Prevention of Important HAIs: Principle & Case Scenario in VAP/CAUTI. CPT. Pasri Maharom MD, MPH Dec 15, 2015

Transcription

1 Prevention of Important HAIs: Principle & Case Scenario in VAP/CAUTI CPT. Pasri Maharom MD, MPH Dec 15, 2015

2 Catheter Associated Urinary Tract Infection CAUTI

3 CAUTI Epidemiology Key Principles of Preventing CAUTI Current Controversies Conclusion

4 Trends in CAUTIs in Adult ICUs: Pooled Annual Urinary Catheter Utilization by ICU type, Infect Control Hosp Epidemiol 2011;32(8):

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

6 CAUTI Trends by ICU Type Infect Control Hosp Epidemiol 2011;32(8):

7 Sensitivity Analysis of 7-year Trends of CAUTIs by ICU type: NNIS and NHSN ICU type All reporting units Relative change (95% CI), % P Change in incidence of SUTI a Frequently reporting units b Relative change (95% CI), % P Cardiothoracic 1.9 ( 17.5 to 16.6) ( 5.2 to 54.9).03 Coronary 34.3 ( 22.9 to 44.1)! ( 17.1 to 54.6).002 Medical 30.2 ( 23.3 to 36.5)! ( 15.5 to 38.2)!.001 Medical/surgical with major teaching affiliation 35.5 ( 28.2 to 42.1)! ( 28.6 to 55.7)!.001 Medical/surgical without major teaching affiliation 18.4 ( 9.9 to 26.0)! ( 12.5 to 37.7)!.001 Surgical 34.6 ( 27.6 to 41.0)! ( 50.5 to 67.3)!.001 note. CI, confidence interval; SUTI, catheter-associated symptomatic urinary tract infection. Infect Control Hosp Epidemiol 2011;32(8):

8 Trends of Device-associated Infections Rates, Taiwan: Incidence rate (n/1,000 device-days) Year Ventilator-associated pneumonia (mean 3.18%, p<0.001) Catheter-associated urinary tract infection (mean 3.76%, p<0.001) Central line-associated bloodstream infection (mean 2.11%, p<0.001) BMC Infectious Diseases 2012;12:209.

9 Mortality in Device-associated Infections, Taiwan: day Mortality In-hospital Mortality Year Ventilator-associated pneumonia (mean 3.18%, p<0.001) er of infected Catheter-associated urinary tract infection (mean 3.76%, p<0.001) Central line-associated bloodstream infection (mean 2.11%, p<0.001) BMC Infectious Diseases 2012;12:209.

10 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.

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

12 306 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

13 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:

14 Scenario I CAUTI

15 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???

16 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.

17 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)

18 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???

19 Scenario II CAUTI

20 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???

21 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)

22 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)

23 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)

24 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)

25 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)

26 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)

27 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)

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

29 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.

30 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):

31 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

32 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

33 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.

34 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):

35 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:

36 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:

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

38 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):

39 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):

40 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.

41 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