Journal of Pediatric Surgery 50 (2015) 428–430
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Infectious complications following serial transverse enteroplasty in infants and children with short bowel syndrome Wendy K. Fujioka a, Robert A. Cowles a, b,⁎ a b
Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
a r t i c l e
i n f o
Article history: Received 5 February 2014 Received in revised form 19 June 2014 Accepted 19 July 2014 Key words: Enteroplasty Short bowel syndrome Bacteremia Fungemia Infection Complication
a b s t r a c t Background: Serial transverse enteroplasty (STEP) lengthens and tapers dilated small bowel in patients with short bowel syndrome (SBS). Previous reports document encouraging outcomes with regard to tolerance for enteral nutrition (EN) and complications appear related to the re-operative nature of many cases and to the presence of multiple staple lines. However, infectious complications following STEP have not been examined. Since infections, especially catheter-related blood stream infections (CRBSI), are considered detrimental in infants and children with SBS, we sought to define the frequency and outcomes of peri-operative infections associated with STEP. Methods: All children with SBS who underwent a STEP between 2004 and 2012 were indentified and their medical records were reviewed. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. For the purpose of this study, infections occurring within a 14day period after STEP were considered procedure-related and were the focus of the study. Results: A total of 18 patients underwent 23 STEP procedures. Primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, and midgut volvulus. After the STEP, eight patients (35%) developed CRBSI, three developed wound infections, and two had urinary tract infections. Organisms isolated from either blood, wound or urine cultures included gram-positive cocci, gram-negative rods, and yeast. Perioperative antibiotics were administered in all cases with cefoxitin (43%) and piperacillin/tazobactam (30%) being most common. Neither antibiotic appeared superior in reducing the incidence of CRBSI. In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock resulted in negative blood cultures in all cases. Only one central venous catheter required replacement acutely for persistent fungemia. Conclusion: STEP can improve enteral tolerance. In this fragile patient population, however, STEP carries a documented infectious burden. The optimal antibiotic prophylaxis and the role of ethanol locking in patients undergoing STEP require further study. © 2015 Elsevier Inc. All rights reserved.
Pediatric short bowel syndrome (SBS) is a form of intestinal failure (IF) caused by a variety of prenatal and postnatal events including intestinal atresia, gastroschisis, necrotizing enterocolitis, and intestinal malrotation [1–3]. The loss of small intestinal surface area leaves affected infants and children with insufficient absorptive capacity to sustain growth and development. While parenteral nutrition (PN) can be life-sustaining as the remnant intestine adapts, IF-associated complications such as cholestasis, sepsis, and venous thrombosis complicate management [2,4,5]. During this process of intestinal adaptation, dilation of the adapting small bowel can
⁎ Corresponding author at: Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06520. Tel.: +1 203 785 2701; fax: +1 203 785 3820. E-mail address: [email protected] (R.A. Cowles). http://dx.doi.org/10.1016/j.jpedsurg.2014.07.009 0022-3468/© 2015 Elsevier Inc. All rights reserved.
occur leading to stasis, bacterial overgrowth and deterioration in absorptive function. Serial transverse enteroplasty (STEP) is an intestinal lengthening procedure that both lengthens and tapers the dilated small bowel in patients with SBS [6,7]. Previous reports on STEP document encouraging outcomes with regard to tolerance for enteral nutrition (EN) [5,8,9] and most complications appear related to the reoperative nature of many cases and to the presence of multiple staple lines resulting in leak, perforation, ulcer, or obstruction [1,4,10,11]. Patients with SBS are known to be at high risk for catheter-related blood stream infections (CRBSIs) and these infections have been proven to increase length of stay and health care costs [12–16]. The infectious burden associated with the STEP operation has not been previously examined. Since any infection, especially a CRBSI, is considered so detrimental to infants and children with SBS, we chose to evaluate the frequency and outcomes of perioperative infections associated with performance of STEP operations.
