SHORT COMMUNICATION
Preventing Bloodstream Infection in Patients Receiving Home Parenteral Nutrition Alison Muir, Christine Holden, Elaine Sexton, and James W. Gray ABSTRACT Patients receiving home parenteral nutrition (HPN) are at particularly high risk of meticillin-sensitive Staphylococcus aureus (MSSA) catheter-related bloodstream infections (CRBSI). We developed a multidisciplinary enhanced care pathway encompassing a number of minimal cost interventions involving line/exit site care, training for staff and parents, multidisciplinary discharge planning, and monitoring compliance. Implementation reduced the mean rates of MSSA CRBSI (from 0.93, 95% CI 0.25–1.61, to 0.23, 95% CI 0.06 to 0.52, per 1000 parenteral nutrition [PN] days) and all-cause CRBSI (from 1.98, 95% CI 0.77–3.19, to 0.45, 95% CI 0.10–0.80, per 1000 PN days). A similar approach could be applied to preventing health care–associated infections in other complex, vulnerable patient groups. Key Words: bloodstream infection, central venous catheter, home parenteral nutrition, Staphylococcus aureus
(JPGN 2014;59: 177–181)
I
n 2011 we suggested that prevention of a significant proportion of catheter-related bloodstream infections (CRBSI) with meticillin-sensitive Staphylococcus aureus (MSSA) in children was an achievable goal (1). We also identified that 1 group of patients at highest risk for MSSA CRBSI in our English children’s hospital was children receiving home parenteral nutrition (HPN). These patients present particular challenges from the point of view of MSSA CRBSI because they receive invasive care from parents, caregivers, and health care professionals in the home; limited options for vascular access make central venous catheters precious; patients frequently have comorbidities; oral antibiotic treatment for minor infections is not usually possible; and children commence parenteral nutrition (PN) at a young age, when they are particularly at risk of invasive infection with S aureus (2). S aureus was the most common pathogen isolated from patients receiving HPN in our hospital in the 19-month period before the interventions. The pattern of infection in published series on sepsis in paediatric patients receiving HPN varies markedly. In many studies coagulase-negative staphylococci (CoNS) and enteric Received and accepted April 25, 2014. From the Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK. Address correspondence to Alison Muir, FRCPath, Department of Microbiology, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD, UK (e-mail: alisonmuir1@nhs. net). The present work was shortlisted for the 2012 NHS Innovation Challenge Prizes. The authors report no conflicts of interest. Copyright # 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000419
JPGN
Volume 59, Number 2, August 2014
organisms predominate (3–12). Other centres have also found S aureus to be the most common organism (13,14). In 2011 we established a multidisciplinary working group to develop an enhanced care pathway for patients receiving HPN, with the principal aim of avoiding MSSA CRBSI. In the present article we describe the development and impact of the enhanced care pathway that reduced the incidence not only of MSSA CRBSI but also of all-cause CRBSI. We believe that our approach should be relevant to other groups of patients at risk of health care–associated MSSA CRBSI, whether acquired at home or in hospital.
METHODS Home Parenteral Nutrition Service Between August 2009 and November 2013 the Nutritional Care Nursing Team at Birmingham Children’s Hospital oversaw administration of HPN to 48 children with intestinal failure, median age 2 years (range 0–18 years). The reasons for intestinal failure were short bowel syndrome (23 patients), dysmotility (7 patients), enteropathy (7 patients), phenotypic diarrhoea (8 patients), graftversus-host disease, and immunodeficiency and Crohn disease (1 patient each). HPN is administered by a home care company, with involvement of parents and caregivers depending on assessment of their competence. The home care nurses are also responsible for identifying clinical problems such as early signs of infection.
Microbiology Records The Microbiology Department maintains a prospective database of positive blood cultures, with microbiological (organism cultured, site of blood culture), clinical (focus of infection and treating specialty), and demographic data including the patient’s age. Since October 2010 all bloodstream infections (BSI) with MSSA have been subject to a multidisciplinary root cause analysis. Laboratory-confirmed BSI was defined according to the Centers for Disease Control and Prevention/National Healthcare Safety Network surveillance criteria: a BSI was considered to be catheter-related unless another site of infection was evident.
Development of the Enhanced Care Pathway A care pathway for children receiving HPN that conformed to the recommendations included in the joint European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)–European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on paediatric parenteral nutrition and subsequent ESPEN guidelines on parenteral nutrition was already in use (15,16). In particular, we had well-defined processes for the management of exit site problems and there was an extensive programme of caregiver training before children were discharged, based mainly on observation of, and then supervised setting up of, PN. We established a multidisciplinary group to review all aspects
177
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Muir et al
JPGN
of management of a patient receiving HPN, taking account of published evidence, local experience, and expert opinion. The group met on 3 occasions between April and June 2011; actions were rolled out between April and July 2011, and were fully implemented by the end of July 2011. Using a multidisciplinary approach to considering all stages of clinical care, we identified several opportunities to reinforce existing, or add new, controls to the care of patients receiving HPN (Table 1). The changes that we introduced were mostly simple to implement at little or zero cost. Closer multidisciplinary working is central to our preventive measures. One important observation from root cause analyses was that MSSA CRBSI was often preceded by local signs of infection at the exit site for a short period beforehand. Although these signs were usually observed promptly, treatment was rarely commenced in time to prevent BSI. Given that oral antibiotic treatment is not an option for these patients, we devised a pathway for exit site infections in which a swab is taken and empiric topical mupirocin commenced immediately. A decision on any further management is made after 24 to 48 hours, depending on the clinical response to topical treatment and the microbiology results. Verbal communication of preliminary identification of potential pathogens in swabs by the Microbiology Department was identified as a critical step in optimising treatment. The multidisciplinary team ensured that line removal was considered after each episode of CRBSI: previously there had been a tendency to view line removal as a last resort treatment option, without consideration of the high likelihood of infection recurrence. We also identified that patients receiving HPN frequently have coexisting skin conditions, thus predisposing to S aureus colonisation. These patients are now referred to a dermatologist for assessment and treatment. Finally, a member of the infection control team now briefly attends discharge planning meetings. This helps identify and manage risk factors for individual patients (eg, knowledge of previous colonisation or infection history), and ensure that all caregivers have a clear understanding of infection-related matters.
