1
|
Christison-Lagay ER, Brown EG, Bruny J, Funaro M, Glick RD, Dasgupta R, Grant CN, Engwall-Gill AJ, Lautz TB, Rothstein D, Walther A, Ehrlich PF, Aldrink JH, Rodeberg D, Baertschiger RM. Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee. J Pediatr Surg 2024:S0022-3468(24)00201-X. [PMID: 38637207 DOI: 10.1016/j.jpedsurg.2024.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/08/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management. OBJECTIVES To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)? METHODS Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases. STUDY SELECTION Independently performed by 2 reviewers, disagreements resolved by a third reviewer. DATA EXTRACTION Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology. RESULTS Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions. CONCLUSIONS Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care. LEVEL OF EVIDENCE III. This study was registered as PROSPERO 2019 CRD42019124077.
Collapse
Affiliation(s)
- Emily R Christison-Lagay
- Department of Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Erin G Brown
- Department of Surgery, University of California Davis Children's Hospital, University of California Davis, Sacramento, CA, USA
| | - Jennifer Bruny
- Alaska Pediatric Surgery, Alaska Regional Hospital, Anchorage, AK, USA
| | - Melissa Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Richard D Glick
- Department of Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Roshni Dasgupta
- Department of Surgery, Cincinnati Children's Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christa N Grant
- Department of Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Timothy B Lautz
- Department of Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago IL, USA
| | - David Rothstein
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Ashley Walther
- Department of Surgery, Children's Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Peter F Ehrlich
- Department of Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David Rodeberg
- Department of Surgery, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, USA
| | - Reto M Baertschiger
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Division of Pediatirc Surgery, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebaon, NH, USA.
| |
Collapse
|
2
|
Sierra CM, Rodriquez C, Bahjri K. Ethanol Lock for Prevention of CVC-Related Bloodstream Infection in Pediatric Patients: A Systematic Review and Meta-Analysis. J Pediatr Pharmacol Ther 2023; 28:386-396. [PMID: 38130502 PMCID: PMC10731934 DOI: 10.5863/1551-6776-28.5.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/11/2022] [Indexed: 12/23/2023]
Abstract
Ethanol lock therapy (ELT) can be used in patients with an indwelling central line to assist in the prevention of central venous catheter (CVC)-associated infections. However, its efficacy has not been consistently demonstrated in the pediatric population. The primary objective of this review and meta-analysis was to determine the efficacy and safety of ELT in prevention of central line-associated bloodstream infection (CLABSI) in the pediatric population. A search was conducted with the PubMed, CINAHL, PSCYInfo, Cochrane Library, and Academic Search Premier databases from inception through January 21, 2022. Studies were included if they reported incidence of CVC-related infections with ELT in pediatric patients. Meta-analyses used random-effects models according to the heterogeneity of all included studies. Of 736 studies, 25 met inclusion criteria for review and 10 for inclusion in the meta-analysis. Meta-analysis with pre- and post-ELT treatment showed that use of ELT significantly decreased mean CVC-related infections when compared with pre-treatment with no ELT with a mean difference of -5.79 (95% CI, -9.08 to -2.51; p < 0.001). The number of CVC infections also significantly decreased (OR, 0.42; 95% CI, 0.23-0.75; p = 0.004). Increased risk of thrombosis and increased frequency of catheter breakage, repair, and replacement were noted in several studies. Ethanol lock therapy is effective in preventing infection related to central venous catheter use in pediatric patients. Further study is warranted to determine the optimal protocol for, and incidence of, adverse events related to use of ELT.
