Učinak rizičnih čimbenika i antimikrobnog liječenja na učestalost nozokomijalnih urinarnih infekcija u internističkih bolesnika
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1 Učinak rizičnih čimbenika i antimikrobnog liječenja na učestalost nozokomijalnih urinarnih infekcija u internističkih bolesnika Degoricija Vesna Klinička bolnica Sestre milosrdnice Klinika za unutarnje bolesti Jedinica intenzivne skrbi
2 Urogenitalne bolničke infekcije u internističkih bolesnika Napredak u liječenju kroničnih i akutnih bolesti internističkih bolesnika razvojem novih lijekova i tehnološkim razvitkom endoskopskih i intravaskularnih intervencija rezultirao je: Boljim rezultatima u izlječenju, zalječenju i/ili poboljšanju kvalitete i dužine života Ne rijetko nove metode liječenja zahtijevaju instrumentalne zahvate unutar mokraćnih putova i/ili postavljanje urinarnog katetera što je povezano s povećanom incidencijom bolničkih infekcija urogenitalnog trakta Degoricija et al. ICU Performance and Antimicrobial Therapy in Sepsis Survival. Croat Med J 2006;47:
3 Urogenitalne bolničke infekcije u internističkih bolesnika Cijeli je niz internističkih bolesnika koji su zbog same prirode bolesti izloženi povećanom riziku nastanka bolničke infekcije. anatomske, strukturalne i/ili funkcionalne promjene unutar samog urinarnog trakta priroda same bolesti koja imunološki kompromitira bolesnika: šećerna bolest, zatajenje jetre i/ili bubrega imunosupresivna i/ili citostatska terapija, zračenje akcidentalna i terapijska hipotermija Degoricija et al. ICU Performance and Antimicrobial Therapy in Sepsis Survival. Croat Med J 2006;47:
4 Urogenitalne bolničke infekcije u internističkih bolesnika Prerenalni poremećaj bubrežne funkcije šok, hipotenzija, hipoperfuzija, dehidratacija Renalni poremećaj bubrežne funkcije hipoperfuzija, vazokonstrikcija ili stenoza bubrežnih arterija, dehidratacija interakcija nefrotoksičnih lijekova ne prilagođavanje doze nefrotoksičnih lijekova pogoršanju bubrežne funkcije tijekom liječenja osnovne bolesti Postrenalni poremećaj bubrežne funkcije maligna ili benigna opstrukcija unutar i izvan mokraćnih putova Degoricija et al. ICU Performance and Antimicrobial Therapy in Sepsis Survival. Croat Med J 2006;47:
5 Karakteristike uzročnika-virulencija uropatogena (E.coli) Sposobnost adherencije na mukozne i uroepitelne stanice Adherencija-kolonizacija-crijevo-perineumuretra-mokraćni mjehur-pijelon-bubrežni intersticij Važnost: anatomski normalan urinarni trakt, rekuretni cistitis i infekcije nakon postavljanja urinarnog katetera Oelsschlaeger TA et al. Virulence factors of uropathogensl. Curr Opin Urol 2002;12:33.
6 Karakteristike uzročnika-virulencija uropatogena (E.coli) Prisutnost flagela koji određuju mobilnost bakterije Stvaranje hemolizina koji potiče formiranje pora u staničnoj membrani Stvaranje aerobaktina, siderofora neophodnih za akviziciju željeza u željezom siromašnom miljeu urinarnog trakta Rezistencija na plazmatske baktericidne čimbenike Virulencija nije povezana s rezistencijom na antimikrobne lijekove Oelsschlaeger TA et al. Virulence factors of uropathogensl. Curr Opin Urol 2002;12:33.
7 Urogenitalne bolničke infekcije-indikacije za postavljanja urinarnog katetera Jednokratna kateterizacija (sakupljanje uzoraka, jednokratna evakuacija urina) Intermitentna kateterizacija (drenaža mokraćnog mjehura nakon ozljede kralježnice i zbog neuroloških bolesti) Trajna kateterizacija (sakupljanje urina u vremenu, monitoriranje diureze, komfor bolesnika, kronična nesposobnost kontrole mokrenja, ispiranje krvi iz mokraćnog mjehura) Kronična kateterizacija (urinarni kateter ima 38% bolesnika u bolnicama kroničnog tipa i 9% bolesnika u staračkim domovima) Warren JW et al. The prevalence of urethral catheterization in Marlyland nursing homes. Arch Intern Med 1989;149:1535.
