SandboxAB: Difference between revisions

Latest revision as of 15:21, 29 January 2014

Overview

About 15-25% of hospitalized patients have got a urinary catheter during in-patient management. Catheter associated bacteriuria is the most common infection during hospitalization. however,less than quarter of hospitalized patient develop symptomatic urinary tract infection.

Definition

Catheter associated urinary tract infection is defined by the presence of urinary tract infection symptoms or signs in patients with or indwelling or suprapubic catheters with isolation of one or more bacterial strains≥10³cfu/ml from catheter assembled urine specimen or midstream voided urine specimen in patients who had a catheter removed in the last 48 hours. And this is applied after exclusion of other possible sources of infection.

Catheter associated UTI signs and symptoms

General signs and symptoms
Non specific presentations are the most common. The new onset or worsening of any of the following :

Fever
Rigors
Altered mental status
Malaise or lethargy

After exclusion of alternative diagnosis with thorough evaluation.

Urinary tract specific signs and symptom

Flank pain
Costovertebral angel tenderness
Acute hematuria
Pelvic discomfort

After catheter removal

Urgency
Frequency
Dysuria
Suprapubic pain or tenderness

Patients with spinal cord injury

Increased spasticity
Autonomic dysreflexia
Sence of unease

Pathogenesis and Microbiology

Urinary catheterization disturbs the normal uroepithelial barrier, allowing uropathgenes to access through the lamina.

Microbiology

Short-term catheterization

E.Coli is the most common isolated organism with about third of all isolates, other isolates include Klebsiella spp, Serratia spp, Citrobacter spp, P.aeruginosa and gram positive cocci(coagulase negative)like staphylococci and Enterococci.

Long-term catheterization

It is usually polymicrobial, and in addition to the previous organisms, P.mirabilis, Morganella morganii and P.stuartii are also common.

CA-UTI risk reduction

Avoidance of Unnecessary Catheterization

Indications for indwelling catheters are:30-120-121

1-Significant urinary retention. 2-Urinary incontinence if other less invasive measures fail or contraindicated. 3-Monitoring output for critically ill patients. 4-Anesthetized patients undergoing certain surgical procedures(urological or gynecological).

It's not an indication to use urinary catheters for patients with pressure sacral ulcers.
Using educational methods through hospital or institution guidelines and spreadsheets for indication and contraindication has reduced the inappropriate use of catheters and thereby the rate of CA-UTI. 128
For post-operation patients, a portable ultrasound for bladder has proven to be accurate assessment for bladder volumes, thus reducing unnecessary catheterization. 131-130

Before Catheter Insertion

Discontinuation of Catheter

Catheter removal should be as soon as possible when it's no longer indicated. Early removal of catheters reduced the risk135-136 and the rate137-138 of catheter associated urinary infections.

Alternatives to Indwelling Urethral Catheterization

Infection Intermittent Catheterization Technique

Insertion Techniques for Indwelling Urethral Catheter

Prevention Before Catheter Insertion

Infection prevention

Health institutions should consider providing screening and preventive programs, which include guidelines and recommendations for catheterization placement procedure, replacement and discontinuation requirements, in addition to feedback of UTI rate to the medical staff. These measurements had significant risk reduction of catheter associated UTIs. 146-151-152

Alternatives to Indwelling Catheterization

Condom catheter:an alternative option to short-term and long-term indwelling catheters, to reduce risk of infection for patients with normal post-voiding volume.190-193-195
Intermittent catheterization:also used as alternative for both short-term and long-term indwelling catheters to reduce CA-UTI risk and its complications 22-24-157-158.It's commonly used with neurogenic bladder and spinal cord injuries.16
Suprapubic cathterization:an alternative to short-term indwelling catherterization to reduce CA-bacteriuria161. It's preferable more than long-term indwelling catheterization for reduction of catheter associated bacteriuria and infections.It's more comfortable than indwelling catheter with no effect on sexual function, but knowing that it is invasive procedure needs specially trained caregiver has limited its use

Indwelling Catheter Insertion Technique

Aseptic technique should be used with sterile equipment, although it's there is no significant difference in rates of infection with clean(non-aseptic)technique199, but it is preferable approach know the multi-drug resistant organism that can cause infection in hospitalized patients.199

