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Catheter Associated UTI Bundle
•   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
100%
 90%
80%
70%
60%
50%                             Bacteriuria
40%
30%
20%
10%
 0%
       At Placement   4th day
100%
 90%
80%
70%
60%
50%                          Bacteriuria
40%
30%
20%
10%
 0%
       1st week   4th week
   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
Catheter Associated UTI Bundle
Catheter Associated UTI Bundle
Source of
                                       microorganisms:
                                       Endogenous - meatal,
                                       rectal, or vaginal
                                       colonization
                                       Exogenous -
                                       contaminated hands
                                       of healthcare worker



Maki DG. Emerg Infect Dis 2001;7:1-6
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                          Scanning electron micrograph of S. aureus
                                                bacteria on the luminal surface of an
     and host defenses                          indwelling catheter with interwoven complex
                                                matrix of extracellular polymeric substances
                                                known as a biofilm
    Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
Maki, Emerg Infect Dis 2001; 7: 1-6
Supplemental
Core Strategies          Strategies

 ◦ High levels of         ◦ Some scientific
   scientific evidence      evidence
                          ◦ Variable levels of
 ◦ Demonstrated             feasibility
   feasibility



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_cau
   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   Don sterile gloves before
 before and after          procedure
   procedure
•Sterile technique
must be used
when inserting the
catheter

•Do not use
aggressive
cleaning once
urinary catheter is
in place
Catheter Associated UTI Bundle
Catheter Associated UTI Bundle
   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


                              http://www.cdc.gov/hicpac/cauti/001_cau
•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.


                              http://www.cdc.gov/hicpac/cauti/001_cau
   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

                           http://www.cdc.gov/hicpac/cauti/001_cau
   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
                               http://www.cdc.gov/hicpac/cauti/001_cau
   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
Core Measures                    Supplemental
                                     Measures
   Insert catheters only for           Alternatives to
    appropriate indications              indwelling urinary
   Leave catheters in place only        catheterization
    as long as needed                   Portable ultrasound
   Only properly trained persons        devices to reduce
    insert and maintain catheters        unnecessary
   Insert catheters using aseptic       catheterizations
    technique and sterile               Antimicrobial/antiseptic
    equipment                            -impregnated catheters
   Maintain a closed drainage
    system
   Maintain unobstructed urine
    flow
   Hand hygiene and standard (or
    appropriate isolation)
    precautions
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)


                                  http://www.cdc.gov/hicpac/cauti/001_cau
   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
Catheter Associated UTI Bundle

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Catheter Associated UTI Bundle

  • 1. The presentation is solely meant for Academic purpose
  • 3. 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
  • 4. 100% 90% 80% 70% 60% 50% Bacteriuria 40% 30% 20% 10% 0% At Placement 4th day
  • 5. 100% 90% 80% 70% 60% 50% Bacteriuria 40% 30% 20% 10% 0% 1st week 4th week
  • 6. 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
  • 7. 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.
  • 8. Gold standard is urine culture  Dipstick and other non-culture tests are not reliable  Number of organisms is controversial
  • 11. Source of microorganisms: Endogenous - meatal, rectal, or vaginal colonization Exogenous - contaminated hands of healthcare worker Maki DG. Emerg Infect Dis 2001;7:1-6
  • 12. Tambyah, Halvorson & Maki. Mayo Clin Proc. 1999 Feb;74(2):131-6.
  • 13. Formation of biofilms by urinary pathogens common on the surfaces of catheters and collecting systems  Bacteria within biofilms resistant to antimicrobials Scanning electron micrograph of S. aureus bacteria on the luminal surface of an and host defenses indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
  • 14. Maki, Emerg Infect Dis 2001; 7: 1-6
  • 15. Supplemental Core Strategies Strategies ◦ High levels of ◦ Some scientific scientific evidence evidence ◦ Variable levels of ◦ Demonstrated feasibility feasibility www.cdc.gov/hicpac
  • 16. 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_cau
  • 17. 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
  • 18. 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
  • 19. Good hand hygiene Don sterile gloves before before and after procedure procedure
  • 20. •Sterile technique must be used when inserting the catheter •Do not use aggressive cleaning once urinary catheter is in place
  • 23. 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
  • 24. 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 http://www.cdc.gov/hicpac/cauti/001_cau
  • 25. •Sampling Port: Disinfect port before sampling urine •Look for possible disconnection of catheter from drainage bag
  • 26. System may become an open system if outlet is left hanging or is unclamped
  • 27. 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. http://www.cdc.gov/hicpac/cauti/001_cau
  • 28. Use smallest catheter size effective for patient (14 or 16F)  Catheters should be properly secured to prevent movement and urethral traction
  • 29. 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 http://www.cdc.gov/hicpac/cauti/001_cau
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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 http://www.cdc.gov/hicpac/cauti/001_cau
  • 34. 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
  • 35. 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
  • 36. Core Measures Supplemental Measures  Insert catheters only for  Alternatives to appropriate indications indwelling urinary  Leave catheters in place only catheterization as long as needed  Portable ultrasound  Only properly trained persons devices to reduce insert and maintain catheters unnecessary  Insert catheters using aseptic catheterizations technique and sterile  Antimicrobial/antiseptic equipment -impregnated catheters  Maintain a closed drainage system  Maintain unobstructed urine flow  Hand hygiene and standard (or appropriate isolation) precautions
  • 37. Supplemental measures Core measures
  • 38. 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) http://www.cdc.gov/hicpac/cauti/001_cau
  • 39. 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