Intestinal Failure Population Research Articles

P-886. Small Intestinal Bacterial Overgrowth and Bloodstream Infection in the Pediatric Intestinal Failure Population

Abstract Background Patients with intestinal failure (IF) are reliant on central venous access for adequate nutrition, and thus are at risk of catheter-related infectious complications, including bloodstream infection (BSI) (1). These patients may suffer from small intestinal bacterial overgrowth (SIBO), with symptoms including abdominal bloating and diarrhea. SIBO can lead to poor enteral feeding tolerance and malnutrition (2). SIBO diagnosis is made via jejunal aspirate, hydrogen breath testing, or clinical suspicion based on relevant symptoms, and is often treated with prolonged antibiotics (2). There is a paucity of data investigating the effect of prolonged antibiotic exposure from SIBO on BSI episodes in this population. This study seeks to elucidate the connection between SIBO-related antibiotic exposure, frequency of BSI episodes, and antimicrobial resistance patterns of the causative organisms in the pediatric IF population.Table 1:Demographics of Pediatric Intestinal Failure Cohort (2009 – 2023) Sixty-nine patients met inclusion criteria for this study. Intestinal failure was defined as reliance on parenteral nutrition for ≥ 60 days with an associated diagnosis of short bowel syndrome or other condition associated with intestinal failure. The majority of patients entered the cohort prior to one year of life (median age 4.7 months), a result which was statistically significant among patients ever treated for small intestinal bacterial overgrowth compared to those never treated. Necrotizing enterocolitis was the most common underlying diagnosis leading to intestinal failure. Methods A retrospective chart review was conducted from January 2009 through June 2023 for patients treated in the Duke Pediatric Intestinal Rehabilitation Program. Data was stored within a RedCap database per institutional IRB protocol. Statistical analysis performed using SAS 9.4 (SAS Institute Inc., Cary, NC).Table 2:Description of BSI Episode Characteristics Among Patients Treated for Small Intestinal Bacterial Overgrowth Compared to No Treatment The majority of patients (61%) in the study cohort received treatment for small intestinal bacterial overgrowth (SIBO) at any point. Patients treated for SIBO were more likely to experience a bloodstream infection (BSI) event, and on average had a higher number of BSI events compared to those never treated for SIBO. Patients treated for SIBO were also more likely to have a BSI event including an organism with an identified pattern of resistance. BSI events were defined per CDC/NHSN LCBI 1 criteria, excepting in the case of commensals. Results The cohort included 69 patients, of whom 42 (61%) were treated for SIBO at any point during the study period. Median treatment length was 68 weeks (IQR 17.4 – 196.1). 73% of patients experienced a BSI event, with 263 episodes total. The median number of BSI episodes was higher for patients treated for SIBO at any point (p = 0.002). Klebsiella pneumoniae was the most commonly cultured organism (14% of isolates), followed by Coagulase-negative Staphylococci (13%). Thirteen percent of the isolates had an identified pattern of resistance, most commonly methicillin-resistance. There was a total of 263 bloodstream infection (BSI) episodes in the cohort, with 404 individual isolates identified. Enteric isolates were most common, namely Klebsiella pneumoniae and Enterococcus faecalis. Conclusion The majority of patients with IF received treatment for SIBO based on clinical diagnostic criteria. Treatment duration was prolonged, despite a lack of evidence for this practice. BSI was common in this cohort, most frequently with enteric pathogens. Preliminary analysis shows a higher median number of BSI episodes in patients ever treated for SIBO. Future applications of this data may include developing an institutional algorithm standardizing SIBO treatment. Disclosures All Authors: No reported disclosures

An Interprofessional Quality Improvement Project to Reduce Community-Acquired Central Line-Associated Bloodstream Infections in the Pediatric Intestinal Failure Population

Highlights Abstract Aim: Central line-associated bloodstream infections (CLABSIs) result in significant morbidity but are largely preventable. Methods to reduce hospital-acquired CLABSIs are well described, but few recommendations exist for how these practices might translate to patients with central lines in the ambulatory setting. This team sought to reduce the mean monthly community-acquired CLABSI rate by 25% from 11.7 to 8.8 per 1000 community line-days in children with intestinal failure who require home parenteral nutrition within 12 months. Methods: First, an interprofessional quality improvement team was formed. After baseline data collection, plan-do-study-act cycles began. Tests of change consisted of a central venous catheter (CVC) maintenance bundle. This bundle included a CVC care tote with additional supplies, improved educational materials, and ethanol lock prophylaxis. A control chart was used to display the monthly community-acquired CLABSI rate and observe for special cause variation. Results: At baseline, the average monthly community-acquired CLABSI rate was 11.7 per 1000 community catheter-days. The home CVC maintenance bundle was implemented, after which there were 5 consecutive months with no infections. After enhancements to the care bundle and tote, special cause variation was noted, and the average monthly community-acquired CLABSI rate declined by 66% to 4 per 1000 community catheter-days. Special cause variation was noted at 2 other time points without an identifiable cause. Conclusion: A lower community-acquired CLABSI rate has been sustained for 24 months and reflects approximately 12 fewer infections per year in this at-risk population.