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- {|
+==Overview==
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:25em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Acute Bacterial Uncomplicated Cystitis†}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nitrofurantoin]]  100 mg po q12h×5 days'''''<br>OR<br>▸ '''''[[TMP-SMX]]‡ 1 DS tab po q12h×3 days'''''<br>OR<br>'''''▸[[Fosfomycin]]  3 gm single dose'''''<br>OR<br> ▸'''''[[Pivmecillinam]]♦  400 mg bid×5 days '''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluoroquinolones]] for 3 days  <br>[[Ofloxacin]]  200–400 mg po bid.<br>[[Ciprofloxacin]]  250 mg bid po or Cipro XR 500 mg q24h<br>[[Levofloxacin]]  250–750 mg po q24'''''<br>OR<br>'''''▸[[β-lactam]] agents for 3-7 days<br>[[Amoxicillin-clavulanate]]  500/125 mg po tid or 875/125 mg po bid <br>[[Cefdinir]]  300 mg po q12h or 600 mg po q24 <br>[[Cefaclor]]  250-500 mg po q8h<br>[[Cefpodoxime-proxetil]]  100-200 mg po q12h'''''<br>'''''Others([[Cephalexin]]250-500 mg po q6h  ) not studied well but effective.'''''
-|-
-|}
-|}
-† Acute uncomplicated cystitis: Premenopausal, nonpregnant women with no known urological abnormalities or comorbidities,postmenopausal women or well-controlled diabetes female patient.
-‡Avoid if resistance prevalence is known to exceed 20% or if used for UTI in previous 3 months.
-♦Pivmecillinam is available in some European countries, not licensed in US.
-<br>
- {|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: left; width:25em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Fungal cystitis in the non-neutropenic patient}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Candida''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluconazole]] 200 mg PO/IV ×7-14 days'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amphotericin B ]] 0.3 - 0.6 mg/kg IV once daily×1-7 days'''''
-|}
-<BR>
-*Being the most common cause of cystitis(75-90%), E.Coli susceptibility test should be considered to choose the appropriate empirical antimicrobial.Other organisms like Proteus mirabilis, Klebsiella pneumoniae and Staphylococcus saprophyticus  are  far less common.
-*[[Nitrofurantoin]], [[fosfomycin]] and mecillinam are prefered as first line treatment  because have less resistance among other antibacterials.
-*[[TMP-SMX]] is preferred to use in areas where the resistance rates are less than 20%
-*[[Nitrofurantoin]], [[fosfomycin]] and mecillinam shouldn't be used when pyelonephritis is suspected, because they have weak penetration to the renal tissue.
-*Use of broad-spectrum antimicrobials resulted multi-drug resistant organisms, so they are used as alternative to the first line drugs in case of allergy, availability, or tolerance.
-<br>
-{|
-|-
-| valign=top |
-{| style="margin: 0 0 0em 0em; border: 1px solid #696969; float: Center; width:25em" cellpadding="0" cellspacing="0";
-! style="padding: 0 5px; font-size: 100%; background: #F8F8FF" align=center | ''{{fontcolor|#6C7B8B| Acute Bacterial Uncomplicated Pyelonephritis}}''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Preferred Regimen''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Fluoroquinolones]]'''''<br>'''''[[Ciprofloxacin]] 500 mg PO bid ×7 days<br>[[Levofloxacin]] 750 mg PO q24 × 5 days<br>[[Ofloxacin]] 400 mg Po bid<br>[[Moxifloxacin]] 400 mg PO q24h'''''
-|-
-! style="padding: 0 5px; font-size: 80%; background: #F5F5F5" align=left | ''Alternative Regimen(14 day regimen)''
-|-
-| style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[TMP-SMX]] 160/800 mg PO bid'''''<br>OR<br>'''''▸ Oral[[β-lactam]]<br>[[Amoxicillin-clavulanate]]  875/125 mg po q12h or 500/125 mg po tid or 1000 /125 mg po bid <br>[[Cefdinir]]  300 mg po q12h or 600 mg po q24 <br>[[Cefaclor]]  250-500 mg po q8h<br>[[Cefpodoxime-proxetil]]  100-200 mg po q12h<br>[[Cephalexin]]250-500 mg po q6h not studied well but effective.'''''
-|-
-|}
+About 15-25% of hospitalized patients have got a urinary catheter during in-patient management. Catheter associated bacteriuria is the most common infection during hospitalization. however,less than quarter of hospitalized patient develop symptomatic urinary tract infection.
 ==Definition==
-Catheter associated urniary tract infection is defined by the presnce of urinary tract infection symptoms or signs in patients with or indewlling, condom or suprapubic catheters with isolation of one or more bacterial strains≥10³cfu/ml from catheter assembeld urine specimen or midstream voiding specimen in patients who had catheter removed in the last 48 hours. And this is applied after exclusion of other possible sources of infection.
