Intravascular Infections Research Articles

Evaluation of Central Venous Catheter Associated Blood Stream Infections: A Microbiological Observational Study

There are substantial morbidity and mortality associated with vascular catheter use among crictically ill patients. The attributable mortality is 10% to 25% which is associated with bacteremia among those who are hospitalized. This study was undertaken to identify catheter related blood stream infections, to isolate pathogenic microorganisms present in intravascular catheter related local infections, exit site infections, and to determine the predisposing factors for the development of such infections and antibiotic sensitivity pattern of the isolated organisms in tertiary care hospital.

The Evaluation of Vancomycin Microspheres on Intracellular <i>Staphylococcus aureus</i> and the Effect of Bacteria on Eukaryotic Cell Wall Permeability

Sepsis is a host’s response to an intravascular infection; however, in most patients the disease recurs after a seemingly effective treatment. The reappearance of bacteria in the systemic circulation has been attributed to their ability to enter and hide within host endothelial cells. This study shows that internalized S. aureus is released into circulation by a possible mechanism of exocytosis through actin polymerization. Bacterial cell wall components (permeation enhancers) were significantly more effective in altering endothelial cell monolayer integrity than controls. Vancomycin has been determined to be effective in the treatment of S. aureus infections; however, the microencapsulated formulation of vancomycin was significantly more effective in reducing plasma and intra-tissue S. aureus than the conventional solution formulation. Microencapsulation of vancomycin, using albumin as a matrix, did not alter the bioactivity of the drug.

Clinical Manifestations of 6 Cases of Septic Pulmonary Embolism at Increased Risk Recently

Objectives The aim of this study was to investigate the clinico-radiologic features and microbiologic data of patients with SPE in a tertiary care hospital in Busan. Methods We retrospectively analyzed clinical and radiologic features of 6 cases with septic pulmonary embolism that occurred from March 2009 to March 2011 in Dong-A university medical center. Results The mean age of the study population was 58 years, and two men and four women were included. Clinical symptoms included general weakness (5 patients), febrile sensation (4 patients) and pleuritic chest pain (2 patients). Underlying conditions were chemoport infection (4 patients), dental abscess (1 patients), and cellulitis of hip (1 patient). Chest computed tomography revealed bilateral multiple nodular opacities in most patients, and cavitation, central necrosis, feeding vessels were identified. All patients received parenteral antimicrobial therapy with or without central catheter removal, drainage of the extrapulmonary infection. Causative organisms were Pseudomonas aeruginosa (2 patients), Candida albicans (1 patient), Bacillus species (1 patient), and Klebsiella pneumonia (1 patient). Conclusions Clinical and radiologic features of septic pulmonary embolism were various and nonspecific. The diagnosis was usually suggested by the presence of a predisposing factor of septic pulmonary embolism and CT findings of bilateral multiple nodular opacities in patients with infectious signs and symptoms. Most important underlying condition was intravascular device infection.

Q fever endocarditis associated with a cardiovascular implantable electronic device

Cardiovascular implantable electronic devices (CIEDs) are frequently related to endocarditis. Most cases of intravascular CIED infections are usually related to skin flora, but a few cases may occur with negative blood culture. Coxiella burnetii is one of the main causes of blood culture-negative endocarditis in native and prosthetic valves, but to date no cases related to CIED have been published. Herein we report two cases of Q fever endocarditis related to these non-valvular cardiovascular devices.

Telavancin in the treatment of invasive Gram-positive infections

Telavancin in the treatment of invasive Gram-positive infections Yoav Keynan,1–4 Ethan Rubinstein2,31Department of Community Health Sciences, 2Department of Medical Microbiology, 3Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; 4Department of Medical Microbiology, University of Nairobi, Nairobi, KenyaAbstract: Telavancin is a newer once-daily lipoglycopeptide with activity against Gram-positive bacteria, including those that are resistant to conventional antibiotics like beta-lactams. The results of recent clinical trials led to registration of telavancin for use in skin and skin structure infections in the US and Canada and for nosocomial pneumonia in Europe, based primarily on the favorable results of clinical trials. We review the evidence for use of telavancin in Gram-positive intravascular infections, focusing on bacteremic subpopulations in the large clinical trials as well as anecdotal evidence for use of the drug in the setting of infective endocarditis.Keywords: telavancin, Gram-positive bacteria, skin infections, infective endocarditis

