Use of Catheter Lock Solutions in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Individual-Patient Data Meta-Analysis

Abstract

Background: Use of catheter lock solutions (CLSs) as a strategy to prevent catheter-related bloodstream infections (CRBSIs) has been evaluated in recent clinical trials. Our aim was to identify the most effective CLS formulation in patients receiving home parenteral nutrition (HPN).

Methods: We conducted a systematic review and individual-patient data meta-analysis (IPDMA). Prospective randomized clinical trials in adult HPN patients using CLS were identified from PubMed, EMBASE, Web of Science, CINAHL, Cochrane library, and ClinicalTrials.gov. Primary outcome was the number of CRBSIs per 1000 catheter days for each CLS. Other outcomes included time to CRBSI and identification of patients with a higher risk for CRBSIs.

Results: In total, 1107 studies were screened for eligibility, of which three studies comprising 162 HPN patients and 45,695 catheter days were included in the IPDMA. CRBSI rates were significantly decreased in patients using taurolidine (rate 0.13; 95% confidence interval [CI], 0.05-0.32) when compared with saline (rate 0.74; 95% CI, 0.31-1.74; P = .002) or heparin (rate 2.01; 95% CI, 1.03-3.91; P < .001). The cumulative proportion of CRBSI-free patients using taurolidine, saline, and heparin after 1 year was 88%, 56%, and 14%, respectively. Three risk factors for CRBSIs were identified: type of CLS, intestinal dysmotility as underlying condition, and use of central venous catheters.

Conclusions: Taurolidine was the most effective CLS formulation in HPN patients for the prevention of CRBSIs. We suggest discussing with patients the benefits and risks when starting taurolidine, especially in patients who are considered to have a higher risk for CRBSIs.

Keywords: catheter lock solution; catheter-related bloodstream infection; central venous access device; ethanol; heparin; home parenteral nutrition; intestinal failure; saline; systematic review; taurolidine.

Figure 1

Search strategy for prospective randomized studies in adult home parenteral patients using catheter lock solutions. CRBSI, catheter‐related bloodstream infection; CVAD, central venous access device; IPDMA, individual‐patient data meta‐analysis.

Figure 2

Comparison of Adjusted CRBSI Rates per CLS^a. Presented data were obtained from individual‐patient data of 3 studies (Bisseling et al, Klek et al, and Wouters et al).15, 30, 31. CI, confidence interval; CLS, catheter lock solution; CRBSI, catheter‐related bloodstream infection; CVAD, central venous access device. ^aRates are expressed as number of CRBSIs per 1000 catheter days. ^bCRBSI rates were adjusted for center, history of CRBSIs, type of CVAD, and type of infusion fluids.

Figure 3

Survivor functions for the 3 treatment groups. Results of a Cox proportional hazards model adjusted for center clustering, representing the time to CRBSI with CVADs locked with taurolidine (striped green line), saline (continuous blue line), or heparin (dotted red line). The cumulative proportion of CRBSI‐free patients after 1 year was 88% in the taurolidine group, 56% in the saline group, and 14% in the heparin group. Presented data were obtained from individual‐patient data of 3 studies (Bisseling et al, Klek et al, and Wouters et al).15, 30, 31 CRBSI, catheter‐related bloodstream infection; CVAD, central venous access device.

Figure 4

Survivor functions of patients stratified for risk factors for CRBSIs. Results of survivor functions according to a Cox proportional hazards model adjusted for center clustering with stratification for risk factors for CRBSIs (Table 3): (1) type of lock solution (taurolidine [striped line], saline [continuous line], or heparin [dotted line]); (2) underlying disease (SBS, motility disorder, or other underlying diseases); (3) type of central venous access device (CVC or SPS). Presented data were obtained from individual‐patient data of 3 studies (Bisseling et al, Klek et al, and Wouters et al).15, 30, 31 CRBSI, catheter‐related bloodstream infection; CVC, central venous catheter; motil, motility disorder; other, other underlying diseases; SBS, short bowel syndrome; SPS, subcutaneous port system.