Ethanol lock therapy increases mechanical catheter complications in a pediatric intestinal failure population: A retrospective cohort study.

Ethanol lock therapy (ELT) decreases central line-associated bloodstream infections; however, the effect on mechanical catheter complications is unclear. In recent years, ELT has become unavailable for many patients, often resulting in high-risk patients switching back to heparin locks. We investigated the impact of ELT on mechanical catheter complications during this period. We performed a retrospective cohort study of the Boston Children's Hospital intestinal rehabilitation program from January 1, 2018, to December 31, 2020. Pediatric patients with a central venous catheter requiring parenteral support for 3 months were included. The primary outcome was the composite rate of mechanical catheter complications (repairs and replacements). The pediatric intestinal failure cohort consisted of 122 patients. Forty-four percent received ELT for the entirety of the study period, 29% used only heparin locks, and 27% used ELT and heparin locks at different periods. During ELT use, there was 1.65 times the risk of mechanical catheter complications (composite outcome of repairs and replacements) compared with heparin locks (adjusted incidence rate ratio [aIRR] = 1.65, 95% CI = 1.18-2.31). Current ELT use was associated with 2.3 times the risk of catheter repairs (aIRR = 2.30, 95% CI = 1.36-3.89) but no significant increase in catheter replacement risk (aIRR = 1.41, 95% CI = 0.91-2.20). In the largest pediatric intestinal failure cohort evaluated to date, the use of ELT, compared with heparin locks, increased the risk of mechanical catheter complications. Mechanical complications carry morbidity requiring urgent clinic or emergency department visits and additional procedures. The investigation of alternative lock solutions is warranted.

Systematic Review: Noninvasive Assessments of Intestinal Failure-Associated Liver Disease in the Adult Population.

Chronic intestinal failure (CIF) patients are at risk for developing intestinal failure-associated liver disease (IFALD), which can progress to end-stage liver disease. Liver biopsy is the current reference standard to diagnose and monitor IFALD. However, due to its associated complications, biopsy is an unattractive tool in this respect. Our aim was to assess the evidence regarding non-invasive assessment of IFALD in the adult population and provide ideas to take this field further. We searched the PubMed, EMBASE and Web of Science databases in accordance with the PRISMA guideline. We included studies in the adult/mixed intestinal failure population, performing non-invasive diagnostic assessment of IFALD and using liver biopsy, 1H-MRS or MRI-PDFF as reference. Quality of the included studies was assessed using the QUADAS-2 tool. Four studies were included, assessing two serum (vitamin B12, FGF21) and two imaging tests (Fibroscan, CAUS). Three used liver biopsy as reference, all according to a different histological scoring system. One used 1H-MRS as reference. Vitamin B12 did not correlate with liver injury, Fibroscan did not correlate with fibrosis, but with cholestasis. FGF21 correlated with steatosis grade. Several CAUS parameters correlated with the degree of steatosis assessed by 1H-MRS. In conclusion, three tests show promise to non-invasively assess IFALD, but the limited data do not justify conclusions on the diagnostic value of the tested biomarkers. Hence, additional studies are needed. Identification of and validation for grading and staging of clinically relevant histomorphological parameters of IFALD is also crucial and a conceptual study set up is provided.

Development of venous thrombi in a pediatric population of intestinal failure

Background/PurposeAlthough pediatric intestinal failure (IF) is now a survivable diagnosis, children are still at risk for complications. Loss of venous access persists as a leading indication for intestinal transplantation. The goal of this study was to identify risk factors for loss of venous access in a pediatric intestinal failure population on long-term PN. MethodsWe identified all patients who were PN dependent. ResultsPatients that developed venous thrombosis had significantly more lines placed in the first 2 years of life compared to those who did not develop thrombosis. Multivariate regression analysis revealed that diagnosis (NEC and gastroschisis) and parental education were significant predictors of venous thrombosis. ConclusionBy identifying potential risk factors for thrombus development, interventions can be developed to improve the overall outcome in pediatric IF patients. Type of StudyDiagnostic Level of EvidenceIII