Ethics The present study examined outcomes from changes in routine clinical practice. As such, ethical committee approval was not required.
RESULTS The mean duration of HPN per patient was 608 days, median 344 days, range 46 to 1583 days. A total of 26 patients entered, and 10 left, the HPN service during the study period: 8 patients received HPN for the full duration of the study period. The number of episodes of CRBSI and the causative organisms at different stages of implementing the revised pathway are shown in Table 2. The 17 episodes of MSSA BSI occurred in 8 patients (5 episodes: 1 patient; 3 episodes: 1 patient; 2 episodes: 3 patients; 1 episode: 3 patients). Multiple recurrent episodes of infection occurred despite line removal and replacement, and occurred mainly in patients with primary gastrointestinal disorders (especially phenotypic diarrhoea), instead of in those with short bowel syndrome. The mean rates of CRBSI before and during implementation were 1.98 (95% CI 0.77–3.19) and 1.82 (95% CI 0.95 to 4.59)/ 1000 catheter days, respectively, compared with 8.6/1000 days in another recent English study, indicating that our baseline infection rate was not unusually high (17). S aureus was the pathogen most commonly isolated at all stages. Following implementation, we
178
Volume 59, Number 2, August 2014
reduced the rate of MSSA CRBSI from 0.93/1000 PN days (95% CI 0.25–1.61) to 0.23/1000 PN days (95% CI 0.06 to 0.52). The rates of other BSI also decreased, so that the overall rate of CRBSI fell to 0.45/1000 PN days (95% CI 0.10–0.80).
DISCUSSION Staphylococci have generally been reported to be the most common cause of CRBSI in patients receiving HPN of all ages, and although the body of published data on the causative microorganisms of CRBSI in children receiving HPN is relatively small, most studies report CoNS or enteric organisms to predominate. Therefore, the present study is rare in showing the prominence of S aureus in children (3–10,14,18). Part of the reason for the preponderance of MSSA in our patient population is the low rate of occurrence of other line-associated pathogens, especially CoNS. The potential for S aureus to cause invasive infections in the paediatric HPN population is further evident from our observation that only 7 of our 48 patients had never been documented to be colonised or infected with S aureus. Of the patients who had MSSA BSI, all had been documented to be colonised or infected with MSSA at some time before commencing HPN. For this reason we decided to screen patients for S aureus (nasal and line site swabs) before discharge from hospital, and then every 3 months postdischarge. Early experience suggests that this strategy of screening and decolonisation is of limited value. Reductions in the overall rate of CRBSI of a similar magnitude have been reported previously following routine use of prophylactic line locking solutions such as taurolidine 2% and ethanol. Taurolidine has antimicrobial activity against many bacteria, yeasts, and moulds that prevents biofilm formation with no evidence of antimicrobial adaptation (17,19,20). Two recent small studies in patients receiving HPN have shown that taurolidine is effective as an agent for secondary prevention of CRBSI (21,22). Ethanol line locks have also been proposed as a means of reducing CRBSI in the paediatric HPN setting (23–25). Line thrombosis is a recognised complication, and concerns have been raised about catheter degeneration (24–26). A systematic review of the literature concluded that, although promising, there was insufficient evidence to recommend routine use of taurolidine to prevent CRBSI, and this view was echoed in the ESPEN guidelines for both taurolidine and ethanol and indeed all flushing/locking solutions (16,27). Additionally, line locks are expensive (approximately £4000 per patient per year). By contrast, the design and implementation of our prevention strategy carried almost no financial cost: only 2 patients with poor line infection histories (3 or more BSI within a 12-month period) were treated with taurolidine line locks. One patient had no further BSI after commencing taurolidine; the other (who had 3 episodes of MSSA BSI within 6 months) had 1 further episode of MSSA BSI within 1 month of commencing taurolidine, but has since been infection-free for 27 months. We have previously found that 80% of CRBSI in patients receiving HPN occur within 1 year of commencing HPN (unpublished observation). Taking into consideration that 19 of the 26 patients joining the HPN programme commenced after our interventions were implemented, our observed infection rate may understate the success of our project in preventing CRBSI. In summary, the present systematic, multidisciplinary approach to developing and implementing an enhanced care pathway has had clear benefits in reducing both MSSA and all-cause CRBSI in our paediatric patients receiving HPN. In 2005 the ESPGHAN Committee on Nutrition recommended that multidisciplinary nutritional support teams be available in paediatric units to perform tasks such as staff training and audit and that further research should be performed to evaluate their impact (28). www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 59, Number 2, August 2014
Preventing Bloodstream Infection in Patients Receiving HPN
TABLE 1. Existing and additional controls for central venous catheter care in children receiving home parenteral nutrition Aspect of care CVC and exit site care CVC insertion
Existing controls
Additional controls
