Healthcare Associated Urinary Tract Infection Epidemiology And

Healthcare Associated Urinary Tract Infection Epidemiology And Pathogenesis CHENG-HUA HUANG, M.D. VICE-SUPERINTENDENT CATHAY GENERAL HOSPITAL

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

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

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 noninfectious conditions  Only 30% (2-4 days short-term catheterized) with presence of constitutional S/S

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

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

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 +)

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)

Pathogenesis of HAI-UTI  Role of the catheter  Bacterial factors  Pathways of infection  Host factor

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

Routes of Infection in Catheter Associated UTI: 1 Through Insertion 2 Intraluminal 3 Extraluminal

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

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

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

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

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)

CGH醫療照護相關感染微生物排名-UTI 排 98年度 名

99年度

100年度

1

E. coli

E. coli

E. coli

2

Fungi

P. aeruginosa

Fungi

3

P. aeruginosa

Fungi

P. aeruginosa

4

K. pneumoniae

K. pneumoniae

K. pneumoniae

5

E. faecalis

E. faecalis

E. faecalis

CGH加護單位醫療照護相關感染微生物排名-UTI 排 98年度 名

99年度

100年度

1

Fungi

E. coli

E. coli

2

E. coli

Fungi

Fungi

3

K. pneumoniae

S. marcescens

P. aeruginosa

4

P. aeruginosa

K. pneumoniae

E. faecalis

5

E. faecalis

E. faecalis

K. pneumoniae

TNIS(醫中)加護單位醫療照護相關感染微生物排名 -UTI 排 98年度 名

99年度

1

Fungi

Fungi

2

E. coli

E. coli

3

P. aeruginosa

P. aeruginosa

4

K. pneumoniae

K. pneumoniae

5

A. baumannii

A. baumannii

100年度

TNIS(區域）加護單位醫療照護相關感染微生物排名-UTI 排 98年度 名

99年度

1

Fungi

Fungi

2

E. coli

E. coli

3

K. pneumoniae

K. pneumoniae

4

P. aeruginosa

P. aeruginosa

5

A. baumannii

A. baumannii

100年度

E.coli

S%

98 98

100 89

80

79

82 82 80 80 81

93 91 86

60

85

83 82 82

80 81

86 84 85

2001年

75

74 64

89

95

2003年

67

2005年

52

2007年

43

40

2009年 24

2011年

20 0 GM

CF

CIP

CXM

CTX

抗生素

K.pneumoniae

S% 100

99 92

94

92 91 92

95 95 89 85 80

80

93 91

90

95

93 88

89

95 91 90 90

89 84 83 84

83 79

2001年

77

2003年

69

2005年

60

2007年 2009年

40

2011年

20 0

抗生素 GM

CF

CIP

CXM

CTX

E.cloacae

S% 100 80

95 96

93

91 88 90

92 92

95

2001年

90 78 79 79

78 78

2003年

76 72 72

2005年

66 58

60

61 53

2007年

51 44

2009年

40

2011年 17

20

12 11 7 3

6

0 GM

CF

CIP

CXM

CTX

抗生素

Ps.aeruginosa

S% 100

98 98

97 98 96 95

93 90 90 9190 90

96 97 95 94

92 92

97 94

97 91

99

99 97

95

92

89

87 8886

83 83

90

2001年

78 76

80

2003年 2005年

60

2007年

40

2009年 2011年

20 0 IPM

CIP

CAZ

ATM

FEP

LVX

抗生素

A.baumannii S% 100

95

97 93

91 91

80

78

76 73

62

64 65 65

68

65

63 58

60

70

69

68

2001年

77

72 73 68

70

2003年

66

60 55

53

52

53

2007年

39

40

2005年

2009年

26 23

20

2011年

11 12 5

0 IPM

CIP

CAZ

ATM

FEP

LVX

抗生素

S.aureus

S%

100 100100 100100 100

100

9190 83

80

100 100100 100100 100

81

77

84

2001年

76 72

73 70

69

60

2003年 2005年

5354 43

2007年

39

40

34

35

2009年 2011年

20 3

5

3

5 4

1

0 SXT

E

P

CIP

VA

TEC

抗生素

S.pneumoniae

S%

100

100

100 98

100100100 100100100

100100

94

80

2001年 2003年

60

55

2005年 2007年

46 42

40

36

35

35

32 29 26

2009年

3130

29 25

26

2011年

21 16

20

7 3

0 SXT

E

P

CIP

VA

TEC

抗生素

GAS

S%

10010099 100100100

98

100

95

98 99

100100100100100100 96 97

93

90

2001年

83

80

2003年 61

2005年

60

2007年 2009年

40 21 22

20

2011年

23

9

0 SXT

E

P

CIP

VA

抗生素

GBS

S%

10010010099100100

100

95 95

98

100100100100100100

92

2001年

81 78

80

75

2003年

77 67 66

2005年

60

2007年 2009年

40

2011年

20

18

9

7

9

0

抗生素 SXT

E

P

CIP

VA

E.faecalis

S% 100

95

100100100 100 98 96

97 96 96

100100100

92 85 82

81

80

77 71

78

2001年

70

2003年

61

60

2005年 2007年 2009年

40

31

29 26

2011年

27

23

20

11 11

9

0

抗生素 SXT

E

P

CIP

VA

TEC

E.faecium

S%

100 100 96

100

100100 95

92

89

2001年

83

80

2003年

74 70 63

63

62

60 46

36

40

2007年

46

41 38

40

2009年

34

3029 23

20

2005年

53

2011年

22 17

14 6

3

0 SXT

E

P

CIP

VA

TEC

抗生素

2008年 ~ 2011年ESBL 比較(1)--數量 數量(株) 400 350

339

350 312

300

2008年

282

250

2009年

200

2010年

150

126 131

100

2011年 86

77

50 6

0 E.coli

K. pneumoniae

10 13

4

K. oxytoca

ESBL菌株

2008 ~ 2011 ESBL 比較(2)--百分比 百分比 25% 21.31%

2008年

20%

2009年 15%

2010年 11.32%

2011年

10.99%

10% 8.03% 6.90%

6.76% 6.72% 5.58%

5.94%

5.70% 5.72% 4.59%

5%

0% E.coli

K. pneumoniae

K. oxytoca

ESBL菌株

ESBL 菌株

E.coli

Klebsiella pneumoniae

Klebsiella oxytoca 平均

年度

數量

ESBL

百分比

2584 97

ESBL

百分比

1105 339

6.76%

數量

126

5.70%

1105

35

2491

1057

43

350

6.72%

131

5.72%

2719

1233

48

2527

955

46

99

282

5.58%

86

4.59%

2523

920

15

2232

669

30

100

312

8.03%

1655 19165

77

5.94%

627 1283

6.69%

7671

ESBL

百分比

6

11.32%

6.47%

10

10.99%

6.47%

13

21.31%

5.45%

4

6.90%

7.50%

33

12.55%

6.47%

18

2434

98

平均

數量

28 420

5.48%

263

Therapeutic Plans  Host risk-factor consideration  Microbiologic factors  Clinical essential data  Recognizing situation where the usual treatment

may be inappropriate  Trend of antimicrobial resistance and D.Dx colonization or infection

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

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

Mortality Related to HAI-UTI  Uncertain, but