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  6. Prophylaxis against gram negative and fungal infections in immunocompromised babies, children & young people with a Central Venous Access Device (CVAD) (868)

Prophylaxis against gram negative and fungal infections in immunocompromised babies, children & young people with a Central Venous Access Device (CVAD) (868)

1. INTRODUCTION

Gram negative and fungal infections are a well-recognised cause of morbidity and mortality in immunocompromised babies, children and young people. Both fungi and Gram negative bacteria are recognised environmental organisms.

The campus of the Queen Elizabeth University Hospital and the Royal Hospital for Children, Glasgow have had documented, environmentally acquired, infections in immunocompromised patients.

Prophylaxing against environmental fungal infections is standard practice and there are well established criteria for this. Please see RHC-HAEM-ONC-020 (Anti-Fungal Policy) for further information.

Prophylaxing against environmental Gram negative bacteria in children has a much smaller evidence base and there is no national or international consensus on whether or how this should be done. There is however published literature which shows the potential for using line locks to decrease the number of gram negative infections in children with cancer.

Standard technique in this document refers to turbulent push pause technique finishing with positive pressure.

2. RELATED DOCUMENTATION

  • GG&C Management of Line-related Sepsis in Adults and Children - Version 13
  • RHC-HAEM-ONC-011 - The Role of Phlebotomists
  • NHS GG&C Acute Division Intravenous Flush Policy 2015
  • Vascular Access Procedure and Practice Guideline 2019

3. AUTHORISED PERSONNEL/SPECIFIC STAFF COMPETENCIES

All medical staff, registered nurses, pharmacists, allied health professionals and phlebotomists need to be competent (appropriate to role) in the prescribing of, dispensing and administering prophylaxis.

4. EQUIPMENT/MATERIALS

  • TauroLock and TauroLock Hep 100 (Heparinised TauroLock 100iu/ml)
  • Sodium Chloride 0.9%
  • PPE
  • Syringes/Needles
  • Clinell wipes
  • Port Protector
  • Smartsites if require to be changed

5. PROCEDURE

5.1   Gram Negative Infection Prophylaxis:

General

All Central Venous Access Devices, Percutaneous Intravenous Catheters (PICs) Hickman Lines (Lines) and Port-a-Caths (Ports) should be locked as part of the Gram negative infection prophylaxis programme

Care and management of dialysis lines, ECMO, filter and exchange circuits are not covered in this SOP.

The maximum time permitted for a line lock to remain in situ is

  • ONE WEEK FOR HICKMAN LINES OR PIC LINES
  • FOUR WEEKS FOR PORT–A-CATHS

Drug Storage

Two distinct TauroLock products will be kept as stock within the Haemato-oncology unit. Within the ward and day care areas, in order to minimise risk of incorrect drug selection, different storage conditions are in place for each product

  • TauroLock ( containing Taurolidine, Citrate 4%) 5ml ampoule
    For use in Hickman lines, PIC lines and Ports in regular use
    Stored in clean utility areas and drug cupboards
  • TauroLock Hep 100 (containing Taurolidine, Citrate 4%, Heparin 100iu/ml) 3ml ampoule
    For use in Ports only when removing the Gripper needle and locking the chamber(s)
    Stored in ward controlled drug cupboard.

Other areas will demonstrate physically separate storage options for the two products and these locations will form a core part of the associated prophylaxis training package.

Prescribing

NB: The HEPMA inpatient prescribing system lists Taurolidine as an allergy although the product is prescribed as Taurolock. This is therefore NOT automatically flagged by the in-built allergy checker. Always check the drug allergy section before prescribing.

A current prescription is required for every patient receiving TauroLock or TauroLock Hep 100. Refer to Appendix 1 for appropriate lock volumes

During an inpatient admission, the appropriate product should be prescribed on an inpatient prescription chart.

When a patient is attending the day care unit, or outpatient department the appropriate prescription chart should be generated or the previous chart retrieved.

POONs attending patients at home who require a line flush and lock must retrieve the appropriate prescription chart before their home visit.

 

5.2   Hickman Lines or PICs:

Inpatients

  1. If the Hickman line or PIC will not be accessed for the duration of the inpatient stay, the following procedure should only be necessary to change line locks in situ prior to discharge from the ward if it has been in situ for the maximum permissible duration of 1 week.
  2. Double lumen Hickman lines should have any lumen which is not being accessed locked as per procedure below. Both lumens must be locked prior to discharge.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to line locking.
  5. For Hickman lines or PICs which are being accessed intermittently (e.g. for blood samples, drug administration, fluids or chemotherapy), follow steps 3 and 4 above before and after each intervention as per standard procedure. The line should then be locked using TauroLock, which will remain in situ until the lumen is next accessed.
  6. Prior to discharge, ensure Hickman line or PIC is locked with TauroLock, unless a different antibiotic lock has been requested by a consultant microbiologist.

