Catheter-associated UTI3 significant bacteriuria .symptoms and signs attributable to UTI .a person who is currently catheterized -has been catheterized within the previous 48 hours Urinary Tract Infection (UTI) .Catheter-Associated (CA) Infection . Definition Asymptomatic Bacteriuria (ASB) -significant bacteriuria -without signs and symptoms attributable to UTI Bacteriuria -non specific term that can refer to ASB or UTI . 24(Suppl 1):S44-S48 The incidence of bacteriuria associated with indwelling catheters is 3% . Saint S.Epidemiology CA-bacteriuria is the most common healthcare associated infection worldwide. Tambyah PA. 291:215–219. . Garibaldi RA. Dickman ML. Factors predisposing tobacteriuria during indwelling urethral catheterization. et al. Burke JP. Int J Antimicrob Agents 2004. Lipsky BA. Catheter Associated urinary tract infections: diagnosis and prophylazixs. N Engl J Med1974. Preventing catheter-related bacteriuria: shouldwe? Can we? How? Arch Intern Med 1999. 159:800–808.8% per day. duration The of catheterization is the most important risk factor for the development of CA-bacteriuria. CONS. Pseudomonas. Drugs Aging 2005. Catheter-related urinary tract infection. Nicolle LE. Arch Intern Med 2000. Gram positive cocci. Other Enterobacteriaceae (Klebsiella. 22:627–639. E. Catheter-related urinary tract infection.497 catheterized patients. Enteroccocus Nicolle LE. Drugs Aging 2005. Serratia. 22:627–639. 160:678– 682. . Tambyah PA. coli is the most frequent species isolated. Citrobacter. Enterobacter).Microbiology ▪ Bacteriuria in patients with short-term catheters is usually caused by a single organism. Maki DG. Catheter-associated urinary tract infection israrely symptomatic: ▪ ▪ a prospective study of 1. mirabilis. 22:627–639. Morganella morganii. stuartii are common. Nicolle LE. P. A prospective microbiologicstudy of bacteriuria in patients with chronic indwelling urethral catheters. New episodes of infection often occur periodically in the presence of existing infection.Microbiology ▪ ▪ UTIs in patients with long-term catheterization is usually polymicrobial…species such as P. et al. Drugs Aging 2005. J Infect Dis 1982. Warren JW. 146:719– 723. . Tenney JH. Hoopes JM. Catheter-related urinary tract infection. .Complications of Short-Term Catheterization Patients who develop CA-bacteriuria have their hospital stays extended by 2-4 days. Bacteriuria is the most common source of gramnegative bacteremia among hospitalized patients. . Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997.Complications of Long-Term Catheterization (>30 days) ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Universal bacteriuria Lower and upper CA-UTI Bacteremia Frequent febrile epdisodes Renal and bladder stone formation Catheter obstruction Local GU infections Fistula formation incontinence Bladder cancer Warren JW. 11:609–622. 1 . UTI in patients with indwelling urethral or suprapubic catheter or in those undergoing intermittent catheterization is termed as CA-UTI. suprapubic or condom catheter or has been removed within the previous 48 hours.When is catheter-associated UTI (CA-UTI) suspected or diagnosed? 1.There is no sufficient evidence to define the quantitative cut-off for CA-UTI among men with condom catheters. Low quality of evidence 1 . Low quality of evidence 2. Strong recommendation. CA-UTI is diagnosed when: (1)signs or symptoms compatible with UTI are present with no oth identified source of infection (2)≥ 103 colony forming units (CFU)/ml of ≥ 1 bacterial species are present in a single catheter urine specimen or in a midstream voided urine specimen (3) in a patient with an indwelling urethral. Weak recommendation. Nicolle LE. Ireton RC. et al. Diagnosis of bacteriuria in men: specimen collection and culture interpretation. * Has a 97% sensitivity and 97% specificity . Fihn SD. Clin Infect Dis 2005. 155: 847–854. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Bradley S.III).