W.K. Fujioka, R.A. Cowles / Journal of Pediatric Surgery 50 (2015) 428–430
1. Methods A retrospective chart review of all infants and children who underwent a STEP procedure between 2004 and 2012 was performed. STEP operations were performed by a single surgeon with experience with the procedure. Medical records were reviewed from birth until the date of discharge following STEP. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. One infant underwent STEP at the time of intestinal atresia repair and therefore did not meet both of these criteria. Blood and urine were collected for culture and wounds and were assessed based on clinical signs suspicious for infection. These signs included fever, hemodynamic instability, unexplained leukocytosis or a concern regarding the healing wound. For the purpose of this study, infections occurring within a 14-day period after STEP were considered procedure-related and were the focus of the study. Data including sex, gestational age at birth, age at time of surgery, primary diagnosis, indication for surgery, and pre and post-STEP bowel length were obtained. Perioperative and postoperative antibiotic coverage were assessed and any positive blood, wound, sputum, and urine culture results along with their associated antimicrobial susceptibility profiles were examined. The use of other infection control measures such as antibiotic or ethanol lock therapy was recorded. The study was approved by the Institutional Review Board (Protocol # IRBAAAD6042) of Columbia University. Analysis of variance was used for statistical comparison of antibiotic therapy in patients with or without infection. Statistical results were considered significant when the p-value was b0.05. Analysis was performed in Statview.
429
Following the 23 STEP procedures, 14 (61%) had no documented perioperative infections whereas nine (39%) had documented infections. Of these, eight (35%) were complicated by CRBSI, three (13%) by wound infection, and two (9%) by urinary tract infection. Organisms isolated from the blood, wound, or urine cultures were identified and underwent antibiotic susceptibility testing. The isolates included gram-positive cocci, gram-negative rods, and yeast (Table 2). In three patients with CRBSI, more than one organism was cultured from the blood. While perioperative care varied depending on the patient, certain procedures were routinely followed. A bowel preparation was not performed because most patients were felt to have dysmotility that would preclude the administration of a cathartic. Vascular catheters were cared for by the nursing staff according to hospital protocol although the anesthesia service was given the responsibility for the intraoperative care of these catheters. A 10% povidone–iodine solution was used for skin preparation prior to surgery because all patients either had a gastrostomy present or were felt to be too young for other skin antiseptics. Finally, a single dose of perioperative intravenous antibiotics was administered prior to the start of all cases, with cefoxitin being the most commonly used (n = 10) followed by piperacillin/tazobactam (n = 5). Additional doses were administered in the operating room if the case extended beyond 4 hours. Neither antibiotic appeared superior in reducing the incidence of CRBSI (p = 0.23 for cefoxitin and p = 0.47 for piperacillin/tazobactam). In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock of the indwelling Broviac catheter resulted in negative blood cultures in all cases. Only one central venous catheter was replaced acutely for persistent fungemia.
2. Results 3. Discussion Of the 18 patients (7 male) who underwent the STEP procedure, five patients had repeated STEP procedures, for an overall total of 23 separate STEP operations. The median age at the time of surgery was 16 months (range, 13 days–6 years) and primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, midgut volvulus, or a combination of these disorders (Table 1). The most common indications for the STEP procedure were dilated small bowel and failure to advance enteral feeds. Overall, the median increase in bowel length was 40% (range 21–63%). On long-term follow-up at a median of 2.6 years (range 0.8–8.4 years), PN independence was achieved in 8 of 18 (44%) patients and there was one death 4 years after STEP resulting in an overall survival of 94% for the entire cohort. One patient required an intestinal transplant after the STEP and another underwent a liver transplant because of IF-associated liver disease prior to the STEP procedure. Table 1 Demographics of patient population. Age at surgery Range Median, months Interquartile range, months Gender Males, n (%) Females, n (%) Gestational age Range, weeks Median, weeks Length of stay Range, days Median, days Interquartile range, days Primary diagnosis Intestinal atresia, n (%) Gastroschisis, n (%) Necrotizing enterocolitis, n (%) Combination, n (%)
The STEP procedure has gained popularity as an adjunct in the care of children with short bowel syndrome and dilated bowel. It can lengthen and taper the bowel and has been shown to improve enteral tolerance. The current study provides additional evidence of its utility because almost half of the patients who underwent STEP were eventually weaned from PN. Despite these encouraging results of STEP on nutritional tolerance in this fragile patient population, this study has identified a concerning and previously unrecognized infectious burden associated with this operation. Of particular concern is the 35% incidence of CRBSI because these not only expose the patient to the detrimental effects of sepsis but also may require catheter removal with associated loss of vascular access sites.