Compliance with Department of Health HIIs Use of single-lumen tunnelled/implanted catheters where possible Ultrasound-guided venepuncture Maximal barrier precautions for insertion 2% chlorhexidine for skin antisepsis Chlorhexidine/isopropyl alcohol Disinfection of hubs, stopcocks, and needle-free connectors Regular change of administration sets Existing guideline including use of appropriate dressing None (MRSA screening before CVC insertion) Existing guideline
Insertion site selected to minimise risk of infection
Accessing CVC
Exit site care MSSA colonisation Action if local signs of infection Education and training Hospital staff
Mandatory study day and additional PN training
Parents and caregivers
Home care staff Discharge management Predischarge housing review Multidisciplinary discharge planning meeting
Transition from hospital to home care
Housing reviewed before discharge and hygiene standards discussed Line history reviewed; liaison with ICT if required Ad hoc arrangements for managing comorbidities/complex situations
Use of closed intravenous systems Emphasis on adequate cleaning and allowing product to evaporate
Use of Biopatch Screening for MSSA before discharge and every 3 months thereafter Exit site swabbed promptly Robust system for communication of positive culture results Microbiologist involved in treatment
Improved staff educational material CVC sepsis diagnosis and treatment protocols revised Training video covering key aspects of line care Additional training and assessment for parents administering PN Specialist nurse supervision of parental care at home Home care company provides training according to BCH policies Families given detailed verbal and written instructions regarding expected environmental standards ICT member attends to ensure: - Review of infection history in hospital - Caregivers understand early signs of infection - MSSA screening undertaken CAF used to evaluate child’s medical, social, and educational needs Follow-up arrangements for other key professionals determined, for example, dermatology referral if concerns about skin condition On first night of discharge NCNT visits family with the home care company NCNT makes further visits to facilitate ongoing care and family independence
None
Ongoing competency assessment NCNT family training using teaching tools and written information before discharge
Compliance with good practice Hand hygiene
Hospital hand hygiene policy
Hand hygiene audits for home care staff, parents, and caregivers
Use of glow and tell equipment to ensure correct
Audits
hand washing technique Audit of compliance with HIIs for inpatients
Regular HII audits for parents and home care staff with review and feedback NCNT monitors practices of home care company Regular review of line histories of patients receiving HPN Exit site care admissions audited and reviewed with support of ICT
BCH ¼ Birmingham Children’s Hospital; CAF ¼ Common Assessment Framework; CVC ¼ central venous catheter; HII ¼ high-impact intervention; HPN ¼ home parenteral nutrition; ICT ¼ infection control team; MRSA ¼ meticillin-resistant Staphylococcus aureus; MSSA ¼ meticillin-sensitive S aureus; NCNT ¼ nutritional care nursing team; PN ¼ parenteral nutrition.
Relatively little evidence concerning their effectiveness has since been published. Although infection was not specifically considered, a retrospective review of paediatric patients with intestinal failure in the United States reported that the only intervention to improve survival was involvement of a comprehensive care team (29). A www.jpgn.org
recent review of registry data and published literature also underlines the importance of a multidisciplinary approach to the management of children with intestinal failure, particularly with regard to prevention, early detection, and prompt treatment for infection (30, and references therein). These factors are also instrumental in the
179
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Muir et al
JPGN
Volume 59, Number 2, August 2014
TABLE 2. Details of catheter-related bloodstream infections before, during, and after implementation of an enhanced care pathway Number of episodes of CRBSI during the period
Species
Preimplementation (August 2009–March 2011)
During implementation (April–July 2011)
Postimplementation (August 2011–November 2013)
8 3 5 2 18 8127
4 — — — 4 2079
5 2 5 — 12 19,001
Staphylococcus aureus Coagulase-negative staphylococci Gram-negative bacteria Polymicrobial Total Number of HPN days
CRBSI ¼ catheter-related bloodstream infection; HPN ¼ home parenteral nutrition.
management of adult patients receiving HPN (31). Our work further emphasises the benefits of close multidisciplinary working and a comprehensive, clear pathway for dealing with patients receiving HPN, particularly with regard to prevention and timely treatment for infectious complications. Our work has important limitations, such as the relatively small sample size (although this was comparable to most previous reports) and the fact that we implemented a large number of interventions simultaneously, not all of which may have contributed to the reduction in CRBSI. We believe that the present systematic, multidisciplinary approach to developing and implementing an enhanced care pathway can be generally applicable to the prevention of specific health care–associated infections in complex and vulnerable patient groups. We have recently begun applying the same multidisciplinary approach to patients in other specialties with similarly promising preliminary results.