8 Urogenitalne bolničke infekcijepatogeneza Uvođenje katetera u mokraćni mjehur Ekstraluminalna infekcija (prisustvo bakterija u eksudatu koji se formira oko katetera u uretri) Intraluminalna infekcija (nije zatvoren sustav drenaže ili je kontaminiran izvana) U studiji Tambyaha i sur. u 69% bolesnika otkriven je put ulaska infekcije 66% ekstraluminalna infekcija, 34% intraluminalna infekcija Tambyah PA et al. A prospective study of pathogenesis of catheter-associated urinary tract infection. Mayo Clin Proc 1999;74:131.
9 Urogenitalne bolničke infekcijepatogeneza Bakterije produciraju biofilm s vanjske i unutarnje strane katetera Biofilm olakšava adherenciju bakterija za kateter Istovremeno eliminacija adheriranih bakterija je otežana Sabbuba N et al. The migration of proteus mirabillis and other urinary tract pathogens over Foley catheters. BJU Int 2002;89:55.
10 Urogenitalne bolničke infekcijerizični čimbenici Incidencija bakteriurije u kateteriziranih bolesnika proporcionalna je s trajanjem nošenja katetera 3-10% bolesnika razvije signifikantnu bakteriuriju svaki dan Od njih 10-25% razvije simptome infekcije urinarnog trakta, a manje od 4% bakteriemiju Tambyah PA et al. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 patients. Arch Intern Med 2000;160:678. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68.
11 Urogenitalne bolničke infekcijerizični čimbenici Sterilnost prilikom uvođenja katetera Održavanje drenažnog sistema zatvorenim Kunin CM et al. Prevention of catheter-induced urinary tract infections by sterile closed drainage. N Engl J Med 1966;274:1155. Ženski spol Kolonizacija bakterija u vreći za sakupljanje urina Šećerna bolest Greške kod njege bolesnika s urinarnim kateterom Stephan F et al. Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis 2006;42:1544.
12 Urogenitalne bolničke infekcijeprevencija Izbjeći nepotrebnu kateterizaciju 21-50% bolesnika ima urinarni kateter neopravdano Inkontinencija ili štednja rada medicinskog osoblja Cravenos DD et al. Urinary catheter management. Am Fam Physician 2000;61:369. Dugotrajna kateterizacija Nemogućnost otklanjanja uzroka retencije urina, nezaustavljivo oštećenje kože zbog urinarne inkontinencije, neurogeni mjehur, palijativna skrb Kratkotrajna kateterizacija Urološki ili kirurški zahvat duži od 4 sata, mjerenje diureze u kritično bolesnih i akutna retencija urina Stephan F et al. Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis 2006;42:1544.
13 Urogenitalne bolničke infekcijerizični čimbenici Odstraniti kateter što ranije Huang WC et al. Catheter-associated urinary tract infections in ICUs can be reduced by prompting physiscians to remove unnecessary catheters. Infect Control Hosp Epidemiol 2004;25:974. Njega bolesnika s urinarnim kateterom DA Sterilno postavljanje, učvršćivanje, zatvoren sustav drenaže bez regurgitacije urina, čišćenje katetera sapunom i vodom NE dezinfekcija tjelesnih otvora, instilacija ureteralnih lubrikanata (srebrni sulfadiazin), ispiranje mjehura otopinom antibiotika Huth TS et al. Randomized trial of meatal care with silver sulfadiazine creame for the prevention of catheter-associated bacteriuria. J Infect Dis 1992;165:14. Schneeberger PM. Hosp Infect 1992;21:223.
14 Urogenitalne bolničke infekcijeprevencija Zamjena urinarnog katetera Kod opstrukcije katetera, kliničke slike infekcije i nakon 3-4 tjedna Tenney JH et al. Bacteriuria in women with long-term catheters:paired comparison of indwelling and replacement catheters. J Infect Dis 1988;157:199. Kateteri obloženi filmom antimikrobnog lijeka Nitrofurazon, minociklin, rifampin, srebrna aloa Preveniraju ili odlažu nastanak bakteriurije u kratkotrajno kateteriziranih bolesnika Johnson JR et al. Systemic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med 2006;144:116. Kondom kateter-lokalna iritacija i ulceracije kože U 53% nekooperabilnih bolesnika razvitak infekcije urinarnog trakta Suprapubični kateteri-rijetka indikacija, operativni uvjeti Hirsh DD et al. Do condom catheter collesting systems cause urinary tract infection? JAMA 1979;242:340.
