Catheter-related sepsis during home parenteral nutrition

Catheter-related sepsis (CRS) in patients receiving home parenteral nutrition (HPN) is the most frequent complication, with an annual incidence rate of 0.30-0.50 in investigative/approved centres. CRS is responsible for patient deaths in 2.5% of cases which represent 50% of HPN-related deaths. A detailed and strictly applied protocol is the basis of prevention; therefore a low rate of CRS can be used as a marker of quality of care. Skin and hub cultures are used to rule out CRS since their predictive negative value assessed against (semi) quantitative cultures of cannulae were reported to be almost 100%. In the absence of catheter removal, clinical assessment plus quantitative blood cultures with a threshold ratio of 4:1 in central and peripheral blood is a reasonable basis of established CRS. Removal of the infected external cannula is necessary and immediate in cases of tunnel infection, virulent bacteria (e.g. Candida, Staph aureus or pseudomonas species) and for all occurrences of CRS on implantable chambers since conventional treatment fails to sterilise such devices. Thus standard antibiotic treatment may be effective in the absence of tunnel sepsis in the majority of CRS cases due to non-virulent bacteria (mainly Staph coagulase negative species). In these cases of CRS, our experience suggests that the antibiotic-lock technique offers definite advantages over conventional systemic antibiotic treatment, since external catheters were sterilised without recurrent sepsis in more than 85% of cases.