(From the July 2015 Issue of PediatricsOnline)
Children with intestinal failure often depend on a central venous catheter to deliver nutrition essential for their growth and survival directly to the bloodstream — this is called parenteral nutrition. However, these children are at high risk for developing central catheter-associated bloodstream infections.
A team at Nationwide Children’s Hospital has implemented a preventive measure that significantly reduces these infections. Published in JAMA Pediatrics, the study demonstrates that the addition of ethanol as part of the catheter care process safely reduces infection rates in this patient population both in the hospital and at home.
“Prevention of central catheter-associated bloodstream infections in children with intestinal failure remains a cornerstone of therapy and a continued challenge to improving patient care and clinical outcomes,” states Monica Ardura, DO, an infectious disease specialist at Nationwide Children’s Hospital and lead author of the study. Dr. Ardura notes that current published studies and national efforts to prevent bloodstream infections have focused on the hospital setting. However, little progress has been made on infection prevention with central catheter care in the home following a hospital discharge.
Previous retrospective studies indicated the addition of ethanol in catheter care as a potentially effective and inexpensive infection-prevention measure. In addition to other properties, ethanol can kill bacteria and fungi without promoting antimicrobial resistance.
Based on this promising data, Dr. Ardura and her colleagues conducted a quality-improvement initiative at Nationwide Children’s to evaluate whether adding ethanol to catheter care measures could safely reduce bloodstream infection rates in both hospital and home settings. Parents of study participants also received training and a detailed guide for using the new care bundle, which included alcohol wipes for the catheters.
The addition of ethanol to catheter maintenance was offered in February 2012 to patients with intestinal failure who had experienced two or more bloodstream infections during the previous year. During the first seven months of the initiative, overall bloodstream infection rates dropped from 6.99 to 3.83 infections per 1,000 catheter days.
Given this improvement, all patients with intestinal failure, regardless of their infection history, were offered the use of ethanol in catheter care. During the next 14 months, bloodstream infection rates decreased to 0.42 infections per 1,000 catheter days.
“To our knowledge, this study has demonstrated the greatest reduction in bloodstream infection rates, with more than 90 percent total reduction in this high-risk population,” says Dr. Ardura, who is also an assistant professor of Clinical Pediatrics at The Ohio State University.
“Although we have confirmation of ethanol use in catheter care in the patients’ homes, we were unable to measure how compliant our patient families were with the procedure,” states Jane Balint, MD, co-author of the study, medical director of the Intestinal Support Service at Nationwide Children’s and an associate professor of Clinical Pediatrics at The Ohio State University. “Thus, it’s difficult to determine how much the reduction of overall bloodstream infection rates was because of the improvement with catheter care compliance or simply the introduction of ethanol itself. Despite this limitation, to our knowledge, this study is the largest of its kind evaluating the use of ethanol in catheter maintenance in both hospital and home settings. Use of QI methods has also allowed us to quantify and confirm the effect and sustainability of this intervention over a prolonged period of time.”
Ardura M, Lewis J, Tansmore J, Harp P, Dienhart M, Balint J. Central catheter-associated bloodstream infection reduction with ethanol lock prophylaxis in pediatric intestinal failure: Broadening quality improvement initiatives from hospital to home. JAMA Pediatrics. 2015 Apr 1;169(4)324-31.