VAP & CAUTI. CPT. Pasri Maharom MD, MPH Nov 22, 2016

Transcription

1 VAP & CAUTI CPT. Pasri Maharom MD, MPH Nov 22, 2016

2 Pooled Prevalence of HAIs in Southeast Asia Clin Infect Dis 2015;60(11):

3 Pooled Incidence Density of VAP in Southeast Asia Clin Infect Dis 2015;60(11):

4 Ventilator Associated Pneumonia VAP

5 VAP & its Controversy Diagnosis Surveillance Prevention

6 Scenario I 30 Y/O Male OSA, presented with CAP w respiratory failure After 2 weeks of hospitalization, he developed New onset of fever Purulent endotracheal suction CXR: new lobar infiltration RUL Diagnosis:

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8 Scenario II 50 Y/O Female CA Breast S/P Right MRM, on CMT (last 15 days) Diagnosis : UTI w septic shock Intubation, on ventilator from day 1 New onset of fever on day 10, ET tube in place Tracheal suction showed purulent sputum Increase FiO2 (0.4 to 0.6) and more support of ventilator (Peep 3 to 8) CXR : Bilateral infiltration

9 Scenario II Diagnosis: VAP?

10 Controversy in VAP: Diagnosis & Surveillance System Ventilator Associated Pneumonia (VAP) Ventilator Associated Event (VAE) Surveillance system

11 Pneumonia Event Ventilator-associated [VAP] and Non-ventilator-associated Pneumonia [PNEU]

12 Diagnosis Pneumonia [PNEU]: Identified by using a combination of imaging, clinical and laboratory criteria. Date of event: The date when the first element used to meet the PNEU infection criterion occurred for the first time within the 7-day Infection Window Period. Ventilator: A device to assist or control respiration inclusive of the weaning period, through a tracheostomy or by endotracheal intubation.

13 Definition PNU1 For clinically defined pneumonia PNU2 For pneumonia with common bacterial or filamentous fungal pathogens and specific laboratory findings For viral, Legionella, and other bacterial pneumonias with definitive laboratory findings PNU3 For pneumonia in immunocompromised patients

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16 Underlying diseases means pulmonary or cardiac disease (e.g. respiratory distress syndrome, BPD, pulmonary edema, or COPD)

17 VAE Surveillance Algorithm

18 Figure 1: Ventilator-Associated Events (VAE) Surveillance Algorithm Patient has a baseline period of stability or improvement on the ventilator, defined by 2 calendar days of stable or decreasing daily minimum* FiO 2 or PEEP values. The baseline period is defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO 2. * Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour. After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: 1) Increase in daily minimum * FiO 2 of 0.20 (20 points) over the daily minimum FiO 2 in the baseline period, sustained for 2 calendar days. 2) Increase in daily minimum * PEEP values of 3 cmh 2O over the daily minimum PEEP in the baseline period, sustained for 2 calendar days. * Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour. Daily minimum PEEP values of 0-5 cmh2o are considered equivalent for the purposes of VAE surveillance. Ventilator-Associated Condition (VAC) On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: 1) Temperature > 38 C or < 36 C, OR white blood cell count 12,000 cells/mm 3 or 4,000 cells/mm 3. AND 2) A new antimicrobial agent(s) (see Appendix for eligible antimicrobial agents) is started, and is continued for 4 calendar days. Infection-related Ventilator-Associated Complication (IVAC) On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met (taking into account organism exclusions specified in the protocol): 1) Criterion 1: Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol, without requirement for purulent respiratory secretions: Endotracheal aspirate, 10 5 CFU/ml or corresponding semi-quantitative result Bronchoalveolar lavage, 10 4 CFU/ml or corresponding semi-quantitative result Lung tissue, 10 4 CFU/g or corresponding semi-quantitative result Protected specimen brush, 10 3 CFU/ml or corresponding semi-quantitative result 2) Criterion 2: Purulent respiratory secretions (defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field [lpf, x100]) plus organism identified from one of the following specimens (to include qualitative culture, or quantitative/semi-quantitative culture without sufficient growth to meet criterion #1): Sputum Endotracheal aspirate Bronchoalveolar lavage Lung tissue Protected specimen brush If the laboratory reports semi-quantitative results, those results must correspond to the above quantitative thresholds. See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. 3) Criterion 3: One of the following positive tests: Organism identified from pleural fluid (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube) Lung histopathology, defined as: 1) abscess formation or foci of consolidation with intense neutrophil accumulation in bronchioles and alveoli; 2) evidence of lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms); 3) evidence of infection with the viral pathogens listed below based on results of immunohistochemical assays, cytology, or microscopy performed on lung tissue Diagnostic test for Legionella species Diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus January Possible Ventilator-Associated Pneumonia (PVAP)