REFERENCES 1. Gray J, O’Donoghue B. Bacteraemia with meticillin-sensitive Staphylococcus aureus in an English children’s hospital. J Hosp Infect 2011; 78:158–9. 2. Harrison LM, Morris JA, Telford DR, et al. The nasopharyngeal bacterial flora in infancy: effects of age, gender, season, viral upper respiratory tract infection and sleeping position. FEMS Immunol Med Microbiol 1999;25:9–28. 3. Donnell SC, Taylor N, van Saene HK, et al. Infection rates in surgical neonates and infants receiving parenteral nutrition: a five-year prospective study. J Hosp Infect 2002;52:273–80. 4. Mueller-Premru M, Gubina M, Kaufmann ME, et al. Use of semiquantitative and quantitative culture methods and typing for studying the epidemiology of central venous catheter-related infections in neonates on parenteral nutrition. J Med Microbiol 1999;48:451–60. 5. Sondheimer JM, Asturias E, Cadnapaphornchai M. Infection and cholestasis in neonates with intestinal resection and long-term parenteral nutrition. J Pediatr Gastroenterol Nutr 1998;27:131–7. 6. Yeung CY, Lee HC, Huang FY, et al. Sepsis during total parenteral nutrition: exploration of risk factors and determination of the effectiveness of peripherally inserted central venous catheters. Pediatr Infect Dis J 1998;17:135–42. 7. Pichler J, Soothill J, Hill S. Reduction of blood stream infections in children following a change to chlorhexidine disinfection of parenteral nutrition catheter connectors. Clin Nutr 2014;33:85–9. 8. Goulet O, Larchet M, Gaillard JL, et al. Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters. Clin Nutr 1990; 9:73–8. 9. Dobson R, McGuckin C, Walker G, et al. Cycled enteral antibiotics reduce sepsis rates in paediatric patients on long-term parenteral nutrition for intestinal failure. Aliment Pharmacol Ther 2011;34:1005–11. 10. Greenberg RG, Moran C, Ulshen M, et al. Outcomes of catheterassociated infections in pediatric patients with short bowel syndrome. J Pediatr Gastroenterol Nutr 2010;50:460–2.
180
11. Hojsak I, Strizic H, Misˇ ak Z, et al. Central venous catheter related sepsis in children on parenteral nutrition: a 21-year single-center experience. Clin Nutr 2012;31:672–5. 12. Drews BB, Sanghavi R, Siegel JD, et al. Characteristics of catheterrelated bloodstream infections in children with intestinal failure: implications for clinical management. Gastroenterol Nurs 2009;32: 385–90. 13. Huang FC, Chang MH, Chen CC. Home parenteral nutrition in children. J Formos Med Assoc 1996;95:45–50. 14. Gandullia P, Lugani F, Costabello L, et al. Long-term home parenteral nutrition in children with chronic intestinal failure: a 15-year experience at a single Italian centre. Dig Liver Dis 2011;43:28–33. 15. Koletzko B, Goulet O, Hunt J, et al. 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 (suppl 2):S1–87. 16. Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28:365–77. 17. Chu HP, Brind J, Tomar R, et al. Significant reduction in central venous catheter related blood stream infections in children on home parenteral nutrition after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55:403–7. 18. Mohammed A, Grant FK, Zhao VM, et al. Characterisation of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN J Parenter Enteral Nutr 2011;35:581–7. 19. Shah CB, Mittelman MW, Costerton JW, et al. Antimicrobial activity of a novel catheter lock solution. Antimicrob Agents Chemother 2002;46: 1674–9. 20. Olthof ED, Rentenaar RJ, Rijs AJ, et al. Absence of microbial adaptation to taurolidine in patients on home parenteral nutrition who develop catheter related bloodstream infections and use taurolidine locks. Clin Nutr 2013;32:538–42. 21. Al-Amin AH, Sarveswaran J, Wood JM, et al. Efficacy of taurolidine on the prevention of catheter-related bloodstream infections in patients on home parenteral nutrition. J Vasc Access 2013;14:379–82. 22. Toure´ A, Lauverjat M, Peraldi C, et al. Taurolidine lock solution in the secondary prevention of central venous catheter-associated bloodstream infection in home parenteral nutrition patients. Clin Nutr 2012;31:567– 70. 23. Pieroni KP, Nespor C, Ng M, et al. Evaluation of ethanol lock therapy in pediatric patients on long-term parenteral nutrition. Nutr Clin Pract 2013;28:226–31. 24. 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;46:951–6. 25. Wong T, Clifford V, McCallum Z, et al. Central venous catheter thrombosis associated with 70% ethanol locks in pediatric intestinal failure patients on home parenteral nutrition: a case series. JPEN J Parenter Enteral Nutr 2012;36:358–60.
www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 59, Number 2, August 2014
Preventing Bloodstream Infection in Patients Receiving HPN
26. Maiefski M, Rupp ME, Hermsen ED. Ethanol lock technique: review of the literature. Infect Control Hosp Epidemiol 2009;30:1096–108. 27. Bradshaw JH, Puntis JW. Taurolidine and catheter-related bloodstream infection: a systematic review of the literature. J Pediatr Gastroenterol Nutr 2008;47:179–86. 28. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2005;41:8–11.
29. Hess RA, Welch KB, Brown PI, et al. Survival outcomes of pediatric intestinal failure patients: analysis of factors contributing to improved survival over the past two decades. J Surg Res 2011;170:27–31. 30. Krawinkel MB, Scholz D, Busch A, et al. Chronic intestinal failure in children. Dtsch Arztebl Int 2012;109:409–15. 31. Dibb M, Teubner A, Theis V, et al. Review article: the management of long-term parenteral nutrition. Aliment Pharmacol Ther 2013;37:587– 603.
Maternal Milk Paraphernalia II During the 17th and 18th centuries, following the scandals of ‘‘baby-farming’’ and wet nurses who hired themselves out to numerous families, society began to take notice of malnourished infants and infant mortality. Many of these newborn deaths were blamed on neglect and starvation, but some were attributed to ‘‘overlaying’’ (mothers lying on top of infants). Fifteenth-century Canterbury (England) parish registries recorded ‘‘overlaying’’ as leading among all of the causes of newborn deaths. These incidents became so common that by the early 16th century, to prevent sleepy mothers from smothering nursing infants, a ‘‘cage’’—the arcutio—was manufactured, which encased the baby and provided an opening for breast-feeding.
