Catheter Associated UTI Bundle
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Transcript of Catheter Associated UTI Bundle
The presentation is solely meant for Academic purpose
• 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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
At Placement 4th day
Bacteriuria
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st week 4th week
Bacteriuria
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
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.
Gold standard is urine culture
Dipstick and other non-culture tests are not reliable
Number of organisms is controversial
Maki DG. Emerg Infect Dis 2001;7:1-6
Source of microorganisms:
Endogenous - meatal, rectal, or vaginal colonization
Exogenous - contaminated hands of healthcare worker
Tambyah, Halvorson & Maki. Mayo Clin Proc. 1999 Feb;74(2):131-6.
Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems
Bacteria within biofilms resistant to antimicrobials and host defenses
Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm
Maki, Emerg Infect Dis 2001; 7: 1-6
Core Strategies
Supplemental Strategies
◦ High levels of scientific evidence
◦ Demonstrated feasibility
◦ Some scientific evidence
◦ Variable levels of feasibility
www.cdc.gov/hicpac
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_cauti.html
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
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
Good hand hygiene
before and after
procedure
Don sterile gloves before
procedure
•Sterile technique
must be used
when inserting the
catheter
•Do not use
aggressive
cleaning once
urinary catheter is
in place
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
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_cauti.html
•Sampling Port:
Disinfect port
before sampling
urine
•Look for possible
disconnection of
catheter from
drainage bag
System may
become an
open system
if outlet is left
hanging or is
unclamped
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_cauti.html
Use smallest catheter size effective for patient (14 or 16F)
Catheters should be properly secured to prevent movement and urethral traction
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_cauti.html
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
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
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
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_cauti.html
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
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
Insert catheters only for appropriate indications
Leave catheters in place only as long as needed
Only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment
Maintain a closed drainage system
Maintain unobstructed urine flow
Hand hygiene and standard (or appropriate isolation) precautions
Alternatives to indwelling urinary catheterization
Portable ultrasound devices to reduce unnecessary catheterizations
Antimicrobial/antiseptic-impregnated catheters
Core Measures Supplemental Measures
Supplemental measures Core measures
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_cauti.html
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