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Catheter Associated UTI Bundle

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  • 1. The presentation is solely meant forAcademic purpose
  • 2. • Developed in the 1920s by Dr. Frederick Foley• Originally an open system with the urethral tube draining into an open container• Closed system (1950’s) developed in which the urine flowed through a catheter into a closed bag 3
  • 3. 100% 90%80%70%60%50% Bacteriuria40%30%20%10% 0% At Placement 4th day
  • 4. 100% 90%80%70%60%50% Bacteriuria40%30%20%10% 0% 1st week 4th week
  • 5.  Most common type of healthcare-associated infection ◦ > 30% of HAIs reported to NHSN ◦ Estimated > 560,000 nosocomial UTIs annually Increased morbidity & mortality ◦ Estimated 13,000 attributable deaths annually ◦ Leading cause of secondary BSI with ~10% mortality Excess length of stay : 2-4 days Increased cost : $0.4-0.5 billion per year nationally Unnecessary antimicrobial use Hidron AI et al. ICHE 2008;29:996-1011 Givens CD, Wenzel RP. J Urol 1980;124:646-8 Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72 Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S Cope M et al. Clin Infect Dis 2009;48:1182-8 Saint S. Am J Infect Control 2000;28:68-75
  • 6. In patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization Presence of symptoms or signs compatible with UTI with No other identified source of infection 103 colony forming units (cfu)/mL of 1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose catheter has been removed in previous 48 hrs.
  • 7.  Gold standard is urine culture Dipstick and other non-culture tests are not reliable Number of organisms is controversial
  • 8. Source of microorganisms: Endogenous - meatal, rectal, or vaginal colonization Exogenous - contaminated hands of healthcare workerMaki DG. Emerg Infect Dis 2001;7:1-6
  • 9. Tambyah, Halvorson & Maki. Mayo Clin Proc. 1999 Feb;74(2):131-6.
  • 10.  Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems Bacteria within biofilms resistant to antimicrobials Scanning electron micrograph of S. aureus bacteria on the luminal surface of an and host defenses indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
  • 11. Maki, Emerg Infect Dis 2001; 7: 1-6
  • 12. SupplementalCore Strategies Strategies ◦ High levels of ◦ Some scientific scientific evidence evidence ◦ Variable levels of ◦ Demonstrated feasibility feasibilitywww.cdc.gov/hicpac
  • 13.  Insert catheters only for appropriate indications Leave catheters in place only as long as needed Ensure that only properly trained persons insert and maintain catheters Insert catheters using aseptic technique and sterile equipment (acute care setting) Maintain a closed drainage system Maintain unobstructed urine flow Hand hygiene and Standard precautions http://www.cdc.gov/hicpac/cauti/001_cau
  • 14.  Acute urinary retention or obstruction Accurate measurements in critically ill patients Selected surgical procedures e.g. urologic Healing of open sacral or perineal wounds End of life comfort Prolonged immobilisation http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf
  • 15.  Urinary incontinence Immobility Use of diuretics Ignorance of published guidelines Clinical uncertainty of the patient’s medical course Convenience of staff Jain et al (1995) Arch Intern Med 155:1425-9
  • 16. Good hand hygiene Don sterile gloves before before and after procedure procedure
  • 17. •Sterile techniquemust be usedwhen inserting thecatheter•Do not useaggressivecleaning onceurinary catheter isin place
  • 18.  12 month control period followed by 12 month intervention with nurse generated daily reminders after D5 ◦ Catheterization rate reduced from 7.0 + 1.1 days to 4.6 +/- 0.7 days; P < .001 ◦ CAUTI rate reduced from 11.5 +/- 3.1 to 8.3 +/- 2.5 per 1,000 catheter-days; P = .009 ◦ Antibiotic cost reduced reduced by 69% (from 4021 dollars +/- 1800 dollars to 1220 dollars +/- 941 dollars; P = .004) Huang et al Infect Control Hosp Epidemiol. 2004 Nov;25:974-8
  • 19.  Maintain a closed drainage system (I B) ◦ If breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system ◦ Consider systems with preconnected, sealed catheter-tubing junctions (II B) ◦ Obtain urine samples aseptically http://www.cdc.gov/hicpac/cauti/001_cau