Antibacterial and antifouling catheter coatings using surface grafted PEG-b-cationic polycarbonate diblock copolymers

Intravascular catheter-associated infections (CAIs), which are normally induced by microbial adhesion and subsequent biofilm formation, are a major cause of morbidity and mortality. Therefore, strategies to prevent CAIs are in great demand. In this study, a series of diblock copolymers of PEG and cationic polycarbonate with various compositions were synthesized by metal-free organocatalytic ring-opening polymerization, and coated onto silicone rubber (a commonly used catheter material) at different concentrations via a reactive polydopamine coating. Static contact angle and X-ray photoelectron spectroscopy measurements proved the successful coating, and quartz crystal microbalance results showed that the coating thickness increased as polymer concentration increased. Methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) isolates – leading causes of intravascular CAIs – were employed to evaluate the antibacterial and antifouling activities of the polymer coatings. Polymer coatings with a hydrophobic component effectively killed planktonic MSSA and MRSA in solution and prevented their fouling on silicone rubber surface. Live/dead cell staining experiments revealed that polymer coatings with the optimal polymer composition possessed significantly higher antifouling activity than PEG coating. In addition, scanning electron microscopic studies showed that the polymer coating inhibited S. aureus biofilm formation over a period of 7 days. Furthermore, the polymer coating caused no significant hemolysis, and there was no blood protein adsorption or platelet adhesion observed. Therefore, PEG-b-cationic polycarbonates with optimal compositions are effective antifouling and antibacterial coatings for the prevention of intravascular CAIs.

Symmetrical Peripheral Gangrene in an Octagenerian Asian male with Multiple Morbidities: A Case Report

Introduction: Symmetrical peripheral gangrene (SPG, or peripheral symmetrical gangrene, PSG) is defined as acute onset of symmetrical ischemic gangrene over multiple sites of acral area, mostly extremities and sometimes nose, ear or scalp, without vascular occlusion or vasculitis. The pathogenesis is still unknown but related to local ischemia due to disseminated intravascular coagulation, infection, or medications. Case presentation: A 87 year-old Asian man was admitted to the intensive care unit under the impression of septic shock. Vasopressors were administered due to hypotension. However, bilateral cyanosis over limbs was noted gradually few days after the medications given. Dry gangrene over distal limbs developed even after we stopped the medication as early as possible. Discussion: Symmetrical peripheral gangrene may be an indicator for disseminated intravascular coagulation and poor prognosis. Quick reversal of underlying disease and elimination of precipitating factors are both significant managements once symmetrical peripheral gangrene is diagnosed.

Angiopoietin-1 variant reduces LPS-induced microvascular dysfunction in a murine model of sepsis

IntroductionSevere sepsis is characterised by intravascular or extravascular infection with microbial agents, systemic inflammation and microcirculatory dysfunction, leading to tissue damage, organ failure and death. The growth factor angiopoietin (Ang-1) has therapeutic potential but recombinant Ang-1 tends to aggregate and has a short half-life in vivo. This study aimed to investigate the acute effects of the more stable Ang-1 variant matrilin-1-angiopoietin-1 (MAT.Ang-1) on the function of the microcirculation in an experimental model of sepsis, and whether any protection by MAT-Ang-1 was associated with modulation of inflammatory cytokines, angiogenic factors or the endothelial nitric oxide synthase (eNOS)-Akt and vascular endothelial (VE)-cadherin pathways.MethodsAluminium window chambers were implanted into the dorsal skinfold of male C3H/HeN mice (7 to 10 weeks old) to expose the striated muscle microcirculation. Endotoxemia was induced by intraperitoneal injection of lipopolysaccharide (LPS, 1 mg/kg at 0 and 19 hours). MAT.Ang-1 was administered intravenously 20 hours after the onset of sepsis. Microcirculatory function was evaluated by intravital microscopy and Doppler fluximetry.ResultsEndotoxemia resulted in macromolecular leak, which was ameliorated by MAT.Ang-1 post-treatment. LPS induced a dramatic reduction in tissue perfusion, which was improved by MAT.Ang-1. Proteome profiler array analysis of skeletal muscle also demonstrated increased inflammatory and reduced angiogenic factors during endotoxemia. MAT.Ang-1 post-treatment reduced the level of IL-1β but did not significantly induce the expression of angiogenic factors. MAT.Ang-1 alone did not induce leak or increase angiogenic factors but did reduce vascular endothelial growth factor expression in controls.ConclusionAdministration of MAT.Ang-1 after the onset of sepsis protects the microcirculation from endotoxemia-induced vascular dysfunction through reducing inflammation but without pro-angiogenic actions, thus representing a novel, potential pharmacotherapeutic agent for the treatment of sepsis.