19 Figure 1: Ventilator-Associated Events (VAE) Surveillance Algorithm Patient has a baseline period of stability or improvement on the ventilator, defined by 2 calendar days of stable or decreasing daily minimum* FiO 2 or PEEP values. The baseline period is defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO 2. * Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour. After a period of stability or improvement on the ventilator, the patient has at least one of the following indicators of worsening oxygenation: 1) Increase in daily minimum * FiO 2 of 0.20 (20 points) over the daily minimum FiO 2 in the baseline period, sustained for 2 calendar days. 2) Increase in daily minimum * PEEP values of 3 cmh 2 O over the daily minimum PEEP in the baseline period, sustained for 2 calendar days. * Daily minimum defined by lowest value of FiO2 or PEEP during a calendar day that is maintained for at least 1 hour. Daily minimum PEEP values of 0-5 cmh2o are considered equivalent for the purposes of VAE surveillance. Ventilator-Associated Condition (VAC)

20 Ventilator-Associated Condition (VAC) On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria: 1) Temperature > 38 C or < 36 C, OR white blood cell count 12,000 cells/mm 3 or 4,000 cells/mm 3. AND 2) A new antimicrobial agent(s) (see Appendix for eligible antimicrobial agents) is started, and is continued for 4 calendar days. Infection-related Ventilator-Associated Complication (IVAC)

21 Infection-related Ventilator-Associated Complication (IVAC) On or after calendar day 3 of mechanical ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met (taking into account organism exclusions specified in the protocol): 1) Criterion 1: Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol, without requirement for purulent respiratory secretions: Endotracheal aspirate, 10 5 CFU/ml or corresponding semi-quantitative result Bronchoalveolar lavage, 10 4 CFU/ml or corresponding semi-quantitative result Lung tissue, 10 4 CFU/g or corresponding semi-quantitative result Protected specimen brush, 10 3 CFU/ml or corresponding semi-quantitative result 2) Criterion 2: Purulent respiratory secretions (defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field [lpf, x100]) plus organism identified from one of the following specimens (to include qualitative culture, or quantitative/semi-quantitative culture without sufficient growth to meet criterion #1): Sputum Endotracheal aspirate Bronchoalveolar lavage Lung tissue Protected specimen brush If the laboratory reports semi-quantitative results, those results must correspond to the above quantitative thresholds. See additional instructions for using the purulent respiratory secretions criterion in the VAE Protocol. 3) Criterion 3: One of the following positive tests: Organism identified from pleural fluid (where specimen was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube) Lung histopathology, defined as: 1) abscess formation or foci of consolidation with intense neutrophil accumulation in bronchioles and alveoli; 2) evidence of lung parenchyma invasion by fungi (hyphae, pseudohyphae or yeast forms); 3) evidence of infection with the viral pathogens listed below based on results of immunohistochemical assays, cytology, or microscopy performed on lung tissue Diagnostic test for Legionella species Diagnostic test on respiratory secretions for influenza virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus January Possible Ventilator-Associated Pneumonia (PVAP)

22 Measurement VAP Rate # VAP identified x 1,000 # Ventilator Days Device Utilization Ratio # Ventilator Days # Patient-Days

23 Role of Device-Utilization Ratio Unit A Unit B Event 10 1 Ventilator-day 1, VAP Rate

24 Role of Device-Utilization Ratio Unit A Unit B Event 10 1 Ventilator-day 1, VAP Rate 10/1,000 ventilator-day 10/1,000 ventilator-day

25 Role of Device-Utilization Ratio Unit A Unit B Event 10 1 Ventilator-day 1, VAP Rate 10/1,000 ventilator-day Patient-day 2,000 Device- Utilization Ratio /1,000 ventilator-day

26 Role of Device-Utilization Ratio Unit A Unit B Event 10 1 Ventilator-day 1, VAP Rate 10/1,000 ventilator-day 10/1,000 ventilator-day Patient-day 2, Device- Utilization Ratio