An arcutio, as illustrated in Gentleman’s Magazine, January 1746 —Contributed by Angel R. Colo´n, MD
www.jpgn.org
181
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Preventing Bloodstream Infection in Patients Receiving Home Parenteral Nutrition Alison Muir, Christine Holden, Elaine Sexton, and James W. Gray ABSTRACT Patients receiving home parenteral nutrition (HPN) are at particularly high risk of meticillin-sensitive Staphylococcus aureus (MSSA) catheter-related bloodstream infections (CRBSI). We developed a multidisciplinary enhanced care pathway encompassing a number of minimal cost interventions involving line/exit site care, training for staff and parents, multidisciplinary discharge planning, and monitoring compliance. Implementation reduced the mean rates of MSSA CRBSI (from 0.93, 95% CI 0.25–1.61, to 0.23, 95% CI 0.06 to 0.52, per 1000 parenteral nutrition [PN] days) and all-cause CRBSI (from 1.98, 95% CI 0.77–3.19, to 0.45, 95% CI 0.10–0.80, per 1000 PN days). A similar approach could be applied to preventing health care–associated infections in other complex, vulnerable patient groups. Key Words: bloodstream infection, central venous catheter, home parenteral nutrition, Staphylococcus aureus
(JPGN 2014;59: 177–181)
I
n 2011 we suggested that prevention of a significant proportion of catheter-related bloodstream infections (CRBSI) with meticillin-sensitive Staphylococcus aureus (MSSA) in children was an achievable goal (1). We also identified that 1 group of patients at highest risk for MSSA CRBSI in our English children’s hospital was children receiving home parenteral nutrition (HPN). These patients present particular challenges from the point of view of MSSA CRBSI because they receive invasive care from parents, caregivers, and health care professionals in the home; limited options for vascular access make central venous catheters precious; patients frequently have comorbidities; oral antibiotic treatment for minor infections is not usually possible; and children commence parenteral nutrition (PN) at a young age, when they are particularly at risk of invasive infection with S aureus (2). S aureus was the most common pathogen isolated from patients receiving HPN in our hospital in the 19-month period before the interventions. The pattern of infection in published series on sepsis in paediatric patients receiving HPN varies markedly. In many studies coagulase-negative staphylococci (CoNS) and enteric Received and accepted April 25, 2014. From the Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK. Address correspondence to Alison Muir, FRCPath, Department of Microbiology, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD, UK (e-mail: alisonmuir1@nhs. net). The present work was shortlisted for the 2012 NHS Innovation Challenge Prizes. The authors report no conflicts of interest. Copyright # 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000419
JPGN
Volume 59, Number 2, August 2014
organisms predominate (3–12). Other centres have also found S aureus to be the most common organism (13,14). In 2011 we established a multidisciplinary working group to develop an enhanced care pathway for patients receiving HPN, with the principal aim of avoiding MSSA CRBSI. In the present article we describe the development and impact of the enhanced care pathway that reduced the incidence not only of MSSA CRBSI but also of all-cause CRBSI. We believe that our approach should be relevant to other groups of patients at risk of health care–associated MSSA CRBSI, whether acquired at home or in hospital.
METHODS Home Parenteral Nutrition Service Between August 2009 and November 2013 the Nutritional Care Nursing Team at Birmingham Children’s Hospital oversaw administration of HPN to 48 children with intestinal failure, median age 2 years (range 0–18 years). The reasons for intestinal failure were short bowel syndrome (23 patients), dysmotility (7 patients), enteropathy (7 patients), phenotypic diarrhoea (8 patients), graftversus-host disease, and immunodeficiency and Crohn disease (1 patient each). HPN is administered by a home care company, with involvement of parents and caregivers depending on assessment of their competence. The home care nurses are also responsible for identifying clinical problems such as early signs of infection.
Microbiology Records The Microbiology Department maintains a prospective database of positive blood cultures, with microbiological (organism cultured, site of blood culture), clinical (focus of infection and treating specialty), and demographic data including the patient’s age. Since October 2010 all bloodstream infections (BSI) with MSSA have been subject to a multidisciplinary root cause analysis. Laboratory-confirmed BSI was defined according to the Centers for Disease Control and Prevention/National Healthcare Safety Network surveillance criteria: a BSI was considered to be catheter-related unless another site of infection was evident.
Development of the Enhanced Care Pathway A care pathway for children receiving HPN that conformed to the recommendations included in the joint European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)–European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on paediatric parenteral nutrition and subsequent ESPEN guidelines on parenteral nutrition was already in use (15,16). In particular, we had well-defined processes for the management of exit site problems and there was an extensive programme of caregiver training before children were discharged, based mainly on observation of, and then supervised setting up of, PN. We established a multidisciplinary group to review all aspects
177
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Muir et al
JPGN
of management of a patient receiving HPN, taking account of published evidence, local experience, and expert opinion. The group met on 3 occasions between April and June 2011; actions were rolled out between April and July 2011, and were fully implemented by the end of July 2011. Using a multidisciplinary approach to considering all stages of clinical care, we identified several opportunities to reinforce existing, or add new, controls to the care of patients receiving HPN (Table 1). The changes that we introduced were mostly simple to implement at little or zero cost. Closer multidisciplinary working is central to our preventive measures. One important observation from root cause analyses was that MSSA CRBSI was often preceded by local signs of infection at the exit site for a short period beforehand. Although these signs were usually observed promptly, treatment was rarely commenced in time to prevent BSI. Given that oral antibiotic treatment is not an option for these patients, we devised a pathway for exit site infections in which a swab is taken and empiric topical mupirocin commenced immediately. A decision on any further management is made after 24 to 48 hours, depending on the clinical response to topical treatment and the microbiology results. Verbal communication of preliminary identification of potential pathogens in swabs by the Microbiology Department was identified as a critical step in optimising treatment. The multidisciplinary team ensured that line removal was considered after each episode of CRBSI: previously there had been a tendency to view line removal as a last resort treatment option, without consideration of the high likelihood of infection recurrence. We also identified that patients receiving HPN frequently have coexisting skin conditions, thus predisposing to S aureus colonisation. These patients are now referred to a dermatologist for assessment and treatment. Finally, a member of the infection control team now briefly attends discharge planning meetings. This helps identify and manage risk factors for individual patients (eg, knowledge of previous colonisation or infection history), and ensure that all caregivers have a clear understanding of infection-related matters.
