Prevention of the Catheter-associated urinary tract ...

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Hull, R., D. Rudy, et al. (2000). "Urinary tract ... Mobley, H. L. and J. W. Warren (1987). "Urease-positive ... Mobley, H. L. and R. P. Hausinger (1989). "Microbial ...
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Prevention of the catheterassociated urinary tract infections

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Jakhongir F. Alidjanov Republican Specialized Center of Urology. Tashkent, Uzbekistan

Baku 2009 1

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Indwelling catheterization

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• Short-term < 7 days • Indications:

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– Indications

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• Long-term > 28 days

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• urinary drainage following surgery; • monitoring urine output; • monitoring core body temperature; • urinary retention. (bacteriuria develops in 10-50% of cases) *

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• urinary retention associated with BOO (cannot be managed by other methods); • ischuria paradoxa - urinary incontinence coexisting with urinary retention (cannot be managed by other methods); • delayed healing of a highstage pressure ulcer owing to urinary incontinence; • toileting is compromised by pain or immobility. (bacteriuria develops in approx. 100% of cases) * * See list of references

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Bacteriuria Symptomatic UTIs Epididymitis Prostatitis Trauma Obstruction Urinary stones Bacteraemia Bladder cancer

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• • • • • • • • •

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Complications of indwelling urinary catheters

Survey of medical intensive care units in the United States revealed that 95% of urinary tract infections are catheter associated.* Risk of bacteriuria associated with catheter insertion is 3 to 10% per day.* Strategies to prevent catheter-associated infections can significantly reduce morbidity, mortality, and health care costs. 3 * See list of references

Risk factors Female sex Previous episodes of UTIs Other active sites of infection Preexisting chronic condition (e.g. diabetes, malnutrition, renal insufficiency) • Inserting the catheter outside the operating room or late in hospitalization • Prolonged catheterization • Improper position of the drainage tube, or urine collecting bag

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• • • •

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Transmission of infections within hospitals

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Ways for pathogens to enter into urinary tract

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66%

34%

Extraluminally

Intraluminally 6

Tambyah, P. A., K. T. Halvorson, et al. (1999) Mayo Clin Proc

initial attachment

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Biofilm formation

irreversible attachment

maturation I maturation II

dispersion

7 Autor: D. Davis Published: November 13, 2007

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Experimental Setup of CAUTIs Model

Goto, T., Nakame, Y., et al. (1999) Int J Antimicrob Agents 8

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Scanning electron micrograph of biofilm formed on a catheter surface in artificial urine

Goto, T., Nakame, Y., et al. (1999) Int J Antimicrob Agents9

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Biofilm on teflon catheters

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Day 8

Goto, T., Nakame, Y., et al. (1999) Int J Antimicrob Agents10

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Medical significance of biofilm

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• Decreases susceptibility to antimicrobials • Results of urine culture based on planctonic organisms may be false and not apply to sessile organisms living within biofilms.

Trautner, B. W. and R. O. Darouiche (2004). Arch Intern Med 11

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CDC guidelines for prevention of CAUTIs

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http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html

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European and Asian guidelines on CAUTIs

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The best way for CAUTIs prevention is avoid to use catheter or its remove Main questions: • does this patient really need to be catheterized? • how long duration of catheterization will be?

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Inappropriate catheter use

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• Initial indication for catheter use was inappropriate in

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21% of cases;

• Continued catheterization was inappropriate for almost

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half of patient-days;

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• Total unjustified patient-days resulted from prolonged

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use for monitoring urine output – 64%; • Urinary incontinence was the major cause of unjustified catheter use. Jain, P., Parada, JP, et al. (1995) Arch Intern Med

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To choose a method of urine drainage, we should consider the costs and benefits of a method. Costs include both financial costs incurred by the patient and risks of adverse outcomes (such as influence to QoL, development of symptomatic UTIs, resistant flora, trauma, haematuria etc.). Benefits include both symptomatic relief and the prevention of more serious conditions (such as bladder incompetence, renal failure, decreased risk for symptomatic UTIs ).

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Treatment threshold

16 Friedland D et al (1998). Evidence-Based Medicine: A Framework for Clinical Practice, 1st ed.

Personnel should:

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• Use written protocols on catheter insertion and handwashing • Insert catheter under antiseptic conditions. A catheterization set should be used; • Wash, dry and disinfect hands before and after any manipulation on catheter; • Try to minimize urethral trauma, by the use of smallest possible catheter diameter and antiseptic lubricant gel; • Remove catheter as soon as possible; • Keep catheter system closed; • Empty drainage bags at a minimum of every 4 to 6 h to avoid bacteria entering the catheter lumen; Computer-based reminders on catheter removal terms may be useful 17

Alternative methods of urine drainage

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Intermittent catheterisation

Disadvantages

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• elevated urethral trauma • urethral stricture • false passage • urethritis, epididymitis, prostatitis • cooperative and skilled patient • difficult process in men

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• less local periurethral infection, febrile episodes, stones and deterioration of renal failure • clean catheterization

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Advantages

N.B. Evidence that post-operative intermittent catheterisation reduces the risk of bacteriuria is limited.

Tenke P., Kovacs B., Johansen T.E.B., Matsumoto T., Tambyah P.A., Naber K.G. (2008). 18 Int J Antimicrob Agents

Alternative methods of urine drainage Advantages no urethral interference no urethral stricture lower rate of nosocomial UTI measurement of spontaneous micturition and residual urine • possibility of transurethral procedures • less troublesome for the patient • lower amount of nursing workload

Disadvantages

• installation by physician • has relative and absolute contraindications such as: • bladder shrinkage • pregnancy • bladder volume