:e51.
15. Nahata MC, King DR, Powell DA, et al. Management of catheter-related infections in pediatric patients. JPEN J Parenter Enteral Nutr 1988; 12:58–59.
16. Wiener ES. Catheter sepsis: the central venous line Achilles’ heel. Semin Pediatr Surg 1995; 4:207–214.
17. Wiener ES, McGuire P, Stolar CJ, et al. The CCSG prospective study of venous access devices: an analysis of insertions and causes for removal. J Pediatr Surg 1992; 27:155–163.discussion 163–164.
18. Cuntz D, Michaud L, Guimber D, et al. Local antibiotic lock for the treatment of infections related to central catheters in parenteral nutrition in children. JPEN J Parenter Enteral Nutr 2002; 26:104–108.
19. Goldstein AM, Weber JM, Sheridan RL. Femoral venous access is safe in burned children: an analysis of 224 catheters. J Pediatr 1997; 130:442–446.
20▪. Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN J Parenter Enteral Nutr 2011; 35:67–73.

Retrospective study of 15 patients with intestinal failure treated with ethanol lock for a mean of 263 days. The article showed signficant reduction in CRBSI rate compared to previous 12 months.

21. 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; 45:1287–1293.
22. Mouw E, Chessman K, Lesher A, et al. Use of an ethanol lock to prevent catheter-related infections in children with short bowel syndrome. J Pediatr Surg 2008; 43:1025–1029.
23▪. Wales PW, Kosar C, Carricato M, et al. Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience. J Pediatr Surg 2011; 46:951–956.

Retrospective review of 10 patients with intestinal failure treated with an ethanol lock protocol. The authors found a significant reduction in both CRBSIs and catheter replacements with the protocol.

24. Broom J, Woods M, Allworth A, et al. Ethanol lock therapy to treat tunnelled central venous catheter-associated blood stream infections: results from a prospective trial. Scand J Infect Dis 2008; 40:399–406.
25▪▪. 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–S34.

Most recently published evidence-based general guidelines for prevention of CRBSIs. The article provides references for each guideline.

26. Jeffries HE, Mason W, Brewer M, et al. Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative. Infect Control Hosp Epidemiol 2009; 30:645–651.
27▪▪. Secola R, Lewis MA, Pike N, et al. ‘Targeting to zero’ in pediatric oncology: a review of central venous catheter-related bloodstream infections. J Pediatr Oncol Nurs 2012; 29:14–27.

Reviews several studies at institutions where standard protocols for CVC insertion and maintenance were put into place and CRBSIs were reduced. The article includes a summary table of recently published studies.

28. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007; 82:672–678.
29. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725–2732.
30. Shuman EK, Washer LL, Arndt JL, et al. Analysis of central line-associated bloodstream infections in the intensive care unit after implementation of central line bundles. Infect Control Hosp Epidemiol 2010; 31:551–553.
31. Lorente L, Jimenez A, Iribarren JL, et al. The micro-organism responsible for central venous catheter related bloodstream infection depends on catheter site. Intensive Care Med 2006; 32:1449–1450.
32. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81:466–479.
33. Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units. Crit Care Med 2005; 33:1276–1280.
34. Deshpande KS, Hatem C, Ulrich HL, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med 2005; 33:13–20.discussion 234–235.
35. Murai DT. Are femoral Broviac catheters effective and safe? A prospective comparison of femoral and jugular venous broviac catheters in newborn infants. Chest 2002; 121:1527–1530.
36. Klein MD, Rood K, Graham P. Central venous catheter sepsis in surgical newborns. Pediatr Surg Int 2003; 19:529–532.
37. Bowen A, Carapetis J. Advances in the diagnosis and management of central venous access device infections in children. Adv Exp Med Biol 2011; 697:91–106.
38▪. Gillanders L, Angstmann K, Ball P, et al. A prospective study of catheter-related complications in HPN patients. Clin Nutr 2012; 31:30–34.