Day Care Patients

  1. If the Hickman line or PIC will not be accessed for the duration of the day care stay, check patient notes and appropriate prescription to determine how long the current line lock has been in situ. The following procedure should only be necessary to change the line lock if the current lock has been in situ for the maximum permissible duration of 1 week.
  2. Double lumen Hickman lines should have any lumen which is not being accessed locked as per procedure below. Both lumens must be locked prior to discharge.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to line locking.
  5. If the Hickman line or PIC is to be accessed on multiple occasions during the day care stay (e.g. for GFR estimations or PK studies), the line does NOT need to be locked every time it is accessed. The line should be flushed with 10ml Sodium Chloride 0.9% using standard technique following each intervention. The line should only be locked using TauroLock when the patient is ready to leave day care.
  6. If the Hickman line or PIC is being accessed for blood samples which may subsequently lead to a requirement for further infusions or blood product support, the line should be locked with TauroLock pending results becoming available. If further intervention is required, follow steps 3 and 4 above before and after accessing the line. The line should then be locked with TauroLock when the patient is ready to leave day care
  7. For Hickman lines or PICs which are being accessed intermittently (e.g. for drug administration, fluids or chemotherapy), follow steps 3 and 4 above before and after each intervention as per standard procedure. The line should then be locked using TauroLock which will remain in situ until the lumen is next accessed, and when the patient is ready to leave day care.
  8. Prior to a patient leaving day care, ensure Hickman line or PIC is locked with TauroLock, unless a different antibiotic lock has been requested by a consultant microbiologist.

Outpatient Clinic

  1. If the Hickman line or PIC will not be accessed for the duration of the outpatient visit, check patient notes and appropriate prescription to determine how long the current line lock has been in situ. The following procedure should only be necessary to change the line lock if the current lock has been in situ for the maximum permissible duration of 1 week.
  2. Double lumen Hickman lines should have any lumen which is not being accessed locked as per procedure below. Both lumens must be locked prior to discharge.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to line locking.
  5. If the Hickman line or PIC is being accessed for blood samples which may subsequently lead to a requirement for further infusions or blood product support, the line should be locked with TauroLock pending results becoming available. If further intervention is required, the patients’ care will transfer to the day care unit. Follow steps 3 and 4 above before and after accessing the line. The line should then be locked with TauroLock when the patient is ready to leave the day care unit.
  6. For Hickman lines or PICs which are being accessed for chemotherapy, follow steps 3 and 4 above before and after drug administration as per standard procedure. The line should then be locked using TauroLock when the patient is ready to leave.

Home

  1. Patients who are at home with Hickman lines or PICs in situ should have these flushed and re-locked once a week by a Paediatric Oncology Outreach Nurse. Double lumen Hickman lines should have both lumens locked.
  2. POON must obtain the appropriate drug prescription prior to each home visit
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to line locking.
  5. The line should then be locked using TauroLock.

 

5.3   PORT-A-CATHS (Ports):

Inpatients

TAUROLOCK HEP 100 WILL ONLY BE REQUIRED WHEN REMOVING GRIPPER NEEDLE OR IF PATIENT IS BEING DISCHARGED WITH GRIPPER NEEDLE REMAINING IN SITU

  1. If the Port is not be accessed for the duration of the inpatient stay, the following procedure should only be necessary to change the lock prior to discharge from the ward if the current lock has been in situ for the maximum permissible duration of 4 weeks.
  2. Double chamber Ports should have any chamber which is not to be accessed locked as per procedure below. Both chambers must be locked prior to discharge.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10ml Sodium Chloride 0.9%, using standard percussive techniques, prior to port locking.
  5. For Ports which are being accessed intermittently (e.g. for blood samples, drug administration, fluids or chemotherapy), follow steps 3 and 4 above before and after each intervention as per standard procedure. The Port should then be locked using TauroLock, which will remain in situ until the device is next accessed.
  6. Prior to discharge, ensure Port is locked with TauroLock Hep 100 before removing gripper needle, unless a different antibiotic lock has been requested by a consultant microbiologist. If the gripper needle is remaining in situ on discharge lock with TauroLock Hep 100.

