RECURRENT SEPSIS IN-HOME PARENTERAL-NUTRITION PATIENTS - AN ANALYSIS OF RISK-FACTORS

Septicemia is the major cause of morbidity in home parenteral nutrition patients, accounting for approximately 70% of rehospitalizations. To identify risk factors, the incidence of infection was examined in 41 current home parenteral nutrition patients, 30 with short-bowel syndrome (including 16 with inflammatory bowel disease and 11 with bowel infarction) and 11 with chronic obstructive disorders. Management, which was followed for a mean duration of 78.6 months (range, 1 to 15 1/2 years), was standardized by protocol. Ten patients never experienced infection during the average follow-up of 61 months (range, 14 to 174 months), whereas seven patients experienced frequent infections during the mean follow-up of 77 months (range, 24 to 180 months). Significant distinguishing features in the frequent-infection group were younger age (45 +/- 12 vs 66.9 +/- 14.3 years, p < .05), Crohn's disease (in five of seven vs zero of 10 subjects, p < .05), jejunostomies (in seven of seven vs one of 10 subjects, p < .0005), and central vein thrombosis (in five of seven vs zero of 10 subjects, p < .05). A greater proportion of the frequent-infection group had poor catheter-care technique and more were smokers. One hundred fifty septicemias were confirmed by blood culture, giving an average infection rate of one every 31 months, 52% caused by Gram-positive organisms (chiefly coagulase-negative staphylococci and Staphylococcus aureus), 30% caused by Gram-negative organisms, and 16% caused by fungus (chiefly Candida albicans). In conclusion, these results indicate that catheter sepsis is not invariably associated with long-term intravenous feeding but that a combination of host factors (Crohn's disease, jejunostomy, and central vein thrombosis) and environmental factors (catheter management technique) increase the risk of recurrent sepsis. The results suggest that early preventative measures, such as maintenance of hydration, long-term anticoagulation, and decontamination of catheter hub and locking solution, should be considered in patients with the combination of Crohn's disease and jejunostomies to decrease the risk of frequent septicemias.