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Nosocomial Urinary Infections

Hani Jokhdar
Jokhdar,, MD.
Consultant of Communicable Disease Control

Case one
‰ An 60 y.o.
y.o. female admitted to the ICU
on 27
27//9/06
06;; known
k
case off CVA
CVA, dementia,
d
ti
bedsore and hypothyroidism.
‰ Acquired
A
i d the
th following:
f ll i
ƒ 4/10
10//06
06;; UTI Pseudomonas a. ESBL
t t d with
treated
ith Meropenem
M
ƒ 10
10//10
10//05
05;; Extension of infection to
secondary
d
b
baceteremia
t
i (Pseudomonas
P d
a.) treated with Meropenem and
Gentamicin

ƒ 18/
18/11
11//06
06;; Bedsore get heavily colonized
(E. coli and Proteus M.)
ƒ 26
26//11
11//06
06;; UTI (E. coli) treated with
Gentamicin
ƒ 26
26//10
10//06
06;; vaginal infection (E. coli)

Th ttotal
The
t l money spentt for
f the
th
treatment of the previous HA
UTI and its consequences
was > 50,
50,000 SR

Case two
‰ 54 yy.o male,, admitted on 17/
17/12
12//06
‰ Acute MI; Known IHD & cirrhotic liver
‰ Occupied ICU bed until death on March
20th.
‰ Acquired
A
i d the
th following
f ll i UTIs
UTI with
ith the
th
following organisms throughout
h
hospitalization
it li ti
ƒ ESBL pseudomonas a. treated with 3
antibiotic for 3 weeks.

ƒ Enterobacter also ESBL that was treated
with Gentamicin
ƒ The patient has also colonized his
sputum with MDR Acinetobacter spp.
Which was demonstrated in urine two
days prior to death.

Introduction
‰ They
Th are the
th infections
i f ti
acquired
i d iin th
the
hospital after admission

NI

Patient’s own flora
Other patient

Medical equipment
Environment

Staff member

The alert
‰With the best hospital
p
care;; medical statistics
demonstrates that at least 10% of total hospital
admission end upp with nosocomial infections
‰Nearly 100,000 people die of NI in the USA
each year
‰Adding an extra 4 days of hospital stay costing an
average
g of $2000 pper patient
p

It is increasing: why?
‰The widespread
p
use of antimicrobial in the
hospitals together with the easy access in
ppharmacies led to emergence
g
of resistant strains
‰Failure to follow appropriate infection control
measures in
i hospital
h it l settings
tti
‰Increase in the number of the
immunocompromised in hospitals

‰More people undergoing extensive
extensive, invasive
surgical procedure
‰Increase demand for blood transfusion
‰Increasing renovation in the aged hospital
b ildi
building

Main Types of Infections

17%
44%
18%
10%

11%

UTI
SSI
BSI
P
Pneumo
Others

HA - UTI
‰It is the most common type (± 40%) of NI
involving both LTC and acute hospital settings
‰Instrumentation is almost always associated
with
ith all
ll cases
‰Beingg the most common it is the most
preventable
‰Adults and children are equally affected

History
‰Frederick Foley in 1927
ƒFirst to control bleedingg ppost-operatively
p
y
ƒThen to drain the obstructed tract
ƒDrain incontinent patient
ƒMeasure
M
urinary
i
output

‰1950s and the close sterile drainage system
‰1970 knows
‰1970s
k
th
the routine
ti surveillance
ill

Epidemiology
‰Catheter use
ƒIt is an instrumentation that is almost used in all
h i l
hospitals
ƒEndemics occurs throughout
g
the hospital
p
ƒThe daily IR is 2-16% for the first 10 days in the
close system drainage
ƒUniversal infection by 30 days in the close
system drainage
d i

Cont…Epidem
Cont…
Epidem
‰Magnitude
g
of the problem
p
ƒ Incidence and cost
ƒ 15 – 20 % of total hospital admission have FC
ƒ Nearly 900
900,,000 nosocomial UTI in the US
ƒ It cost $600
$600 million if LOS increased by 1 day
ƒ In reality LOS increased by average of 3.8 days
costing $3
$3 billion

Cont…Epidem
Cont…
Epidem
ƒ Mortality
ƒ Related to bacteremia which accounts for
0.3 – 3.9% of total UTIs
ƒ Out of which fatality exceed 30
30%
% (4500
(4500
death/year)

ƒ Morbidity
ƒ Spread of infection through out urinary tract
causing; absesses,
absesses, epididymitis,
epididymitis,
orchitis…etc.
orchitis
…etc.
ƒ Other
O h complications
li i
like
lik stones and
d polyps
l

ƒ Consequences
q
of antibiotic use
ƒ Emergence of resistant strains

ƒ Epidemics of HA UTI
ƒ Urinary drainage bag act as a reservoir for
the organisms to colonize and to transfer the
resistant plasmid
ƒ With p
poor hand hygiene
yg
cross
cross--infection lead
to hospital wide organisms

Etiologic Agents
‰ Fecal Flora
15%
25%
7%

8%
11%

16%

E.Coli Enterococcus P.aeruginosa C.albican K.Pneumoniae Others

Pathogenesis
‰ Role of catheter
ƒ Transurethral catheter break the normal defense
mechanism
ƒ The
Th retention
i balloon
b ll
prevents complete
l emptying
i
ƒ Open channel to the bladder
ƒ Foreign
i body
b d

‰ Bacterial factors
ƒ Pili
ƒ Hemolysin
ƒ Urease

‰ Pathways of infection
ƒ Intraluminal (exogenous organism)
ƒ Extraluminal (endogenous organism)

‰ Host factors
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ

Duration of use
Female gender
Absence of systemic
y
antibiotics
DM
Renal insufficiencyy
Advanced age
Severe underlying illnesses

Diagnosis
‰CDC definition
ƒExclude infections that acquired prior to admission
ƒAsymptomatic bacteriuia should
have > 100,000 cfu/cc
ƒCulturingg the catheter tip
p is of NO VALUE
ƒUses of symptoms; only fever

Specimen collection
‰ It is preferable to obtain specimen from
new catheter rather than old catheter
‰ Urine obtained through inserting needle
into catheter or through diaphragm
‰ For suprapubic and straight catheter;
specimen obtained directly from bladder

Prevention
‰Close sterile drainage system
‰Infection control and surveillance programs
‰Guidelines
‰Adjunct to closed drainage
‰Alternative to FC
‰Secondary prevention

Surveillance data

13 66
13.66
11.6
72
7.2
4

November

11.03
9.43

9.1

69
6.9

6.2

69
6.9

3.6

3.8

3.4

3.4

December

January

February

8.45

Hospital
p 1

Hospital
p 2

Hospital
p 3

March

16
14
12
10
8
6
4
2
0

P er 10000 F -d ays

Benchmarking

Recommendation
‰ Put your evidence
evidence--based IC guidelines
‰ HCW behavioral modification
o your
you surveillance
u
a
properly
p op y
‰ Do
‰ Benchmark yourself overtime
‰ PI projects
‰ NNIS
ƒ Fully computerized patient records
ƒ Data
Data--mining
mining--derived epidemiology