1. Infectious Disease Epidemiology Section Office of Public Health Louisiana Dept of Health & Hospitals (504) 219-4563 *** 800-256-2748 www.infectiousdisease.dhh.louisiana.gov Your taxes at work

2. Source of Infection

3. Normal Bladder  Bladder content sterile  Micturition empties bladder completely  Exfoliation of urethral cells pushes microbes out  Any interference will increase risk of infection

4. Urinary Catheter Risks  Catheter  Breaches barrier  Balloon prevents complete emtying  Distends bladder  Pool of urine  Condom catheter  Warm moist conditions inside  high inoculum  Travel upwards  Closed systems  Never completely closed  Bag may have high counts  Travel upwards

5. Source of bacteria  Endogenous: meatal, rectal or vaginal colonization  Exogenous:  Contaminated hands of HCP  Contaminated equipment  Use of closed sterile urinary drainage system led to marked reduction in bacteriuria risk  implying importance of intraluminal route  BUT even with closed system UTI do occur  extra-luminal route cannot be eliminated Extra- luminal Intra-luminal

6. Microbe Migration  Microbes migrate  Up lumen: even non-motile bacteria  Up external surface of catheter  Biofilm = matrix of polysacharides  with encased bacteria, up to 4 spcies (usually 1 in urine)  Microcolonies  Water channels  Bacteria in biofilms express different genes  Increase production of extracell polymeric substance (EPS)  50-90% of biofilm mass  Biofilms  Poor antibiotic diffusion  Slow bacterial multiplication  Less effectiveness of antibiotics

7. Asymptomatic Bacteriuria  Clinical significance of ASB in catetherized patients undetermined  75-90% of ASB in catetherized patients never develop SUTI  Monitoring and treatment of ASB does not reduce SUTI incidence  Most SUTI are not preceded by bacteriuria

8. Personal Risk Factors  Female  Advanced age  Duration  Diabetes  Renal insufficiency (Creatinine > 2mg/dL)

9. Incidence  Most common in  Acute and long term care  Pediatric and geriatric populations  Urinary instrument: catheter  Incidence function of duration  1-5% per day  Almost 100% after 30 days  Prevalence in LTCF 5% at any time

10. Urinary Catheter Use  Used in about  Wards: 10% pf patients days  ICU: 50% pf patients days  Over-utilization in some hospitals  50% insertions without proper indication  50% continuation without proper indication  30% of physicians unaware of patient status re: Ucath  Hospital wide protocols  For insertion, continuation  Computerized charting  Allow nurse to remove

11. UTI Agents  Patient fecal flora in OP: Ecoli 80%  Hospitalization:  Shift to hospital flora  Klebsiella, Pseudomonas, Proteus, Enterobacter, Candida  More resistant strains  Shift with duration of  Catheter  Hospitalization NNIS  E.coli 25%  Enterococci16%  Pse.aeruginosa11%  Candida 5%  Klebs.pneumo 7%  Enterobacter 5%  Proteus 5%  StaphCoagNeg 4%  Staph.au 2%

12. Prevention

13. Appropriate Urinary Catether Use  Insert ONLY for appropriate indications  Minimize use and duration particularly in high risk patients:  Women  Elderly  Immuno-compromissed  Post operative:  Urologic surgery  Long duration surgery (remove as soon as possible)  Monitoring of urinary output

14. Inappropriate Urinary Catether Use  MANAGING INCONTINENCE Periodic /night time may be OK  Obtaining urine for culture

15. Proper Technique for Insertion  Hand hygiene, standard precaution before and after insertion  Proper training of person performing insertion  Aseptic technique and sterile equipment in acute care  Clean technique in LTCF for intermittent cath  Properly secure cath after insertion  Use smallest bore effective to minimize bladder neck and urethral trauma  Prevent bladder distension with intermittent cath, Use ultra-sound to assess urine volume in intermittent cath

16. Proper Technique for Insertion  Replace cath and collecting system if break in aseptic technique, disconnection or leakage  Maintained unobstructed urinary flow:  Avoid kinking  Collecting bag below bladder level  Empty collecting bag regularly, prevent contact of drainage spigot with collecting container  Change cath on clinical indications, not routinely

17. Proper Technique for Insertion  Do not use systematic antibiotic prophylaxis  Do not clean peri-urethral areawith antiseptics while cath in place  No bladder irrigation (except after bleeding after prostatic or bladder surgery  No antiseptic or antimicrobial solutions in urinary drainage bag

18. Catether Material  Hydrophilic caths in patients requiring intermittent catetherization  Silicone to reduce risk of encrustation in long term cathy users with frequent obstruction

19. Specimen Collection  Aspirate urine from needleless portwith a sterile syringe after cleansing the port with a disinfectant  Obtain large volumes aseptically from drainage bag – Not for culture