* Lipsky BA. et al. Colgan R. J Infect Dis 1987.Diagnosis CA-UTI is defined by presence of symptoms or signs compatible with UTI with no other identified source along with >= 1000 cfu/mL of >= 1 bacterial species (A. 40:643– 654. What is the approach to the presence of the indwelling urinary catheter once the diagnosis of CA-UTI is made? Whenever possible. Strong recommendation. High quality of evidence 2 . High quality of evidence For patients in whom indwelling bladder catheterization is necessary. the indwelling catheter should be removed to help eradicate the bacteriuria. Strong recommendation. long-term indwelling catheters should be replaced with new catheters before initiating antimicrobial therapy for symptomatic UTI. Strategies for reducing the risk of CA-UTI Strategy Strength of Recommendation Level of Evidence Use indwelling catheters only when necessary Strong Low Use aseptic technique including appropriate hand hygiene and sterile gloves Strong Low to Moderate Allow only trained health personnel to insert foley catheters Weak Low Properly secure catheters after insertion to prevent movement and urethral traction Weak Low Maintain a closed sterile drainage system. Weak Low 2 . Strong Moderate Maintain good hygiene at the catheterurethral interface. Strong High Do not change indwelling catheters or drainage bags at fixed intervals.Table 5. Strong Moderate Maintain unobstructed urine flow Strong Moderate Remove catheters when no longer needed. it may be considered at patients request. * Munasinghe RL. Yazdani H. Gardam MA. 22:647– 649. * When all approaches to management of incontinence have not been effective. . Infect Control Hosp Epidemiol 2001. Saint S. 159:800–808. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. et al. Amihod B. Lipsky BA. Appropriateness of use of indwelling urinary catheters in patients admitted to themedical service. et al. Clin Perform Qual Health Care 1998. 6:99–102. Siddique M. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med 1999. Indwelling urinary catheters should not be used for the management of urinary incontinence (A-III). Orenstein P.Prevention (Limiting Unnecessary Catheterization) Indwelling catheters should be placed only when they are indicated (A-III). if less invasive measures fail and external collection devices are not an acceptable alternative .Prevention (Limiting Unnecessary Catheterization) Acceptable Indications for Indwelling Catheter Use ▪ ▪ Clinically significant urinary retention Temporary relief or long-term drainage if medical therapy is NOT effective and surgical correction is not indicated ▪ For comfort in terminally ill patient. selected urological and gynecologic procedures in the perioperative period .Prevention (Limiting Unnecessary Catheterization) Acceptable Indications for Indwelling Catheter U▪s Accurate urine output ▪ Frequent or urgent monitoring required monitoring needed. e such as in critically ill patients ▪ Patient unwilling or unable to collect urine ▪ During prolonged surgical procedures with general or spinal anesthesia. Halvorson KT.Prevention (Indwelling Catheter Insertion Technique) Indwelling urethral catheters should be inserted using aseptic technique and sterile equipment . Maki DG. A prospective study of pathogenesis of catheterassociated urinary tract infections. Tambyah PA. . 74:131–136. Mayo Clin Proc 1999. Buchman B. II. Bacteriuria during indwelling catheter drainage. Thornton GF. Effect of a closed sterile drainage system. 4:15– 18. . JAMA 1970. Indwelling catheter and risk of urinary infection: a clinical investigation with a new closed-drainage system. should be used to reduce CA-bacteriuria and CA.Prevention (Closed Catheter System) A closed catheter drainage system. 214:339–342. Gradel E. Urol Res 1976. Andriole VT. Wolff G.UTI in patients with short-term indwelling urethral or suprapubic catheters and to reduce CAbacteriuria and CA-UTI in patients with longterm indwelling urethral or suprapubic catheters. Reduction of mortality associated with nosocomial urinary tract infection. Huth TS. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria. et al. . 152:807–812. Murdock B.Prevention (Closed Catheter System) Use of a preconnected system may be considered to reduce CA-bacteriuria. 1:893–897 Use of a complex closed drainage system or application of tape at the junction after catheter insertion is NOT recommended to reduce CA-bacteriuria or CA-UTI. Larsen RA. Lancet 1983. Arch Intern Med 1992. Platt R. Polk BF. et al. Burke JP. Elmore JG. Systematic review: antimicrobial urinary catheters to prevent catheterassociated urinary tract infection in hospitalized patients. Am J Med 1998. et al. Drekonja DM. Antimicrobial urinary catheters: a systematic review. Expert Rev Med Devices 2008. Johnson JR. Ann Intern Med 2006. antimicrobial (silver alloy or antibiotic)-coated urinary catheters may be considered to reduce or delay the onset of CAbacteriuria. .Wilt TJ. The efficacy of silver alloycoated urinary catheters in preventing urinary tract infection: a metaanalysis. Kuskowski MA. 105:236– 241. 