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.
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 microg/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.
Department of Pediatrics, St Joseph's Hospital, Milwaukee, Wisconsin, USA.
Jeffery S
JS
Garland
Colleen P
CP
Alex
Kelly J
KJ
Henrickson
Timothy L
TL
McAuliffe
Dennis G
DG
Maki
D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D000925:Anticoagulants / Q000008:administration & dosage*; D016470:Bacteremia / Q000209:etiology / Q000382:microbiology / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D002408:Catheters, Indwelling / Q000009:adverse effects*; D016638:Critical Illness; D003428:Cross Infection / Q000517:prevention & control*; D004311:Double-Blind Method; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal; D013203:Staphylococcal Infections / Q000209:etiology / Q000517:prevention & control; D014640:Vancomycin / Q000008:administration & dosage* / Q000009:adverse effects; D020713:Vancomycin Resistance
D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D014640:Vancomycin; D006493:Heparin