Hospital acquired UTI

and

Antibiotic resistance

Gernot Bonkat

Department of Urology

University Hospital Basel

Basel / Switzerland

bonkatg@uhbs.ch

Rabat, Morocco

23rd April 2016

Setting the scene

1. What is Healthcare Associated Infections (HAI)?

2. Why do HAIs occur?

3. Healthcare Associated Urinary Tract Infections (HAUTI)

4. HAUTI pathogens prevalence

5. HAUTI pathogens resistance

6. HAUTI risk factors

Question

What are Hospital and healthcare

acquired infections?

New infections that patients acquire

as a result of healthcare interventions to

treat other conditions

Two more questions

• 48 hours after admission

or receiving medical

care

• Within 30 days of having

a surgical procedure

Across a continuum of care

Acute setting One day procedure Dialysis centres

Ambulatory

Outpatient

Long term care Nursing house

Where? When?

Development of

infection

Healthcare Associated Infections

Definition:

A localized or systemic condition that results

from adverse reaction to the presence of an

infectious agent(s) or its toxin(s) and that was

not present or incubating at the time of

intervention

Colonisation is NOT HAI

Inflammation is NOT HAI

Why do HAIs occur?

• As a complicating factor of health care

• Because sometimes mistakes are done

(Usually by more than one person)

• Individual patient characteristics

• Pathogens and resistance

Patient characteristics

O NO known/ associated RF • Healthy premenopausal women

R RF of recurrent UTI; but no risk of severe outcome • Sexual behaviour and

contraceptive devices

• Hormonal deficiency in

menopause

• Secretory type of certain blood

groups

• Controlled diabetes mellitus

E Extra-urogenital RF; with risk of more severe

outcome

• Pregnancy

• Male gender

• Uncontrolled Diabetes Mellitus

N Nephropathic disease, with risk of more severe

outcome

• Relevant renal insufficiency

• Polycystic nephropathy

U Urological RF, with risk of more sever outcome,

which can be resolved during therapy

• Ureteral obstruction

• Transient short term urinary

catheter

C Permanent urinary Catheter and non-resolvable

urological RF, with risk of more severe outcome

• Long term indwelling urinary

catheter

• Non-resolvable urinary obstruction

Health care associated UTI (HAUTI)

Features of HAUTIs:

• Almost always complicated

• Heterogenous group of complicating factors, co-morbidities

• Great diversity of microorganisms compared to

uncomplicated UTI

Classification of HAUTIs

• Symptomatic urinary tract infection (SUTI)

• Asymptomatic bacteremic urinary tract infection (ABUTI)

• Other urinary tract infection (OUTI)

CDC definition effective since January 2009

Prevalence of HAUTI

In general:

• 19% to 30% of HAIs are HAUTIs

– Different surveillance studies

In urology departments:

• 12.4% diagnosed with HAUTI based on clinical

findings

• 9.8% with confirmed microbiological proof

– GPIU study 2003-2013 surveillance

Prevalence of HAUTI

Sources – Surveillance:

Global Prevalence of Infections in Urology

(GPIU)

ECDC

CDC

ECO-SENS

Main types of infections

associated with urological care

ESU AMU UTI Apr 2016/MG

Wound infections

Surgical site

infeciton (SSI)

Urinary tract

infection

Male accesory

gland infection

(MAGI)

Systemic and

Other organ

infection

Female

resproductive

organ infection

Types of HAUTIs

GPIU 2003-2010 surveillance (representative of urology

departments)

MAGI 12%

Urosepsis 19%

ASB 21%

Pyelonephritis 21%

Cystitis 27%

Why do HAUTIs develop?

ORENUC

Medical history

Intervention history

Risk of infection of intervention

Prophylaxis

Environment

Pathogens

Resistance

Beware higher risk of infection

Urinary tract obstruction -48%

Previous antibiotic consumption -45%

Catheter -69%

Previous hospitalization -46%

GPIU 2003-2013 surveillance (representative of urology departments)

Prophylaxis failure

Resource restrictions etc.

0%

10%

20%

30%

40%

50%

60%

Urethral Suprapubic Ureteral stent Nephrostomy Others

HAUTI Patients with catheters

30% with multiple catheters

Patient

Healthcare intervention

Infection

Pathogens in HAUTI

0%5%

10%15%20%25%30%35%40%45%

E. coli

Enterococcus spp.

Klebsiella spp.

P. aeruginosa

Enterobacter spp.

4/5

GPIU 2003-2010 surveillance (representative of urology

departments)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Beware of pathogens in HAUTI both local and global Will help guide treatment

Each HAUTI is unique – pathogens and resistance have similarities but they are not the same

Each HAUTI diagnosis

outcomes should reported and interpreted separately

GPIU 2003-2010 surveillance (representative of urology

departments)

MAG, ASB, Cystitis,

Pyelonephritis, Urosepsis

Pathogens in HAUTI

0%

10%

20%

30%

40%

50%

60%

70%

80%

Average Resistance rate

North Europe

South Europe

Asia

South America + Africa

Resistance in HAUTI – Overall

GPIU 2003-2010 surveillance (representative of urology

departments)

Multidrug Resistance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MDR

resistance not MDR

No resistance

0%

5%

10%

15%

20%

25%

30%

35%

40%

GPIU 2003-2010 surveillance (representative of urology

departments)

Catheter Associated UTI - HAUTI

Good practice:

1. Appropriate catheter usage

2. Proper techniques for catheter insertion

3. Proper techniques for catheter maintenance

4. Quality improvement programs

5. Administrative infrastructure

6. Surveillance

17-69% of CA-UTIs preventable with these measures

Reminder

Appropriate antimicrobial

• Avoid unnecessary prescription, use correct antimicrobials

• Use local and global surveillance data to select the most

appropriate antimicrobial

Appropriate duration

• Inform the patient to use the antimicrobial for the duration

you have prescribed even if patients feel better

Patient history

• Take into account previous antimicrobials used

Use antimicrobials wisely

Take home messages

1. Colonisation is not HAI (don’t treat)

2. Join surveillance programs

3. Follow catheter practice guidelines

4. Beware of high resistance rates (Local and

Global)

5. Identify patient related risk factors