PEDIATRICS Vol. 116 No. 2 August 2005, pp. e198-e205 (doi:10.1542/peds.2004-2674)
ELECTRONIC ARTICLE |
A Vancomycin-Heparin Lock Solution for Prevention of Nosocomial Bloodstream Infection in Critically Ill Neonates With Peripherally Inserted Central Venous Catheters: A Prospective, Randomized Trial
* Department of Pediatrics, St Joseph's Hospital
Pediatrics
Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
|| Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin
Objective.Critically ill neonates are at high risk for vascular catheter–related bloodstream infection (CRBSI), most often caused by coagulase-negative staphylococci. Most CRBSIs with long-term devices derive from intraluminal contaminants. The objective of this study was to ascertain the safety and the efficacy of a vancomycin-heparin lock solution for prevention of CRBSI.
Methods.A prospective, randomized double-blind trial was conducted during 2000–2001 at a community hospital level III NICU. Very low birth weight and other critically ill neonates with a newly placed peripherally inserted central venous catheter were randomized to have the catheter locked 2 or 3 times daily for 20 or 60 minutes with heparinized normal saline (n = 43) or heparinized saline that contained vancomycin 25 µg/mL (n = 42). The origin of each nosocomial bloodstream infection (BSI) was studied by culturing skin, catheter hubs, and implanted catheter segments and blood cultures, demonstrating concordance by restriction-fragment DNA subtyping. Surveillance axillary and rectal cultures were performed to detect colonization by vancomycin-resistant organisms. The main outcome measures were (1) CRBSIs and (2) colonization or infection by vancomycin-resistant Gram-positive bacteria.
Results.Two (5%) of 42 infants in the vancomycin-lock group developed a CRBSI as compared with 13 (30%) of 43 in the control group (2.3 vs 17.8 per 1000 catheter days; relative risk: 0.13; 95% confidence interval: 0.01–0.57). No vancomycin-resistant enterococci or staphylococci were recovered from any cultures. Vancomycin could not be detected in the blood of infants who did not receive systemic vancomycin therapy. Twenty-six neonates (8 vancomycin-lock group, 18 control group) had at the end of a catheter-lock period asymptomatic hypoglycemia that resolved promptly when glucose-containing intravenous fluids were restarted.
Conclusions.Prophylactic use of a vancomycin-heparin lock solution markedly reduced the incidence of CRBSI in high-risk neonates with long-term central catheters and did not promote vancomycin resistance but was associated with asymptomatic hypoglycemia. The use of an anti-infective lock solution for prevention of CRBSI with long-term intravascular devices has achieved proof of principle and warrants selective application in clinical practice.
Key Words: bacteremia • bloodstream infection • central venous catheter/access device • nosocomial infections • premature infants • sepsis • vancomycin
Abbreviations: CRBSI, catheter-related bloodstream infection • CDC, Centers for Disease Control and Prevention • RR, relative risk • CI, confidence interval
Accepted Feb 15, 2005.
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