Catheter associated Urinary Tract Infection SCFT Infection Prevention and Control Team 2018

Learning Outcomes To have a clinical appreciation of a CAUTI and its impact To be able to critically discuss contributory factors and Prevention strategies To Understand Gram Negative Bloodstream Infections (BSIs) and how to prevent and detect them

Urinary Tract Infection UTI is the most common HCAI Up to 13% of Community patients will have a catheter, making it the most common indwelling device in use (HPSC 2012) Large numbers of bacteria occur within days of catheterisation The duration of catheterisation greatly increases the risk of developing a CAUTI (Nicolle 2014) Safety Thermometer • The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. • Focused audits for areas with high CAUTI • Care planning

Indwelling Urinary Catheters Long-term catheters common in both hospital and community care settings but are they always needed? They carry a significant risk of symptomatic of serious complications - sepsis and death They increase the use of antibiotics leading to antimicrobial resistance and C.diff

Entry points for bacteria Needle and syringe method for taking specimens no longer used , needless port (discuss careers options ) Clean gloves for any manipulation Sterile gloves for sample Aseptic non touch technique for changing catheter Bacteria introduced into the drainage bag take only a few days to reach the bladder via the tubing. Wilson (2006)

CAUTI contributory factors Perineal colonisation -  with age and in females The bladder is incompetent when there is a foreign body in it Abnormal bladder emptying Poor fluid intake Duration of catheterisation Risk ↑ 3-6% for each day of catheterisation

NHS Improvement: Plans to reduce GNBSI Ambition to halve GNBSI by 2021(10% per year) Improve Antimicrobial prescribing for UTIs Gram negative blood stream infections account for 5000 deaths per year

Reduction in Gram Negative Bloodstream Infections (BSIs) Ecoli is the main target at this time .

New Trends: CPE – Carbapenemase producing Enterobacteriaceae ESBLs – Extended Spectrum Beta-lactamases Gram negative bloodstream infections Contact the Infection control team with these and any multi Drug resistant infections. nclude what to do if a specimen result returns MDR (multi-drug resistance) as a reminder to check the sample and let us know.

SCFT Gram neg. Learning to date Lack of documented reason for catheter Lack of catheter passport Missed opportunities for antibiotic cover Haematuria/ blood clots common factor Dip sticking CSU Inappropriate treatment for blocked catheters Specimen labelling - MSU/ CSU Lack of education – Residential homes/ carers

Weekly Urinary Catheter Care Plan (including Supra Pubic) June 2018

Weekly Catheter Care Plan State reason for ongoing catheter Does the patient have a Catheter Passport? Catheter entry site washed? Drainage bag secured to patients leg? Urine draining well and clear? Drainage bag changed weekly- Date of change Catheter tap with sterit (alcohol) when emptying . If samples needed take via needless port and label CSU. (Never distick CSU)

Biofilm Dangers of catheter maintenance solutions – toxic effects, resistant organisms and break the closed system. Use for specific reasons only ie Urologist advice, Suby G recommended in Epic 2 for crystallisation. If a catheter blocks first line should be to remove it.

Prophylaxis - Learning from Blood Stream infections When changing catheters, antibiotics should not be used routinely but be considered for the following patients: History of CAUTI Trauma to the urethra History of Gram Negative Bloodstream infections (STAT Gentamicin IM. Usual dose 80mg to 120mg) Findings from our gram neg work

Catheter specimens urine Do not dipstick CSU Only send if patient symptomatic- eg. confusion, temp ↑, abdo pain Use aseptic technique and sampling port Microbiology form - clearly state details Specify MSU/CSU Transport container – rigid UN5573 It must be clear to staff that using near patient testing such as “dip stick” is not the process to confirm CAUTI Dipstick non-catheterised patients only for leucocytes, esterase and nitrite. CSU have different criteria as organisms will be present after 72hours S&S often missing with catheterised patients, consider other causes of pyrexia if present

Maintenance of Drainage System Maintain sterile closed system Avoid unnecessary breaches e.g. disconnection of bag Hang to allow free-flow of urine into bag Bag should not touch the floor Ensure catheter tubing secured

Standard Infection Control Principles Hand washing Personal Protective Equipment [PPE] Patient information and education Compliant sinks

Preventing cross infection Decontaminate hands and wear CLEAN gloves to empty/handle Decontaminate hands after ANY contact with drainage system Use CLEAN container

QUIZ How can you prevent CAUTI QUIZ How can you prevent CAUTI? How many people per year die due to Gram negative infections?

Q Which Gram Negative Organism causes the most Blood Stream Infection. A (Klebsiella Pneumonia) B (Escherichia Coli ) C ( Pseudomonas aeruginosa )

Q Contributory Factors for CAUTI A (Insertion of urinary catheter) B (Poor fluid intake) C (Underlying uropathology)

Q What action can you take to prevent cross infection A (Keep the patient well hydrated) B (Decontaminate hands and wear CLEAN gloves to empty/handle) C (Avoid disconnecting system) Although A cannot prevent cross contamination is it important for reducing UTIs

References EPIC3 2014: ‘National evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England’ Loveday et al 2014 NICE 2014 ‘Infection Prevention and Control Quality Standard 61’ SIGN 2012 Management of suspected bacterial UTI in adults. Chapter 5 HPSC Health Protection Surveillance centre 2012 Nicolle 2014 Journal of Infection Prevention 2018 SIGN is Scottish Intercollegiate Guidelines which our local Microbiologist believes is the most evidence based work on urinary catheters available