urinary tract infections - who.int · catheter-associated uti risk of bacteriuria is ~ 5%/day (long...
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Urinary Tract Infections
Leading cause of morbidity and health care expenditures in persons of all ages.
An estimated 50 % of women report having had a UTI at some point in their lives.
8.3 million office visits and more than 1 million hospitalizations, for an overall annual cost > $1 billion.
Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden
Virulence Host factors
Infection No infection
UTIs may occur either because ofthe pathogenicity of the organism,the susceptibility of the host or a
combination of both factors
Virulence factors of the gram-negative uropathogens E. coli and P. mirabilis
Host defenses Host defenses Antibacterial properties of urineAntibacterial properties of urine• Osmolality (extremes of
high or low osmolalities inhibit bacterial growth)
• High urea concentration• High organic acid
concentration• pH
AntiAnti--adherence mechanismsadherence mechanisms• Bacterial interference
(naturally endogenous bacteria in the urethra, vagina, and periurethral region)
• Urinary oligosaccharides (have the potential to detach epithelial-bound E.coli
• Tamm-Horsfall protein (uromucoid): coating of E.coli by this protein might prevent attachment
MiscellaneousMiscellaneous• Mucopolysaccharide lining of the bladder• Urinary immunoglobulins• Spontaneous exfoliation of uroepithelial cells with bacterial
detachment• Mechanical flushing of micturition
Urinary Catheterization
alters these
defensive mechanisms
CatheterCatheter--Associated UTIAssociated UTI
Risk of bacteriuria is ~ 5%/day (long Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable).term catheter bacteriuria is inevitable).40% of nosocomial infections40% of nosocomial infectionsMost common source of gramMost common source of gram--negativenegativebacteremia.bacteremia.Etiology: E.coli, Proteus, Enterococcus, Etiology: E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Pseudomona, Enterobacter, Serratia, CandidaCandida
Duration of cahteterizationDaily Prevalence of Acquired Bacteriuria in Patients
Receiving Bladder Drainage by Indwelling Urethral Catheters
Garibaldi et al. Factors predisposing to bacteriuria during indwelling uretheral catheterization. N Engl J Med 1974;291:215.
Risk Factors Associated with the Development of CAUTI
Increasing duration of catheterizationNot receiving system antibiotic therapyFemale sexDiabetes mellitusOlder ageRapidly fatal underlying diseasesNonsurgical diseasesFaulty aseptic management of the indwelling catheterBacterial colonization of drainage bagAzotemia (serum creatinine concentration > 2 mg/dlCatheter not connected to a urine meterPeriurethral colonization with uropathogens
Asymptomatic Bacteriuria
• The best way to avoid having patients develop IUC-related UTIs is to avoid initial catheter insertion or to minimize the duration of catheter use.
• UTIs are the tenth most likely reason for a Medicare patient to have an unplanned readmission to the hospital
Lee EA Perm J 2011
CA-UTI reduction initiatives began in late
2007 by creation of a catheter
management and removal policy:
• nurse and care partner education
• check off on sterile technique
• insertion competency
• strict guidelines on catheter and perineal
skin care
• mandatory removal of the urinary catheter
at 5 days unless a counter-order was
written.
Community-Acquired UTI
E. coli
K.pneumoniae
Proteus
S.saprophyticus
S.epidermidis &gram neg enterics
Enterococcus
Nosocomial UTIcatheter associated
Short Term Long TermE.coli
E.coli
Pseudomonas Pseudomonas
Proteus
Proteus
Enterobacter
Candida
ProvidenciaMorganella
S.aureus
Enterococcus
FQ resistance
With time
By patient age
By patient sex
Smithson A EJCMID 2011
Prevalence (%) of ESBL producing isolates by species in Assistance Publique Hopitaux de Paris long-term-care facilities
(2001–2005).
Nicolas-Chanoine et al. CMI 2008
Risk factors for ESBL-producing Escherichia coli and Klebsiella pneumoniae
Mendelson et al EJCMID 2005
Multivariate logistic regression analyses:
• Fluoroquinolone use days: OR 1.33 (1.04–1.69) P=0.02
• History of UTI: OR 2.56 (1.37–4.78) P=0.003
Multidrug-Resistant Organisms in LTCF
• MDRGN were isolated more frequently than MRSA or VRE throughout the study period.
• More than 80% of MDRGN isolates were resistant to ciprofloxacin, TMP/SMX, and ampicillin/sulbactam.
• Resistance to three, four, or more antimicrobials were identified among 122 (67.8%), 47 (26.1%), and 11 (6.1%) MDRGN isolates, respectively.
O’Fallon J Gerontol. 2009
Acquisition of Multidrug-Resistant Gram-Negative Bacteria within a LTCF Population
O’Fallon E et al ICHE 2010
• There were significantly higher antibiotic costs, re-consultation costs and total costs for patients whose infections were resistant to at least one antibiotic.
IJAA 2009
Appropriateness by Site of Infection
0
10
20
30
40
50
Urinary
Respiratory
Gastrointestinal
Skin/Soft Tissue
Ear/Nose/Throat
Genital TractOther
AppropriateInappropriate
p=0.76
Lautenbach, Arch Intern Med 2003;163:601
What factors or conditions are likely to have determined UTI?
What measures should have been put in place to prevent it?