Transcript Antibiotic lock versus systemic antibiotic in catheter

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)
Selected studies:
Pediatric patients only
Prophylaxis with ALT,
Treatment with combined therapy
(SA+ALT)
9 studies met above criteria!
Antibiotic-heparin lock solutions:
adults and children
Antimicrobial lock solutions
Active ingredient
Vancomycin a
Teicoplanin a
Linezolid a
Amikacina,b
Gentamicin
Ciprofloxacin
Ceftazidime
Amphotericin B desoxycholate
Concentration (mg⁄ L)
0.025–10
0.025–2.5
0.2–2
1–10
1–10
0.125–2
0.5–2
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
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
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