Table 2 Infectious complications after serial transverse enteroplasty. 13days–6 years 16.5 8.73–28.4 7 (39) 11 (61)
Total patients, n (%) Total infections, n Appearance Range, days Median, days Gram-positive cocci
29-37.5 34 6–67 11.00 9–18 2 (11) 3 (17) 6 (33) 7 (39)
Gram-negative rod
Fungi
Blood-stream infections
Wound infections
UTI
8 (35) 11
3 (13) 6
2 (9) 2
0-13 3 5 E. faecalis E. faecium S. epidermidis S. hominis (2) 5 K. pneumoniae (2) K. oxytoca S. marcesans E. coli 1 Candida albicans
5-14 4 4 E. faecalis E. faecium S. coag neg S. viridans 2 E. coli P. aeruginosa
2-11 6.5 1 S. aureus
0
1 E. Clocae
0
430
W.K. Fujioka, R.A. Cowles / Journal of Pediatric Surgery 50 (2015) 428–430
This study represents an initial attempt to characterize the burden of infection associated with complex gastrointestinal procedures on this particularly vulnerable group of patients with SBS. The lack of a control group that did not undergo a STEP procedure for comparison is unavoidable and therefore it is impossible to determine with certainty that the STEP itself was independently responsible for all the documented infections. In addition, the study was not able to identify specific factors that may prevent CRBSI or other infections in patients undergoing STEP and this is likely a result of the relatively small sample size. Classically, the perioperative antibiotic dose is administered in an attempt to prevent perioperative infections during gastrointestinal surgery. In this study, it appears that the perioperative antibiotic was insufficient to prevent infections even when broad spectrum agents such as piperacillin/tazobactam were used. One could postulate that poor catheter care during the perioperative period could be responsible for the high incidence of CRBSI. While this may indeed be a factor, other theories may also adequately explain the findings of the study. It is accepted that dilated segments of small bowel promote bacterial overgrowth and that bacterial translocation occurs in this patient population. While the current study cannot prove that bacterial translocation with seeding of vascular catheters, the operative wound, and the urinary tract occurs, this remains a plausible explanation for the findings presented here. For comparison, and in contrast, two recent studies documenting blood and surgical site infections after cardiac surgery reported infection rates of b 10% [17,18]. These data suggest that there is a distinct aspect of the STEP, apart from the perioperative catheter care, that may result in higher rates of blood, surgical site, and urinary infections. Many studies have examined the efficacy of ethanol [19–25], heparin [24], or antibiotic [20,21] lock therapies, as well as alcoholswabbed caps [26], to prevent CRBSI in patients with indwelling central-venous catheters receiving PN. In this study, the use of 74% ethanol locking successfully resulted in negative blood cultures in all cases with persistent bacteremia despite appropriate antibiotic treatment. In summary, the data presented here suggest that the infectious burden associated with the STEP operation is significant and that the causes are likely multifactorial. Although no specific causes for infections were identified, the results of this study underscore the importance of meticulous central venous catheter care both in and out of the OR, timely administration of perioperative antibiotics and possibly the expansion of the use of ethanol locking protocols in this patient population. Since the perioperative antibiotic dose does not seem to reliably prevent the occurrence of blood, wound, and urinary tract infections, this patient population must be carefully monitored for an infectious complication after the STEP procedure. While not formally evaluated in this study, it is possible that other adjuncts such as preoperative gut decontamination in patients undergoing the STEP procedure would be beneficial and should be further examined.
Acknowledgment This study was funded by a grant from the Charles Edison Fund (Newark, NJ).
