Introduction

A central line-associated bloodstream infection (CLABSI) is a common and potentially life-threatening complication for patients with intestinal failure (IF) receiving home parenteral nutrition (HPN). In uncomplicated infections, The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines advocate for central venous access (CVC) salvage for venous access preservation (1). Existing knowledge regarding the risk factors of HPN-related CLABSIs have been extrapolated from European and North American studies (2-4), and the effects of tropical climates and its potentially higher support requirements on the incidence of infection has not yet been studied.

Aims & Methods

We sought to analyse the risk factors of developing HPN-related CLABSI, and assess CLABSI management, in a large Australian state with a highly dispersed population. A retrospective observational cohort study was conducted on 34 adult patients receiving HPN via a central venous catheter (CVC) at a Queensland tertiary referral centre, between 2016 and 2023. CLABSI was defined according to the criteria of the Australian Commission on Safety and Quality in Health Care (5). Patient charts were reviewed, and a univariate cox regression analysis model was used to identify predictors of CLABSI in the first CVC during the study period. Kaplan-Meier analysis was employed to build survival curves of time to CLABSI, and log-rank tests analysed survival between patient and CVC characteristics.

Results

Nineteen patients had ≥1 CLABSI(s) episode, accounting for a total of 39 episodes. Patients with ≥1 CLABSI(s) used regular opioids more than those who did not develop CLABSI (p=0.016) but did not differ by age, gender, body mass index, geography, aetiology of intestinal failure or catheter weeks. Fourteen patients (41%, n=14/34) developed a CLABSI in their first CVC. No patient or line characteristics, including geographical remoteness and tropical climate, were found to be predictive of CLABSI in their first CVC. The overall infection rate was 1.02 per 1000 catheter days. Most CLABSIs were caused by Enterobacterales (22%, n=12/55), followed by coagulase-negative Staphylococcus (18%, n=10/55). Administration of empiric antimicrobials within the standardised 3-hour sepsis timeframe was inadequate (50%, n=14/28), with only 25% (n=7/28) providing adequate cover of causative pathogens. The median time to effective antibiotic therapy was 22.7 hours (IQR 4.8-29.8). There were 3 CVC salvages (8%, n=3/39), all of which were successful.

Conclusion

In this cohort of patients, regular opioid use was associated with an increased risk of developing CLABSI which is consistent with international studies (2-4). We also found a low CVC salvage rate in our cohort, representing potential missed opportunities for venous access preservation. Based on our findings, an empiric antimicrobial regime of vancomycin, cefepime and caspofungin for all HPN-related CLABSI cases would be expected to be effective for 84.6%. We recommend that Australian IF units with a similar antimicrobial distribution and resistance pattern adopt this regime.

References

1. Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, et al. ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020;39(6):1645-66.

2. Gompelman M, Causevic E, Bleeker-Rovers CP, Wanten GJA. Catheter-related bloodstream infection management in patients receiving home parenteral nutrition: An observational cohort study. Clin. Nutr. ESPEN. 2022;50:155-61.

3. Adgey C, Raine T, Lawrence H, Sharkey LM, Woodward JM, Massey DCO. ADWE-10 Risk factors for line infections in a cambridge HPN cohort. Gut. 2018;67(1):A7.

4. Ashley B, Paul C, Trevor RS, Jeremy MDN, Simon L. Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition. Frontline Gastroenterol. 2020;11(1):48.

5. Australian Commission on Safety and Quality in Health Care. Surveillance of Central Line-Associated Bloodstream Infection. [Internet]. Sydney: Australian Commission on Safety and Quality in Health Care; July 2019. Available from: https://www.safetyandquality.gov.au/sites/default/files/2019-08/implementation-guide-for-surveillance-of-central-line-associated-blood-stream-infection-2019-final.pdf.

