Catheter associated UTI: Reducing the risk

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Catheter associated UTIReducing the risk

• Tom Ladds

13th May 2009
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In the next 45 minutes...

• What is a UTI?
• The scale of the problem
• Strategies to reduce risk
• Is a catheter necessary?
• ANTT catheter insertion
• Ongoing education
• Discussion

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Problem Number 1What is a UTI?

• Lots of conflicting definitions
• Google 753,000 (in 0.33 seconds!)
• Bacteria in urine
• Symptoms

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Problem number 2What is a CAUTI?

• UTI associated with a urinary catheter!
• How long after insertion?
• How long after removal?
• Varying definitions inconsistent findings

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Acceptable definition?

• Is it catheter related?
• The patient has an indwelling urinary catheter OR
  has had a urinary catheter during the previous 7
  days .
• There is no evidence that a urinary tract
  infection was present or incubating before
  catheterisation.
• The infection became evident 48 hours or more
  after catheterisation.

Third Prevalence Survey of Healthcare Associated
Infections in Acute Hospitals
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Symptoms

• Criterion 1
• Patient has at least one of the following signs
  or symptoms with no other recognised cause fever
  (gt38oC), urgency, frequency, dysuria, or
  suprapubic tenderness
• and
• patient has a positive urine culture, that is,
  105 microorganisms per cm3 of urine with no more
  than two species of microorganisms.

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Or...criterion 2

• Patient has at least two of the following signs
  or symptoms with no other recognised cause fever
  (gt38oC), urgency, frequency, dysuria, or
  suprapubic tenderness
• and...

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at least one of the following

• positive dipstick for leukocyte esterase and/or
  nitrate
• Pyuria (urine specimen with 10 WBC/mm3 or 3
  WBC/high power field of unspun urine)
• Organisms seen on Gram stain of unspun urine
• At least two urine cultures with repeated
  isolation of the same uropathogen (gram negative
  bacteria or S. saprophyticus) with 102 colonies /
  ml in nonvoided specimens
• 105 colonies/Ml or a single uropathogen (gram
  negative bacteria or S. saprophyticus) in a
  patient being treated with an effective
  antimicrobial agent for a urinary tract infection
• Physician diagnosis of a urinary tract infection
• Physician institutes appropriate therapy for a
  urinary tract infection

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How common?

• 12.6 of acute patients are catheterised
• 20 - 30 of acute catheterised patients will
  develop bacteruria
• 8-10 of acute catheterised patients will develop
  symptoms of urinary tract infection
• A UTI increases the length of patient
  hospitalisation by 75 (8 to 14 days)
• A single UTI costs 1327

Plowman et al 1999
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HCAI Comparison 2000
UTI
Multiple (may inc. UTI)
Incidence (national UK)
LRTI
SWI
Other
Skin
BSI
Socio-Economic Burden of Hospital Acquired
Infection-PHLS report 2000
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Cost Estimate 2000
UTI
LRTI
millions
Other
SWI
Skin
BSI
Socio-economic Burden of Hospital Acquired
Infection-PHLS report 2000
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What about...

• Urethritis
• Prostatitis
• Nephritis
• Epidydimitis

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Urethritis

• 4 papers
• Mean 9
• Range 1-18
• FU Up to 3 years

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Prostatitis

• Cuckier et al 1976 5
• Perrouin Verbe et al 1995 33
• Mean 19 FU 5yrs

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Nephritis

• No studies in live patients
• But
• Evidence of nephritis in 33 of long-term
  catheterised patients at post mortem

Gomlin McCue 2000
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Epididymitis

• 7 papers
• Mean 10
• Range 1-28
• FU up to 5 yrs

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Reducing Risk!
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Education

• Need for catheter?
• Early removal
• 5 risk per day
• Correct products
• Correct insertion
• Correct care

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Catheter should be MDT decision

• No routine catheterizations
• Individualized decision
• Discuss with patient
• Alternative management
• Drugs
• Surgery
• MITs
• CISC
• Sheath
• Pads

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Other tools

• Standardize available products
• Use national initiatives
• www.dh.gov.uk/publications
• HII
• Saving Lives
• Top-down approach
• Management
• ICP Team
• Urology

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Do you have a catheter formulary?
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ANTT Catheter Insertion

• Standardized insertion training using ANTT
  principles
• ALL relevant clinical staff
• Management engagement
• Training
• Assessment
• Annual updates

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ANTT Catheter Insertion

• Embedded with ANTT for other procedures
• Vascular Access
• IV therapy
• Intubation
• Blood cultures
• Insertion using EAUN guidelines
• www.uroweb.org/fileadmin/user_upload/EAUN/EAUN2.pd
  f

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Manchester ANTT Implementation

• ANTT included as a part of Trust IPC strategy
• Implementation process started September 2006
• Education and training provided to all clinical
  staff
• Individual assessment of staff
• Weekly reporting of staff trained to director

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Audit Results ANTT Compliance
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MRSA Bacteraemia
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ANTT Effect on UTI

• Not measured in isolation
• Audit 2005 - 16
• Audit 2008 9.6

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Conclusions

• Multifaceted catheter policy needed
• Insertion policy
• ANTT
• Product formulary
• Education
• Assessment
• Audit

• Much of the work has already been done
• EAUN
• BAUN www.baun.co.uk
• HII
• SIGN (Scotland) www.sign.ac.uk

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Discussion

• Coello R et al., J Hosp Inf 2003
• Rowley S, Nursing Times 2001
• Dodgson K et al., SHEA conference 2009