1. Infections in the intensive care unit Wanida Paoin Thammasat University

2. EPIDEMIOLOGY Contributing factors Patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements. The high frequency of indwelling catheters among ICU patients The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens. Multidrug-resistant pathogens such as methicillin- resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs

3. EPIDEMIOLOGY A multicenter, prospective cohort surveillance study of 46 hospitals in Central and South America, India, Morocco, and Turkey. Rates of device-associated infection were determined between 2002 and 2005; an overall rate of 14.7 percent or 22.5 infections per 1000 ICU days was found. Specific devices: Ventilator associated pneumonia (VAP); 24.1 cases/1000 ventilator days (range 10.0-52.7) CVC-related bloodstream infections; 12.5/1000 catheter days (7.8-18.5) Catheter-associated urinary tract infections; 8.9/1000 catheter days (1.7-12.8)

4. CATHETER-ASSOCIATED UTI UTI is the most common nosocomial infection (> 40% of all nosocomial infections) CAUTIs are the second most common cause of nosocomial bloodstream infection, which have an attributable mortality Risk factors The major risk factor is an indwelling urinary catheter The risk increases directly with the duration of catheterization. The daily incidence of catheter-associated bacteriuria is approximately 5% After catheters have been in place for 1 week, bacteriuria or candiduria develop in 25%; after 30 days, the great majority of patients will have bacteriuria.

5. CATHETER-ASSOCIATED UTI Other important risk factors for CAUTI Patients with other sites of active infection Long hospital stay Malnutrition Female sex Abnormal serum creatinine Improper catheter care (particularly placement of the drainage tube above the level of the bladder)

6. Prevention The most effective method to prevent CAUTI is to avoid unnecessary placement of indwelling urinary catheters and to limit the duration of catheterization once a catheter is in place. Use of indwelling catheters should be limited to patients with anatomic or physiologic urinary obstruction; patients undergoing surgery of the genitourinary tract; patients requiring accurate monitoring of urine output (ie, critically ill or postoperative patients); debilitated, comatose, or paralyzed patients. Once a catheter is in place, it should be removed as quickly as possible, when it is no longer needed.

7. Prevention The condom catheter is a good alternative to the indwelling catheter for men and is associated with lower rates of bacteriuria Intermittent bladder catheterization has been shown to reduce the incidence of UTI in long-term spinal cord injury patients compared to an indwelling catheter, this approach has not been studied in patients with shorter- term indwelling bladder catheters. Suprapubic catheters might be more comfortable for patients and have been shown to lower the incidence of bacteriuria

8. Catheter insertion and maintenance Aseptic technique: handwashing, sterile gloves, a sterile drape, antiseptic solution Once in place, Maintaining a closed drainage system The only part of the drainage system that should be opened is the bag drainage tube The number of manipulations and accesses of the drainage system should be minimized. The collecting tubing and bag should always be placed below the patient and the tubing should be maintained at a level above the drainage bag

9. Antimicrobial therapy Topical antimicrobials Place between the catheter and urethral mucosa Soaking catheters in, continuous irrigation of the bladder with an anti-infective solution, Placement of anti-infective solutions into the collection bag Not been shown to effectively prevent CAUTI Systemic antimicrobial prophylaxis Can reduce the risk for CAUTI in short-term catheterization; Increased long term risk for infections caused by multidrug resistant organisms Treatment of asymptomatic bacteriuria does not decrease the incidence of febrile episodes but does increase the recovery of antibiotic-resistant bacteria

10. Different catheter composition Catheters impregnated with antimicrobial agents (minocycline and rifampin) and the antiseptic agent nitrofurazone have been demonstrated to reduce CAUTI rates in small studiesminocyclinerifampin The potential for selection of multidrug-resistant pathogens The silver-hydrogel catheter prevents adherence of bacterial and yeast pathogens to the catheter surface. Catheters coated with antiseptic silver compounds have shown promise by some investigators but have been ineffective in other large, well-controlled trials.

11. Strategies for Prevention of CAUTI Avoid unnecessary placement of indwelling urinary catheters +++ Remove catheters as quickly as possible+++ Alternative condom catheter, intermittent bladder catheterization +++ Aseptic technique in catheter insertion+++ Appropriate catheter maintenance++ Antimicrobial therapy- Different catheter composition+