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
4/10
10//06
06;; UTI Pseudomonas a. ESBL
t t d with
treated
ith Meropenem
M
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

 18/
18/11
11//06
06;; Bedsore get heavily colonized
(E. coli and Proteus M.)
26
26//11
11//06
06;; UTI (E. coli) treated with
Gentamicin
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
ESBL pseudomonas a. treated with 3
antibiotic for 3 weeks.

 Enterobacter also ESBL that was treated

with Gentamicin
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

Patients 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
First to control bleedingg ppost-operatively
p
y
Then to drain the obstructed tract
Drain incontinent patient
Measure
M
urinary
i
output

1950s and the close sterile drainage system

1970 knows
1970s
k
th
the routine
ti surveillance
ill

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

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

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

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

 Consequences
q
of antibiotic use
Emergence of resistant strains

Epidemics of HA UTI
Urinary drainage bag act as a reservoir for
the organisms to colonize and to transfer the
resistant plasmid
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
Transurethral catheter break the normal defense
mechanism
The
Th retention
i balloon
b ll
prevents complete
l emptying
i
Open channel to the bladder
Foreign
i body
b d

 Bacterial factors
Pili
Hemolysin
Urease

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

 Host factors

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

Diagnosis
CDC definition
Exclude infections that acquired prior to admission
Asymptomatic bacteriuia should
have > 100,000 cfu/cc
Culturingg the catheter tip
p is of NO VALUE
Uses 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
Fully computerized patient records
Data
Data--mining
mining--derived epidemiology