Ethanol Lock Therapy for Catheter-Related Blood Stream Infections in Children

Background: Limited data suggest that ethanol lock therapy (ELT) administered concurrently with intravenous antibiotics is a safe, effective approach to treat catheter-related blood stream infections (CRBSIs) and to maintain the use of central venous catheters (CVC). However, there is very little data regarding the use of this therapy in children with limited central venous access.

Objective: We evaluated the use of a hospital policy for adjunctive ELT to treat and salvage CVC access in patients with bacterial CRBSIs. Analysis of the patient characteristics, outcomes, and effectiveness of ELT adds needed pediatric data on using ELT to treat patients with bacterial CRBSIs who require long-term central venous access.

Methods: We retrospectively reviewed the use of ELT from September 2007 to August 2010 in a cohort of pediatric patients with bacterial CRBSIs at a single US children’s hospital.  We reviewed patient medical records and pharmacy utilization data to identify all ELT orders. ELT was considered complete if the patient received proper volume of 70% ethanol solution (0.5 – 2 mL) for their catheter size and the ethanol was instilled for 24 hours dwell time consecutively for 2 – 4 days. Successful ELT was defined as no recurrence of infection with the same pathogen within 30 days.

Results: 18 instances of ELT in 11 patients were ordered. 3 instances were excluded that did not follow the lock protocol. 12 catheters treated with 15 instances of ELT (10 patients) met inclusion criteria. 86.7% of ELT instances were successful; with CVC access maintained a median of 51 days (range 21 - 595 days) after onset of initial infection and ELT. There were 2 ELT failures (13.3%) occurring in a single patient with a single CVC, both caused by coagulase negative Staphylococcus spp, within 10 days of ELT. 5 non-failure CVC events occurred within 30 days of ELT. One patient expired 26 days after ELT due to her underlying condition and 4 patients had new CRBSIs with different organisms. No adverse events related to ELT were noted.

 

Characteristic	Total #
Male : Female	6 : 4
Age, median (range), years	7.69 (0.8-22.9)
Total Parenteral Nutrition Dependent	6
Immunocompromised	4
Diagnosis ( n = 10 patients)
Short gut syndrome	2
Chronic enteropathy	3
Megacystic microcolon	1
Acute myelogenous leukemia	1
Wilms’ tumor	1
Pulmonary hypertension	1
Camptomelic dysplasia	1
Catheter Type (n = 12 catheters)
Double lumen Broviac	3
Single lumen Broviac	7
Port-a-cath	2
Pathogens (n = 15 infections)
Coagulase-negative Staphylococcus spp	4 (26.7%)
Enterococcus spp	3 (20%)
Escherichia coli	1 (6.7%)
Klebsiella pneumoniae	2 (13.3%)
Methicillin sensitive Staphylococcus aureus	1 (6.7%)
Methicillin resistant Staphylococcus aureus	1 (6.7%)
Polymicrobial infection	3 (20%)

Conclusions: ELT had an 86.7% success rate with zero reported adverse events in our pediatric cohort.  It appears to be a safe and effective adjunctive treatment for bacterial CRBSIs in patients who require long-term CVC access.