15 Urogenitalne bolničke infekcijeprofilaktička primjena antibiotika Bez učinka na razvoj infekcije urinarnog trakta bila je profilaktička primjena kotrimoksazola u bolesnika s kroničnim kateterom i ozljedom kralježnice Sandock DS et al. Trimethoprim-sulfamethoxazole prophylaxis against urinary tract infection in the chronic spinal cord injury patient. Paraplegia 1995;33:156. Flourokinoloni u prevenciji urinarne infekcije u kronično kateteriziranih bolesnika Redukcija Gram negativnih izolata i redukcija broja simptomatskih urinarnih infekcija Rutschman TO et al. Use of norfloxacin for prevention of symptomatic urinary tract infection in chronically catheterized patients. Eur J Clin Microbiol Infect Dis 1995;14:441. Usporedba profilakse i kliničke indikacije za antibiotik pokazala je smanjenje broja urinarnih infekcija u: Internističkih i neuroloških bolesnika, žena s operacijom trbuha i kateterom duže od 24 sata, prva 3 postoperativna dana ili od 2. postoperativnog dana do odstranjenja katetera Niel-Weise BS et al. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev 2005;:CD
16 Urogenitalne bolničke infekcijepreporuke NE Rutinska primjena urinarnih katetera obloženih filmom antimikrobnog lijeka Profilaktička primjena antimikrobnih lijekova Rutinsko traženje i liječenje asimptomatske bakteriurije OSIM: trudnice, prije TUR prostate i urološkog zahvata s očekivanim mukoznim krvarenjem Fungurija (kandidurija) čest nalaz, bolesnici su asimptomatski, predstavlja kolonizaciju, progresija u kandidemiju je rijetka (1,3%), stariji bolesnici, višestruka primjena antibiotika, dijabetičari Stark RP et al. Bacteriuria in the catheterized patients. What quantitative level of bacteriuria is relevant? N Eng J Med 1984;311:560. Kauffman CA et al. Prospective multicenter surveillance study of funguria in hospitalized patients. NIAID Mycoses Study Group. Clin Infect Dis 2000;30:14.
17 Urogenitalne bolničke infekcijepreporuke DA Urinokultura u dugotrajno kateteriziranih bolesnika s temperaturom, zamućenjem urina i/ili sistemnim manifestacijama infekcije Promjena mentalnog statusa, hipotenzija, metabolička acidoza i/ili respiracijska alkaloza Promjena katetera i uzimanje uzorka urina kroz novi kateter, nikada drenažni sustav Raz R et al. Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection. J Urol 2000;164:1254.
18 Urogenitalne bolničke infekcijeprofilaktička primjena antibiotika DA Urinokultura 48 sati nakon odstranjenja katetera u žena kateteriziranih unutar tjedan dana Liječenje pozitivne urinokulture i bez kliničke slike infekcije (2005 IDSA Guidelines) Harding GK et al. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med 1991;114:713. Nicolle LE et al. IDSA guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643. Ciljano liječenje urinarne infekcije prema antibiogramu Empirijsko liječenje infekcije s negativnom urinokulturom prema Gram analizi, rezultatima ranijih urinokultura i osjetljivosti bakterija u lokalnom medicinskom miljeu U slučaju infekcije odstraniti urinarni kateter, intermitentne kateterizacije do izlječenja infekcije ili zamjena urinarnog katetera Raz R et al. Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection. J Urol 2000;164:1254.
19 Urogenitalne bolničke infekcije u internističkih bolesnika Produženje života kroničnih bolesnika: s uznapredovalom aterosklerozom krvnih žila i šećernom bolesti i bolesnika s malignom bolesti izdvojio je značajnu skupinu u kojoj su bolničke infekcije urogenitalnog trakta česte i uzrokuju akutne komplikacije koje ne rijetko zahtijevaju složena bolnička liječenja u jedinicama intenzivne skrbi Jedini učinkovit način smanjenja ovih komplikacija otkrivanje je rizičnih čimbenika za razvitak bolničke infekcije i njihovo pravovremeno liječenje empirijskom i ciljanom antimikrobnom terapijom Degoricija et al. ICU Performance and Antimicrobial Therapy in Sepsis Survival. Croat Med J 2006;47:
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