Ethics The present study examined outcomes from changes in routine clinical practice. As such, ethical committee approval was not required.
RESULTS The mean duration of HPN per patient was 608 days, median 344 days, range 46 to 1583 days. A total of 26 patients entered, and 10 left, the HPN service during the study period: 8 patients received HPN for the full duration of the study period. The number of episodes of CRBSI and the causative organisms at different stages of implementing the revised pathway are shown in Table 2. The 17 episodes of MSSA BSI occurred in 8 patients (5 episodes: 1 patient; 3 episodes: 1 patient; 2 episodes: 3 patients; 1 episode: 3 patients). Multiple recurrent episodes of infection occurred despite line removal and replacement, and occurred mainly in patients with primary gastrointestinal disorders (especially phenotypic diarrhoea), instead of in those with short bowel syndrome. The mean rates of CRBSI before and during implementation were 1.98 (95% CI 0.77–3.19) and 1.82 (95% CI 0.95 to 4.59)/ 1000 catheter days, respectively, compared with 8.6/1000 days in another recent English study, indicating that our baseline infection rate was not unusually high (17). S aureus was the pathogen most commonly isolated at all stages. Following implementation, we
178
Volume 59, Number 2, August 2014
reduced the rate of MSSA CRBSI from 0.93/1000 PN days (95% CI 0.25–1.61) to 0.23/1000 PN days (95% CI 0.06 to 0.52). The rates of other BSI also decreased, so that the overall rate of CRBSI fell to 0.45/1000 PN days (95% CI 0.10–0.80).
DISCUSSION Staphylococci have generally been reported to be the most common cause of CRBSI in patients receiving HPN of all ages, and although the body of published data on the causative microorganisms of CRBSI in children receiving HPN is relatively small, most studies report CoNS or enteric organisms to predominate. Therefore, the present study is rare in showing the prominence of S aureus in children (3–10,14,18). Part of the reason for the preponderance of MSSA in our patient population is the low rate of occurrence of other line-associated pathogens, especially CoNS. The potential for S aureus to cause invasive infections in the paediatric HPN population is further evident from our observation that only 7 of our 48 patients had never been documented to be colonised or infected with S aureus. Of the patients who had MSSA BSI, all had been documented to be colonised or infected with MSSA at some time before commencing HPN. For this reason we decided to screen patients for S aureus (nasal and line site swabs) before discharge from hospital, and then every 3 months postdischarge. Early experience suggests that this strategy of screening and decolonisation is of limited value. Reductions in the overall rate of CRBSI of a similar magnitude have been reported previously following routine use of prophylactic line locking solutions such as taurolidine 2% and ethanol. Taurolidine has antimicrobial activity against many bacteria, yeasts, and moulds that prevents biofilm formation with no evidence of antimicrobial adaptation (17,19,20). Two recent small studies in patients receiving HPN have shown that taurolidine is effective as an agent for secondary prevention of CRBSI (21,22). Ethanol line locks have also been proposed as a means of reducing CRBSI in the paediatric HPN setting (23–25). Line thrombosis is a recognised complication, and concerns have been raised about catheter degeneration (24–26). A systematic review of the literature concluded that, although promising, there was insufficient evidence to recommend routine use of taurolidine to prevent CRBSI, and this view was echoed in the ESPEN guidelines for both taurolidine and ethanol and indeed all flushing/locking solutions (16,27). Additionally, line locks are expensive (approximately £4000 per patient per year). By contrast, the design and implementation of our prevention strategy carried almost no financial cost: only 2 patients with poor line infection histories (3 or more BSI within a 12-month period) were treated with taurolidine line locks. One patient had no further BSI after commencing taurolidine; the other (who had 3 episodes of MSSA BSI within 6 months) had 1 further episode of MSSA BSI within 1 month of commencing taurolidine, but has since been infection-free for 27 months. We have previously found that 80% of CRBSI in patients receiving HPN occur within 1 year of commencing HPN (unpublished observation). Taking into consideration that 19 of the 26 patients joining the HPN programme commenced after our interventions were implemented, our observed infection rate may understate the success of our project in preventing CRBSI. In summary, the present systematic, multidisciplinary approach to developing and implementing an enhanced care pathway has had clear benefits in reducing both MSSA and all-cause CRBSI in our paediatric patients receiving HPN. In 2005 the ESPGHAN Committee on Nutrition recommended that multidisciplinary nutritional support teams be available in paediatric units to perform tasks such as staff training and audit and that further research should be performed to evaluate their impact (28). www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 59, Number 2, August 2014
Preventing Bloodstream Infection in Patients Receiving HPN
TABLE 1. Existing and additional controls for central venous catheter care in children receiving home parenteral nutrition Aspect of care CVC and exit site care CVC insertion
Existing controls
Additional controls
