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Catheter associated UTI: Reducing the risk Tom Ladds 13th May 2009 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 2 Problem Number 1 What is a UTI? Lots of conflicting definitions Google 753,000 (in 0.33 seconds!) Bacteria in urine Symptoms 3 Problem number 2 What is a CAUTI? UTI associated with a urinary catheter! How long after insertion? How long after removal? Varying definitions = inconsistent findings 4 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 5 Symptoms Criterion 1: Patient has at least one of the following signs or symptoms with no other recognised cause: fever (>38oC), 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. 6 Or...criterion 2 Patient has at least two of the following signs or symptoms with no other recognised cause: fever (>38oC), urgency, frequency, dysuria, or suprapubic tenderness and... 7 at least one of the following: positive dipstick for leukocyte esterase and/or nitrate Pyuria (urine specimen with ≥10 WBC/mm3 or 3WBC/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 8 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 Plowman et al 1999 £1327 9 HCAI Comparison 2000 Incidence % (national UK) UTI Multiple (may inc. UTI) LRTI SWI Other Skin BSI Socio-Economic Burden of Hospital Acquired Infection-PHLS report 2000 10 Cost Estimate 2000 £ millions UTI LRTI Other SWI Skin BSI Socio-economic Burden of Hospital Acquired Infection-PHLS report 2000 11 What about... Urethritis Prostatitis Nephritis Epidydimitis 12 Urethritis 4 papers Mean 9% Range 1-18% FU Up to 3 years 13 Prostatitis Cuckier et al 5% 1976 Perrouin Verbe et al 33% 1995 Mean 19% FU 5yrs 14 Nephritis No studies in live patients But Evidence of nephritis in 33% of long-term catheterised patients at post mortem Gomlin & McCue 2000 15 Epididymitis 7 papers Mean 10% Range 1-28% FU up to 5 yrs 16 Reducing Risk! 17 Education Need for catheter? Early removal 5% risk per day Correct products Correct insertion Correct care 18 Catheter should be MDT decision No routine catheterizations Individualized decision Discuss with patient Alternative management Drugs Surgery MITs CISC Sheath Pads 19 Other tools Standardize available products Use national initiatives www.dh.gov.uk/publications HII Saving Lives Top-down approach Management IC&P Team Urology 20 Do you have a catheter formulary? 21 ANTT Catheter Insertion Standardized insertion training using ANTT principles ALL relevant clinical staff Management engagement Training Assessment Annual updates 22 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.pdf 23 Manchester ANTT Implementation ANTT included as a part of Trust IP&C 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 24 Audit Results – ANTT Compliance 100% 94% 97% 95% 92% 91% 90% 84% 83% 86% 81% 80% 77% 80% 72% 68% 70% 65% 60% Original Audit Re-Audit 50% 40% 30% 20% 10% 0% Children's MREH/Dental Surgery CSS St Mary's Medicine Total 25 MRSA Bacteraemia MRSA Bacteraemia 12 Month Pre & Post ANTT 9 8 7 Number 6 Pre ANTT 5 Post ANTT 4 Pre ANTT Trend Post ANTT Trend 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 Month 26 ANTT – Effect on UTI Not measured in isolation Audit 2005 - 16% Audit 2008 – 9.6% 27 Conclusions Multifaceted catheter policy needed Much of the work has already been done EAUN BAUN www.baun.co.uk HII SIGN (Scotland) www.sign.ac.uk Insertion policy ANTT Product formulary Education Assessment Audit 28 Discussion 1. Coello R et al., J Hosp Inf 2003 2. Rowley S, Nursing Times 2001 3. Dodgson K et al., SHEA conference 2009 29