Elsevier

Clinical Nutrition

Volume 32, Issue 1, February 2013, Pages 16-26
Clinical Nutrition

Review
Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: A systematic review

https://doi.org/10.1016/j.clnu.2012.08.004Get rights and content

Summary

Background and aims

Catheter-related infection (CRI) is the most common and serious complication for adult patients receiving home parenteral nutrition (HPN). Our aim is to provide epidemiological data on infection incidence, infecting pathogens and contributing risk factors.-

Methods

Four electronic databases (Embase, Medline, IPA, CINAHL) were screened for eligible studies published between 1970 and March 2012. Methodological quality was evaluated and terminology/definitions were re-categorized.

Results

Thirty-nine studies were included. Extensive variability was observed in terminology/definitions as well as in expression of CRI rate. After correct interpretation of definitions, overall catheter-related bloodstream infection rate (CRBSI) ranged between 0.38 and 4.58 episodes/1000 catheter days (median 1.31). Gram-positive bacteria of human skin flora caused more than half of infections. An analysis of the reported risk factors showed that the origin of a CRBSI is often multifactorial. The risk factors were related to the patient, the venous access device, the education, HPN therapy and follow-up.

Conclusions

This review on CRI in adult HPN patients revealed that included studies are of low quality and used poorly described risk factors and different definitions. The human skin flora caused most of infections; therefore, hand hygiene and training remain essential.

Introduction

Home parenteral nutrition (HPN) is a therapy for patients with severe or long-term intestinal failure. These patients are unable to receive their nutritional requirements by oral intake and/or enteral tube feeding but are clinically stable enough to leave the hospital. HPN can be life-saving or life-extending as all nutrient requirements are administered systemically. For adequate venous access, the presence of a central venous catheter (CVC) is necessary. In general, two types of venous access devices are used: i.e. catheters for short-term or long-term use. As HPN patients usually receive therapy during a long period of time, tunneled catheters and infusion ports are mostly used.1 Peripherally inserted CVC’s (PICCs) are only preferred if the estimated duration of HPN is limited to 12–18 months.2

The most common venous access-related complications for HPN patients are infection, thrombosis, functional complications (for example total occlusion) and pneumothorax.3 Catheter-related infections are the most serious threat.3, 4 These infections include both local and systemic infections. Local infections are exit-site, tunnel and pocket infections. Generalized systemic infections include catheter-related bloodstream infection (CRBSI). The latter is defined as isolation of the same organism from semi-quantitative or quantitative cultures of both blood drawn from the catheter lumen and the blood peripherally drawn of the patient with clinical symptoms of a bloodstream infection and no other apparent source of infection.5, 6 The major causes of CRBSI are contamination of the catheter hub and migration of the skin organisms at the insertion site into the catheter tract.5 Important determinants of CRBSI are the material of the device, the intrinsic virulence factors of the infecting organism and protein adhesions, such as fibrin and fibronectin, which form a sheath around the catheter.6

Catheter-related infections can lead to an increased morbidity and mortality. Moreover, these infections usually require hospital admission and cause high costs for the healthcare system.7 Therefore a better understanding of the epidemiology of these infections is necessary to prevent harm. The aim of this review is to provide an overview of catheter-related infection rates, causative pathogens and associated risk factors.

Section snippets

Search strategy

Four electronic databases (Embase, Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA)) were screened for studies concerning catheter-related infections of adult HPN patients, published between 1970 and March 2012. The following search string was used: (total parenteral nutrition, home OR home parenteral nutrition OR home total parenteral nutrition OR home ambulatory nutrition OR home infusion therapy) AND

Results of search strategy

Searches in Embase, Medline, CINAHL and IPA identified 45, 174, 77 and 84 studies, respectively. There were 326 unique studies of which 71 were retained after evaluation of the relevance of titles and abstracts (Fig. 1). Finally, full-text evaluation resulted in inclusion of 39 publications. Nine of these were found through manual search of bibliographies.

Characteristics of selected studies

Characteristics of the included studies are summarized in Table 1. All studies were performed and published between 1984 and March 2012. The

Discussion

To our knowledge, this is the first systematic review describing the incidence of catheter-related infections in combination with microbiological information and contributing risk factors in adult patients receiving HPN. Catheter-related infection rates and causative pathogens in adult HPN patients have already been reviewed in 199741 and 2008,50 however without detailed specifications on risk factors.

Conflict of interest statement

Mira Dreesen has an unconditional educational grant from the Baxter company in Belgium. However this company was not involved in the study design, in the collection, analysis and interpretation of the data, in writing the manuscript and in the decision to submit the manuscript for publication.

Each author has completed the checklist for conflict of interest statements. Mira Dreesen (corresponding author) submitted these documents during the submission process.

Author contribution

All authors made substantial contributions and approved the final version of the conceptions, drafting and the final version. They participated sufficiently, intellectually or practically, in the work to take public responsibility for the content of the article, including the conception, design and data interpretation.

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