References [1] Modi BP, Javid PJ, Jaksic T, et al. First report of the international serial transverse enteroplasty data registry: indications, efficacy, and complications. J Am Coll Surg 2007;204(3):365–71. [2] Modi BP, Jaksic T. Pediatric intestinal failure and vascular access. Surg Clin North Am 2012;92(3):729–43. [3] Wales PW, de Silva N, Kim J, et al. Neonatal short bowel syndrome: populationbased estimates of incidence and mortality rates. J Pediatr Surg 2004;39(5):690–5. [4] Ching YA, Fitzgibbons S, Valim C, et al. Long-term nutritional and clinical outcomes after serial transverse enteroplasty at a single institution. J Pediatr Surg 2009;44 (5):939–43. [5] Javid PJ, Kim HB, Duggan CP, et al. Serial transverse enteroplasty is associated with successful short-term outcomes in infants with short bowel syndrome. J Pediatr Surg 2005;40(6):1019–23 [discussion 1023–1024]. [6] Kim HB, Fauza D, Garza J, et al. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg 2003;38(3):425–9. [7] Suri M, Dicken B, Nation PN, et al. The next step? Use of tissue fusion technology to perform the serial transverse enteroplasty–proof of principle. J Pediatr Surg 2012; 47(5):938–43. [8] Kaji T, Tanaka H, Wallace LE, et al. Nutritional effects of the serial transverse enteroplasty procedure in experimental short bowel syndrome. J Pediatr Surg 2009;44(8):1552–9. [9] Oliveira C, de Silva N, Wales PW. Five-year outcomes after serial transverse enteroplasty in children with short bowel syndrome. J Pediatr Surg 2012;47(5): 931–7. [10] King B, Carlson G, Khalil BA, et al. Intestinal bowel lengthening in children with short bowel syndrome: systematic review of the Bianchi and STEP procedures. World J Surg 2013;37(3):694–704. [11] Wales PW, de Silva N, Langer JC, et al. Intermediate outcomes after serial transverse enteroplasty in children with short bowel syndrome. J Pediatr Surg 2007;42(11):1804–10. [12] Cole CR, Frem JC, Schmotzer B, et al. The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses. J Pediatr 2010;156(6):941–7. [13] Cole CR, Hansen NI, Higgins RD, et al. Bloodstream infections in very low birth weight infants with intestinal failure. J Pediatr 2012;160(1):54–9. [14] Gutierrez IM, Kang KH, Calvert CE, et al. Risk factors for small bowel bacterial overgrowth and diagnostic yield of duodenal aspirates in children with intestinal failure: a retrospective review. J Pediatr Surg 2012;47(6):1150–4. [15] Mohammed A, Grant FK, Zhao VM, et al. Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN J Parenter Enteral Nutr 2011;35(5):581–7. [16] Goudie A, Dynan L, Brady PW, et al. Attributable cost and length of stay for central line-associated bloodstream infections. Pediatrics 2014;133(6):e1525–32. [17] Abou Elella R, Najm HK, Balkhy H, et al. Impact of bloodstream infection on the outcome of children undergoing cardiac surgery. Pediatr Cardiol 2010;31(4): 483–9. [18] Murray MT, Krishnamurthy G, Corda R, et al. Surgical site infections and bloodstream infections in infants after cardiac surgery. J Thorac Cardiovasc Surg 2014;148(1):259–65. [19] Chambers ST, Peddie B, Pithie A. Ethanol disinfection of plastic-adherent microorganisms. J Hosp Infect 2006;63(2):193–6. [20] Chu HP, Brind J, Tomar R, et al. Significant reduction in central venous catheterrelated bloodstream infections in children on HPN after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55(4):403–7. [21] Huang EY, Chen C, Abdullah F, et al. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2011;46(10):2000–11. [22] Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010;45(6):1287–93. [23] Oliveira C, Nasr A, Brindle M, et al. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. J Pediatr 2012; 129(2):318–29. [24] Wales PW, Kosar C, Carricato M, et al. Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience. J Pediatr Surg 2011;46(5):951–6. [25] Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN J Parenter Enteral Nutr 2011;35(1):67–73. [26] Castello FV, Maher A, Cable G. Reducing bloodstream infections in pediatric rehabilitation patients receiving parenteral nutrition. J Pediatr 2011;128(5): 1273–8.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Infectious complications following serial transverse enteroplasty in infants and children with short bowel syndrome Wendy K. Fujioka a, Robert A. Cowles a, b,⁎ a b
Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
a r t i c l e
i n f o
Article history: Received 5 February 2014 Received in revised form 19 June 2014 Accepted 19 July 2014 Key words: Enteroplasty Short bowel syndrome Bacteremia Fungemia Infection Complication
a b s t r a c t Background: Serial transverse enteroplasty (STEP) lengthens and tapers dilated small bowel in patients with short bowel syndrome (SBS). Previous reports document encouraging outcomes with regard to tolerance for enteral nutrition (EN) and complications appear related to the re-operative nature of many cases and to the presence of multiple staple lines. However, infectious complications following STEP have not been examined. Since infections, especially catheter-related blood stream infections (CRBSI), are considered detrimental in infants and children with SBS, we sought to define the frequency and outcomes of peri-operative infections associated with STEP. Methods: All children with SBS who underwent a STEP between 2004 and 2012 were indentified and their medical records were reviewed. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. For the purpose of this study, infections occurring within a 14day period after STEP were considered procedure-related and were the focus of the study. Results: A total of 18 patients underwent 23 STEP procedures. Primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, and midgut volvulus. After the STEP, eight patients (35%) developed CRBSI, three developed wound infections, and two had urinary tract infections. Organisms isolated from either blood, wound or urine cultures included gram-positive cocci, gram-negative rods, and yeast. Perioperative antibiotics were administered in all cases with cefoxitin (43%) and piperacillin/tazobactam (30%) being most common. Neither antibiotic appeared superior in reducing the incidence of CRBSI. In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock resulted in negative blood cultures in all cases. Only one central venous catheter required replacement acutely for persistent fungemia. Conclusion: STEP can improve enteral tolerance. In this fragile patient population, however, STEP carries a documented infectious burden. The optimal antibiotic prophylaxis and the role of ethanol locking in patients undergoing STEP require further study. © 2015 Elsevier Inc. All rights reserved.
Pediatric short bowel syndrome (SBS) is a form of intestinal failure (IF) caused by a variety of prenatal and postnatal events including intestinal atresia, gastroschisis, necrotizing enterocolitis, and intestinal malrotation [1–3]. The loss of small intestinal surface area leaves affected infants and children with insufficient absorptive capacity to sustain growth and development. While parenteral nutrition (PN) can be life-sustaining as the remnant intestine adapts, IF-associated complications such as cholestasis, sepsis, and venous thrombosis complicate management [2,4,5]. During this process of intestinal adaptation, dilation of the adapting small bowel can
⁎ Corresponding author at: Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06520. Tel.: +1 203 785 2701; fax: +1 203 785 3820. E-mail address: [email protected] (R.A. Cowles). http://dx.doi.org/10.1016/j.jpedsurg.2014.07.009 0022-3468/© 2015 Elsevier Inc. All rights reserved.
occur leading to stasis, bacterial overgrowth and deterioration in absorptive function. Serial transverse enteroplasty (STEP) is an intestinal lengthening procedure that both lengthens and tapers the dilated small bowel in patients with SBS [6,7]. Previous reports on STEP document encouraging outcomes with regard to tolerance for enteral nutrition (EN) [5,8,9] and most complications appear related to the reoperative nature of many cases and to the presence of multiple staple lines resulting in leak, perforation, ulcer, or obstruction [1,4,10,11]. Patients with SBS are known to be at high risk for catheter-related blood stream infections (CRBSIs) and these infections have been proven to increase length of stay and health care costs [12–16]. The infectious burden associated with the STEP operation has not been previously examined. Since any infection, especially a CRBSI, is considered so detrimental to infants and children with SBS, we chose to evaluate the frequency and outcomes of perioperative infections associated with performance of STEP operations.