27 VAP Rate & DUR table 1. Rates of Ventilator-Associated Pneumonia (VAP) According to Type of ICU Rate (95% CI) Variable 1st period (January 1, December 31, 2013) 2nd period (January 1, March 31, 2015) 3rd Period (April 1, December 31, 2015) Medical ICU - VAP rate 9.6 ( ) 7.5 ( ) 7.03 ( ) - Ventilation utilization rate 0.44 ( ) 0.45 ( ) 0.44 ( ) General surgery ICU - VAP rate 9.9 ( ) 1.6 ( ) 9.8 ( ) - Ventilation utilization rate 0.28 ( ) 0.18 ( ) 0.24 ( ) Cardiothoracic surgery ICU - VAP rate 19.2 ( ) 1.7 ( ) 22.5 ( ) - Ventilation utilization rate 0.29 ( ) 0.25 ( ) 0.33 ( ) Neurosurgery ICU - VAP rate 19.1 ( ) 4.3 ( ) 16.8 ( ) - Ventilation utilization rate 0.36 ( ) 0.46 ( ) 0.43 ( ). VAP rate was calculated for 1,000 ventliation-days. ICU; ıntensive care unit. Infection Control & Hospital Epidemiology / FirstView Article / July 2016, pp 1 2.

28 VAP Management Clinical Infectious Clinical Diseases Infectious Diseases Advance Access published July 14, 2016 IDSA GUIDELINE Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society Andre C. Kalil, 1,a Mark L. Metersky, 2,a Michael Klompas, 3,4 John Muscedere, 5 Daniel A. Sweeney, 6 Lucy B. Palmer, 7 Lena M. Napolitano, 8 Naomi P. O Grady, 9 John G. Bartlett, 10 Jordi Carratalà, 11 Ali A. El Solh, 12 Santiago Ewig, 13 Paul D. Fey, 14 Thomas M. File Jr, 15 Marcos I. Restrepo, 16 Jason A. Roberts, 17,18 Grant W. Waterer, 19 Peggy Cruse, 20 Shandra L. Knight, 20 and Jan L. Brozek

29 Controversy in VAP: Prevention Evidence-based intervention VAP prevention bundle and implementation

30 Key Principles of Preventing VAP

31 Key Principles of Preventing VAP Limit the development, selection and spread of pathogenic organisms in the ICUs Minimize exposure to the ventilator Mechanically prevent aspiration Reduce colonization of the aerodigestive tract Prevent inoculation of the patient from the ventilator circuit Michael Klompas in Decision Support Medicine 2014

32 Evidence-based Interventions Decrease VAP rate Do not impact patients lengths of stay or mortality Interventions included: Regular oral care with chlorhexidine Elevation of the head of the bed Continuous subglottic secretions Silver-coated endotracheal tubes Additional intervention: Daily spontaneous breathing trials and sedative interruptions

33 Regular Oral Care with Chlorhexidine Gram Positive Gram Negative AJRCCM 2006;173:

34 Regular Oral Care with Chlorhexidine Endotracheal colonization. Proportion of patients colonized With either gram-positive or gram-negative microorganisms or both, in window periods of 4 d. Chlorhexidine (CHX) or CHX plus colistin (COL) v placebo in mechanically ventilated patients* OutcomeÀ CHX CHX + COL Placebo RRR (95% CI) NNT (CI) Ventilator associated pneumonia 10% 18% 63% (19 to 83) 10 (7 to 30) 13% 18% 52% (7 to 76) 11 (8 to 83) *Abbreviations defined in glossary; RRR, NNT, and CI calculated from control event rates and hazard ratios in article. ÀFollow up to diagnosis of ventilator associated pneumonia, death, or extubation. AJRCCM 2006;173: ; Evid Based Nurs 2007;10:19.

35 Elevation of the Head of the Bed Semirecumbent vs. Supine Clinical pneumonia 39 (8%) vs. 16 (34%), p=0.03 Figure 2: Cumulative proportion of patients with clinically suspected pneumonia Comparison of semirecumbent and supine body position (log-rank test, p=0 018). Pneumonia when enteral feeding in the position: 2/22 (9%) vs. 14/28 (50%) Lancet 1999;354:

36 Elevation of the Head of the Bed No Survival Benefit Figure 3: Survival of patients in semirecumbent compared with supine body position Log-rank test, p= Lancet 1999;354:

37 Feasibility and Effects of the Position Semirecumbent 112 patients enrolled Average position Day 1: 28.1 o Day 7: 22.6 o Supine 109 patients enrolled Average position Day 1: 9.8 o Day 7: 16.1 o Target NOT achieved: 85% VAP: 13 (10.7%) Mean to VAP (days): 7 (3-12) VAP: 8 (6.5%), p=ns Mean to VAP (days): 6 (3-9) Crit Care Med 2006;34(2):

