Healthcare AssociatedUrinary 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 non-infectious 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 infectionHost 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 effectGlycocalix/ 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 immobilizationOthers

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 genderDelay recognized of systemic infectionDM/ Renal insufficiencyAdvanced ageSeverity of underlying diseaseMeatal colonization(peri-urethral) (72% in

female; 30% in male)

CGH 醫療照護相關感染微生物排名 -UTI

排名 98 年度 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

排名 98 年度 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

排名 98 年度 99 年度 100 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

TNIS( 區域）加護單位醫療照護相關感染微生物排名 -UTI

排名 98 年度 99 年度 100 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

E.coli

79

64

8993

98

82

74

8691

98

82

67

8389

95

80

52

8285 86

80

43

82 8084

81

24

7581

85

0

20

40

60

80

100

GM CF CIP CXM CTX 抗生素

S%

2001年

2003年

2005年

2007年

2009年

2011年

K.pneumoniae

92

80

95

89

9594

85

95 93

99

92

83

9389

9591

79

91

84

9192

77

90

83

9089

69

8884

90

0

20

40

60

80

100

GM CF CIP CXM CTX抗生素

S%

2001年2003年2005年2007年2009年2011年

E. cl oacae

93

17

95

66

7878

12

96

58

7978

11

92

61

79

88

7

92

53

76

90

3

95

44

72

91

6

90

51

72

0

20

40

60

80

100

GM CF CIP CXM CTX 抗生素

S%

2001年2003年2005年2007年2009年2011年

Ps.aeruginosa

98

90

96 9497

78

9893

97 9799

76

9590

9591

97

87

97

9194

89

99

88

98

9092

83

95

86

96

9092

83

9290

0

20

40

60

80

100

IPM CIP CAZ ATM FEP LVX 抗生素

S%

2001年2003年2005年2007年2009年2011年

A.baumannii

95

76

68

26

70

77

97

64

58

39

72

65

93

65

73

23

73

68

91

65

60

11

6366

91

68 69

12

78

70

62

5255

5

53 53

0

20

40

60

80

100

IPM CIP CAZ ATM FEP LVX 抗生素

S%

2001年

2003年

2005年

2007年

2009年

2011年

S.aureus

70

34

3

72

100 100

77

39

5

76

100 100

73

35

3

69

100 100

83

43

5

81

100 100

91

53

4

100 100

90

54

1

84

100100

0

20

40

60

80

100

SXT E P CIP VA TEC 抗生素

S%

2001年2003年2005年2007年2009年2011年

S.pneumoniae

4642

21

100 100

36

55

29

94

100

3235

25

98 100 100

35

16

31

100 100 100

26

7

30

100

29

3

26

100

0

20

40

60

80

100

SXT E P CIP VA TEC 抗生素

S%

2001年2003年2005年2007年2009年2011年

GAS

21

83

100 98 100

22

98 100 99 100

23

90

9996

100

9

95100

97100

61

100 100

93

100 100

0

20

40

60

80

100

SXT E P CIP VA 抗生素

S%

2001年2003年2005年2007年2009年2011年

GBS

18

78

100

92

100

9

81

10095

100

7

75

10095

100

9

77

99 98 100

67

100 100

66

100 100

0

20

40

60

80

100

SXT E P CIP VA抗生素

S%

2001年2003年2005年2007年2009年2011年

E.faecalis

11

31

95 96

11

26

97

77

100

9

23

96

81

100

71

29

96

85

100 100

27

92

78

98100

61

70

82

100 100

0

20

40

60

80

100

SXT E P CIP VA TEC抗生素

S%

2001年2003年2005年2007年2009年2011年

E.faecium

14

41

74

100

6

23

62

38

100

3

30

46

40

96

70

29

53

63

8992

1722

34

83

100

63

36

46

95100

0

20

40

60

80

100

SXT E P CIP VA TEC 抗生素

S%

2001年2003年2005年2007年2009年2011年

2008年 ~ 2011年ESBL 比較(1)--數量

339

126

6

350

131

10

282

86

13

312

77

40

50

100

150

200

250

300

350

400

E.coli K. pneumoniae K. oxytoca ESBL菌株

( )數量 株

2008年

2009年

2010年

2011年

2008 ~ 2011 ESBL 比較(2)--百分比

6.76%5.70%

6.72%5.72%5.58%

4.59%

21.31%

8.03%

5.94%6.90%

11.32%10.99%

0%

5%

10%

15%

20%

25%

E.coli K. pneumoniae K. oxytoca ESBL菌株

百分比

2008年

2009年

2010年

2011年

ESBL

菌株 E.coli Klebsiella pneumoniae Klebsiella oxytoca

平均年度 數量 ESBL 百分比 數量 ESBL 百分比 數量 ESBL 百分比

972584

339 6.76%1105

126 5.70%18

6 11.32% 6.47%2434 1105 35

982491

350 6.72%1057

131 5.72%43

10 10.99% 6.47%2719 1233 48

992527

282 5.58%955

86 4.59%46

13 21.31% 5.45%2523 920 15

1002232

312 8.03%669

77 5.94%30

4 6.90% 7.50%1655 627 28

平均 19165 1283 6.69% 7671 420 5.48% 263 33 12.55% 6.47%

Therapeutic Plans

Host risk-factor considerationMicrobiologic factorsClinical essential data Recognizing situation where the usual

treatment may be inappropriateTrend of antimicrobial resistance and D.Dx

colonization or infection

Treatment Goals

Draumatic reduce or eradicate pathogenic strains

Limit the extent and severity of HAI-UTIMinimize 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 <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)