Health-related quality of life and neurodevelopmental outcomes among children with intestinal failure

Treatment results of pediatric intestinal failure have improved markedly during the last decades. With improved survival the attention is turning to other essential outcomes including quality of life and neurodevelopment. So far, relatively few studies with limited number of patients and variable methodology have addressed these issues. Based on these studies using generic health related quality of life tools, children with intestinal failure demonstrate decreased physical health, while PN-dependence is also associated with compromised emotional functioning. Impairments of social functioning are frequently observed among older children and parents. Few recent studies on neurodevelopment imply significant impairments in motor and mental skills among children with intestinal failure despite small sample sizes and limited follow-up times. Development of a disease-specific survey designed for the pediatric intestinal failure population could better reveal the health issues with greatest impact on quality of life. Robust studies with appropriate methodology on neurodevelopment in pediatric intestinal failure with extended follow-up times are urgently needed. Quality of life and neurodevelopment requires greater attention from medical professionals managing children with intestinal failure.

SUN-P048: The Use of Fistuloclysis in an Adult Intestinal Failure Population in a South African Tertiary Hospital

SUN-P048: The Use of Fistuloclysis in an Adult Intestinal Failure Population in a South African Tertiary Hospital

Challenging the 48-Hour Rule-Out for Central Line-Associated Bloodstream Infections in the Pediatric Intestinal Failure Population: A Retrospective Pilot Study.

While parenteral nutrition (PN) has revolutionized the management of patients with intestinal failure (IF), central line-associated bloodstream infections (CLABSIs) remain a leading cause of mortality and morbidity in this population. The objective of this study is to characterize the presentation of CLABSIs in pediatric IF and to determine the time to positivity of blood cultures. A retrospective cohort study of children with IF who presented to our institution for evaluation of a possible CLABSI from January 1, 2012, to December 31, 2012, was performed. Sixty patients with IF were identified. There were 33 cases of CLABSI in 16 patients, with a rate of 1.5 infections per 1000 catheter days. There were no significant differences in age, growth parameters, or catheter days between patients with or without CLABSI. Fever was documented in 85% of patients with CLABSI. These patients demonstrated an increased percentage of neutrophils and higher C-reactive protein levels compared with patients without CLABSI. The mean time to culture positivity was 13.2 hours, and 97% of cultures were positive within 24 hours. Our data suggest that most pediatric patients with IF who have CLABSI develop positive cultures within 24 hours, and the absence of fever and leukocytosis does not necessarily indicate the absence of infection. These findings may support clinical practice guidelines in favor of shorter hospital stay when CLABSI is suspected; however, a prospective analysis of CLABSI in this population is recommended to determine the safety and appropriate setting prior to any practice change.

Moving Toward Decreasing the Length of Hospital Stay in Admissions for Suspected Central Line-Associated Blood Stream Infections in the Pediatric Intestinal Failure Population

Moving Toward Decreasing the Length of Hospital Stay in Admissions for Suspected Central Line-Associated Blood Stream Infections in the Pediatric Intestinal Failure Population

Characteristics of Catheter-Related Bloodstream Infections in Children With Intestinal Failure

Catheter-related bloodstream infection is a major cause of mortality and morbidity in the intestinal-failure population. This study reports characteristics of CRBSI with implications for clinical management in parenteral nutrition-dependent children with intestinal failure. The researchers report the rate of central catheter infections, and the causative organisms, as well as identify risk factors in our intestinal-failure patients that would be amenable to preventive measures.The study is a retrospective review of the medical records of 101 patients with intestinal failure (IF), seen in the Intestinal Rehabilitation Clinic at Children's Medical Center of Dallas from May 2005 to March 2007. Catheter-related bloodstream infections (CRBSIs) were categorized as nosocomial or community-acquired. Data collected for each episode include microorganisms isolated from blood and potential risk factors. Z test was done to compare the infection rates.There were 92 episodes of CRBSIs in 45 parenteral nutrition (PN)-dependent patients with central venous catheters (CVC) in place for a total of 13,978 days. Eighty-three percent (n = 76) of CRBSIs developed in the community at a rate of 7.0 per 1,000 days. Seventeen percent (n = 16) nosocomial CRBSIs were observed at a rate of 5.5 per 1,000 catheter days. CRBSI rate was not statistically different between the two groups (7.0 vs. 5.5, p = .378).CRBSI in the intestinal-failure population is due to a wide variety of organisms with numerous risk factors. Education of CVC management with the practice of consistent guidelines may reduce CRBSI incidence, thus reducing the morbidity and mortality in the intestinal-failure patients.