Fibrin formation by staphylothrombin facilitates Staphylococcus aureus-induced platelet aggregation

Interactions of Staphylococcus aureus (S. aureus) and platelets play an important role in the pathogenesis of intravascular infections such as infective endocarditis (IE). A typical feature of S. aureus is the ability to generate thrombin activity through the secretion of two prothrombin activating molecules, staphylocoagulase and von Willebrand factor-binding protein (vWbp), which bind to human prothrombin to form the enzymatically active staphylothrombin complex. The role of staphylothrombin in the interaction between S. aureus and platelets has not yet been studied. We found that in contrast with thrombin, staphylothrombin did not directly activate human platelets. However, the staphylothrombin-mediated conversion of fibrinogen to fibrin initiated platelet aggregation and secondary activation and facilitated S. aureus-platelet interactions. Both the genetic absence of staphylocoagulase and vWbp and pharmacological inhibition of staphylothrombin increased the lag time to aggregation, and reduced platelet trapping by S. aureus in high shear stress conditions. The combined inhibition of staphylothrombin and immunoglobulin binding to platelets completely abolished the ability of S. aureus to aggregate platelets in vitro. In conclusion, although staphylothrombin did not directly activate platelets, the formation of a fibrin scaffold facilitated bacteria-platelet interaction, and the inhibition of staphylothrombin resulted in a reduced activation of platelets by S. aureus.

Bartonellae in animals and vectors in New Caledonia

Bartonellae are gram-negative facultative intracellular alpha-proteobacteria from the family Bartonellaceae. The natural history of bartonellae consists of a reservoir/host, which is a vertebrate with chronic intravascular infection with sustained bacteremia, and a vector (usually an arthropod) that transfers the bacteria from the reservoir to a susceptible yet uninfected host. In order to reveal the sources and reservoirs of Bartonella infection in animals and vectors in New Caledonia, we collected the blood samples of 64 dogs, 8 cats, 30 bovines, 25 horses and 29 wild deer Cervus timorensis russa and 308 associated blood-sucking parasites (14 keds Hippobosca equina, 258 ticks (22 Rhipicephalus microplus, 235 Rhipicephalus sanguineus, and 1 Haemaphysalis longicornis), 12 fleas Ctenocephalides felis and 24 dog lice Trichodectes canis). We isolated ten strains of Bartonella: four Bartonella henselae from cats and six Bartonella chomelii from cattle. The strains were characterized by sequencing of five genes (16S, ITS, rpoB, gltA and ftsZ). The six strains isolated from cattle were close to the reference strain of B. chomelii and were, probably, imported from France with cattle of Limousin race. PCR showed that 35% of keds collected from deer and 31% of deer were infected by B. aff. schoenbuchensis; all other samples were negative. Our data confirmed that in New Caledonia, as in other regions of the world, cats are the major reservoirs of B. henselae. We also confirmed that Hippoboscidae flies may serve as the vectors of ruminant-associated bartonellae.

