Catheter-Associated Urinary tract infections: What works in prevention? Anucha Apisarnthanarak, MD

Transcription

1 Catheter-Associated Urinary tract infections: What works in prevention? Anucha Apisarnthanarak, MD

2 Financial disclosure Research Support: Baxter, Interimmune, Lily, Merck Sharpe Dohme, Wyeth Honoraria/Speaker gifts: Pfizer, Bristol-Meyers-Squibb, Wyeth, Johnson& Johnson,

3 Catheter-associated UTI Most common nosocomial infection Approx 1 million episodes in US hospitals and nursing homes annually, approx 10 million episodes worldwide Each episode costs US$500/- Tambyah, Maki. Infect Control Hosp Epidemiol 2002

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6 Risk factors for CAUTI Maki & Tambyah Emerg Infect Dis Mar-Apr;7(2):342-7

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8 Catheter associated UTI and resistance CAUTI are the major reservoir for resistant nosocomial pathogens in hospitals and NHs Wagenlehner FM, Niemetz A, Dalhoff A, Naber KG, Int J Antimicrob Agents Jun;19(6):

9 Diagnosis of catheter UTI Gold standard is urine culture Dipstick and other non-culture tests are not reliable Number of organisms is controversial

10 Guideline from NIDDR 10^2 for CIC; 10^4 for condom catheters and any level of bacteriuria in IDCs The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, J Am Paraplegia Soc Jul;15(3):

11 European surveillance (ESGNI)

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13 Diagnosis of catheter UTI In the absence of antibiotics, even one microorganism will eventually multiply in the catheterised urinary tract

14 Stark & Maki NEJM 1984;311:560-4

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16 Symptoms and Catheter UTI?? Results of a large prospective study Tambyah, Maki Arch Intern Med Mar 13;160(5):

17 Symptoms and Catheter UTI?? Symptoms are uncommon with catheter UTI Tambyah, Maki Arch Intern Med Mar 13;160(5):

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19 Pyuria and Catheter UTI?? Mainly with gram-negative bacilli Tambyah, Maki Arch Intern Med Mar 13;160(5):673-7.

20 Pyuria and Catheter UTI?? Only with high colony counts Tambyah, Maki Arch Intern Med Mar 13;160(5):673-7.

21 Pyuria and Catheter UTI?? Tambyah, Maki Arch Intern Med Mar 13;160(5):673-7.

22 Pathogenesis of CAUTI Maki & Tambyah Emerg Infect Dis Mar-Apr;7(2):342-7

23 Mechanism of CAUTI Tambyah, Halvorson & Maki. Mayo Clin Proc Feb;74(2):131-6.

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25 CAUTI and Morbidity/Mortality Almost always associated with obstruction or structural urinary tract disease Kunin, Chin, Chambers. J Am Ger Soc 1987;35: Bryan, Reynolds J Urol 1984;132:494-8

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27 Prevention: The biofilm is the problem Maki & Tambyah Emerg Infect Dis Mar-Apr;7(2):342-7

28 Many interventions have been tried Maki & Tambyah Emerg Infect Dis Mar-Apr;7(2):342-7

29 Interventions vs CAUTI Maki & Tambyah Emerg Infect Dis Mar-Apr;7(2):342-7

30 Interventions: Intraluminal Sealed catheter junctions: Huth et al Arch Intern Med 1992;152: Platt et al Lancet 1983;1: Classen et al Am J Infect Control 1990;19: Bladder irrigation: Warren et al N Engl J Med 1978;299; Gillespie et al Lancet 1983;1: Thompson et al. JAMA 1984;251:747-51

31 Interventions: Extraluminal Antiseptic lubricants: Kunin et al J Urol 1971;106: Butler et al J Urol 1968:100: Schiotz Arch Gyn Obst 1996;258: Topical therapies: Burke et al Am J Med 1981:70: Classen et al Am J Infect Control 1990;19: Burke et al. J Urol 1983;129:331-4

32 Historic Coated Urinary Catheters 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

33 Johnson Ann Intern Med 2006;144:116-26

34 Siver hydrogel catheters: 852 newly catheterised patients studied daily CAUTI in controls: 21.2% CAUTI in coated catheters: 15.4% RR 0.72, 95% CI , P=0.03 Most effective for yeasts, staphylococci/enterococci Little effect for gram-negative bacilli Maki, Knasinski, Halvorson, Tambyah SHEA 1998

35 Nitrofurazone coated catheters: 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, Tambyah SHEA 1997

36 New technologies on the horizon Anti-infective coatings problem of resistance Urethral stents?? Valves with release of antiseptics Inhibitors of quorum sensing???

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38 J Infect Dis 2003;187:625-30

39 Bacterial interference Darouiche et al Clinical Infectious Diseases 2005;41:

40 Saint et al Am J Med 2000;109:476-80

41 Alternatives to urethral catheterisation Saint S, Lipsky BA, Goold SD Ann Intern Med 2002;137:125-7

42 Alternatives to urethral catheterisation Saint, Lipsky Arch Intern Med. 1999;159:

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45 Interventions work! 12 month control period followed by 12 month intervention with nurse generated daily reminders after D5 Catheterization rate reduced from days to 4.6 +/- 0.7 days; P <.001 CAUTI rate reduced from /- 3.1 to 8.3 +/- 2.5 per 1,000 catheter-days; P =.009 Antibiotic cost reduced reduced by 69% (from 4021 dollars +/ dollars to 1220 dollars +/- 941 dollars; P =.004) Huang et al Infect Control Hosp Epidemiol Nov;25:974-8

46 Post-op In Nigeria

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