How Broad Should Gram‐Negative Coverage Be for Febrile Parenteral Nutrition Dependent Short Bowel Syndrome Patients?

Abstract

Broader spectrum Gram-negative antibiotics are commonly utilized empirically for central line-associated bloodstream infections (CLABSI) in febrile short bowel syndrome (SBS) patients receiving home parenteral nutrition compared to those used empirically for inpatient-acquired CLABSI. This analysis reports 57 CLABSI in 22 patients with SBS admitted from the community and 78 inpatient-acquired CLABSI in 76 patients over a 5-year period. Proportional Gram-negative CLABSI was similar between the SBS and inpatient-acquired cohorts (43.8% vs42.3%, respectively, P = 0.78). 1.8% and 10.3% (P = 0.125) of Gram-negative CLABSI were non-susceptible to ceftriaxone and 0% and 3.8% (P = 0.52) were non-susceptible to ceftazidime in the SBS and inpatient-acquired cohorts, respectively. In the SBS cohort, home ethanol lock therapy and prior culture results impacted Gramnegative pathogen distribution. Broader empiric Gram-negative coverage for CLABSI among SBS patients compared to inpatients is unnecessary. Third-generation cephalosporins represent appropriate empiric Gramnegative agents for febrile SBS patients presenting from the community to our institution.

Comparison of catheter‐related bloodstream infection rates in pediatric patients receiving parenteral nutrition with soybean oil‐based intravenous fat emulsion versus a mixed oil fat emulsion

“…Our study was able to address most of the previously described deficiencies through rate‐based analysis focusing on overall IFE exposure, obtaining a sufficient count of infections to allow for adequate statistical testing, and inclusion of multiple settings. A proportional analysis was another option to assess outcomes and help determine appropriate empiric antimicrobial choices for possible infections 22 . However, rate‐based analyses are often utilized for assessing the impact of interventions on CR‐BSIs over extended time periods to account for differences in exposure and multiple infections per patients 2,24 …”

“…Among the microbes analyzed in the present analysis, CoNS demonstrated differences in infection rates between SO‐IFE and MO‐IFE; however, C. albicans and S. aureus did not, despite the inclusion of MCT and fish oil in MO‐IFE. Our working definition for CR‐BSIs may have been sensitive for infections from common commensals such as CoNS, but our practice for the management of CR‐BSI by common commensals did not change during the review period 21,22 . Alternatively, this was a single‐center study, so the number of other infections, especially with C. albicans and S. aureus , was low and likely unable to detect significant differences, despite numerically lower infection rates with MO‐IFE.…”

“…Days of exposure were counted if patients were aged <18 years at IFE initiation during the review period, had a CVC placed for PN administration, received IFE at least three times weekly, and for at least for 7 days. CR‐BSI occurrence was noted during the exposure period and identified by collection of a positive blood culture with no other identifiable source of infection and receipt of at least 7 days of appropriate antimicrobial therapy, in congruence with a prior definition 21,22 . LBCH inpatients received IFE separately from amino acids and dextrose (2‐in‐1); however, outpatients may have received admixtures containing all three macronutrients depending on outpatient pharmacy compounding practice and patient/parent preference.…”

“…CR-BSI occurrence was noted during the exposure period and identified by collection of a positive blood culture with no other identifiable source of infection and receipt of at least 7 days of appropriate antimicrobial therapy, in congruence with a prior definition. 21,22 LBCH inpatients received IFE separately from amino acids and dextrose (2-in-1); however, outpatients may have received admixtures containing all three macronutrients depending on outpatient pharmacy compounding practice and patient/parent preference. Ethanol lock therapy (ELT) is typically employed in patients with long-term CVCs and recurrent CR-BSIs, which applies to the PN patients managed as outpatients.…”

“…A proportional analysis was another option to assess outcomes and help determine appropriate empiric antimicrobial choices for possible infections. 22 However, rate-based analyses are often utilized for assessing the impact of interventions on CR-BSIs over extended time periods to account for differences in exposure and multiple infections per patients. 2,24 Our findings are in line with in vitro investigations suggesting that the presence of select fatty acids influences microbial virulence and propensity for causing CR-BSIs for C. albicans and S. aureus.…”