cefepime | gutsandgrowth

A recent study (BP Raphael et al. JPGN 2019; 70: 59-63) describes 309 central line-associated bloodstream infections (CLABSI) in 90 children were dependent on parenteral nutrition (median age 3.8 years).

Key findings:

60% of isolated organisms were gram-positive, 34% were gram-negative, and 6% fungi.
For gram-positive organisms, 51% were sensitive to methicillin
For gram-negative organisms, 71% were sensitive to piperacillin-tazobactam, 97% to cefepime, and 99% to meropenem

Based on these findings, the authors advocate the following:

“Vancomycin and cefepime provide improve coverage over vancomcyin piperacillin-tazobactam for” CLABSI
Empiric use of vancomycin and meropenem “may be justified” in septic shock “where maximal probability of cure outweighs risks of long-term drug resistance”
If there is an increased fungemia risk, such as prior fungal infections, shock, or immunodeficiency, the authors recommend adding fluconazole

Another advantage of cefepime over piperacillin-tazobactam is a reduced risk of acute kidney injury which has been associated with the latter.

My take: Individual institutions may have variable organism sensitivity. In the absence of institutional data, this recommendations are a good starting point.

Related blog post: #NASPGHAN19 Intestinal Failure Session Part 1

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Old Montreal

Here are some notes and a few slides from NASPGHAN’s plenary session. There could be errors of transcription in my notes.

Benjamin Gold, NASPGHAN president and part of our GI group, GI Care For Kids, welcomed everyone to the meeting.

Link to NASPGHAN_Annual_Meeting_Program 2019

John Kerner Potential Role of New Fat Emulsions

Key points:

Both SMOFlipid and Omegaven help prevent and/or treat parenteral nutrition associated cholestasis.
SMOFlipid is much less expensive (see slide below) -50 gm of SMOFlipid ~$5 compared to 10 gm of Omegaven at $35, thus omegaven costs more than 30 times SMOFlipid.
Though SMOFlipid is not FDA approved in children, it is being used widely and allows for increased calories compared to lipid minimization with intralipid and could improve neurocognitive outcomes.
SMOF dosing (listed below) with goal of 3 g/kg in preterm infants.
Resolution of cholestasis does not mean reversal of cirrhosis. Thus, lipid emulsion intervention at earlier stage may be important.

Bram Raphael Getting In Line: Towards a Clinical Practice Guideline For CVC Salvage

Key points:

Several infections are very difficult to clear, especially yeast, enterococcus, and pseudomonas
Salvaging central lines may obviate the need for multi-visceral transplant which carries a 5-year ~50% mortality rate
Cefepime provides good gram-negative coverage; consider meropenem in those with septic shock