Reduction of Central Line-Associated Bloodstream Infections and Line Occlusions in Pediatric Intestinal Failure Patients Receiving Long-Term Parenteral Nutrition Using an Alternative Locking Solution, 4% Tetrasodium Ethylenediaminetetraacetic Acid.

BACKGROUND: Patients with intestinal failure (IF) are dependent on parenteral nutrition (PN), however, they are at risk of central line-associated bloodstream infections (CLABSIs) and line complications. Four-percent tetrasodium ethylenediaminetetraacetic acid (EDTA) solution is an effective nonantibiotic, antimicrobial, antibiofilm, and anticoagulant agent. Our objective was to determine 4% tetrasodium EDTA efficacy in preventing CLABSIs and reducing line occlusions in pediatric IF patients. METHODS: We conducted a retrospective cohort study of patients managed at 2 tertiary Canadian pediatric centers between April 2016 and December 2018 who received 4% tetrasodium EDTA solution under the brand name Kitelock. Data were collected for 12 months pre and post-Kitelock. CLABSIs and alteplase administration were compared using a Wilcoxon matched-pairs signed-rank test. Data were reported as medians and frequencies. RESULTS: Twenty patients were included (10 boys; median age, 83 months [range, 8-232 months]). The rate of CLABSIs before 4% tetrasodium EDTA was 2.7+4 per 1000 catheter days. Patients received 4% tetrasodium EDTA for a median of 365 (278-365) days, with no infections in the 12 months post-therapy (P = .002). Median rates of occlusive episodes for the entire cohort before 4% tetrasodium EDTA were 0 (0-5.0) and 0 (0-2.0) after starting therapy (P = .018). In patients with previous occlusions (n = 9), the median episodes of alteplase use previously was 5.5 (2.7-19.2) compared with 2.7 (0-2.7) (P = .018). CONCLUSIONS: Our preliminary findings suggest 4% tetrasodium EDTA solution is effective in reducing CLABSIs and catheter occlusions in pediatric patients with long-term central-access.

Starving the Gut: A Deficit of Butyrate in the Intestinal Ecosystem of Children With Intestinal Failure.

BACKGROUND: Intestinal epithelial integrity is influenced by short-chain fatty acids (SCFAs) and is of critical importance for children with intestinal failure (IF) given the known devastating infectious and gastrointestinal complications. The composition of the microbiome in IF represents an important variable in the physiology and prognosis of this disease. AIM: We sought to compare the intestinal microbiome and SCFA concentration of children who require parenteral nutrition (PN) with that of children with short-bowel syndrome (SBS) who have discontinued PN and with age-matched controls, using high-throughput sequencing to investigate host-microbe interactions. METHODS: Fifty-three samples were submitted over 6-15 months. Six children with SBS + IF submitted 34 samples, and 6 children with SBS with discontinued PN submitted 15 samples; these were compared with samples from 5 control children. Fecal samples were analyzed by 16S ribosomal RNA partial gene sequencing using the MiSeq Illumina sequencer. SCFAs were measured in stool samples by mass spectrometry. RESULTS: Butyrate quantity was near absent in children with IF compared with that in controls (median 0.37 nmol/mg vs 10.92 nmol/mg; P < .0001). Similarly, commensal anaerobes known to produce SCFA, including Ruminococcaceae and Lachnospiraceae, were reduced in those with SBS. SBS + IF enteric samples demonstrated a 168-fold increase in the relative abundance of the Escherichia genus seemingly attributable to the species Escherichia coli. CONCLUSION: The reduced relative abundance of butyrate-producing Clostridia as well as decreased intestinal butyrate concentration in children with IF support further investigation in therapeutic options that target butyrate-producing bacterial communities or butyrate supplementation.

Implementation of a multidisciplinary team approach and fish oil emulsion administration in the management of infants with short bowel syndrome and parenteral nutrition-associated liver disease.

OBJECTIVE: To describe the authors' experience with the implementation of a multidisciplinary approach and use of fish oil emulsion (FOE) in the management of infants with short bowel syndrome (SBS) and parenteral nutrition-associated liver disease (PNALD). METHODS: Between August 2006 and June 2009, four cases of SBS and severe PNALD were managed by the team using specifically developed protocols. The FOE was initiated if serum direct bilirubin levels were ≥100 µmol/L. To quantify the degree of exposure to high serum direct bilirubin levels over time, the area under the curve (AUC) for each patient was calculated before and after initiation of FOE. Linear regression analyses were performed to evaluate correlations between the AUC, duration of cholestasis and initiation of FOE. RESULTS: All patients survived and no complications were observed during the study period. After the first patient, FOE was initiated progressively earlier, but poor correlation between the AUC before and after its introduction was observed (r(2)=0.41924). However, there was strong correlation between the duration of PNALD before FOE initiation and time to resolution (r(2)=0.72133): the earlier the FOE was initiated, the shorter the time to resolution. CONCLUSION: The authors report a positive experience with the implementation of a multidisciplinary approach and the use of FOE in infants with SBS and severe PNALD. The earlier the FOE was initiated during the cholestatic process, the shorter the time to resolution. The present study is a hypothesis generator, raising the question of whether an earlier introduction of this particular therapy can effectively shorten the cholestasis process in these patients.