W.K. Fujioka, R.A. Cowles / Journal of Pediatric Surgery 50 (2015) 428–430
1. Methods A retrospective chart review of all infants and children who underwent a STEP procedure between 2004 and 2012 was performed. STEP operations were performed by a single surgeon with experience with the procedure. Medical records were reviewed from birth until the date of discharge following STEP. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. One infant underwent STEP at the time of intestinal atresia repair and therefore did not meet both of these criteria. Blood and urine were collected for culture and wounds and were assessed based on clinical signs suspicious for infection. These signs included fever, hemodynamic instability, unexplained leukocytosis or a concern regarding the healing wound. For the purpose of this study, infections occurring within a 14-day period after STEP were considered procedure-related and were the focus of the study. Data including sex, gestational age at birth, age at time of surgery, primary diagnosis, indication for surgery, and pre and post-STEP bowel length were obtained. Perioperative and postoperative antibiotic coverage were assessed and any positive blood, wound, sputum, and urine culture results along with their associated antimicrobial susceptibility profiles were examined. The use of other infection control measures such as antibiotic or ethanol lock therapy was recorded. The study was approved by the Institutional Review Board (Protocol # IRBAAAD6042) of Columbia University. Analysis of variance was used for statistical comparison of antibiotic therapy in patients with or without infection. Statistical results were considered significant when the p-value was b0.05. Analysis was performed in Statview.
429
Following the 23 STEP procedures, 14 (61%) had no documented perioperative infections whereas nine (39%) had documented infections. Of these, eight (35%) were complicated by CRBSI, three (13%) by wound infection, and two (9%) by urinary tract infection. Organisms isolated from the blood, wound, or urine cultures were identified and underwent antibiotic susceptibility testing. The isolates included gram-positive cocci, gram-negative rods, and yeast (Table 2). In three patients with CRBSI, more than one organism was cultured from the blood. While perioperative care varied depending on the patient, certain procedures were routinely followed. A bowel preparation was not performed because most patients were felt to have dysmotility that would preclude the administration of a cathartic. Vascular catheters were cared for by the nursing staff according to hospital protocol although the anesthesia service was given the responsibility for the intraoperative care of these catheters. A 10% povidone–iodine solution was used for skin preparation prior to surgery because all patients either had a gastrostomy present or were felt to be too young for other skin antiseptics. Finally, a single dose of perioperative intravenous antibiotics was administered prior to the start of all cases, with cefoxitin being the most commonly used (n = 10) followed by piperacillin/tazobactam (n = 5). Additional doses were administered in the operating room if the case extended beyond 4 hours. Neither antibiotic appeared superior in reducing the incidence of CRBSI (p = 0.23 for cefoxitin and p = 0.47 for piperacillin/tazobactam). In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock of the indwelling Broviac catheter resulted in negative blood cultures in all cases. Only one central venous catheter was replaced acutely for persistent fungemia.
2. Results 3. Discussion Of the 18 patients (7 male) who underwent the STEP procedure, five patients had repeated STEP procedures, for an overall total of 23 separate STEP operations. The median age at the time of surgery was 16 months (range, 13 days–6 years) and primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, midgut volvulus, or a combination of these disorders (Table 1). The most common indications for the STEP procedure were dilated small bowel and failure to advance enteral feeds. Overall, the median increase in bowel length was 40% (range 21–63%). On long-term follow-up at a median of 2.6 years (range 0.8–8.4 years), PN independence was achieved in 8 of 18 (44%) patients and there was one death 4 years after STEP resulting in an overall survival of 94% for the entire cohort. One patient required an intestinal transplant after the STEP and another underwent a liver transplant because of IF-associated liver disease prior to the STEP procedure. Table 1 Demographics of patient population. Age at surgery Range Median, months Interquartile range, months Gender Males, n (%) Females, n (%) Gestational age Range, weeks Median, weeks Length of stay Range, days Median, days Interquartile range, days Primary diagnosis Intestinal atresia, n (%) Gastroschisis, n (%) Necrotizing enterocolitis, n (%) Combination, n (%)
The STEP procedure has gained popularity as an adjunct in the care of children with short bowel syndrome and dilated bowel. It can lengthen and taper the bowel and has been shown to improve enteral tolerance. The current study provides additional evidence of its utility because almost half of the patients who underwent STEP were eventually weaned from PN. Despite these encouraging results of STEP on nutritional tolerance in this fragile patient population, this study has identified a concerning and previously unrecognized infectious burden associated with this operation. Of particular concern is the 35% incidence of CRBSI because these not only expose the patient to the detrimental effects of sepsis but also may require catheter removal with associated loss of vascular access sites.