Preventing postoperative infection: the anaesthetist's role

Postoperative surgical patients are at risk of developing multiple types of hospital-acquired infections. These include surgical site infections which are relatively common (incidence 5–20%), can prolong hospital stay, cause morbidity, increase the cost of health care, and even lead to mortality. Other hospital-acquired infections affecting surgical patients include respiratory and urinary tract infections, methicillin-resistant Staphylococcus aureus bacteraemias, antibiotic-related Clostridium difficile enteritis, and intravascular cannulaerelated infections. All surgical wounds are likely to become contaminated, usually by resident bacterial flora from skin or viscera. This may not be of clinical significance and contaminated wounds may go unnoticed. However, progression from wound contamination to clinical infection is largely determined by the adequacy of host defence, the most important immune mechanism of which is neutrophil phagocytosis which occurs during a crucial few hours intraoperatively and after operation. When a neutrophil ingests bacteria (or any foreign debris), it undergoes a ‘respiratory burst’, temporarily increasing its oxygen consumption which results in the production of anti-microbial oxygen free radicals. Oxygen free radicals such as superoxide ions and hydrogen peroxide are produced by the enzymes superoxide dismutase and myeloperoxidase. Variables that affect tissue oxygen delivery or enzyme function can impair the production of oxygen free radicals and allow bacteria to survive and infection to become established. Well-known variables that influence surgical site infection include surgical factors (e.g. haematoma, anastomotic leak, poor surgical technique, choice of antiseptic, prolonged or technically difficult procedure) and patient factors (immunosuppression, age, ASA status, comorbidities, colonization by S. aureus) (Table 1). However, there are now a number of emerging factors that can also affect the incidence of bacterial infections of the surgical site. Some of these other variables are pre-existing or unmodifiable, whereas several can be altered by the anaesthetist. These modifiable factors will be the focus of this discussion. Factors that can be optimized in the perioperative period can be divided into:

CD23b Isoform Expression in Human Schistosomiasis Identifies a Novel Subset of Activated B Cells

Resistance to schistosomiasis is associated with increased levels of serum parasite-specific IgE. IgE exerts its functions through its cellular receptors, FcεRI and FcεRII/CD23; however, its functional significance in humans requires further characterization. We previously reported that increased levels of CD23(+) B cells correlate with resistance to schistosomiasis in hyperexposed populations and sought to define their potential function and relationship with IgE. We found that CD23(+) B cells are a heterogeneous cell population with functional and phenotypic differences. Circulating CD23(+) B cells are uniquely activated in schistosomiasis and express the CD23b isoform and CXCR5, the homing receptor for lymphoid follicles. High CXCR5 expression by CD23(+) B cells was associated with the capacity to home to the cognate ligand CXCL13. CD23-bound IgE cross-linking increased surface expression of CXCR5, suggesting that CD23(+) B cells home directly into the lymphoid follicles upon antigen capture. As human schistosomiasis is an intravascular parasitic infection associated with a high antigenic burden in the blood, circulating CD23(+) B cells may play a role in the capture and shuttling of antigens directly to splenic follicles, highlighting a new role for circulating B cells. This function likely plays an important role in the development of protective immunity to infection with schistosomes.

Physiology and Pathophysiology of Selectins, Integrins, and IgSf Cell Adhesion Molecules Focusing on Inflammation. A Paradigm Model on Infectious Endocarditis

The development of adhesion bonds, either among cells or among cells and components of the extracellular matrix, is a crucial process. These interactions are mediated by some molecules collectively known as adhesion molecules (CAMs). CAMs are ubiquitously expressed proteins playing a central role in controlling cell migration, proliferation, survival, and apoptosis. Besides their key function in physiological maintenance of tissue integrity, CAMs play an eminent role in various pathological processes such as cardiovascular disorders, atherogenesis, atherosclerotic plaque progression and regulation of the inflammatory response. CAMs such as selectins, integrins, and immunoglobulin superfamily take part in interactions between leukocyte and vascular endothelium (leukocyte rolling, arrest, firm adhesion, migration). Experimental data and pathologic observations support the assumption that pathogenic microorganisms attach to vascular endothelial cells or sites of vascular injury initiating intravascular infections. In this review a paradigm focusing on cell adhesion molecules pathophysiology and infective endocarditis development is given.