+Catheter associated urinary tract infection is defined by the presence of urinary tract infection symptoms or signs in patients with or indwelling or suprapubic catheters with isolation of one or more bacterial strains≥10³cfu/ml from catheter assembled urine specimen or midstream voided urine specimen in patients who had a catheter removed in the last 48 hours. And this is applied after exclusion of other possible sources of infection.
 ===Catheter associated UTI signs and symptoms===
 '''General signs and symptoms'''<br>
-The new onset or worsening of any of the following :
+Non specific presentations are the most common. The new onset or worsening of any of the following :
 *Fever
 *Rigors
 *Altered mental status
-*Malasie or lethargy
+*Malaise or lethargy
-After exclusion of alternative diagnosis
+After exclusion of alternative diagnosis with thorough evaluation.
 '''Urinary tract specific signs and symptom'''<br>
 *Flank pain
-*Costcovertebral angel tenderness
+*Costovertebral angel tenderness
 *Acute hematuria
 *Pelvic discomfort
@@ Line 99: / Line 31: @@
 *Autonomic dysreflexia
 *Sence of unease
+==Pathogenesis and Microbiology==
+Urinary catheterization disturbs the normal uroepithelial barrier, allowing uropathgenes to access through the lamina.
+===Microbiology===
+'''Short-term catheterization'''
+[[E.Coli]] is the most common isolated organism with about third of all isolates, other isolates include Klebsiella spp, Serratia spp, Citrobacter spp, P.aeruginosa and gram positive cocci(coagulase negative)like staphylococci and Enterococci.
+'''Long-term catheterization'''
+It is usually polymicrobial, and in addition to the previous organisms, P.mirabilis, Morganella morganii and P.stuartii are also common.
+==CA-UTI risk reduction==
+===Avoidance of Unnecessary Catheterization===
+*Indications for indwelling catheters are:30-120-121
+-Significant urinary retention.
+-Urinary incontinence if other less invasive measures fail or contraindicated.
+-Monitoring output for critically ill patients.
+-Anesthetized patients undergoing certain surgical procedures(urological or gynecological).
+*It's not an indication to use urinary catheters for patients with pressure sacral ulcers.
+*Using educational methods through hospital or institution guidelines and spreadsheets for indication and contraindication has reduced the inappropriate use of catheters and thereby the rate of CA-UTI. 128
+*For post-operation patients, a portable ultrasound for bladder has proven to be accurate assessment for bladder volumes, thus reducing unnecessary catheterization. 131-130
+===Before Catheter Insertion===
+===Discontinuation of Catheter===
+*Catheter removal should be as soon as possible when it's no longer indicated. Early removal of catheters reduced the risk135-136 and the rate137-138 of catheter associated urinary infections.
+===Alternatives to Indwelling Urethral Catheterization===
+===Infection Intermittent Catheterization Technique===
+===Insertion Techniques for Indwelling Urethral Catheter===
+==Prevention Before Catheter Insertion==
+===Infection prevention===
+Health institutions should consider providing screening and preventive programs, which include guidelines and recommendations for catheterization placement procedure, replacement and discontinuation requirements, in addition to feedback  of UTI rate to the medical staff. These measurements had significant risk reduction of catheter associated UTIs. 146-151-152
+===Alternatives to Indwelling Catheterization===
+*'''Condom catheter''':an alternative option to short-term and long-term indwelling catheters, to reduce risk of infection for patients with normal post-voiding volume.190-193-195
+*'''Intermittent catheterization''':also used as alternative for both short-term and long-term indwelling catheters to reduce CA-UTI risk and its complications 22-24-157-158.It's commonly used with neurogenic bladder and spinal cord injuries.16
+*'''Suprapubic cathterization''':an alternative to short-term indwelling catherterization to reduce CA-bacteriuria161. It's preferable more than long-term indwelling catheterization for reduction of catheter associated bacteriuria and infections.It's more comfortable than indwelling catheter with no effect on sexual function, but knowing that it is invasive procedure needs specially trained caregiver has limited its use
+==Indwelling Catheter Insertion Technique==
+Aseptic technique should be used with sterile equipment, although it's there is no significant difference in rates of infection with clean(non-aseptic)technique199, but it is preferable approach know the multi-drug resistant organism that can cause infection in hospitalized patients.199