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Urinary Catheter-Related Infections and Infection Prevention Systems

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					Urinary Catheter-Related
Infections and Infection
  Prevention Systems
      Carol E. Chenoweth, M.D.
Medical Director, Infection Control and
            Epidemiology
          Prevention of Infections:
            “Bench to Bedside”

• Research findings “translated” into improved clinical
  care using the resources already in place at the UMHS
    Infection Control and Epidemiology
    UMHS Patient Safety Committee
    Continuous Quality Improvement
    Office of Clinical Affairs
       Prevention of Infections

• Prevention of urinary catheter infections

• Prevention of central venous catheter
  infections

• New methods of promoting hand hygiene
    Urinary Catheter-related Infection:
              Background

• Urinary tract infection (UTI) causes over 40%
  of hospital-acquired infections

• Most infections due to urinary catheters

• 25% of inpatients are catheterized

• Leads to increased morbidity and costs
    Prevention of Catheter-related
              Infection

#1) Use a closed drainage system, aseptic placement
  and care

#2) Make sure the catheter is indicated

#3) Remove the catheter as soon as possible

#4) Consider other methods for prevention
   UTI Prevention Rule #2: Make Sure the
     Patient Really Needs the Catheter

  Appropriate indications
                                             Percent unjustified
• Bladder outlet obstruction
• Incontinence and sacral                   50
  wound                                     40
                                            30
• Urine output monitored
                                            20
• Patient‟s request (end-of-life)           10
                                                                            Unjustified


• During or just after surgery              0




                                                           Pt Days
                                                 Initial
             (Wong and Hooton - CDC 1983)

                                                                     (Jain, Arch Int
                                                                     Med 1995)
  Why are Catheters Used Inappropriately?

• Perhaps physicians “forget” that their patient
  has a urinary catheter

• Study to determine the extent to which
  physicians are aware which of their inpatients
  have urinary catheters

• Surveyed 56 medical teams at 4 sites; 256
  providers completed the survey (response rate
  = 89%)           (Saint S, Wiese J, Amory J, et al. Am J Med 2000)
Urethral Catheters: Lost in Place?

Training Level       Proportion                 95% CI
                      Unaware
Medical Student            18%                  8-32%

Intern                     22%                 13-34%

Resident                   28%                 20-38%

Attending                  38%                 26-45%

                  (Saint S, Wiese J, Amory J, et al. Am J Med 2000)
  Systems Approach to Reducing Urethral
  Catheterization – U of M Medical Center
• Funding provided by the Blue Cross Blue Shield of
  Michigan Foundation

• Written reminder placed on the chart by a research
  nurse after 48 hours of catheter use

• Before-and-after study on 2 hospital wards with 2
  concurrent control wards

• Data collection underway; also will evaluate UTI rates
** URINARY CATHETER REMINDER **

Date: __ __ / __ __ / __ __


This patient has had an indwelling urethral catheter since __ __ / __ __ / __ __.
Please indicate below EITHER (1) that the catheter should be removed OR (2) that the catheter
should be retained. If the catheter should be retained, please state ALL of the reasons that apply.
        Please discontinue indwelling urethral catheter; OR
        Please continue indwelling urethral catheter because patient requires indwelling catheterization
        for the following reasons (please check all that apply):
                Urinary retention
                Very close monitoring of urine output and patient unable to use urinal or bedpan
                Open wound in sacral or perineal area and patient has urinary incontinence
                Patient too ill or fatigued to use any other type of urinary collection strategy
                Patient had recent surgery
                Management of urinary incontinence on patient’s request
                Other - please specify: ___________________________________________________

        __________________________________________                         _____________
                        Physician’s Signature                                 Doctor Number
 Methods for Preventing Urinary
   Catheter-related Infection


• Bladder irrigation: NOT
• Antibacterial agents in collection bag:
  NOT
• Rigorous meatal cleaning: NOT
• Use of antiseptic urinary catheters
   Prevention of Catheter-related UTI using
     Silver Catheters: The Silver Bullet?
• Silver has in vitro antibacterial activity

• Efficacy of silver catheters shown in meta-
  analysis of randomized trials (Saint, et al. Am J Med, 1998)

