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Dickerson et al
single-component NaGP injection has not received full FDAapproval, this salt is used in some FDA-approved multichamber PN products. Despite these promising findings,
until NaGP becomes widely available in the United States
and more confirmative data are published, calcium gluconate
should be the calcium salt of choice in compounding PNs.
6.

Dibb et al. Central venous catheter salvage in home
parenteral nutrition catheter-related bloodstream
infections: long-term safety and efficacy data.3

For patients requiring long-term HPN, the ability to maintain central venous access is vital. Any catheter-related
bloodstream infection (CRBSI) event that results in central
venous catheter (CVC) removal and replacement increases
the risk of thrombotic occlusion that may ultimately lead to
loss of central venous access. It is therefore prudent to limit
CVC replacement to those CRBSI events that fail or are
anticipated to fail medical management. The purpose of this
study was to evaluate the efficacy and safety of a standardized protocol that incorporated CVC salvage for patients
requiring long-term HPN who presented with suspected
CRBSI.
The study included 588 patients receiving long-term PN
from a maintained database over an 18 year period (19932011). Diagnosis of CRBSI was based on quantitative and
qualitative assessment of central and peripheral blood cultures and pour plates.38 Two hundred ninety-seven CRBSI
episodes in 137 patients and an overall infection rate of 0.38
per 1000 catheter days were identified. The CVC was
removed in 49 CRBSI episodes due to septic shock, fungal
infection, mechanical complications, or tunnel infection.
CVC salvage was attempted in the remaining 248 CRBSI
episodes. The standardized treatment protocol for CVC salvage included initial treatment with vancomycin (systemic
and CVC lock), urokinase CVC lock, and prohibited infusion of PN via the CVC. Antibiotic therapy was adjusted
based on microbiologic data, when available, and continued
for 14 days. CVC salvage was successful (defined as no
recurrent CRBSI within 30 days) in 73% of the CRBSI
episodes.
This report is significant because the success of CVC salvage is not well documented and it can have a major impact
on maintaining long-term central venous access in this
patient population. Even though European guidelines encourage CVC salvage whenever possible for patients with a longterm CVC,38 this recommendation is not consistently
recognized as standard of care in the United States. This
study outlines a standardized approach to the diagnosis and
management of CRBSI that appears safe and effective. There
are other aspects of this protocol that may differ from standard of care in the United States, such as the use of antibiotic
and urokinase CVC lock and the practice to withhold infusion of PN via the CVC during the entire 14-day course of
treatment. It is unclear how these differences may impact

success of CVC salvage. However, the study does support
attempts at CVC salvage in patients requiring long-term
HPN.
7.

Elke et al. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and
meta-analysis of randomized controlled trials.4

The 2016 SCCM-ASPEN guidelines suggest the use of
EN over PN in critically ill patients who require nutrition
support therapy.16 EN has historically been associated with
less infectious complications than PN.39-44 In contrast to previous literature, a recent large randomized controlled trial
demonstrated no differences in outcomes between EN and
PN.45 The purpose of this systematic review and meta-analysis was to evaluate the effect of the route of nutrition (EN vs
PN) on clinical outcomes in critically ill adult patients.
In this meta-analysis, 18 studies met inclusion criteria for
evaluating critically ill adult patients who were randomized
to receive EN (n = 1681) or PN (n = 1666). There was no
difference in overall mortality with EN compared with PN.
When compared with PN, EN was associated with a significant decrease in infectious complications (RR, 0.64). This
significant difference was maintained in the subgroup analysis in which the PN group received higher caloric intake than
the EN group (RR, 0.55). However, in trials where EN and
PN groups received similar caloric intake, there was no difference in infectious complications. EN compared with PN
was associated with decreased ICU LOS, but there was no
significant difference in hospital LOS or length of mechanical ventilation. The authors concluded that the use of EN
rather than PN does not impact mortality but decreases infectious complications and ICU LOS.
The authors acknowledge limitations of the study. There
were missing outcome data points for some of the included
studies, and only 4 trials reported data for ICU LOS and
duration of mechanical ventilation. There were variations in
the reporting of caloric intake, timing of nutrition intervention, and definitions used for identifying infections.
Covariates, such as protein provision by enteral versus parenteral routes, that were not adjusted for in the meta-analysis
may have impacted the observed findings. The homogeneous
population makes it difficult to evaluate the effect of route of
nutrition in subpopulations of critically ill patients (eg, high
nutrition risk on admission).
While this study appears to counter the recent literature
suggesting there is no difference in clinical outcomes such as
infectious complications with EN versus PN, the authors
suggest that the differences between groups may be due to
avoiding complications associated with overfeeding with PN
rather than the route of nutrition delivery. Alternatively, the
reduction in infectious complications observed with EN may
be the result of the positive effects of EN on gut integrity and
immunity. Additional studies are needed to ascertain the
potential immunologic role of EN versus overfeeding and

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2017