Presentation on theme: "Antibiotic lock versus systemic antibiotics for catheter related infections in immunocompromised pediatric patients. Ewelina Mamcarz M.D., Divya-Devi Joshi."— Presentation transcript:
Antibiotic lock versus systemic antibiotics for catheter related infections in immunocompromised pediatric patients. Ewelina Mamcarz M.D., Divya-Devi Joshi M.D.
Objectives Describe indications for systemic antibiotics versus antibiotic lock therapy Evaluate type of antibiotic and treatment duration for antibiotic lock Timing of the antibiotic lock: early/late Antibiotic lock as prevention of catheter associated bacteremia
Background: Catheter related infections Leading cause of morbidity and mortality in critically ill hospitalized patients Organisms: –Coagulase – negative staphylococci –Staphylococcus aureus –Gram-negative bacteria –Candida ssp.
Sources of infection Colonization from the skin Intraluminal / hub contamination Hematologic seeding
Clinical evaluation -CRI Local inflammation Sepsis Blood culture Catheter dysfunction Rapid improvement following catheter removal
Treatment Type of device Infecting pathogens Presence of alternative venous access sites Duration of anticipated need for access
Treatment Catheter removal Systemic antibiotics Antibiotic lock therapy (ALT)- little evidence to support recommendation
Data Guidelines from the Infectious Diseases Society of America (IDSA): CRI documented, pathogen identified-narrow spectrum systemic abx and consider ALT Onder at al: timing of antbc locks: ALT more effective early in therapy, diminished need for catheter removal Pervez at al: ALT for prevention of CRI: decreased incidence of CRI, improved survival of catheters
Antibiotic lock First publication 1988-Messing et al Higher concentration, longer duration of activity at the infected site without potential side-effects of systemic exposure Concentration and intra-luminal dwell time: lack of evidence based recommendations
Lack of firm recommendations for individual patients Immunocompromised population Pathogenesis of CRI complicated Virulence of the pathogens variable Host factors not well defined Lack of diversity between studied populations Absence of compelling clinical data to form recommendations
Data Uncomplicated catheter-related bacteremias: Infectious Disease Society of America – systemic antibiotics (7days) +ALT (14 days) Local, systemic, extra-luminal CRI – ALT should be combined with systemic treatment for at least 72 hours
Data Search strategy: Pub Med (1990-2008) Pub Med (1990-2008) Selected studies: Selected studies: Pediatric patients only Pediatric patients only Prophylaxis with ALT, Prophylaxis with ALT, Treatment with combined therapy (SA+ALT) Treatment with combined therapy (SA+ALT) 9 studies met above criteria!
Antibiotic-heparin lock solutions: adults and children Antimicrobial lock solutions Active ingredient Concentration (mg⁄ L) Vancomycin a 0.025–10 Teicoplanin a 0.025–2.5 Linezolid a 0.2–2 Amikacina,b 1–10 Gentamicin 1–10 Ciprofloxacin 0.125–2 Ceftazidime 0.5–2 Amphotericin B desoxycholate 2 (in glucose 5% w⁄ v) A: Stable for ‡ 24 h without loss of efficacy when combined with heparin 100 U⁄ mL. B: Vancomyin 25 mg ⁄ L + amikacin 25 mg⁄ L + heparin 100 000 U⁄ L in NaCl 0.9% Note: Standard antibiotic lock technique ampoules prepared by the hospital pharmacy must be protected carefully against contamination with bacteria and fungi, and should be filter-sterilized and stored in a refrigerator.
Data: Prevention 3 studies: –prospective double blind study, prospective cohort study, literature review (both children and adults) Vancomycin/heparin/ciprofloxacin, vancomycin/heparin, minocycline/ethylenediaminetetraacetate, vancomycin/teicoplanin Results: Time to develop CRI longer with ALT, rate of total line infections decreased, no port infections or thrombotic events were observed compared to ports flushed with heparin only rate of total line infections decreased, no port infections or thrombotic events were observed compared to ports flushed with heparin only
Data: Treatment 6 studies: –2 case reports, 4 open pilot studies Vancomycin/heparin, ciprofloxacin/heparin, amikacin/heparin, urokinase /vancomycin, ampicilin alone+ systemic antibiotics 168 episodes of CRI: 143 (85%) episodes cured (negative bld cx – mean: 4days-1month),10 catheter removals, median catheter follow up -96 days,168 days (1 study),25 (15%) episodes of therapeutic failure (recurrence of febrile bacteremia),1 death.
ALT Evidence based guidelines - Significance Decrease in mortality and morbidity related to catheter related infections Limit use of systemic antibiotic Prevent resistance Improve quality of life Lack of serious complications Cost effective?