• Additional cost of $5.30 per silver catheter tray

• Is the reduction in catheter-related infection
  worth the extra cost?
     Economic Evaluation of Silver
             Catheters


• Decision analytic model comparing silver
  catheters with standard non-coated catheters

• Patient population: hospitalized patients at
  high risk for infection requiring catheterization
  for 2 to 10 days
Results of base-case analysis: Silver
catheters prevent morbidity and save
               money

                 Costs       Symptomatic Bacteremia
                                UTI
    Silver
   Catheter     $16.78              1.6%              0.25%
  Standard
  Catheter      $20.87               3%               0.45%

  Difference     -$4.09            -1.4%               -0.2%

         (Saint, Veenstra,, Sullivan, Chenoweth, Fendrick. Arch Intern
                                                            Med 2000)
      Silver Catheters: Policy
            Implications

• Silver catheters should be considered in
  appropriate patients requiring
  catheterization for 2 to 10 days

• Evaluate if silver catheters work at U-M
        Catheter-related UTI Prevention:
         Summary Recommendations

• Use only a closed drainage system and aseptic
  technique
• Use urethral catheters only when necessary
• Consider using an administrative catheter “stop order”
  to limit inappropriate catheterization
• Consider silver catheters in high-risk patients who
  require catheterization for 2 to 10 days
        Prevention of Infections

• Prevention of urinary catheter infections



• Prevention of central venous catheter infections



• New methods of promoting hand hygiene
Catheter-related Bloodstream Infection (CR-BSI):
                  Background


• Vascular catheters are the leading cause of
  nosocomial bacteremia; most due to central
  venous catheters
• 150,000 cases of CR-BSI annually in U.S.
• 4% to 25% attributable mortality rate
• Annual cost between $300 million and $2
  billion
Attributable Mortality and Costs of
            BSIs, UMHS
         DiGiovine et al, Am J Crit Care Med, 1999



                    Cases          Controls          p-value
Attributable
Mortality           35.3%          30.9%             0.51

Survivors
 ICU LOS            17.4d           7.1d             0.007
 Hospital LOS       35.4d           30.3d            0.026
 Costs              $79,835        $45,327           0.008
    Prevention of Bloodstream
            Infections

• Aseptic placement of CVC catheters



• Antimicrobial catheters



• Site disinfection
Full Barrier Protection for Insertion of CVCs
         Raad, Infection Control Hosp Epidemiol, 1994
                  Effect of Maximal Barrier Precautions during
                           Insertion on CVC Infections
                          Raad et al, Infect Control Hosp Epidemiol, 1994



                  8
                  7
                                                     p=0.03
%CVC Infections




                  6
                  5                                                     Total Infection
                                                          p=0.01
                  4
                                                                        Infections First 2
                  3                                                     Mo.
                  2
                  1
                  0
                      Precautions           No Precautions
                         N=176                  N=167
Meta-analysis of Antiseptic Catheters: CR-BSI

   Tennenberg
         Maki
      Hannan
        Bach
        Heard
        Collin
       Ciresi
    Pemberton
      Ramsay
     Trazzera
      George
    Summary                      OR 0.56, 95% CI (0.37-0.84)

             0.0   0.5     1.0                2.0                 3.0
                         Odds      (Veenstra, Saint, Saha, et al. JAMA 1999)
                         Ratio
    Economic Evaluation of Antiseptic
              Catheters

• Is the benefit worth the extra $25 per
  catheter?


• Decision model comparing antiseptic with
  standard catheters in patients at high-risk for
  CR-BSI (e.g. critically ill) using central lines
  for 2 to 10 days
                Results:
Antiseptic catheters saves money & lives

               Costs   CR-BSI         Death
  Antiseptic
   Catheter    $336     3.0%          0.45%
  Standard
   Catheter    $532     5.2%          0.78%

 Difference    -$196   -2.2%          -0.33%

                         (Veenstra etal, JAMA 1999)
  Antiseptic Catheters: Implications

• Antiseptic catheters recommended in critically ill
  patients requiring central venous access for 2 to 10
  days




• UM now using these catheters and recently evaluated
  the results
intervention
        “Back of the Envelope”
          Economic Analysis

                      Annual Cost Savings for the
                        University of Michigan

Base Case                      $ 110,000

Best Case Scenario             $ 423,000

Worst Case Scenario            $ 41,250
 Which Disinfectant Should be Used for
          Catheter Site Care?