144:116–126.Prevention (Antimicrobial-Coated Catheters) In patients with short-term indwelling urethral catheterization. et al. Sullivan SD. Kuskowski MA. 5:495–506. Saint S. Wilt TJ. Chemotherapy 1985. 31:476–479. Prophylactic ciprofloxacin for catheter-associated urinary-tract infection. Cochrane Database Syst Rev 2005: CD005428. Fejgin M. Mintjes-de Groot J. Niel-Weise BS. et al. 339:946–951. Altaras M. Jaffe R. van der Wall E. et al. Verkooyen RP. to reduce CAbacteriuria or CA-UTI because of concern about selection of antimicrobial resistance. van den Broek PJ. . Lancet 1992. Antibiotic policies for short-term catheter bladder drainage in adults. Prophylactic single-dose co-trimoxazole for prevention of urinary tract infection after abdominal hysterectomy.Prevention (Prophylaxis with Systemic Antimicrobials) Systemic antimicrobial prophylaxis should NOT be routinely used in patients with short-term (A-III) or long-term (A-II) catheterization. Prevention (Prophylaxis with Cranberry Products) Cranberry products should NOT be used routinely to reduce CA-bacteriuria or CA-UTI in patients with neurogenic bladders managed with intermittent or indwelling catheterization . Jepson RG. . Craig JC. Cochrane Database Syst Rev 2008:CD001321. Cranberries for preventing urinary tract infections. Prevention of catheter-associated urinary tract infections: efficacy of daily meatal care regimens. Garibaldi RA. et al. Methods for evaluating topical antibacterial agents on human skin. 70:655–658. Britt MR. polyantibiotic ointment or cream. et al. Kligman AM. Marples RR. J Urol 1983.Am J Med 1981. Antimicrob Agents Chemother 1974. Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheterassociated bacteriuria. . or green soap and water is NOT recommended for routine use in men or women with indwelling urethral catheters to reduce CAbacteriuria . Garibaldi RA. Burke JP. 129:331–334. Burke JP. Jacobson JA. silver sulfadiazine. 5:323–329.Prevention (Enhanced Meatal Care) Daily meatal cleansing with povidoneiodine solution. Rao GG. Once-daily irrigation of long-term urethral catheters with normal saline: lack of benefit.Prevention (CatheterIrrigation) Catheter irrigation with normal saline should NOT be used routinely to reduce CAbacteriuria. et al. Muncie HL Jr. 149:441–443. Reid L. Elliott TS. Bladder irrigation or irritation? Br J Urol 1989. CA-UTI or obstruction in patients with long-term indwelling catheterization . 64:391–394. Arch Intern Med 1989. Damron DJ. Hoopes JM. et al. . Am J Med 1987. Indwelling urinary catheters in the elderly: relation of “catheter life” to formation of encrustations in patients with and without blocked catheters.Prevention (Routine Catheter Change) Data are insufficient to make a recommendation as to whether routine catheter change (eg. . even in patients who experience repeated early catheter blockage from encrustation. every 2-4 weeks) in patients with functional long-term indwelling urethral or suprapubic catheters reduces the risk of CA-ASB or CA-UTI. 82: 405– 411. Chin QF. Kunin CM. Chambers S. et al. J Hosp Infect 1992. 94:1048–1050. 21:223–229. et al. given systemically or by bladder irrigation. . Ann Surg 2009. Cravarezza P. J Chemother 1990. Urinary Catheter Guidelines • CID 2010:50 (1 March) • 663 Schneeberger PM. Antibiotic prophylaxis aturinary catheter removal prevents urinary tract infections: a prospective randomized trial. Pfefferkorn U. Wazait HD. 2:178–181. BJU Int 2004. 249:573–575. Lea S.Prevention (Prophylactic Antimicrobials at Time of Catheter Removal or Replacement) Prophylactic antimicrobials. Bogdanowicz JF. Patel HR. van der Meulen JH. A randomized study on the effect of bladder irrigation with povidone-iodine Before removal of an indwelling catheter. Vreede RW. et al. should NOT be administered routinely to patients at the time of catheter placement to reduce CAUTI or at the time of catheter-removal or replacement to reduce CA-bacteriuria. Moldenhauer J. et al. Romanelli G. Giustina A. A single dose of aztreonam in the prevention of urinary tract infections in elderly catheterized patients. A pilot randomized double-blind placebo-controlled trial on the use of antibiotics On urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin. THANK YOU LISTENING .