Anti-Infective Locks for Treatment of Central Line-Associated Bloodstream Infection: A Systematic Review and Meta-Analysis

Abstract

Central line-associated bloodstream infections (CLABSI) are associated with considerable morbidity, mortality and economic costs. In most cases, catheter removal is considered an essential component of managing CLABSI. However, in patients with poor access, catheter salvage may have to be attempted rather than removal and replacement of catheters. Anti-infective lock therapy (ALT) – instilling an antibiotic or antiseptic into the catheter lumen – is a novel way of treating CLABSI while attempting to salvage the catheter. However, data on the efficacy of ALT for catheter salvage is limited. In this systematic review, we critically review the evidence regarding the use of ALT for catheter salvage. We identified 8 studies including a total of 396 patients that compared ALT with systemic antibiotic therapy alone or an alternate method of catheter salvage (guidewire replacement). We found that the combination of systemic antibiotics and culture-guided lock therapy was superior to systemic antibiotics alone (OR: 0.20, 95% CI: 0.10–0.39), with 10% of locked patients requiring replacement compared to 33% of subjects without locks. There was a 20% relapse rate in the ALT group and a 30% relapse rate in the control group (OR: 0.43, 95% CI: 0.18–1.03). There was insufficient data on catheter exchange over a wire compared with ALT to permit conclusions. Our data support the use of ALT in conjunction with systemic antibiotics for catheter salvage. Large randomized controlled trials of ALT examining dose, dwell times and relapse rates stratified by infecting pathogen are needed.

Coagulase-Negative Staphylococci

“…Alternatively, a short antibiotic treatment (5 to 7 days) subsequent to removal of the catheter might be appropriate for uncomplicated CoNS-caused CRBSIs. If the catheter is retained, antibiotics should be administered for 10 to 14 days, along with antibiotic lock therapy (607,609). However, the question of whether catheter removal and/or antibiotic therapy is preferred is still a matter of debate because of the lack of controlled study data.…”

Antimicrobial lock therapy in central-line associated bloodstream infections: a systematic review

“…The antibiotic is prescribed as ALT using concentrations ranging from 1 to 5 mg/ml. Duration of locks varies from 3 to 27 days and ALT is generally associated with systemic treatment [6]. Indeed, Bookstaver et al [23] showed that active systemic therapy, associated with vancomycin ALT, alone or together with gentamicin or ethanol, allowed good success rates while avoiding catheter removal.…”

“…O'Horo et al [6] analyzed studies which compared ALT to systemic therapy, finding that the combination of both was superior (OR 0.2, 95 % CI: 0.10-0.39) to systemic antibiotic alone for catheter salvage, with 10 % of locked patients requiring replacement, compared to 33 % of subjects without lock.…”

“…It consists in instilling an antibiotic solution into the hub of the central venous catheter when it is not in use, to achieve a concentration of the antibiotic that is manyfold higher than the minimal inhibitory concentration (MIC) for the bacteria involved [6,7]. The antibiotic should remain for a specified duration, typically between 18 and 24 h and this strategy appears particularly useful for patients in whom reintroducing a catheter may be difficult [6].…”

Increased Anti‐Flagellin and Anti‐Lipopolysaccharide Immunoglobulins in Pediatric Intestinal Failure

“…13 Although various preventive measures have been established, reducing the incidence of CLABSI in this population remains a challenge. 14,15 Due to the morbidity and mortality associated with a CLABSI in IF, these children are routinely hospitalized at the time of the febrile episode pending blood culture results. Identification of biomarkers that can reliably differentiate bacterial infections from other causes of fever could make a significant impact in clinical care for these children and their providers.…”