• Povidone-iodine (PI) is currently the most widely used
  agent for site disinfection


• Chlorhexidine gluconate (CHG) has been compared to
  PI with mixed results


• We performed a formal meta-analysis of published and
  unpublished studies to clarify relative efficacy
      Chlorhexidine for Site Disinfection: CR-BSI
                    Favors CHG                          Favors P-I
    Study                                                   Risk ratio (95% CI)



            7
Maki et al, 1991                                             0.18 (0.02,1.46)
                8
Sheehan et al, 1993                                          1.05 (0.07,16.61)

Meffre et al,9 1995                                          0.97 (0.20,4.77)
Mimoz et al,10 1996                                          0.64 (0.15,2.81)

Legras et al,11 1997                                         0.13 (0.01,2.45)

Humar et al,13 2000                                          0.75 (0.20,2.75)

Knasinski et al,14 2000                                      0.36 (0.14,0.95)


Overall (95% CI)                                             0.49 (0.28,0.88)


                            .1 .2   .5 1   2      5 10
                                               Risk ratio
                                       (Chaiyanupruk et al. Ann Intern Med 2002)
  Which Disinfectant Should be Used for
      Catheter Site Care? Caveats

• Chlorhexidine gluconate costs 2-fold more than
  povidone-iodine

    $0.41 vs $0.92 for same amount

• Effect of CHG in addition to antimicrobial catheters
  unclear

• UM now using this new disinfectant and we plan to
  evaluate the results
Washing Hands to Stop Spread of Disease
        Ignaz Semmelweis (1818-1865)




                          Handwashing is still
                          the most important
                          intervention to
                          prevent health-care
                          associated infections
Handwashing Compliance in
Healthcare Workers, 1998-9
Site       Compliance     Reference
Geneva            48%     Pittet,‟99
Duke Univ         17%     Kirkland, „99
Salford, UK       37%     Keaney, „99
Youngstown,OH             Watanakunakorn,‟98
  Med ICU         39%
  General units   23%
Physicians had lowest compliance in all
 studies (17-30%)!
      Handwashing among Physicians
                      Tibballs, Med J Aust,1996



80
70                                                  Handwashing rate
60                                                  (%)
50
40
30
20                                               "Careful and caring
10                                               doctors can be
 0                                               extraordinarily
                                     and after
                 contact


                           contact
     estimated

                 Before




                                      Before
                            After




                                                 self-delusional
        Self-




                                                 about their behavior"
                                                 Pritchard and Raper, 1996
    Barriers to Handwashing Compliance
               Boyce, Ann Intern Med, 1999




•   Perceived or real time constraints
•   Skin irritation and dryness
•   Inconvenient locations of sinks
•   Lack of personal responsibility
•   Lack of awareness that hand hygiene effects
    clinical outcome
               Antiseptic Hand Rinses


• 60-70% alcohol solutions

• Effective against most
  bacteria, viruses, fungi

• Protective against hand
  drying

• Faster, increased
  compliance
     Effect of Hospital-Wide Hand Hygiene
                              Pittet, Lancet, 2000



     Hand hygiene compliance                    Infections/100 admissions
70                                        20
60                                        18
                                          16
50                                        14
                                          12
40
                                          10
30                                         8
                                           6
20
                                           4
10                                         2
                                           0
0
                                              93

                                              94

                                              95

                                              96

                                              97

                                              98
       1     2   3   4    5     6    7
                                           19

                                           19

                                           19

                                           19

                                           19

                                           19
           Study times, 1994-97
    Antiseptic Hand Rubs as Supplement to
                 Handwashing
                  Summary


• Avoid if hands visibly soiled or contaminated with
  organic material

• Increases compliance with hand hygiene

• Decreases nosocomial infections?

• Consider placement and dispenser carefully
  Prevention of Infections
               Summary

• Prevention of urinary tract infections
     • Decrease urinary catheterization
     • Administrative stop orders?
     • Antiseptic urinary catheters
• Prevention of central venous catheters
     • Maximal barriers at placement
     • Antiseptic catheter
     • Chlorhexidine site disinfection
• New approaches to hand hygiene