Table 2 Infectious complications after serial transverse enteroplasty. 13days–6 years 16.5 8.73–28.4 7 (39) 11 (61)
Total patients, n (%) Total infections, n Appearance Range, days Median, days Gram-positive cocci
29-37.5 34 6–67 11.00 9–18 2 (11) 3 (17) 6 (33) 7 (39)
Gram-negative rod
Fungi
Blood-stream infections
Wound infections
UTI
8 (35) 11
3 (13) 6
2 (9) 2
0-13 3 5 E. faecalis E. faecium S. epidermidis S. hominis (2) 5 K. pneumoniae (2) K. oxytoca S. marcesans E. coli 1 Candida albicans
5-14 4 4 E. faecalis E. faecium S. coag neg S. viridans 2 E. coli P. aeruginosa
2-11 6.5 1 S. aureus
0
1 E. Clocae
0
430
W.K. Fujioka, R.A. Cowles / Journal of Pediatric Surgery 50 (2015) 428–430
This study represents an initial attempt to characterize the burden of infection associated with complex gastrointestinal procedures on this particularly vulnerable group of patients with SBS. The lack of a control group that did not undergo a STEP procedure for comparison is unavoidable and therefore it is impossible to determine with certainty that the STEP itself was independently responsible for all the documented infections. In addition, the study was not able to identify specific factors that may prevent CRBSI or other infections in patients undergoing STEP and this is likely a result of the relatively small sample size. Classically, the perioperative antibiotic dose is administered in an attempt to prevent perioperative infections during gastrointestinal surgery. In this study, it appears that the perioperative antibiotic was insufficient to prevent infections even when broad spectrum agents such as piperacillin/tazobactam were used. One could postulate that poor catheter care during the perioperative period could be responsible for the high incidence of CRBSI. While this may indeed be a factor, other theories may also adequately explain the findings of the study. It is accepted that dilated segments of small bowel promote bacterial overgrowth and that bacterial translocation occurs in this patient population. While the current study cannot prove that bacterial translocation with seeding of vascular catheters, the operative wound, and the urinary tract occurs, this remains a plausible explanation for the findings presented here. For comparison, and in contrast, two recent studies documenting blood and surgical site infections after cardiac surgery reported infection rates of b 10% [17,18]. These data suggest that there is a distinct aspect of the STEP, apart from the perioperative catheter care, that may result in higher rates of blood, surgical site, and urinary infections. Many studies have examined the efficacy of ethanol [19–25], heparin [24], or antibiotic [20,21] lock therapies, as well as alcoholswabbed caps [26], to prevent CRBSI in patients with indwelling central-venous catheters receiving PN. In this study, the use of 74% ethanol locking successfully resulted in negative blood cultures in all cases with persistent bacteremia despite appropriate antibiotic treatment. In summary, the data presented here suggest that the infectious burden associated with the STEP operation is significant and that the causes are likely multifactorial. Although no specific causes for infections were identified, the results of this study underscore the importance of meticulous central venous catheter care both in and out of the OR, timely administration of perioperative antibiotics and possibly the expansion of the use of ethanol locking protocols in this patient population. Since the perioperative antibiotic dose does not seem to reliably prevent the occurrence of blood, wound, and urinary tract infections, this patient population must be carefully monitored for an infectious complication after the STEP procedure. While not formally evaluated in this study, it is possible that other adjuncts such as preoperative gut decontamination in patients undergoing the STEP procedure would be beneficial and should be further examined.
Acknowledgment This study was funded by a grant from the Charles Edison Fund (Newark, NJ).