Day Care Patients

  1. If the Port will not be accessed for the duration of the day care stay, check patient notes and appropriate prescription to determine how long the current lock has been in situ. The following procedure should only be necessary to change the lock if the current lock has been in situ for the maximum permissible duration of 4 weeks, or this time period will have elapsed prior to their next home visit/ return to hospital.
  2. Double chamber Ports should have any chamber which is not being accessed locked as per procedure below. Both chambers must be locked prior to discharge if the current lock has been in situ for the maximum permissible duration of 4 weeks.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to port locking.
  5. Ports accessed on multiple occasions for GFR estimations or PK studies, do NOT need to be locked every time it is accessed. The port should be flushed with 10ml Sodium Chloride 0.9% using standard technique following each intervention. This is to ensure the assays are not contaminated. The port should only be locked using TauroLock Hep 100 when the patient is ready to leave day care.
  6. If the Port is being accessed for blood samples which may subsequently lead to a requirement for further infusions or blood product support, the port should be locked with TauroLock Hep 100 pending results becoming available. If further intervention is required, follow steps 3 and 4 above before and after accessing the port. The port should then be locked with TauroLock Hep 100 when the patient is ready to leave day care
  7. For Ports which are being accessed intermittently (e.g. for drug administration, fluids or chemotherapy), follow steps 3 and 4 above before and after each intervention as per standard procedure. The Port should then be locked using TauroLock, which will remain in situ until the device is next accessed. When the patient is ready to leave day care, Port should be locked using TauroLock Hep 100.
  8. Prior to a patient leaving day care, ensure Port is locked with TauroLock Hep 100, unless a different antibiotic lock has been requested by a consultant microbiologist.

Outpatient Clinic

  1. If the Port will not be accessed for the duration of the outpatient visit, check patient notes and appropriate prescription to determine how long the current lock has been in situ. It should only be necessary to change the lock if the current lock will have been in situ for the permitted maximum of 4 weeks prior to the next home or hospital visit.
  2. Double chamber Ports should have any chamber which is not being accessed locked as per procedure below. Both chambers must be locked prior to discharge if the current lock has been in situ for the maximum permissible duration of 4 weeks.
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard technique, prior to port locking.
  5. If the Port is being accessed for blood samples which may subsequently lead to a requirement for further infusions or blood product support, the port should be locked with TauroLock Hep 100 pending results becoming available. If further intervention is required, the patients’ care will be transferred to the day care unit. Follow steps 3 and 4 above before and after accessing the port. The port should then be locked with TauroLock Hep 100 when the patient is ready to leave day care.
  6. For Ports which are being accessed for chemotherapy, follow steps 3 and 4 above before and after drug administration as per standard procedure. The port should then be locked using TauroLock Hep 100 when the patient is ready to leave.

Home

  1. Patients who are at home with Ports in situ should have these flushed and re-locked every 4 weeks by a Paediatric Oncology Outreach Nurse. Double chamber ports should have both chambers locked. This needs to be appropriately documented
  2. POON must obtain the appropriate drug prescription prior to each home visit
  3. Take a discard of 2.5-5ml from the CVAD to remove any previous lock solution, each time it is accessed.
  4. Flush with 10 ml Sodium Chloride 0.9%, using standard percussive techniques, prior to port locking.
  5. The port should then be locked using TauroLock Hep 100

Management of Patients in other areas

All patients with lines locked with TauroLock or TauroLock Hep 100 should have their central venous access devices managed in accordance with this document.

Allergy to Taurolock/not exposed to Taurolock

Use Hepsal = Heparin Sodium I.V flush (see Appendix 2 for volumes)

Appendix 1: Lock volumes

TAUROLOCK

Line type

Lock volume

PIC (any manufacturer, any size)

1.0ml

 

 

Single Lumen Hickman

1.0ml

Double Lumen Hickman

1.0ml in each lumen

 

 

Single Chamber Port

1.5ml

Double Chamber Port

1.5ml in each chamber

 

TAUROLOCK HEP 100
**only when removing gripper needle**

Line type

Lock volume

Single Chamber Port

1.5ml

Double Chamber Port

1.5ml in each chamber

 

TAUROLOCK
in patients <5kg or under 6months old

Line type

Lock volume

PIC (any manufacturer, any size)

0.5ml

Single Lumen Hickman

0.5mls

Double Lumen Hickman

0.5ml in each lumen

Single Chamber Port

1.5ml

Double Chamber Port

0.5ml in each chamber

Appendix 2: Lock volumes if Taurolock Allergy

Hepsal 10iu/ml

Line type

Lock volume

PIC 

1.0ml

 

 

Single Lumen Hickman

1.0ml

Double Lumen Hickman

1.0ml

 

 

Single Chamber Port

1.5ml

Double Chamber Port

1.5ml 

 

Hepsal 100iu/ml

**only when removing gripper needle**

Line type

Lock volume

Single Chamber Port

1.5ml

Double Chamber Port

1.5ml

Editorial Information

Last reviewed: 28/08/2025

Next review date: 31/08/2027

Author(s): Diana McIntosh.

Version: 3

Approved By: Sch Clin Gov Group & Hosp Gov Group

Document Id: 868

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