References Chatzinikolaou IChatzinikolaou I, Zipf TF, Hanna H, Umphrey J, Roberts WM, Sherertz R, Hachem R, Raad I. Minocycline-ethylenediaminetetraacetate lock solution for the prevention of implantable port infections in children with cancer. Clin Infect Dis. 2003 Jan 1;36(1):116-9. Epub 2002 Dec 11. Zipf TFHanna HUmphrey JRoberts WMSherertz R Hachem RRaad I Chatzinikolaou IZipf TFHanna HUmphrey JRoberts WMSherertz R Hachem RRaad I Henrickson KJHenrickson KJ, Axtell RA, Hoover SM, Kuhn SM, Pritchett J, Kehl SC, Klein JP. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: A randomized, multicenter, double-blind trial. J Clin Oncol. 2000 Mar;18(6):1269-78. Axtell RAHoover SMKuhn SMPritchett JKehl SCKlein JP Henrickson KJAxtell RAHoover SMKuhn SMPritchett JKehl SCKlein JP van de Wetering MDvan de Wetering MD, van Woensel JB. Prophylactic antibiotics for preventing early central venous catheter Gram positive infections in oncology patients. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD003295. van Woensel JB van de Wetering MDvan Woensel JB Fernandez-Hidalgo NFernandez-Hidalgo N, Almirante B, Calleja R, Ruiz I, Planes AM, Rodriguez D, Pigrau C, Pahissa A. Antibiotic-lock therapy for long-term intravascular catheter-related bacteraemia: results of an open, non-comparative study. J Antimicrob Chemother. 2006 Jun;57(6):1172-80. Epub 2006 Apr 5. Almirante BCalleja RRuiz IPlanes AMRodriguez DPigrau CPahissa A Fernandez-Hidalgo NAlmirante BCalleja RRuiz IPlanes AMRodriguez DPigrau CPahissa A
References De Sio LDe Sio L, Jenkner A, Milano GM, Ilari I, Fidani P, Castellano A, Gareri R, Donfrancesco A. Antibiotic lock with vancomycin and urokinase can successfully treat colonized central venous catheters in pediatric cancer patients. Pediatr Infect Dis J. 2004 Oct;23(10):963-5. Jenkner AMilano GMIlari IFidani PCastellano AGareri R Donfrancesco A De Sio LJenkner AMilano GMIlari IFidani PCastellano AGareri R Donfrancesco A Bernardi MBernardi M, Cavaliere M, Cesaro S. The antibiotic-lock therapy in oncoematology pediatric unit. Assist Inferm Ric. 2005 Jul-Sep;24(3):127- 31. Cavaliere MCesaro S Bernardi MCavaliere MCesaro S Viale PViale P, Pagani L, Petrosillo N, Signorini L, Colombini P, Macri G, Cristini F, Gattuso G, Carosi G. Antibiotic lock-technique for the treatment of catheter- related bloodstream infections. J Chemother. 2003 Apr;15(2):152-6. Pagani LPetrosillo NSignorini LColombini PMacri GCristini F Gattuso GCarosi G Viale PPagani LPetrosillo NSignorini LColombini PMacri GCristini F Gattuso GCarosi G Gattuso GGattuso G, Tomasoni D, Ceruti R, Scalzini A. Multiresistant Stenotrophomonas maltophilia tunneled CVC-related sepsis, treated with systemic and lock therapy. J Chemother. 2004 Oct;16(5):494-6. Tomasoni DCeruti RScalzini A Gattuso GTomasoni DCeruti RScalzini A Mermel LAMermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, Craven DE; Infectious Diseases Society of America; American College of Critical Care Medicine; Society for Healthcare Epidemiology of America. Guidelines for the management of intravascular catheter-related infections Clin Infect Dis. 2001 May 1;32(9):1249-72. Epub 2001 Apr 3. Farr BMSherertz RJRaad IIO'Grady NHarris JSCraven DEInfectious Diseases Society of AmericaAmerican College of Critical Care MedicineSociety for Healthcare Epidemiology of America Mermel LAFarr BMSherertz RJRaad IIO'Grady NHarris JSCraven DEInfectious Diseases Society of AmericaAmerican College of Critical Care MedicineSociety for Healthcare Epidemiology of America
References Elwood RLElwood RL, Spencer SE. Successful clearance of catheter-related bloodstream infection by antibiotic lock therapy using ampicillin. Ann Pharmacother. 2006 Feb;40(2):347-50. Epub 2006 Jan 31. Spencer SE Elwood RLSpencer SE Simon A, Bode U, Beutel K. Diagnosis and treatment of catheter-related infections in paediatric oncology: an update. Clin Microbiol Infect. 2006 Jul;12(7):606-20. Simon A, Bode U, Beutel K. Diagnosis and treatment of catheter-related infections in paediatric oncology: an update. Clin Microbiol Infect. 2006 Jul;12(7):606-20.Simon ABode UBeutel KSimon ABode UBeutel K Band JD. Pathogenesis of and risk factors for central venous catheter- related infections. Diagnosis of central venous catheter –related bloodstream infections. Treatment of central venous catheter-related infections. www. uptodate. Com. Bagnall-Reeb HBagnall-Reeb H. Evidence for the use of the antibiotic lock technique. J Infus Nurs. 2004 Mar-Apr;27(2):118-22. Bagnall-Reeb H Robinson JLRobinson JL, Tawfik G, Roth A. Barriers to antibiotic lock therapy in children with intravascular catheter-related bloodstream infections. Pediatr Infect Dis J. 2005 Oct;24(10):944. Tawfik GRoth A Robinson JLTawfik GRoth A