Collapse
Affiliation(s)
- Caroline M. Sierra
- Department of Pharmacy Practice (CMS), Loma Linda University School of Pharmacy, Loma Linda University, Loma Linda, CA
| | - Cristian Rodriquez
- Loma Linda University School of Pharmacy (CR), Loma Linda University, Loma Linda, CA
| | - Khaled Bahjri
- Department of Pharmaceutical and Administrative Sciences (KB), Loma Linda University School of Pharmacy, Loma Linda, CA
| |
Collapse
|
3
|
Signorino C, Fusco E, Galli L, Chiappini E. Effectiveness of Antimicrobial Lock Therapy for the Treatment of Catheter-Related and Central-Line-Associated Bloodstream Infections in Children: A Single Center Retrospective Study. Antibiotics (Basel) 2023; 12:antibiotics12050800. [PMID: 37237703 DOI: 10.3390/antibiotics12050800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023] Open
Abstract
Antimicrobial lock solutions (ALT) in combination with systemic antibiotics can represent a valid option to attempt central venous catheter (CVC) salvage in the case of catheter-related and central-line-associated bloodstream infections (CRBSI and CLABSI). However, data concerning the effectiveness and safety of ALT in children are limited. We aimed to share our center's experience in order to contribute to investigations into the causes of ALT failure in the pediatric population. All children consecutively admitted to Meyer Children's Hospital, University of Florence, Italy, from 1 April 2016 to 30 April 2022, who received salvage ALT to treat an episode of CRBSI/CLABSI, were reviewed. According to ALT failure or success, children were compared with the aim of identifying the risk factors for unsuccessful ALT outcome. Data from 28 children, 37 CLABSI/CRBSI episodes, were included. ALT was associated with clinical and microbiologic success in 67.6% (25/37) of children. No statistically significant differences were observed between the two groups, successes and failures, considering age, gender, reason for use, duration, insertion, type and presence of insertion site infection of the CVC, laboratory data and number of CRBSI episodes. Nevertheless, a trend towards a higher success rate was observed for a dwell time of 24 h for the entire duration of ALT (88%; 22/25 vs. 66.7%; 8/12; p = 0.1827), while the use of taurolidine and the infections sustained by MDR bacteria were associated with a tendency toward greater failure (25%; 3/12 vs. 4%; 1/25; p = 0.1394; 60%; 6/10 vs. 33.3%; 8/24; p = 0.2522). No adverse events, except one CVC occlusion, were observed. ALT combined with systemic antibiotics appears to be an effective and safe strategy for treating children with CLABSI/CRBSI episodes.
Collapse
Affiliation(s)
- Claudia Signorino
- Department of Health Sciences, Meyer Children's University Hospital IRCCS, University of Florence, Florence 50139, Italy
| | - Eleonora Fusco
- Department of Health Sciences, Meyer Children's University Hospital IRCCS, University of Florence, Florence 50139, Italy
| | - Luisa Galli
- Division of Pediatric Infectious Disease, Department of Health Sciences, Meyer Children's University Hospital IRCCS, University of Florence, 50139 Florence, Italy
| | - Elena Chiappini
- Division of Pediatric Infectious Disease, Department of Health Sciences, Meyer Children's University Hospital IRCCS, University of Florence, 50139 Florence, Italy
| |
Collapse
|
4
|
Gigola F, Coletta R, Certini M, Del Riccio M, Forsythe L, Morabito A. Combined procedures for surgical short bowel syndrome: experience from two European centres. ANZ J Surg 2023; 93:1012-1016. [PMID: 36514884 DOI: 10.1111/ans.18184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/14/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autologous gastrointestinal reconstructive surgery (AGIR) has become a key component of intestinal rehabilitation programs. However, the best surgical option for short bowel syndrome (SBS) remains unknown. This paper presents our experience using combined procedures as primary treatment. METHODS We collected data on SBS patients who underwent surgery from 2008 to 2021 in two tertiary European Centres. Combined procedures were defined as more than one technique used on the same patient. Charts were reviewed for demographics, type of procedures, complications, and outcomes. Data are presented as median and IQR. Wilcoxon signed rank was used for all paired analyses. RESULTS Twenty-one children (12 females) underwent combined procedures. Preoperative median small bowel length was 20 cm (IQR: 15-35 cm); after lengthening, it was 35.5 cm (IQR: 30.75-50.50 cm) (P < 0.001). Combined procedures were simultaneous in 15 patients and sequential in 6. At a median of 9.2 years (IQR: 7.55-9.78 years) follow-up, complications were three bowel obstructions after strictures of anastomosis and two wound infections. Two patients achieved enteral autonomy, and others followed a weaning home parenteral nutrition regimen with a median of 4 nights off (IQR: 3-4 nights) starting with a median of 7 nights (IQR: 7-7 nights). CONCLUSIONS Combined AGIR techniques are practical and safe in SBS treatment when tailored to meet patients' needs, combining lengthening, tailoring, and reducing transit time procedures. Therefore, combined AGIR may be considered a resource in intestinal rehabilitation units' armamentarium.