  • 20. •Sampling Port:Disinfect portbefore samplingurine•Look for possibledisconnection ofcatheter fromdrainage bag
  • 21. System maybecome anopen systemif outlet is lefthanging or isunclamped
  • 22.  Maintain unobstructed urine flow (I B) ◦ Keep catheter and collecting tube free from kinking ◦ Keep collecting bag below level of bladder at all times (do not rest bag on floor) ◦ Empty collecting bag regularly using a separate, clean container for each patient. Ensure drainage spigot does not contact nonsterile container. http://www.cdc.gov/hicpac/cauti/001_cau
  • 23.  Use smallest catheter size effective for patient (14 or 16F) Catheters should be properly secured to prevent movement and urethral traction
  • 24.  Implement quality improvement programs to enhance appropriate use of indwelling catheters and reduce risk of CA-UTI Eg: • Alerts or reminders • Stop orders • Protocols for nurse-directed removal of unnecessary catheters • Guidelines/algorithms for appropriate perioperative catheter management http://www.cdc.gov/hicpac/cauti/001_cau
  • 25.  Alternatives to indwelling urinary catheterization (II) Portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations (II) Antimicrobial/antiseptic-impregnated catheters (I B) After first implementing core recommendations for use, insertion, and maintenance
  • 26.  Intermittent catheterization – consider for: ◦ Patients requiring chronic urinary drainage for neurogenic bladder  Spinal cord injury  Children with myelomeningocele ◦ Postoperative patients with urinary retention ◦ May be used in combination with bladder ultrasound scanners External (i.e., condom) catheters – consider for: ◦ Cooperative male patients without obstruction or urinary retention
  • 27.  Rationale: fewer catheterizations = lower risk of UTI 2 studies of adults with neurogenic bladder undergoing intermittent catheterization Fewer catheterizations per day but no reported differences in UTI ◦ Significant study limitations: likely underpowered; UTIs undefined Polliak T et al. Spinal Cord 2005;43:615-19 Anton HA et al. Arch Phys Med Rehab 1998;79:172-5
  • 28.  Decreased risk of bacteriuria compared to standard latex catheters in a meta-analysis of RCTs Significant differences for silver alloy but not silver oxide-coated catheters Effect greater for patients catheterized < 1 week Mixed results in observational studies in hospitalized patients ◦ Most used laboratory-based outcomes (bacteriuria) ◦ 1 positive, 2 negative, 5 inconclusive http://www.cdc.gov/hicpac/cauti/001_cau
  • 29.  Polymyxin ◦ Butler HK, Kunin CM. J Urol 1971;106:928 Cephalothin ◦ Lazarus SM, LaGuerre JN, Kay H, Weinberg S, Levowitz BS. J Biomed Mater Res 1971;5:129 Both unsuccessful
  • 30.  344 newly catheterised patients studied daily ◦ RR 0.672, P=0.30 overall ◦ OR 0.22, P=0.02 for GNRs ◦ Not effective for yeasts ◦ Little effect beyond 7 days ◦ Maki, Knasinski SHEA 1997
  • 31. Core Measures Supplemental Measures Insert catheters only for  Alternatives to appropriate indications indwelling urinary Leave catheters in place only catheterization as long as needed  Portable ultrasound Only properly trained persons devices to reduce insert and maintain catheters unnecessary Insert catheters using aseptic catheterizations technique and sterile  Antimicrobial/antiseptic equipment -impregnated catheters Maintain a closed drainage system Maintain unobstructed urine flow Hand hygiene and standard (or appropriate isolation) precautions
  • 32. Supplemental measures Core measures
  • 33.  Changing catheters or drainage bags at routine, fixed intervals Routine antimicrobial prophylaxis Cleaning of periurethral area with antiseptics while catheter is in place (use routine hygiene) Irrigation of bladder with antimicrobials Instillation of antiseptic or antimicrobial solutions into drainage bags Routine screening for asymptomatic bacteriuria (ASB) http://www.cdc.gov/hicpac/cauti/001_cau
  • 34.  Documentation & review of indications for catheter insertion Asepsis during catheter insertion Daily assesment for the need of catheter Hand hygiene during daily catheter care Positioning of the drainage bag below the bladder Regular emptying of the drainage bags

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