38 Continuous Subglottic Suction Figure 1 Figure 3 Am J Med 2005;118:11-18.

39 Silver-Coated Endotracheal Tube 2. Kaplan-Meier Analyses of Occurrence of Microbiologically Confirmed or-associated Pneumonia (VAP) in Patients Intubated for 24 Hours or Longer Patients With VAP, % Uncoated, No. At risk New VAP cases Silver-coated, No. At risk 766 New VAP cases 0 Endotracheal tube Uncoated Silver-coated Generalized Wilcoxon P = Days Silver-Coated vs. uncoated Microbiologically confirmed VAP 4.8% (95% CI ) vs. 7.5% (95% CI ), p=0.03 Delay occurrence of VAP, p=0.005 No significant in duration of intubation, ICU stay, hospital stay, mortality, frequency and severity of adverse events JAMA 2008;300(7):

40 Reduce Colonization of Orodigestive Tract 60 SDD rectal colonization SDD oropharyngeal carriage SOD oropharyngeal carriage Figure 1. Detection of Gram-Negative Bacteria in Patients in the Intensive Care Unit Who Were Treated with Selective Digestive Tract Decontamination (SDD) or Selective Oropharyngeal Decontamination (SOD). SOD: Selective Oropharyngeal Decontamination SDD: Selective Digestive Tract Decontamination N Eng J Med 2009;360:20-31.

41 Reduce Colonization of Orodigestive Tract End Point Death no. (%) Standard Care (N = 1990) Study Group SDD (N = 2045) SOD (N = 1904) Unadjusted Odds Ratio or Hazard Ratio (95% CI) Standard Care SDD SOD Adjusted Odds Ratio or Hazard Ratio (95% CI) Standard Care SDD SOD During the first 28 days 544 (27.5) 546 (26.9) 502 (26.6) ( ) 0.95 ( ) ( ) 0.86 ( ) In the ICU 443 (22.3) 440 (21.5) 416 (21.8) ( ) 0.97 ( ) ( ) 0.87 ( ) In the hospital 632 (31.8) 665 (32.6) 584 (30.7) ( ) 0.94 ( ) ( ) 0.85 ( ) Time to outcome for survivors at day 28 days Cessation of mechanical ventilation ( ) 1.01 ( ) ( ) 1.03 ( ) Median Interquartile range Discharge from ICU ( ) 1.00 ( ) ( ) 1.06 ( ) Median Interquartile range Discharge from hospital ( ) 1.05 ( ) ( ) 1.13 ( ) Median Interquartile range N Eng J Med 2009;360:20-31.

42 Reduce Colonization of Orodigestive Tract Colonization with resistant bacteria during SOD and SDD Rectal Samples Total patients cultured Patients Colonized, No.(%) [95% CI] n=1871 (mean per month, 156 [IQR, ]) SOD SDD Trend in Time a Patients Colonized, Trend in Time a No. (%) % (95% CI) P Value [95% CI] % (95% CI) n=1928 (mean per month, 161 [IQR, ]) HRMO 237 (12.7) [ ] b 1.03 ( ) (7.3) [ ] ESBL 144 (7.7) [ ] b 1.03 ( ) (4.4) [ ] Aminoglycosides c 220 (11.8) 1.04 ( ) b (5.6) [ ] b [ ] Ciprofloxacin 193 (10.3) [ ] b 1.01 ( ) (5.6) [ ] Carbapenems d 52 (2.8) [ ] b 30(1.6) [ ] Colistin e 13 (0.7) [ ] VRE 4 (0.2) [0-0.4] Respiratory Samples 23 (1.1) [0.7-1.] 11 (0.6) [ ] P Value P Value for Difference Proportion Colonized Slope 1.05 ( ) ( ) ( ).02 < ( ) JAMA 2014;312(14):

43 Reduce Colonization of Orodigestive Tract No difference in mortality and length of stay Regimen SOD SDD ORorHR (95%CI) P Value Adjusted Odds (95% CI) P Value Mortality, No. (%) a No ICU 1165 (19.8) 1138 (18.6) 0.92 ( ) ( ).43 Hospital 1625 (27.6) 1629 (26.6) 0.95 ( ) ( ).83 Day (25.4) 1472 (24.1) 0.93 ( ) ( ).42 Time to Discharge for Survivors at Day 28, b Median (IQR), d No From ICU 6 (4-11) 6 (4-11) 0.96 ( ).10 From Hospital 19 (11-35) 19 (11-35) 0.96 ( ).10 Abbreviations: HR, hazard ratio; ICU, intensive care unit; IQR, interquartile b Mixed-model regression analysis was used. Adjusted odds were corrected for JAMA 2014;312(14):

