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

2. In the next 45 minutes...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 2

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

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

5. Acceptable definition?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 5

6. Symptoms  Criterion 1:  Patient has at least one of the following signs or symptoms with no other recognised cause: fever (>38 o C), urgency, frequency, dysuria, or suprapubic tenderness and  patient has a positive urine culture, that is, ≥10 5 microorganisms per cm 3 of urine with no more than two species of microorganisms. 6

7. Or...criterion 2Or...criterion 2  Patient has at least two of the following signs or symptoms with no other recognised cause: fever (>38 o C), urgency, frequency, dysuria, or suprapubic tenderness and... 7

8. at least one of the following:at least one of the following:  positive dipstick for leukocyte esterase and/or nitrate  Pyuria (urine specimen with ≥10 WBC/mm 3 or 3 WBC/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 10 2 colonies / ml in nonvoided specimens  10 5 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 8

9. How common?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 9

10. HCAI Comparison 2000HCAI Comparison 2000 Socio-Economic Burden of Hospital Acquired Infection-PHLS report 2000 Incidence % (national UK) UTI LRTI SWI Skin BSI Other Multiple (may inc. UTI) 10

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

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

13. Urethritis  4 papers  Mean9%  Range1-18%  FUUp to 3 years 13

14. Prostatitis  Cuckier et al1976 5%  Perrouin Verbe et al1995 33% Mean19%FU 5yrs 14

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

16. Epididymitis  7 papers  Mean 10%  Range1-28%  FUup to 5 yrs 16

17. Reducing Risk!Reducing Risk! 17

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

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

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

21. Do you have a catheter formulary?Do you have a catheter formulary? 21

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

23. ANTT Catheter InsertionANTT 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 23

24. Manchester ANTT ImplementationManchester 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 24

25. Audit Results – ANTT Compliance 25

26. MRSA Bacteraemia 26

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

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 28

29. Discussion 1. Coello R et al., J Hosp Inf 2003 2. Rowley S, Nursing Times 2001 3. Dodgson K et al., SHEA conference 2009 29