Antibiotic-lock therapy: a clinical viewpoint

Abstract

Antibiotic lock therapy (ALT) – instillation of high concentrations of anti-microbial agent with or without anti-coagulant into the lumen of central venous catheters – is considered a valid conservative treatment for catheter-related bloodstream infection (CRBSI) in patients highly dependent on maintaining the catheter. Results from randomized controlled studies have indicated that the effectiveness of ALT is moderate, but recent findings from experimental studies and observational case series point to considerable efficacy and safety of this therapy, which is usually associated with concomitant systemic treatment. In this article, the current knowledge about ALT for patients with CRBSI is reviewed and discussed, with emphasis on existing controversies and the results obtained according to the various uses of the catheters and the etiologies of infection.

Keywords::

• antibiotic lock therapy
• catheter-related sepsis
• conservative management
• permanent central venous catheter

Financial & competing interests disclosure

N Fernández-Hidalgo, B Almirante were supported by Ministerio de Economía y Competitividad, Instituto de Salud Carlos III, cofinanced by the European Development Regional Fund (ERDF) “A way to achieve Europe” and the Spanish Network for Research in Infectious Diseases (REIPI RD12/0015). This review was translated from Spanish to English by Celine Cavallo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No other writing assistance was utilized in the production of this manuscript.

Key issues

• It has been amply demonstrated that microorganisms can progress over the internal surface of permanent central venous catheters (CVCs) after the first weeks of implantation. Biofilms then begin to form on the endoluminal surface, where the agents causing infections related to these devices survive and proliferate.

• The treatment of choice for catheter-related bloodstream infection (CRBSI) consists in administration of systemic anti-microbial agents associated with prompt catheter withdrawal.

• In patients with permanent CVCs used for certain purposes (e.g., hemodialysis, chemotherapy or immunosuppressive treatment, parenteral nutrition) and with related bloodstream infection, the possibility of conservative treatment without catheter removal should be examined.

• Antibiotic lock therapy (ALT) consists in instillation of an anti-microbial solution at a high drug concentration (usually 100–1000 times greater than the dose used in systemic therapy) to completely fill the catheter lumen during a certain time, with the aim of sterilizing the device. ALT in combination with systemic antibiotics is a valid option for treating permanent central venous CRBSI in the absence of local or systemic complications.

• Numerous studies in in vitro and in vivo models have proven the efficacy of ALT for eradicating the microorganisms present in biofilms of vascular catheters.

• The clinical efficacy and safety of ALT for conservative treatment of patients with CVC-related infection has been demonstrated in various observational studies.

• It remains to be established which antibiotics are most effective for ALT, as well as the optimal concentration and duration of treatment. The role of heparin and other anti-coagulants in this therapeutic technique must also be defined.

• Because of the elevated percentage of clinical failures in CRBSI episodes caused by Staphylococcus aureus and Candida spp., conservative treatment should be avoided in these etiologies.

• In the future, this conservative technique for CRBSI treatment may be carried out using molecules other than the classic anti-microbials.

Notes