44 Key Components of an Effective Sedation Management Daily interruption of sedation Daily assessment of readiness to extubate Protocol driven decreases in sedative doses

45 Daily Interruption of Sedation Complication Intervention, No. Control, No. VAP 2 5 Upper gastrointestinal 5 4 hemorrhage Bacteremia 4 7 Barotrauma 0 3 VTE 2 5 Cholestasis 0 1 Sinusitis 0 1 Total (No.) Overall complications Study vs. Control 13 (2.8%) vs. 26 (6.2%) p=0.4 Crit Care Med 2004;32(6):

46 Protocol-driven Decrease in Sedative Doses Every 24 h Fail Control (usual care including SBT) SBT safety screen Pass Do SBT Pass Prompt ICU team Fail Enrolment and randomisation Every 24 h Every 24 h Fail Pass Go to SBT safety screen Intervention (SAT plus SBT) SAT safety screen Pass Do SAT Every 24 h Fail Restart sedatives at half dose Figure 1: Treatment protocols ICU=intensive-care unit. SAT=spontaneous awakening trial. SBT=spontaneous breathing trial. Lancet 2008;371:

47 Protocol-driven Decrease in Sedative Doses Ventilator-free days* Intervention group (n=167) Control group (n=168) p value Mean 14 7 (0 9) 11 6 (0 9) 0 02 Median 20 0 (0 to 26 0) 8 1 (0 to 24 3) Time to discharge (days) From intensive care 9 1 (5 1 to 17 8) 12 9 (6 0 to 24 2) 0 01 From hospital 14 9 (8 9 to 26 8) 19 2 (10 3 to NA) day mortality 47 (28%) 58 (35%) year mortality 74 (44%) 97 (58%) 0 01 Duration of brain dysfunction (days) Coma 2 (0 to 4) 3 (1 to 7) Delirium 2 (0 to 5) 2 (0 to 6) 0 50 RASS at first successful SBT 1 ( 3 to 0) 2 5 ( 4 to 0) Complications Any self-extubation 16 (10%) 6 (4%) 0 03 Self-extubation requiring reintubation 5 (3%) 3 (2%) 0 47 Reintubation 23 (14%) 21 (13%) 0 73 Tracheostomy 21 (13%) 34 (20%) 0 06 Data are mean (SD), n (%), or median (IQR). RASS=Richmond agitation-sedation scale. SAT=spontaneous awakening trial. SBT=spontaneous breathing trial. *Ventilator-free days from study day 1 to 28. Greater than 25% of patients in the SBT group remained in the hospital at study day 28. Reintubation within 48 hours of extubation. Table 3: Main outcomes Lancet 2008;371:

48 Program Implementation

49 American Journal of Infection Control 2016;44:320-6.

50 American Journal of Infection Control 2016;44:320-6.

51 Current Controversies

52 Current Controversies in VAP Prevention 1. The definition of VAP is subjective, labor intensive, and of limited accuracy. 2. There is no consensus on how to operationalize the surveillance definition. 3. Endotracheal tubes designed for continuous aspiration of subglottic secretions are associated with decreased VAP rates and antibiotic usage in some studies but not all. No study has yet shown an impact on patients' outcomes. 4. Silver coated endotracheal tubes reduce VAP rates but have not yet been shown to impact patient's outcomes 5. Digestive decontamination with enteral and parenteral antibiotics decreases bacteremia and mortality rates but may cultivate antibiotic resistant flora. 6. The optimal components of a VAP prevention bundle have not been defined. 7. The optimal approach to bundle implementation and monitoring has not been defined.

53 Conclusion VAP Prevention 1. Early weaning, when clinically suitable 2. Implement infection control programs 3. Regular oral care with chlorhexidine 4. Elevation of the head of the bed 5. Continuous subglottic suction

54 Catheter Associated Urinary Tract Infection CAUTI

55 CAUTI Epidemiology Key Principles of Preventing CAUTI Current Controversies Conclusion

56 Incidence of CAUTIs in Hospitalized Catheterized US Adults: CAUTIs/100 Catheterizations Year Am J Infect Control 2014;42:17-22.

57 CAUTI: A US National Cohort of Hospitalized Patients Length of Stay Mortality Median Hospital Length of Stay (Days) CAUTI Non-CAUTI Year Percent Mortality CAUTI Non-CAUTI Year Am J Infect Control 2014;42:17-22.