References [1] Modi BP, Javid PJ, Jaksic T, et al. First report of the international serial transverse enteroplasty data registry: indications, efficacy, and complications. J Am Coll Surg 2007;204(3):365–71. [2] Modi BP, Jaksic T. Pediatric intestinal failure and vascular access. Surg Clin North Am 2012;92(3):729–43. [3] Wales PW, de Silva N, Kim J, et al. Neonatal short bowel syndrome: populationbased estimates of incidence and mortality rates. J Pediatr Surg 2004;39(5):690–5. [4] Ching YA, Fitzgibbons S, Valim C, et al. Long-term nutritional and clinical outcomes after serial transverse enteroplasty at a single institution. J Pediatr Surg 2009;44 (5):939–43. [5] Javid PJ, Kim HB, Duggan CP, et al. Serial transverse enteroplasty is associated with successful short-term outcomes in infants with short bowel syndrome. J Pediatr Surg 2005;40(6):1019–23 [discussion 1023–1024]. [6] Kim HB, Fauza D, Garza J, et al. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg 2003;38(3):425–9. [7] Suri M, Dicken B, Nation PN, et al. The next step? Use of tissue fusion technology to perform the serial transverse enteroplasty–proof of principle. J Pediatr Surg 2012; 47(5):938–43. [8] Kaji T, Tanaka H, Wallace LE, et al. Nutritional effects of the serial transverse enteroplasty procedure in experimental short bowel syndrome. J Pediatr Surg 2009;44(8):1552–9. [9] Oliveira C, de Silva N, Wales PW. Five-year outcomes after serial transverse enteroplasty in children with short bowel syndrome. J Pediatr Surg 2012;47(5): 931–7. [10] King B, Carlson G, Khalil BA, et al. Intestinal bowel lengthening in children with short bowel syndrome: systematic review of the Bianchi and STEP procedures. World J Surg 2013;37(3):694–704. [11] Wales PW, de Silva N, Langer JC, et al. Intermediate outcomes after serial transverse enteroplasty in children with short bowel syndrome. J Pediatr Surg 2007;42(11):1804–10. [12] Cole CR, Frem JC, Schmotzer B, et al. The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses. J Pediatr 2010;156(6):941–7. [13] Cole CR, Hansen NI, Higgins RD, et al. Bloodstream infections in very low birth weight infants with intestinal failure. J Pediatr 2012;160(1):54–9. [14] Gutierrez IM, Kang KH, Calvert CE, et al. Risk factors for small bowel bacterial overgrowth and diagnostic yield of duodenal aspirates in children with intestinal failure: a retrospective review. J Pediatr Surg 2012;47(6):1150–4. [15] Mohammed A, Grant FK, Zhao VM, et al. Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN J Parenter Enteral Nutr 2011;35(5):581–7. [16] Goudie A, Dynan L, Brady PW, et al. Attributable cost and length of stay for central line-associated bloodstream infections. Pediatrics 2014;133(6):e1525–32. [17] Abou Elella R, Najm HK, Balkhy H, et al. Impact of bloodstream infection on the outcome of children undergoing cardiac surgery. Pediatr Cardiol 2010;31(4): 483–9. [18] Murray MT, Krishnamurthy G, Corda R, et al. Surgical site infections and bloodstream infections in infants after cardiac surgery. J Thorac Cardiovasc Surg 2014;148(1):259–65. [19] Chambers ST, Peddie B, Pithie A. Ethanol disinfection of plastic-adherent microorganisms. J Hosp Infect 2006;63(2):193–6. [20] Chu HP, Brind J, Tomar R, et al. Significant reduction in central venous catheterrelated bloodstream infections in children on HPN after starting treatment with taurolidine line lock. J Pediatr Gastroenterol Nutr 2012;55(4):403–7. [21] Huang EY, Chen C, Abdullah F, et al. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2011;46(10):2000–11. [22] Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010;45(6):1287–93. [23] Oliveira C, Nasr A, Brindle M, et al. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. J Pediatr 2012; 129(2):318–29. [24] Wales PW, Kosar C, Carricato M, et al. Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience. J Pediatr Surg 2011;46(5):951–6. [25] Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN J Parenter Enteral Nutr 2011;35(1):67–73. [26] Castello FV, Maher A, Cable G. Reducing bloodstream infections in pediatric rehabilitation patients receiving parenteral nutrition. J Pediatr 2011;128(5): 1273–8.