Collapse
Affiliation(s)
- Francesca Gigola
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Riccardo Coletta
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- School of Health and Society, University of Salford, Salford, UK
| | - Martina Certini
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Marco Del Riccio
- Department of Health Sciences, University of Florence, Postgraduate School in Hygiene and Preventive Medicine, Florence, Italy
| | - Lynette Forsythe
- Department of Dietetics and Nutrition, Royal Manchester Children's Hospital, Manchester, UK
| | - Antonino Morabito
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- School of Health and Society, University of Salford, Salford, UK
| |
Collapse
|
5
|
Nakatani R, Ashiarai M, Yoshihara H, Yada K, Nozaki T, Ushigusa T, Mori N, Hasegawa D. Multidisciplinary management of disseminated Exophiala dermatitidis mycosis in an infant with mixed phenotype acute leukemia: a case report. BMC Infect Dis 2022; 22:797. [PMID: 36274136 PMCID: PMC9590134 DOI: 10.1186/s12879-022-07773-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Exophiala dermatitidis is a dematiaceous fungus isolated from various environmental sources. Systemic E. dermatitidis infections can lead to fatal outcomes, and treatment has not yet been standardized. Although E. dermatitidis is also known to cause cutaneous infection, it has not been previously reported to appear as ecthyma gangrenosum (EG), an uncommon cutaneous lesion in neutropenic patients that is mainly caused by Pseudomonas aeruginosa. Case presentation A 2-month-old male infant with mixed-phenotype acute leukemia presented with prolonged fever unresponsive to antibacterial and antifungal agents during myelosuppression due to remission induction therapy. He also presented with skin lesions on the left wrist and left lower quadrant of the abdomen. The abdominal lesion gradually turned black and necrotic, which was consistent with the findings of the EG. E. dermatitidis was isolated from the blood, stool, wrist skin, and endotracheal aspirate. During hematopoietic recovery, consolidation in both lungs was evident. Multiagent antifungal treatment failed to eliminate E. dermatitidis from blood. In order to salvage the central venous catheter, ethanol lock therapy (ELT) was adopted, following which the blood culture became negative. The abdominal lesion that evolved as a necrotic mass connecting the small intestine and subcutaneous tissue adjacent to the skin was surgically resected. After these interventions, the general condition improved. Conclusion Disseminated E. dermatitidis mycosis in the neutropenic infant was successfully managed with a multidisciplinary treatment consisting of multiagent antifungal treatment, ELT, and surgery.
Collapse
|
6
|
Buonsenso D, Salerno G, Sodero G, Mariani F, Pisapia L, Gelormini C, Di Nardo M, Valentini P, Scoppettuolo G, Biasucci DG. Catheter salvage strategies in children with central venous catheter related or associated bloodstream infections: a systematic review and meta-analysis. J Hosp Infect 2022; 125:1-20. [PMID: 35390396 DOI: 10.1016/j.jhin.2022.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/25/2022] [Accepted: 03/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal management of Central Venous Catheter related, or associated, bloodstream infections (CRBSI or CLABSI) in children is not established. OBJECTIVE To evaluate successful of catheter salvage strategies in pediatric patients. METHODS Studies retrieved from medical databases and article reference lists. Data were collected relating to clinical outcomes of 2 treatments: systemic antibiotics alone or in association with antimicrobial lock therapy (ALT). 95% CIs and OR were calculated from a mixed logistic effects model. Heterogeneity was summarized using I2 statistics. Publication bias was investigated by Egger's regression test and funnel plots. RESULTS From 345 identified publications, 19 met inclusion criteria (total of 914 attempted salvage strategies. To achieve successful catheter salvage, in CRBSI the addition of ALT was superior to systemic antibiotics alone (OR -0.40, 95%CI -1.41 - 0.62): 77% (95%CI 69-85, I2=42.5%, p=0.12) and 68% of success (95%CI 59-77, I2=0, p<0.05), respectively. CRBSI recurrence was less common in studies that used ALT compared with systemic antibiotics alone: 5% (95%CI 0-13, I2=59.7%; p=0.03) and 18% of recurrence (95%CI, 9-28, I2=0, p< 0.05), respectively. Recurrences were low with both antibiotic-locks and ethanol-lock. No clear benefits of ALT addition compared to systemic antibiotic only was found in CLABSI (OR -0.81, 95% CI -0.80 - 2.43). CONCLUSIONS The addition of an antimicrobial lock solution to systemic antibiotic may be beneficial for successful catheter salvage in pediatric patients with CRBSI, depending on etiology, whilst no statistically significant difference between systemic antibiotic with or without addition of an antimicrobial lock solution was found regarding CLABSI.
Collapse
Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy; Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy; Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Gilda Salerno
- Institute of Pediatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giorgio Sodero
- Institute of Pediatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Mariani
- Institute of Pediatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Pisapia
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Camilla Gelormini
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Piero Valentini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Giancarlo Scoppettuolo
- Department of Infectious Diseases, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Rome, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| |
Collapse
|
7
|
Muto M, Kaji T, Onishi S, Yano K, Yamada W, Ieiri S. An overview of the current management of short-bowel syndrome in pediatric patients. Surg Today 2021; 52:12-21. [PMID: 33464414 DOI: 10.1007/s00595-020-02207-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022]
Abstract
Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
Collapse
Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
| |
Collapse
|