Candida catheter-related bloodstream infections (CRBSIs) are known to pose a severe risk to patients undergoing home parenteral nutrition (HPN). A comprehensive review by Phua Andrew Ian-Hong, Hon Kay Yee, Holt Andrew, O’Callaghan Margie, and Bihari Shailesh has emphasized the critical need for enhanced understanding and management of these life-threatening complications. This article delves into their findings published in Clinical Nutrition ESPEN, providing insights into the incidence rates of Candida CRBSIs among HPN patients, identifying the involved Candida species, and discussing established as well as emerging strategies for effective management and prophylaxis.
Incidence and Species Distribution
The review by Andrew et al. analyzed data from 20 studies, encompassing both pediatric and adult HPN patient populations. The researchers showed that Candida species accounted for 9.8% of pediatric CRBSIs and 11.7% of adult CRBSIs, marking a significant portion of infections. Among pediatric cases, _Candida albicans_ emerged as the most prevalent species (46.2%), closely followed by _Candida parapsilosis_ (34.6%). In adults, the distribution slightly differed, with _C. albicans_ and _C. glabrata_ constituting 37.3% and 33.3% of CRBSIs, respectively.
Risk Factors
The study highlights various risk factors for developing Candida CRBSIs in HPN patients. Notably, pediatric patients with underlying hematological diseases and a history of fungemia are at heightened risk. The management of underlying conditions, coupled with vigilance for signs of CRBSIs, is essential for reducing the incidence of these infections.
Outcomes and Complications
Candida CRBSIs are associated with a daunting mortality rate of approximately 30%, signifying the gravity of such infections. The severity underscores the need for prompt and effective interventions to improve patient outcomes.
Management Protocols
Major guidelines put forth by health authorities advocate for the removal of the catheter prior to the initiation of systemic antifungal treatments like fluconazole, amphotericin B, and echinocandins. This strategy, combined with continued treatment for at least 14 days after the first negative blood culture, is considered the gold standard. Despite this, the review by Andrew and colleagues explores emerging practices where systemic therapy is administered while catheters remain in-situ—a practice that is gaining acceptance due to the need to preserve essential line access for patients reliant on HPN.
Prophylaxis and Catheter Lock Techniques
The utilization of various catheter lock solutions has shown promise both as a treatment and prophylactic measure against CRBSIs. Despite not being firmly established in clinical guidelines, these techniques signal a potential shift in the prevention strategies for HPN patients vulnerable to Candida infections.
Conclusion
The comprehensive review suggests that while the standard treatment of catheter removal followed by antifungal treatments remains predominant, there is a discernible shift towards treatments that allow for catheter retention and the use of catheter locks as a preventive measure. These findings pave the way for more refined protocols that could enhance the quality of life for HPN patients while mitigating the risks associated with Candida CRBSIs.
References
1. Phua, A. I.-H., Hon, K. Y., Holt, A., O’Callaghan, M., & Bihari, S. (2019). Candida catheter-related bloodstream infection in patients on home parenteral nutrition – Rates, risk factors, outcomes, and management. Clinical Nutrition ESPEN, 31, 1-9. https://doi.org/10.1016/j.clnesp.2019.03.007
2. Bouza, E., et al. (2009). Catheter-related infections: Diagnosis and intravascular treatment. Clinical Microbiology and Infection, 15(4), 392-402. https://doi.org/10.1111/j.1469-0691.2009.02732.x
3. Mermel, L. A., et al. (2009). Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 49(1), 1-45. https://doi.org/10.1086/599376
4. Rijnders, B. J. A., et al. (2001). Catheter-related bloodstream infections: A prospective randomized study on the effect of a novel antiseptic-impregnated catheter in intensive care patients. Intensive Care Medicine, 27(1), 23-30. https://doi.org/10.1007/s001340000727
5. Shaffer, D., et al. (2002). Prevention of central venous catheter-related infections in pediatric and neonatal patients: Implementing best practice. Journal of Infusion Nursing, 25(4), 256-263. https://doi.org/10.1097/00129804-200207000-00006
Keywords
1. Home Parenteral Nutrition Infections
2. Candida CRBSI Management
3. HPN Candida Infections
4. Catheter Lock Solutions
5. Antifungal Treatment CRBSI
The findings from this notable research offer invaluable guidance for the healthcare community and underscore the ongoing commitment to improving patient care for those who rely on home parenteral nutrition. The blend of rigorous data review and the exploration of new management techniques herald a critical step forward in addressing the challenges posed by Candida catheter-related bloodstream infections.