Introduction

Celiac disease, a chronic autoimmune enteropathy caused by exposure to gluten in genetically predisposed individuals, is characterized by a broad clinical spectrum often with multisystem involvement. Symptoms related to the reproductive system include delayed menarche, early menopause, fertility disorders, miscarriages, and prematurity.

Aims & Methods

To study the impact of celiac disease on fertility in a female Greek population. A retrospective review of all patient records from the celiac disease outpatient clinic at our hospital.

Results

Medical histories of 231 female patients were reviewed (69% of the total patient population) with a mean age of 44.3 years and a mean age at diagnosis of 35.3 years. The mean age of menarche was 12.7 years. Menstrual irregularities were reported in 27% (20% instability, 7% dysmenorrhea). A total of 28% (65/231) were in menopause, with an average age of menopause onset at 50.7 years. A history of miscarriages was recorded in 15% of all women (35/231), but in 29% of women in menopause (19/65). 82% (53/65) of women in menopause had children, with 98% (52/53) having been pregnant before the diagnosis of the disease. Among all women who gave birth, only 12/113 (11%) had been diagnosed before pregnancy. 56% (63/113) and 44% (50/113) had a vaginal delivery and cesarean section, respectively. Pregnancy complications were recorded in 24 women (18 preterm births, 15 low birth weight infants, 1 intrauterine death).

Conclusion

Women with celiac disease tend to have relatively late menarche and an increased rate of miscarriages. However, the disease does not seem to significantly affect fertility.

References

1.Ehud Galron MD, Rayna Boyarsky MD,Ido Sold MD, Chen Ben David MD,and Eyal Gal MD,Interactions between celiac disease and pregnancy:A literature review, Isr Med Assoc J.2023 Dec;25(12):830-835
2.Giovanni Casella et. Al. Celiac disease and obstetrical-gynecological contribution, Gastroenterol Hepatol Bed Bench. 2016 Autumn; 9(4): 241–249.
3.Stephanie M. Moleski et. Al., Increased rates of pregnancy complications in women with celiac disease, Annals of Gastroenterology (2015) 28, 236-240
4.Nafeesa N. Dhalwani et Al., Women With Celiac Disease Present With Fertility ProblemsNo More Often Than Women in the General Population, Gastroenterology 2014;147:1267–1274

Introduction

Intestinal failure in advanced malignancy often results from mechanical bowel obstruction, post-surgical complications, or mucosal diseases. Palliative home parenteral nutrition (HPN) can potentially improve survival and quality of life (QoL). However, there is limited robust data on which factors may predict optimum survival, and its use remains contentious. This study aimed to assess the survival of patients receiving palliative HPN and to examine the impact of patient factors on survival outcomes.

Aims & Methods

This is a single-centre retrospective observational study of 84 patients referred for palliative HPN from the period of 1^st January 2020 to 19^th November 2024. Demographic, nutritional and medical data were analysed. Survival rates were compared using Kaplan-Meier curves and Cox regression.

Results

A total of 84 patients were referred for palliative HPN during the study period and 77 patients were discharged with HPN eventually [median age was 60 yr, (IQR: 51.3-70.4), female 77%]. Underlying primary malignancies of gynaecological and gastrointestinal origin predominated accounting for 78% of the study cohort. Majority of patients had metastatic disease at 95%. Mechanical bowel obstruction was the main indication for HPN (84%). Performance status (PS) scores were ≤ 2 in 88% of patients and 49% had an estimated prognosis of >3 months. The median serum albumin and C-reactive protein (CRP) was 26g/L and 21 mg/L respectively. Median overall survival was 58 days (IQR 31 – 108) with a 3-month mortality of 69%. There was no statistical difference in overall survival when evaluate by PS, estimated prognosis, underlying malignancy or modified Glasgow prognostic score (mGPS).

Conclusion

The overall survival in our study is modest. PS scores, estimated prognosis, mGPS, or tumour type did not show a significant impact on survival. This highlights the challenges in artificial nutrition and emphasizes the role of a multidisciplinary team in the care of these patients.