Anti-infective locks for treatment of central line-associated bloodstream infection: a systematic review and meta-analysis.

Am J Nephrol. 2011;34(5):415-22

Authors: O'Horo JC, Silva GL, Safdar N

Abstract
Central line-associated bloodstream infections (CLABSI) are associated with considerable morbidity, mortality and economic costs. In most cases, catheter removal is considered an essential component of managing CLABSI. However, in patients with poor access, catheter salvage may have to be attempted rather than removal and replacement of catheters. Anti-infective lock therapy (ALT) - instilling an antibiotic or antiseptic into the catheter lumen - is a novel way of treating CLABSI while attempting to salvage the catheter. However, data on the efficacy of ALT for catheter salvage is limited. In this systematic review, we critically review the evidence regarding the use of ALT for catheter salvage. We identified 8 studies including a total of 396 patients that compared ALT with systemic antibiotic therapy alone or an alternate method of catheter salvage (guidewire replacement). We found that the combination of systemic antibiotics and culture-guided lock therapy was superior to systemic antibiotics alone (OR: 0.20, 95% CI: 0.10-0.39), with 10% of locked patients requiring replacement compared to 33% of subjects without locks. There was a 20% relapse rate in the ALT group and a 30% relapse rate in the control group (OR: 0.43, 95% CI: 0.18-1.03). There was insufficient data on catheter exchange over a wire compared with ALT to permit conclusions. Our data support the use of ALT in conjunction with systemic antibiotics for catheter salvage. Large randomized controlled trials of ALT examining dose, dwell times and relapse rates stratified by infecting pathogen are needed.

PMID: 21934302 [PubMed - indexed for MEDLINE]

Outpatient versus inpatient observation after percutaneous native kidney biopsy: a cost minimization study.

Am J Nephrol. 2011;34(1):64-70

Authors: Maripuri S, Penson DF, Ikizler TA, Cavanaugh KL

Abstract
BACKGROUND/AIMS: Percutaneous kidney biopsy (PKB) is the primary diagnostic tool for kidney disease. Outpatient 'day surgery' (ODS) following PKB in low-risk patients has previously been described as a safe alternative to inpatient observation (IO). This study aims to determine if ODS is less costly compared to IO while accounting for all institutional costs (IC) associated with post-PKB complications, including death.
METHODS: A cost minimization study was performed using decision analysis methodology which models relative costs in relation to outcome probabilities yielding an optimum decision. The potential outcomes included major complications (bleeding requiring blood transfusion or advanced intervention), minor complications (bleeding or pain requiring additional observation), and death. Probabilities were obtained from the published literature and a base case was selected. IC were obtained for all complications from institutional activity-based cost estimates. The base case assumed a complication rate of 10% with major bleeding occurring in 2.5% of patients (for both arms) and death in 0.1 and 0.15% of IO and ODS patients, respectively.
RESULTS: ODS costs USD 1,394 per biopsy compared to USD 1,800 for IO inclusive of all complications. IC for ODS remain less when overall complications <20%, major complications <5.5%, and IC per death <USD 1.125 million. ODS remained favored through sensitivity analysis.
CONCLUSION: Outpatient management after PKB for low-risk patients costs less from the institutional perspective compared to IO, inclusive of complications and death. ODS should be considered for low-risk patients undergoing native kidney biopsy.

PMID: 21677428 [PubMed - indexed for MEDLINE]