58 Bad News: Hospitalization for Indwelling Catheter Complications Int Urol Nephrol 2014;46:

59 306 Fig. 2 Hospitalization for indwelling catheter 306 complications by age Int Urol Nephrol (2014) 46: Bad News: Hospitalization for Indwelling Catheter Complications Int Urol Nephrol (2014) 46: Fig. 2 Hospitalization for indwelling catheter complications by age By Age Fig. 3 Hospitalization for indwelling catheter complications by gender By Gender Fig. 3 Hospitalization for indwelling catheter complications by gender Int Urol Nephrol 2014;46: Table 2 Secondary diagnoses for indwelling catheter complication hospitalization, 2001 and 2010

60 able 2 Secondary diagnoses for indwelling catheter complication hospitalization, 2001 and 2010 Indwelling catheter complications 2001 (11,742 cases) Bad News: 2010 (40,429 cases) Cases for Indwelling % Catheter Complications Cases Hospitalization econdary diagnoses % Table 2 Secondary diagnoses for indwelling catheter complication hospitalization, 2001 and 2010 Urinary tract infections 9, catheter complications Indwelling 34,977 Diagnosis Bacterial infection 3, (11,742 cases) , (40,429 cases) ,757 Cases ,639 Cases % 48.6 Adverse effects of medical care Fluid and electrolyte disorders Secondary diagnoses 4,912 % ,318 Septicemia Urinary tract infections 2,475 Adverse effects of medical care 9, , Essential hypertension 2,967 Bacterial infection , Fluid and electrolyte disorders 4,912 Septicemia 2,475 Essential hypertension 2,967 ig. 4 Septicemia in ospitalization for indwelling atheter complications 123 Septicemia ,279 34,977 25, ,491 19, , , , Fig. 4 Septicemia in hospitalization for indwelling catheter complications 123 Int Urol Nephrol 2014;46:

61 Scenario I CAUTI

62 Scenario I 65 Y/O Female 7 days of fever (since Oct 7) CA Bladder w bilateral ureteral obstruction S/P bilateral PCN (Oct 1) UA (left PCN) wbc , UA (right PCN) wbc 30-50, UA (Midstream) wbc All urine cultures grew P.aeruginasa (MDR) > 10 5 CFU/mL Diagnosis: CA-UTI???

63 NHSN Surveillance Definition (Jan 2015, Modified Apr 2015) Indwelling catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a drainage bag. These devices are also called Foley catheters. Condom or straight in-and-out catheters are not included nor are nephrostomy tubes, ileoconduits, or suprapubic catheters unless a Foley catheter is also present. Indwelling urethral catheters that are used for intermittent or continuous irrigation are included in CAUTI surveillance.

64 Catheter-associated UTI (CAUTI) A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated. CDC Device-associated module, Jan 2015 (Modified April 2015)

65 Scenario I 65 Y/O Female 7 days of fever (since Oct 7) CA Bladder w bilateral ureteral obstruction S/P bilateral PCN (Oct 1) UA (left PCN) wbc , UA (right PCN) wbc 30-50, UA (Midstream) wbc All urine cultures grew P. aeruginasa (MDR) > 10 5 CFU/mL Diagnosis: CA-UTI???

66 Scenario I Diagnosis UTI NOT CAUTI Urinary System Infection (USI)

67 Scenario II CAUTI

68 Scenario II 80 Y/O Female T2DM, HT, old CVA status bed ridden admitted to MICU Diagnosis on admission: severe pneumonia w respiratory failure w septic shock New onset of fever for 3 days (day 7 of admission) More dyspnea, purulent sputum, more support of respirator setting, new infiltration from CXR Cloudy urine Central line, ET-tube w respirator and UC were in place on day 1 of hospitalization Diagnosis???

69 UTI Criteria Symptomatic UTI SUTI 1a: CAUTI SUTI 1b: Non-CAUTI SUTI 2: CAUTI or Non-CAUTI in patients 1 year of age or less Asymptomatic Bacteremic UTIs (ABUTI) Urinary System Infection (USI) (Formerly OUTI): kidney, ureter, bladder, urethra, or tissue surrounding the retroperitoneal or perinephric space) CDC Device-associated module, Jan 2015 (Modified April 2015)

70 Symptomatic UTI: SUTI 1a (CAUTI) Patient must meet 1, 2, and 3 below: Patient had an indwelling urinary catheter that had been in place for > 2 days on the date of event (day of device placement = Day 1) AND was either: Still present on the date of event, OR Removed the day before the date of event Patient has at least one of the following signs or symptoms: fever (>38.0 C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period CDC Device-associated module, Jan 2015 (Modified April 2015)