Compliance with Department of Health HIIs Use of single-lumen tunnelled/implanted catheters where possible Ultrasound-guided venepuncture Maximal barrier precautions for insertion 2% chlorhexidine for skin antisepsis Chlorhexidine/isopropyl alcohol Disinfection of hubs, stopcocks, and needle-free connectors Regular change of administration sets Existing guideline including use of appropriate dressing None (MRSA screening before CVC insertion) Existing guideline
Insertion site selected to minimise risk of infection
Accessing CVC
Exit site care MSSA colonisation Action if local signs of infection Education and training Hospital staff
Mandatory study day and additional PN training
Parents and caregivers
Home care staff Discharge management Predischarge housing review Multidisciplinary discharge planning meeting
Transition from hospital to home care
Housing reviewed before discharge and hygiene standards discussed Line history reviewed; liaison with ICT if required Ad hoc arrangements for managing comorbidities/complex situations
Use of closed intravenous systems Emphasis on adequate cleaning and allowing product to evaporate
Use of Biopatch Screening for MSSA before discharge and every 3 months thereafter Exit site swabbed promptly Robust system for communication of positive culture results Microbiologist involved in treatment
Improved staff educational material CVC sepsis diagnosis and treatment protocols revised Training video covering key aspects of line care Additional training and assessment for parents administering PN Specialist nurse supervision of parental care at home Home care company provides training according to BCH policies Families given detailed verbal and written instructions regarding expected environmental standards ICT member attends to ensure: - Review of infection history in hospital - Caregivers understand early signs of infection - MSSA screening undertaken CAF used to evaluate child’s medical, social, and educational needs Follow-up arrangements for other key professionals determined, for example, dermatology referral if concerns about skin condition On first night of discharge NCNT visits family with the home care company NCNT makes further visits to facilitate ongoing care and family independence
None
Ongoing competency assessment NCNT family training using teaching tools and written information before discharge
Compliance with good practice Hand hygiene
Hospital hand hygiene policy
Hand hygiene audits for home care staff, parents, and caregivers
Use of glow and tell equipment to ensure correct
Audits
hand washing technique Audit of compliance with HIIs for inpatients
Regular HII audits for parents and home care staff with review and feedback NCNT monitors practices of home care company Regular review of line histories of patients receiving HPN Exit site care admissions audited and reviewed with support of ICT
BCH ¼ Birmingham Children’s Hospital; CAF ¼ Common Assessment Framework; CVC ¼ central venous catheter; HII ¼ high-impact intervention; HPN ¼ home parenteral nutrition; ICT ¼ infection control team; MRSA ¼ meticillin-resistant Staphylococcus aureus; MSSA ¼ meticillin-sensitive S aureus; NCNT ¼ nutritional care nursing team; PN ¼ parenteral nutrition.
Relatively little evidence concerning their effectiveness has since been published. Although infection was not specifically considered, a retrospective review of paediatric patients with intestinal failure in the United States reported that the only intervention to improve survival was involvement of a comprehensive care team (29). A www.jpgn.org
recent review of registry data and published literature also underlines the importance of a multidisciplinary approach to the management of children with intestinal failure, particularly with regard to prevention, early detection, and prompt treatment for infection (30, and references therein). These factors are also instrumental in the
179
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Muir et al
JPGN
Volume 59, Number 2, August 2014
TABLE 2. Details of catheter-related bloodstream infections before, during, and after implementation of an enhanced care pathway Number of episodes of CRBSI during the period
Species
Preimplementation (August 2009–March 2011)
During implementation (April–July 2011)
Postimplementation (August 2011–November 2013)
8 3 5 2 18 8127
4 — — — 4 2079
5 2 5 — 12 19,001
Staphylococcus aureus Coagulase-negative staphylococci Gram-negative bacteria Polymicrobial Total Number of HPN days
CRBSI ¼ catheter-related bloodstream infection; HPN ¼ home parenteral nutrition.
management of adult patients receiving HPN (31). Our work further emphasises the benefits of close multidisciplinary working and a comprehensive, clear pathway for dealing with patients receiving HPN, particularly with regard to prevention and timely treatment for infectious complications. Our work has important limitations, such as the relatively small sample size (although this was comparable to most previous reports) and the fact that we implemented a large number of interventions simultaneously, not all of which may have contributed to the reduction in CRBSI. We believe that the present systematic, multidisciplinary approach to developing and implementing an enhanced care pathway can be generally applicable to the prevention of specific health care–associated infections in complex and vulnerable patient groups. We have recently begun applying the same multidisciplinary approach to patients in other specialties with similarly promising preliminary results.