Recent report of CVC-related complications for 53 patients on home parenteral nutrition. Study includes both adults and children and found a CRBSI rate of 6.9 per 1000 catheter days for children. Discusses potential risk factors and specific organisms.

39. Njere I, Islam S, Parish D, et al. Outcome of peripherally inserted central venous catheters in surgical and medical neonates. J Pediatr Surg 2011; 46:946–950.
40. Advani S, Reich NG, Sengupta A, et al. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit. Clin Infect Dis 2011; 52:1108–1115.
41. Snaterse M, Ruger W, Scholte O, et al. Antibiotic-based catheter lock solutions for prevention of catheter-related bloodstream infection: a systematic review of randomised controlled trials. J Hosp Infect 2010; 75:1–11.
42. Garland JS, Alex CP, Henrickson KJ, et al. A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial. Pediatrics 2005; 116:e198–e205.
43. Onder AM, Kato T, Simon N, et al. Prevention of catheter-related bacteremia in pediatric intestinal transplantation/short gut syndrome children with long-term central venous catheters. Pediatr Transplant 2007; 11:87–93.
44▪▪. Dumichen MJ, Seeger K, Lode HN, et al. Randomized controlled trial of taurolidine citrate versus heparin as catheter lock solution in paediatric patients with haematological malignancies. J Hosp Infect 2012; 80:304–309.

Study in children requiring CVCs for at least 4 weeks. Patients randomized to receive taurolidine/citrate versus heparin. No difference seen in catheter colonization but significantly fewer BSIs were seen in the taurolidine group.

45. Sissons CH, Wong L, Cutress TW. Inhibition by ethanol of the growth of biofilm and dispersed microcosm dental plaques. Arch Oral Biol 1996; 41:27–34.
46. Maiefski M, Rupp ME, Hermsen ED. Ethanol lock technique: review of the literature. Infect Control Hosp Epidemiol 2009; 30:1096–1108.
47. Dannenberg C, Bierbach U, Rothe A, et al. Ethanol-lock technique in the treatment of bloodstream infections in pediatric oncology patients with broviac catheter. J Pediatr Hematol Oncol 2003; 25:616–621.
48. 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; 31:302–305.
49. Metcalf SC, Chambers ST, Pithie AD. Use of ethanol locks to prevent recurrent central line sepsis. J Infect 2004; 49:20–22.
50. Onland W, Shin CE, Fustar S, et al. Ethanol-lock technique for persistent bacteremia of long-term intravascular devices in pediatric patients. Arch Pediatr Adolesc Med 2006; 160:1049–1053.
51▪▪. Oliveira C, Nasr A, Brindle M, Wales PW. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. Pediatrics 2012; 129:318–329.

Meta-analysis of four trials in children with intestinal failure using 70% ethanol lock for long-term CVCs. The authors found that ethanol locks reduced the rate of CRBSIs by 7.67 per 1000 catheter days compared to heparin lock.

52. Kayton ML, Garmey EG, Ishill NM, et al. Preliminary results of a phase I trial of prophylactic ethanol-lock administration to prevent mediport catheter-related bloodstream infections. J Pediatr Surg 2010; 45:1961–1966.
53. Rupp ME, Lisco SJ, Lipsett PA, et al. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial. Ann Intern Med 2005; 143:570–580.
54. Ostendorf T, Meinhold A, Harter C, et al. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: a double-blind, randomised, prospective, controlled trial. Support Care Cancer 2005; 13:993–1000.
55. Brun-Buisson C, Doyon F, Sollet JP, et al. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazine-coated catheters: a randomized controlled trial. Intensive Care Med 2004; 30:837–843.
56. Chelliah A, Heydon KH, Zaoutis TE, et al. Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients. Pediatr Infect Dis J 2007; 26:816–820.
57. Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 2007; 334:362–365.
58. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009; 301:1231–1241.
Keywords:

central venous catheter; complications; intestinal failure; pediatrics

© 2013 Lippincott Williams & Wilkins, Inc.