71 Symptomatic UTI: SUTI 1b (non-cauti) Patient must meet 1, 2, and 3 below: One of the following is true: Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days on the date of event OR Patient did not have a urinary catheter in place on the date of event nor the day before the date of event Patient has at least one of the following signs or symptoms: fever (>38.0 C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period CDC Device-associated module, Jan 2015 (Modified April 2015)

72 Symptomatic UTI: SUTI 2 Patient must meet 1, 2, and 3 below: Patient is 1 year of age (with or without an indwelling urinary catheter) Patient has at least one of the following signs or symptoms: fever (>38.0 C) hypothermia (<36.0 C) apnea bradycardia lethargy vomiting suprapubic tenderness Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period CDC Device-associated module, Jan 2015 (Modified April 2015)

73 Asymptomatic Bacteremic UTI: ABUTI Patient must meet 1, 2, and 3 below: 1. Patient with or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age 2. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria of 10 5 CFU/ml 3. Patient has a positive blood culture with at least one matching bacteria to the urine culture, or meets LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of the ABUTI criterion must occur during the Infection Window Period (See Definition Note: Patients > 65 years of age with a non-catheter-associated ABUTI may have a fever and still meet ABUTI criteria CDC Device-associated module, Jan 2015 (Modified April 2015)

74 Urinary System Infection (USI) (Formerly OUTI) Other infections of the urinary tract must meet at least one of the following criteria: 1. Patient has microorganisms isolated from culture of fluid (excluding urine) or tissue from affected site 2. Patient has an abscess or other evidence of infection on gross anatomical exam, during invasive procedure, or on histopathologic exam 3. Patient has at least one of the following signs or symptoms: - fever (>38.0 C), localized pain or tenderness, And at least one of the following: - purulent drainage from affected site, organisms cultured from blood and imaging test evidence of infection (e.g., ultrasound, CT scan, magnetic resonance imaging [MRI], or radiolabel scan [gallium, technetium]) CDC Device-associated module, Jan 2015 (Modified April 2015)

75 Urinary System Infection (USI) (Formerly OUTI) 4. Patient <1 year of age has at least one of the following signs or symptoms: fever (>38.0 C), hypothermia (<36.0 C), apnea, bradycardia, lethargy, vomiting* And at least one of the following: purulent drainage from affected site organisms cultured from blood and imaging test evidence of infection, (e.g., ultrasound, CT scans, magnetic resonance imaging [MRI], or radiolabel scan [gallium, technetium]) *With no other recognized cause CDC Device-associated module, Jan 2015 (Modified April 2015)

76 Measurement CAUTI Rate # CAUTIs identified x 1,000 # Indwelling Urinary Catheter Days Device Utilization Ratio # Indwelling Urinary Catheter Days # Patient-Days

77 Key Principles of Preventing CAUTI 1. Limited unnecessary catheterization, using urinary catheters only when indicated. 2. Insert indwelling catheters using aseptic technique and sterile equipment. 3. Proper catheter management 4. Implement infection control programs 5. Consider alternatives to indwelling catheters including condom catheters or in and out catheterization, when appropriate. Clinical Decision Support: Hospital Infection Control 2014.

78 Indications for Urinary Catheteriz ation Perioperative use for selected surgical procedures Assistance in pressure ulcer healing for incontinent residents Urine output monitoring in critically ill patients Management of acute urinary retention and urinary obstruction As an exception, at patient request to improve comfort Infect Control Hosp Epidemiol Apr;31(4):

79 Unnecessary Urinary Catheterization 330 patients observed 67 (20.3%) cases had UCs in place 31 (46.3%) of them had inappropriate indications inappropriate indication on current date of catheterization than on the date of insertion 31 cases (46.3%) vs. 8 cases (11.9%), p=0.001 Abstract # 290: IDWeek 2015

80 Catheter Management Remove catheter as soon as possible. Daily evaluation of the need for indwelling catheter is paramount. Use a continuously closed drainage system with ports in the distal catheter for needle aspiration of urine. Place the drainage bag and connecting tube below the level of the bladder, maintaining unobstructed urinary flow. Irrigate catheters only when indicated. Obtain urine samples aseptically. Practice hand hygiene and standard (or appropriate isolation) precautions according to CDC HICPAC guidelines

81 Infection Prevention Programs Healthcare facilities should develop and maintain policies and procedures for: recommended urinary catheter insertion indications, insertion and maintenance techniques, discontinuation strategies, and replacement indications. Educate medical personnel, caregivers, and patients on the appropriate indications, aseptic placement technique, and management of indwelling urinary catheters.