REFERENCES 1. Gray J, O’Donoghue B. Bacteraemia with meticillin-sensitive Staphylococcus aureus in an English children’s hospital. J Hosp Infect 2011; 78:158–9. 2. Harrison LM, Morris JA, Telford DR, et al. The nasopharyngeal bacterial flora in infancy: effects of age, gender, season, viral upper respiratory tract infection and sleeping position. FEMS Immunol Med Microbiol 1999;25:9–28. 3. Donnell SC, Taylor N, van Saene HK, et al. Infection rates in surgical neonates and infants receiving parenteral nutrition: a five-year prospective study. J Hosp Infect 2002;52:273–80. 4. Mueller-Premru M, Gubina M, Kaufmann ME, et al. Use of semiquantitative and quantitative culture methods and typing for studying the epidemiology of central venous catheter-related infections in neonates on parenteral nutrition. J Med Microbiol 1999;48:451–60. 5. Sondheimer JM, Asturias E, Cadnapaphornchai M. Infection and cholestasis in neonates with intestinal resection and long-term parenteral nutrition. J Pediatr Gastroenterol Nutr 1998;27:131–7. 6. Yeung CY, Lee HC, Huang FY, et al. Sepsis during total parenteral nutrition: exploration of risk factors and determination of the effectiveness of peripherally inserted central venous catheters. Pediatr Infect Dis J 1998;17:135–42. 7. Pichler J, Soothill J, Hill S. Reduction of blood stream infections in children following a change to chlorhexidine disinfection of parenteral nutrition catheter connectors. Clin Nutr 2014;33:85–9. 8. Goulet O, Larchet M, Gaillard JL, et al. Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters. Clin Nutr 1990; 9:73–8. 9. Dobson R, McGuckin C, Walker G, et al. Cycled enteral antibiotics reduce sepsis rates in paediatric patients on long-term parenteral nutrition for intestinal failure. Aliment Pharmacol Ther 2011;34:1005–11. 10. Greenberg RG, Moran C, Ulshen M, et al. Outcomes of catheterassociated infections in pediatric patients with short bowel syndrome. J Pediatr Gastroenterol Nutr 2010;50:460–2.
180
11. Hojsak I, Strizic H, Misˇ ak Z, et al. Central venous catheter related sepsis in children on parenteral nutrition: a 21-year single-center experience. Clin Nutr 2012;31:672–5. 12. Drews BB, Sanghavi R, Siegel JD, et al. Characteristics of catheterrelated bloodstream infections in children with intestinal failure: implications for clinical management. Gastroenterol Nurs 2009;32: 385–90. 13. Huang FC, Chang MH, Chen CC. Home parenteral nutrition in children. J Formos Med Assoc 1996;95:45–50. 14. Gandullia P, Lugani F, Costabello L, et al. Long-term home parenteral nutrition in children with chronic intestinal failure: a 15-year experience at a single Italian centre. Dig Liver Dis 2011;43:28–33. 15. Koletzko B, Goulet O, Hunt J, et al. 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 (suppl 2):S1–87. 16. Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28:365–77. 17. Chu HP, Brind J, Tomar R, et al. Significant reduction in central venous catheter related blood stream infections in children on home parenteral nutrition after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55:403–7. 18. Mohammed A, Grant FK, Zhao VM, et al. Characterisation of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN J Parenter Enteral Nutr 2011;35:581–7. 19. Shah CB, Mittelman MW, Costerton JW, et al. Antimicrobial activity of a novel catheter lock solution. Antimicrob Agents Chemother 2002;46: 1674–9. 20. Olthof ED, Rentenaar RJ, Rijs AJ, et al. Absence of microbial adaptation to taurolidine in patients on home parenteral nutrition who develop catheter related bloodstream infections and use taurolidine locks. Clin Nutr 2013;32:538–42. 21. Al-Amin AH, Sarveswaran J, Wood JM, et al. Efficacy of taurolidine on the prevention of catheter-related bloodstream infections in patients on home parenteral nutrition. J Vasc Access 2013;14:379–82. 22. Toure´ A, Lauverjat M, Peraldi C, et al. Taurolidine lock solution in the secondary prevention of central venous catheter-associated bloodstream infection in home parenteral nutrition patients. Clin Nutr 2012;31:567– 70. 23. Pieroni KP, Nespor C, Ng M, et al. Evaluation of ethanol lock therapy in pediatric patients on long-term parenteral nutrition. Nutr Clin Pract 2013;28:226–31. 24. 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;46:951–6. 25. Wong T, Clifford V, McCallum Z, et al. Central venous catheter thrombosis associated with 70% ethanol locks in pediatric intestinal failure patients on home parenteral nutrition: a case series. JPEN J Parenter Enteral Nutr 2012;36:358–60.
www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN
Volume 59, Number 2, August 2014
Preventing Bloodstream Infection in Patients Receiving HPN
26. Maiefski M, Rupp ME, Hermsen ED. Ethanol lock technique: review of the literature. Infect Control Hosp Epidemiol 2009;30:1096–108. 27. Bradshaw JH, Puntis JW. Taurolidine and catheter-related bloodstream infection: a systematic review of the literature. J Pediatr Gastroenterol Nutr 2008;47:179–86. 28. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2005;41:8–11.
29. Hess RA, Welch KB, Brown PI, et al. Survival outcomes of pediatric intestinal failure patients: analysis of factors contributing to improved survival over the past two decades. J Surg Res 2011;170:27–31. 30. Krawinkel MB, Scholz D, Busch A, et al. Chronic intestinal failure in children. Dtsch Arztebl Int 2012;109:409–15. 31. Dibb M, Teubner A, Theis V, et al. Review article: the management of long-term parenteral nutrition. Aliment Pharmacol Ther 2013;37:587– 603.
Maternal Milk Paraphernalia II During the 17th and 18th centuries, following the scandals of ‘‘baby-farming’’ and wet nurses who hired themselves out to numerous families, society began to take notice of malnourished infants and infant mortality. Many of these newborn deaths were blamed on neglect and starvation, but some were attributed to ‘‘overlaying’’ (mothers lying on top of infants). Fifteenth-century Canterbury (England) parish registries recorded ‘‘overlaying’’ as leading among all of the causes of newborn deaths. These incidents became so common that by the early 16th century, to prevent sleepy mothers from smothering nursing infants, a ‘‘cage’’—the arcutio—was manufactured, which encased the baby and provided an opening for breast-feeding.
An arcutio, as illustrated in Gentleman’s Magazine, January 1746 —Contributed by Angel R. Colo´n, MD
www.jpgn.org
181
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
