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  1. Catheter associated UTI:Reducing the risk Tom Ladds 13th May 2009

  2. 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

  3. Problem Number 1What is a UTI? • Lots of conflicting definitions • Google 753,000 (in 0.33 seconds!) • Bacteria in urine • Symptoms

  4. Problem number 2What is a CAUTI? • UTI associated with a urinary catheter! • How long after insertion? • How long after removal? • Varying definitions = inconsistent findings

  5. 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

  6. 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.

  7. 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...

  8. 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

  9. 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

  10. 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

  11. Cost Estimate 2000 UTI LRTI £ millions Other SWI Skin BSI Socio-economic Burden of Hospital Acquired Infection-PHLS report 2000

  12. What about... • Urethritis • Prostatitis • Nephritis • Epidydimitis

  13. Urethritis • 4 papers • Mean 9% • Range 1-18% • FU Up to 3 years

  14. Prostatitis • Cuckier et al 1976 5% • Perrouin Verbe et al 1995 33% Mean 19% FU 5yrs

  15. Nephritis • No studies in live patients But • Evidence of nephritis in 33%of long-term catheterised patients at post mortem Gomlin & McCue 2000

  16. Epididymitis • 7 papers • Mean 10% • Range 1-28% • FU up to 5 yrs

  17. Reducing Risk!

  18. Education • Need for catheter? • Early removal • 5% risk per day • Correct products • Correct insertion • Correct care

  19. Catheter should be MDT decision • No routine catheterizations • Individualized decision • Discuss with patient • Alternative management • Drugs • Surgery • MITs • CISC • Sheath • Pads

  20. Other tools • Standardize available products • Use national initiatives www.dh.gov.uk/publications • HII • Saving Lives • Top-down approach • Management • IC&P Team • Urology

  21. Do you have a catheter formulary?

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

  23. 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

  24. 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

  25. Audit Results – ANTT Compliance

  26. MRSA Bacteraemia

  27. ANTT – Effect on UTI • Not measured in isolation • Audit 2005 - 16% • Audit 2008 – 9.6%

  28. 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

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