Hospital acquired infections (HAI) in the elderly: Comparison with the younger patients

The aim of this retrospective study is to determine the frequency, type, microbiological characteristics and outcome of HAIs in the elderly (age ≥ 65) and to compare the data with younger patients in a Turkish Training and Research Hospital. From January 2008 to December 2009, the infection control team analyzed HAIs among 60,585 hospitalized patients (20,109 aged ≥ 65 and 40,747 aged between 18 and 64 years) with a total number of 419,017 patient days. A total of 825 HAIs episodes were detected in 607 patients, of which 395 episodes were in 301 elderly patients. The incidence of HAIs per 1000 patient days was 2.49 in the elderly and 1.64 in the younger patients’ group ( p < 0.001). The most common site of infection in the elderly patients was the urinary tract, whereas in non-elderly group this was the lower respiratory tract. The incidence density of urinary tract infections, respiratory tract infections, surgical site, skin and soft tissue infections, primary bacteremia, and prosthesis infections were significantly higher in the elderly group ( p < 0.05). Gram-negative species were the most frequently isolated agents in both groups. There were no significant differences between the groups in the frequency of isolated pathogens or antibiotic susceptibility patterns. Overall, the fatality rate was found 16.8%. The elderly patients were more likely to have crude mortality rates (22% vs. 12%; p < 0.01). The death was most often related to pneumonia, primary bacteremia or intravascular catheter infections in both groups.

Health Care–Associated Infections in Children

HEALTH CARE–ASSOCIATED INFECTIONS (HAI) REsult in significant morbidity, prolong hospitalization, increase health care costs, and contribute to patient deaths. Among the aggressive national and local endeavors to address HAI, the subtle (and not so subtle) differences between pediatric and adult patients are often overlooked. Rates of central line–associated bloodstream infections (CLABSI), surgical site infections (SSI), and respiratory viral infections differ between children and adults, reflecting the unique susceptibilities of each population. Efforts to reduce the rates of HAI in children are often hampered by the lack of pediatric-specific research, lack of national pediatricspecific quality measures to guide prevention of SSI, and the implementation of infection prevention practices validated only in adult populations. The US Centers for Disease Control and Prevention/ National Healthcare Safety Network surveillance definitions for HAI in children and adults are in general the same, differing slightly for patients 1 year or younger. The commonality of definitions, however, belies the fact that children and adults differ in both susceptibility to infection and in the steps necessary to prevent these infections. Furthermore, identification of pediatric-specific risk factors for infection and the solutions needed to reduce pediatric HAI have not been well investigated. Central line–associated bloodstream infections, SSI, and viral infections in pediatric patients illustrate the important but overlooked differences between adult and pediatric HAI. Pediatric patients younger than 2 years and those requiring care in neonatal intensive care units (ICUs) and pediatric ICUs have especially high rates of HAI, and bloodstream infections are the most common HAI in all pediatric age groups. Pediatric patients have higher rates of bloodstream infections and viral lower respiratory tract infections than adult patients, whereas rates of catheter-related urinary tract infections, ventilator-associated pneumonia, and SSI are higher in adult patients, although rates for particular pediatric surgical procedures may be high. Data on CLABSI illustrate the difference between children and adults. Reported rates for CLABSI are frequently higher in pediatric ICUs than in adult ICUs. In adults, implementation of a multifaceted insertion bundle has been demonstrated to reduce the rates of CLABSI substantially. In contrast with adult data, maximizing insertion-bundle adherence is not sufficient to eliminate CLABSI in children. Data from the National Association of Children’s Hospitals and Related Institutions collaborative demonstrate that the main driver for reducing CLABSI in pediatric patients in the ICU involves optimizing the daily maintenance and care of central line catheters. Unique considerations are involved in the prevention of CLABSI in pediatric patients. Difficult intravenous access often requires placement of catheters in locations that have higher infection rates. In addition, catheters need to be maintained for longer periods of time because of difficult vascular access and the need to obtain blood. Maintenance practices must be tailored to the maturity of an infant’s skin. In very lowbirthweight infants, chlorhexadine may cause a chemical dermatitis or burn, and chlorhexadine-impregnated biopatches may cause pressure ulcers. However, individual neonatal ICUs and pediatric ICUs have been able to decrease their rates of CLABSI substantially, in some cases by incorporating novel technological approaches such as the use of closed intravenous systems to prevent maintenance-related intravascular catheter infections. The Surgical Care Improvement Project (SCIP) is a national quality improvement project to reduce surgical complications. Six of the 9 publicly reported SCIP measures focus on reducing SSI. Adherence rates to individual SCIP measures provide a benchmark to track infection prevention measures, and emerging data suggest that adherence with core SCIP measures may reduce SSI. Although several of the SCIP measures to reduce infection are appropriate for children, some measures such as postoperative glucose control for cardiac surgery and postoperative temperature control after colorectal surgery are intended for adults. It is perhaps not surprising that SCIP measures, and the requirement for hospitals to track and report SCIP adherence, do not apply to patients younger than 18 years. What is surprising is that similar measures are not in place for prevention of SSI in children. It is important that a national quality improvement program to reduce HAI does not apply to pediatric patients. The Surgical Care Improvement Project measures are tracked by the Joint Commission, the agency that accredits and certifies

What Is The Predominant Source of Intravascular Catheter Infections?

