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

http://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




•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.




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




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




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)




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

Health & Medicine

Catheter Associated UTI Bundle