Healthcare Associated Urinary Tract Infection Epidemiology And Pathogenesis

1. Healthcare AssociatedUrinary Tract InfectionEpidemiology And Pathogenesis Cheng-Hua Huang, M.D. Vice-superintendent Cathay General Hospital

2. Definition of HAI-UTI • Asymptomatic UTI: bacteriuria/funguria + no constitutional symptoms • The presence of bacteria/fungi in the urine does not always imply infection or a clinically significant condition • HAI-UTI: indicating clinical, histologic or immunologic evidence of infection

3. Pyuria vs Bacteriuria • Musher:100% of u/c >100000 CFU/ml with presence of pyuria • Musher: presence of pyuria in catheterized p’t, 30% U/C (-) • Intermittent cathetherized p’t (ICP) pyuria with 100% U/C >100000/ml • Tambyah: short-term catheterized p’t :37% each pyuria vs Bacteriuria

4. Infection vs Colonization • Bacteriuria is present in almost all p’t with prolonged catheterization • The usual symptoms of dysuria, hesitancy, urgency are not seen in catheterized p’t • Fever, leukocytosis may also be caused by non-infectious conditions • Only 30% (2-4 days short-term catheterized) with presence of constitutional S/S

5. HAI-UTI • HAI-UTI: 30-45% of total nosocomial infections • 80-85% HAI-UTI related to the use of urethral catheter • 5-10% caused by other genito-urethral procedures

6. Important Events on HAI-UTI • 1927: Frederick E. Foley: invested a retention balloon on indwelling catheter (control bleeding after prostate surgery) • 1950: Cuthbert Dukes: closed drainage system for better infection control (70-85% of UTI are preventable) • 1960s: Calvin Kunin stated the important issue of infection control

7. HAI-UTI • In US, 600,000 p’ts annually and occupy 15% of total hospital infection cost • Bacteriuria occur in 1-5% after single brief catheterization • Bacteriuria: 100% in indwelling catheter, no closed drainage< 4 days • 3-10%/ day of catheterized indwelling with closed drainage system(U/C +)

8. Inappropriated Bladder Catheterization • 28% of physicians were not aware of bladder indwelling catheter • 41% of bladder catheter judged inappropriately • 69% of bladder catheter only for incontinence p’ts (31.7% by Dr and 37.3% by RN)

9. Pathogenesis of HAI-UTI • Role of the catheter • Bacterial factors • Pathways of infection • Host factor

10. Pathogenesis • Normal non-catheterized urethra and bladder with good defense function (epithelial cell) • Each urinations clears 99.9% of existed bladder organisms • Tamm-Horsfall protein and oligoSaccharide will bind the organism and suspended in urine • Bladder mucosa with bactericidal effect • Glycocalix/ Biofilm helps the bacteria survive

11. Routes of Infection in Catheter Associated UTI:1 Through Insertion2 Intraluminal 3 Extraluminal

12. Route of Entry • Tambyah: intra-luminal entry(23%) • Tambyah: extra-luminal route (34%) • Garibaldi et al : peri-urethral colonization (GNB/ Enterococci) →UTI (18%);non-colonized(5%) • Removal of catheter with remain risk for 24 hours

13. Indications of Indwelling Catheter • Acute urine retention/ outlet obstruction • For accurate measurement of urine output in critically ill p’t • Peri-operative use for selected surgery(uro, prolonged surgical time, or large amount of blood or fluid replacement) • To assist in healing of open wound at perineal region in incontinent p’t • P’t requires for prolonged immobilization • Others

14. Inappropriate Uses of Indwelling Catheter • As a substitute for nursing care for incontinent elderly • As a means of obtaining urine for culture or diagnosis need on p’t can voluntarily void. • For prolonged post-operation duration to recovery

15. Alternatives for Indwelling Catheter • External catheter on non-retention or bladder outlet no obstruction • Intermittent catheterization (clean) in spinal cord injury • Frequent change of absorbed diaper and perineal hygiene care plan

16. Risk Factors for HAI-UTI • ↑ duration of use (catheter days) • Female gender • Delay recognized of systemic infection • DM/ Renal insufficiency • Advanced age • Severity of underlying disease • Meatal colonization(peri-urethral) (72% in female; 30% in male)

17. CGH醫療照護相關感染微生物排名-UTI

18. CGH加護單位醫療照護相關感染微生物排名-UTI

19. TNIS(醫中)加護單位醫療照護相關感染微生物排名 -UTI

20. TNIS(區域）加護單位醫療照護相關感染微生物排名-UTITNIS(區域）加護單位醫療照護相關感染微生物排名-UTI

39. Therapeutic Plans • Host risk-factor consideration • Microbiologic factors • Clinical essential data • Recognizing situation where the usual treatment may be inappropriate • Trend of antimicrobial resistanceand D.Dx colonization or infection

40. Treatment Goals • Draumatic reduce or eradicate pathogenic strains • Limit the extent and severity of HAI-UTI • Minimize alterations in normal flora(↓superinfection of candida and MDROs • ↑ hour urine amount 80-100ml/hr for washing out the organism and non-obstructionly

41. Antimicrobial Therapy in HAI-UTI • Most authorities believe that antibiotics to postpone bacteriuria are not indicated, but exception on specific p’ts (renal transplant and febrile neutropenia) • Indication for HAI-UTI with antibiotics is a subject of debate and controversy but also is virtually universal • Routine therapy for culture is not only cost-waste but also increasing adverse reaction and selective of MDROs

42. Mortality Related to HAI-UTI • Uncertain, but <10% Bacteremia from pre-existence of HAI-UTI • 0.3-3.9% total HAI-UTI may progress into sepsis and /or mortality • Transient Bacteremia (6.5%) may occur after bladder catheterization, or removal of catheter (within 24 hours)