Catheter-Associated Urinary Tract Infections

A problem for patients and the System

A/Prof Peter Taylor, Dept Microbiology, SEALS, St George Hospital, Kogarah, NSW 18th February, 2016

What was the starting point for CEC?

Patient level: Unnecessary manipulation of the closed catheter system, which may promote extraluminal contamination and result in catheter-associated urinary tract infection Detection of asymptomatic bacteriuria, which may result in unnecessary antimicrobial treatment.

System level: Unnecessary pathology testing and waste.

Urinalysis – value or not? (Mayo Clinic, on-line)

• If either nitrites or leukocyte esterase — a product of white blood cells — is

detected in your urine, it may be a sign of a urinary tract infection.

• Urinalysis alone usually doesn't provide a definite diagnosis. Depending on the reason your doctor recommended this test, abnormal results may or may not require follow-up. Your doctor may need to evaluate the results along with those of other tests, or additional tests may be necessary to determine next steps.

• …..if you are otherwise healthy and have no signs or symptoms of illness, results slightly above normal on a urinalysis may not be a cause for concern and follow-up may not be needed.

• A negative result is useful to avoid submitting a sample to the laboratory.

•No place to screen for asymptomatic bacteriuria unless there will be an intervention

Red flags

Green flags

Test Selection, Specimen Collection, Specimen Transport

• The most appropriate sample for the patient’s illness.

• Collection of all samples is affected by contamination, especially urine

• Always describe how it was collected. All urine samples look the same

• Keep it in the container, for safety and to avoid contamination

• Bacteria divide every 20 minutes at ambient temperatures or above in urine, or a 10 fold increase in one hour.

• Prompt transport to specimen reception

• High quality samples and requests for high quality reports

• The test may support a clinical diagnosis, it is NOT a diagnosis

Antibiotics for Asymptomatic Bacteriuria • Cochrane review, 2015

• Prevalence higher in pregnancy and diabetic females

• Females <60yrs, 3-5%, rare in males

• Prevalence higher in elderly (>60yrs) • Females, 25 – 50%

• Males, 15 – 40 %

• Urinalysis – leucocyte esterase is not specific, nitrites do not identify contamination

• No benefit from screening, esp in LTCF

• Urinary catheters acquire biofilms and colonizing bacteria

• Treatment eradicates but does not prevent SUTI, increase AMR

For what purpose?

Side-effects of antibiotics

Allergy or rashes?

Drug fever?

Stevens Johnson syndrome? (sulphonamides)

Thrush (Candida species)

Antibiotic associated diarrhoea, (Clost. difficile)

Hearing and vestibular damage (aminoglycosides, glycopeptides)

Nephrotoxicity (aminoglycosides)

Thrombocytopaenia

Fitting (penicillins)

Sudden death – prolonged QT interval (quinolones, macrolides)

Hypokalaemia (trimethroprim)

Antibiotic resistance

Think Global act Local

EARS-NET data

At the end of the day…

WHO Bulletin, 2004

Jan 2001 – Dec 2007 % cipro -res Pseudo aeruginosa, # cipro-res Pseudo aeruginosa per 1000 bd

Effect of Abx restriction

Cook, R P et al, ICHE, 2009

How many urine samples to examine in 2015*

• MSU 44,183

• Urine 10,640

• CSU 7,163

• Clean catch urine 2,475

• In-Out catheter specimen 1,750

• Suprapubic catheter spec 457

• Indwelling catheter spec 529

• Total 67,197#

<107/l 38,857 (56%) Mixed growth 16,000 (23%) >107/l

Reported isolate 14,376 (21%) >107/l

* SEALS North and Central, SESLHD # plus another 250 descriptors for another 1500 samples

What organisms were reported, 2015?

E. coli 6423

Enterococcus faecalis 1211

Pseudomonas aeruginosa 803

Candida spp. 995

Klebsiella pneumoniae 611

Proteus mirabilis 609

Group B Streptococcus 490

Enterobacter cloacae 201

Total 11343 (79%)*

*A total of 250 species were reported in 2015 (n=14,376) in pure or predominant growth

Rate of resistance of E. coli from urine to trimethoprim, 2000-2015, SESLHD

ED samples

Non-ED samples

Unpublished data

Rate of resistance of E. coli from urine to norfloxacin, 2000-2015, SESLHD

Non-ED samples

ED samples

8%

Unpublished data

Age and rate of resistance of E. coli from urine to norfloxacin, 2000-2015, SESLHD

All patients from ED

Aged >60yrs

Aged 0-60 yrs

12%

6%

Unpublished data

St George Aged Care Pilot, In patients Catheter Days No Catheter days

Pre-implementation 200 966

Post- Implementation 154 1034

CSU Specimens Collected All other urine samples

Pre-implementation 26 55

Post-Implementation 12 40

Reduced catheter days, p=0.04 Reduced number of urine samples, p=0.02 Number of CAUTI =2, in each period Savings from testing, $883.65, 8 weeks

Summary • Antimicrobial resistance (AMR) is increasing globally and in SESLHD

• Age (>60yrs) is a risk factor for AMR and asymptomatic bacteriuria

• AMR is in the community as well as in hospital

• All classes of antibiotics are affected

• Urinary catheters have an association with AMR

• Antimicrobial stewardship can have an effect on emergence of AMR

• Multiple efforts are required to change “behaviour”

• The CAUTI Project may be a useful way to preserve the benefits of antibiotics • Catheter days were reduced • Numbers of urine samples collected was reduced • No patient harm was apparent

Acknowledgements

• CEC and CAUTI Programme co-ordinator, Dr Jan Gralton

• Dept Aged Care, St George Hospital, A/Prof Peter Smerdley and staff

• Infection Prevention and Control Team, St George Hospital • Gwen Hughes, Christine Cook, Belinda Straube

• Microbiology Registrar, St George Hospital, Dr Alice Kizny Gordon