Published online Feb 27, 2019. doi: 10.4254/wjh.v11.i2.208
Peer-review started: November 15, 2018
First decision: December 21, 2018
Revised: January 15, 2019
Accepted: January 26, 2019
Article in press: January 26, 2019
Published online: February 27, 2019
Pre-transplant nutrition is a key driver of outcomes following liver transplantation in children. Patients with biliary atresia (BA) may have difficulty achieving satisfactory weight gain with enteral nutrition alone, and parenteral nutrition (PN) may be indicated. While PN has been shown to improve anthropometric parameters of children with BA listed for liver transplantation, less is known about the risks, particularly infectious, associated with this therapy among this specific group of patients.
To describe the incidence, microbiology, and risk factors of central line-associated bloodstream infection (CLABSI) among children with BA listed for liver transplantation.
Retrospective review of children aged ≤ 2-years of age with BA who were listed for primary liver transplantation at Texas Children’s Hospital from 2008 through 2015 (n = 96). Patients with a central line for administration of PN (n = 63) were identified and details of each CLABSI event were abstracted. We compared the group of patients who experienced CLABSI to the group who did not, to determine whether demographic, clinical, or laboratory factors correlated with development of CLABSI.
Nineteen of 63 patients (30%, 95%CI: 19, 43) experienced 29 episodes of CLABSI during 4800 line days (6.04 CLABSI per 1000 line days). CLABSI was predominantly associated with Gram-negative organisms (14/29 episodes, 48%) including Klebsiella spp., Enterobacter spp., and Escherichia coli. The sole polymicrobial infection grew Enterobacter cloacae and Klebsiella pneumoniae. Gram-positive organisms (all Staphylococcus spp.) and fungus (all Candida spp.) comprised 9/29 (31%) and 6/29 (21%) episodes, respectively. No demographic, clinical, or laboratory factors were significantly associated with an increased risk for the first CLABSI event in Cox proportional hazards regression analysis
There is substantial risk for CLABSI among children with BA listed for liver transplantation. No clinical, demographic, or laboratory factor we tested emerged as an independent predictor of CLABSI. While our data did not show an impact of CLABSI on the short-term clinical outcome, it would seem prudent to implement CLABSI reduction strategies in this population to the extent that each CLABSI event represents potentially preventable hospitalization, unnecessary healthcare dollar expenditures, and may exact an opportunity cost, in terms of missed allograft offers.
Core tip: Rates of central line-associated bloodstream infection (CLABSI) are high among children with biliary atresia listed for liver transplantation. While most CLABSI represented enteric flora, Candida was isolated in 21% of events, suggesting that it may be appropriate to consider the use of antifungals in this population when empiric therapy doesn’t lead to expected clinical improvement. Since no factors we tested appeared to predict CLABSI, we propose that prevention efforts should be focused on universal and meticulous application of known CLABSI-reducing strategies, such as line insertion bundles.