82 Approaches that should not be Routinely Considered Do not routinely use antimicrobial/antisepticimpregnated catheters (quality of evidence: I). Do not screen for asymptomatic bacteriuria in catheterized patients (quality of evidence: II). Do not treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (quality of evidence: I). Infect Control Hosp Epidemiol. 2011;32(8):

83 Antimicrobial Catheters for Reduction of SUTIs A 60 years <60 years Female Male No antibiotic use in past 7 days Antibiotic use in past 7 days No prophylactic antibiotic use Prophylactic antibiotic use No bacteriuria before catheterisation Bacteriuria before catheterisation Odds ratio (99% CI) 0 89 ( ) 1 13 ( ) 0 95 ( ) 1 07 ( ) 0 92 ( ) 1 27 ( ) 0 90 ( ) 1 01 ( ) 0 91 ( ) 1 49 ( ) Odds ratio (99% CI) B 60 years <60 years Female Male No antibiotic use in past 7 days Antibiotic use in past 7 days No prophylactic antibiotic use Prophylactic antibiotic use No bacteriuria before catheterisation Bacteriuria before catheterisation Odds ratio (99% CI) 0 75 ( ) 0 91 ( ) 0 78 ( ) 0 93 ( ) 0 70 ( ) 1 27 ( ) 0 76 ( ) 0 84 ( ) 0 77 ( ) 1 24 ( ) Odds ratio (99% CI) Figure 2: Catheter-associated urinary tract infection up to 6 weeks after randomisation for the silver alloy catheter versus control (A) and nitrofural catheter versus control (B) Lancet 2012;380:

84 Antimicrobial Catheters for Reduction of SUTIs 60 years <60 years Female Male No antibiotic use in past 7 days Antibiotic use in past 7 days No prophylactic antibiotic use Prophylactic antibiotic use No bacteriuria before catheterisation Bacteriuria before catheterisation Prevention of CAUTI: simple is beautiful A Odds ratio (99% CI) 0 89 ( ) 1 13 ( ) 0 95 ( ) 1 07 ( ) 0 92 ( ) 1 27 ( ) 0 90 ( ) 1 01 ( ) 0 91 ( ) 1 49 ( ) Odds ratio (99% CI) B 60 years <60 years Female Male No antibiotic use in past 7 days Antibiotic use in past 7 days No prophylactic antibiotic use Prophylactic antibiotic use No bacteriuria before catheterisation Bacteriuria before catheterisation Odds ratio (99% CI) 0 75 ( ) 0 91 ( ) 0 78 ( ) 0 93 ( ) 0 70 ( ) 1 27 ( ) 0 76 ( ) 0 84 ( ) 0 77 ( ) 1 24 ( ) Odds ratio (99% CI) Figure 2: Catheter-associated urinary tract infection up to 6 weeks after randomisation for the silver alloy catheter versus control (A) and nitrofural catheter versus control (B) Lancet 2012;380:

85 Appropriate Indication for Obtaining a Urine Culture Abstract # 292: IDWeek 2015

86 Approaches that should not be Routinely Considered Avoid catheter irrigation (quality of evidence: II). a. Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure. b. If continuous irrigation is being used to prevent obstruction, maintain a closed system. Do not use systemic antimicrobials routinely as prophylaxis (quality of evidence: III). Do not change catheters routinely (quality of evidence: III). Infect Control Hosp Epidemiol. 2011;32(8):

87 Current Controversies 1. Use of antiseptic solution versus sterile saline for meatal cleaning before catheter insertion. 2. Use of urinary antiseptics (eg, methenamine) to prevent UTI. 3. Use of catheters with valves. 4. Spatial separation of patients with urinary catheters in place to prevent transmission of pathogens that could colonize urinary drainage systems. 5. Antimicrobial prophylaxis at catheter removal to prevent symptomatic infection. Infect Control Hosp Epidemiol. 2011;32(8):

88 Conclusion CAUTI Prevention 1. Limited unnecessary catheterization, using urinary catheters only when indicated. 2. Insert indwelling catheters using aseptic technique and sterile equipment. 3. Proper catheter management 4. Implement infection control programs 5. Consider alternatives to indwelling catheters including condom catheters or in and out catheterization, when appropriate. Clinical Decision Support: Hospital Infection Control 2014.

89 Implementation of CAUTI Prevention Strategies FIGURE 2 Monthly CAUTI rates, July 2009 through June Upper control limit set at 3 s: red lines; mean CAUTI rate: green lines. Lower control limits were below zero for both pre- and postintervention periods. Pediatrics 2014;134(3):e