The predominant source of intravascular catheter-related bloodstream infections has been a research and clinical question for more than 30 years. During that time, we've moved from the position of a single source predominating in all clinical scenarios to a more realistic appraisal that both skin at the insertion site and the catheter hub/connector (ie, an extraluminal and an intraluminal source of infection, respectively) are important and that maximally effective prevention programs must address both sources of infection.

Clinical analysis of intravascular catheter-related bloodstream infection in neonatal intensive care unit

Objective To find out the clinical characteristics and morbility factors of intravascular catheterrelated bloodstream infection(CRBSI). Methods Totally 21 patients who had CRBSI in neonatal intensive care unit were investigated retrospectively. Results The distribution of CRBSI was higher in very low birthweight preterm infants, gestational age among 28 ～34week, whose intravascular catheter remaining time were obove three weeks. Principal clinical presentation of CRBSI were poor feeding, unaocountable tachycardia, temperature instability, stressed hyperglycemia,refractoriness metabolic acidosis. The most common pathogens were coagulase-negative staphylococci (35.7%), Klebsiella pneumonia, bacilli ( 11.9% ) Staphylococcus aureus (9.5 % ), Pseudomonas aeruginosa( 7. 1% )and Enterobacter cloacae(7.1% ). Conclusions The clinical manifestations of CRBSI were concealment,and reducing the time of inserted central catherization and total parenteral nutrition, strengthening the nutrition of body would provide effective prevention of CRBSI. Key words: Intravascular catheter; Bloodstream infection; Neonates

Disseminated Intravascular Coagulation, Meningococcal Infection, and Ischemic Changes Affecting the Lower Extremities: A Case Study

A middle-aged woman presented from an outside hospital with a diagnosis of Neisseria meningitidis and meningococcemia. A nonpalpable purpuric skin rash evolved into multiple wounds, with gradual necrosis of bilateral lower and upper extremities. Throughout the course of hospitalization, the patient developed ventricular tachycardia, normocytic anemia, thrombocytosis, Clostridium difficile infection, depression, and transient right eye blindness. The finding of decreased CH50 in the complement cascade was considered as the potential cause of the meningococcemia. The subsequent ischemia and necrosis of extremities were attributed to the systemic effect and trauma ensuing from N. meningitidis.

In vitro Evaluation of Antibiotic Lock Technique for the Treatment ofCandida albicans,C. glabrata, andC. tropicalisBiofilms

Candidaemia associated with intravascular catheter-associated infections is of great concern due to the resulting high morbidity and mortality. The antibiotic lock technique (ALT) was previously introduced to treat catheter-associated bacterial infections without removal of catheter. So far, the efficacy of ALT against Candida infections has not been rigorously evaluated. We investigated in vitro activity of ALT against Candida biofilms formed by C. albicans, C. glabrata, and C. tropicalis using five antifungal agents (caspofungin, amphotericin B, itraconazole, fluconazole, and voriconazole). The effectiveness of antifungal treatment was assayed by monitoring viable cell counts after exposure to 1 mg/mL solutions of each antibiotic. Fluconazole, itraconazole, and voriconazole eliminated detectable viability in the biofilms of all Candida species within 7, 10, and 14 days, respectively, while caspofungin and amphotericin B did not completely kill fungi in C. albicans and C. glabrata biofilms within 14 days. For C. tropicalis biofilm, caspofungin lock achieved eradication more rapidly than amphotericin B and three azoles. Our study suggests that azoles may be useful ALT agents in the treatment of catheter-related candidemia.

ESPEN Guidelines on Parenteral Nutrition: Geriatrics

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.