A 2024 network meta-analysis (NMA) evaluated the comparative efficacy of central venous access device (CVAD) lock solutions used in pediatric patients for the prevention and treatment of catheter-associated complications, including bloodstream infection (BSI), thrombosis, and catheter occlusion. The analysis included 29 randomized controlled trials (RCTs), encompassing 2,970 pediatric patients and 3,053 CVADs, spanning publications from 1990 to 2022. CVAD types varied and included tunneled-cuffed catheters, totally implanted devices, peripherally inserted central catheters, and umbilical venous catheters. Lock solutions were categorized into seven types: heparin, saline, ethanol, chelating agents (e.g., taurolidine-citrate, minocycline-edetic acid), antibiotics (e.g., vancomycin, amikacin), thrombolytics (e.g., urokinase, tissue plasminogen activator), and other (e.g., ascorbic acid). Solutions were analyzed based on their primary or secondary use in either prevention or treatment. The meta-analysis found that chelating and antibiotic lock solutions demonstrated significantly lower odds for CVAD-associated BSI prevention compared to heparinized saline, with odds ratios (ORs) of 0.11 (95% confidence interval [CI]: 0.02–0.67; moderate-quality evidence; 4 trials specific to taurolidine-citrate) and 0.19 (95% CI: 0.05–0.79; high-quality evidence), respectively. Notably, post hoc subgroup analyses conducted for CVAD-BSI (prevention), assessing only taurolidine in the chelating agent group, yielded similar OR to the primary analysis (OR 0.12; 95% CI: 0.01–1.57). Thrombolytic agents were associated with a reduced risk of catheter occlusion (OR: 0.64; 95% CI: 0.44–0.93; low-quality evidence), while ethanol was linked with increased risk (OR: 2.84; 95% CI: 1.31–6.16; high-quality evidence). No conclusive benefits were observed with any lock solution for prevention or treatment of CVAD-associated thrombosis, treatment of CVAD-associated BSI, CVAD failure, or mortality. Overall, the authors reported wide confidence intervals and low certainty of evidence for many comparisons, emphasizing the need for further high-quality, adequately powered investigations to guide optimal lock solution selection in pediatric practice. [1]
Another NMA, published in 2021, evaluated the effectiveness of various catheter lock solutions (CLSs) for preventing catheter-related bloodstream infections (CRBSIs) in pediatric patients with central venous catheters. The analysis included 13 RCTs with a total of 1,335 patients and used a random-effects model to estimate risk ratios. Taurolidine plus heparin was found to be significantly more effective than heparin alone in reducing CRBSI risk (risk ratio [RR] 0.21; 95% CI 0.09 to 0.51), while no significant differences were observed between heparin and other CLSs such as vancomycin, ethanol, fusidic acid, amikacin, or their combinations. Based on the surface under the cumulative ranking curve, taurolidine plus heparin (85.3%) ranked highest for CRBSI prevention, followed by fusidic acid plus heparin (77.0%) and amikacin plus heparin (65.7%). The analysis found no significant global inconsistency among the included studies. Based on these findings, it was concluded that taurolidine appeared to be the most effective CLS for preventing CRBSIs in pediatric patients, though additional well-designed randomized trials are needed to confirm these findings. [2]
A 2020 meta-analysis synthesized data from four RCTs evaluating the efficacy of taurolidine lock solution in preventing CRBSIs among pediatric patients with central venous catheters (CVCs). The trials, conducted across tertiary care centers in European countries, enrolled a total of 476 children under 19, with individual study sample sizes ranging from 35 to 90 participants per group. The included populations primarily consisted of pediatric oncology patients and postsurgical patients requiring long-term central access for nutrition or medication. Across all four RCTs, taurolidine was administered as a 1.35% solution combined with 4% sodium citrate, while comparator arms utilized either heparin or no lock solution. The pooled analysis demonstrated a statistically significant 77% relative risk reduction in the total number of CRBSIs in patients treated with taurolidine compared to controls (RR 0.23; 95% CI 0.13 to 0.40; I²= 0%; p<0.00001). Additionally, the incidence rate of CRBSIs, defined as infections per 1000 catheter-days, was notably reduced in the taurolidine group, with a mean difference of -1.12 (95% CI -1.54 to -0.71; I²= 1%; p<0.00001) across three contributing studies. However, no significant difference was observed in the number of catheters removed due to infection or suspected infection (RR 0.68; 95% CI 0.22 to 2.10; I²= 56%; p= 0.50), likely attributable to heterogeneity in catheter removal criteria and the limited event rate. Notably, methodological quality was limited as stated by the authors; none of the studies were blinded, and only one employed adequate random sequence generation. Despite these limitations, the authors concluded that taurolidine may reduce CRBSI rates in pediatric patients. Still, they emphasized the need for further investigation through larger, rigorously designed trials to confirm these findings. [3]