Urinary Tract Infections

Transcription

1 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.

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5 Virulence Host factors Infection No infection UTIs may occur either because of the pathogenicity of the organism, the susceptibility of the host or a combination of both factors Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden

6 Virulence factors of the gram-negative uropathogens E. coli and P. mirabilis

7 Host defenses Antibacterial properties of urine Osmolality (extremes of high or low osmolalities inhibit bacterial growth) High urea concentration High organic acid concentration ph Miscellaneous Urinary Catheterization alters these defensive mechanisms Mucopolysaccharide lining of the bladder Urinary immunoglobulins Spontaneous exfoliation of uroepithelial cells with bacterial detachment Mechanical flushing of micturition Anti-adherence 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

8 Catheter-Associated UTI Risk of bacteriuria is ~ 5%/day (long term catheter bacteriuria is inevitable). 40% of nosocomial infections Most common source of gram-negative bacteremia. Etiology: E.coli, Proteus, Enterococcus, Pseudomona, Enterobacter, Serratia, Candida

9 Duration of cahteterization Daily 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.

10 Risk Factors Associated with the Development of CAUTI Increasing duration of catheterization Not receiving system antibiotic therapy Female sex Diabetes mellitus Older age Rapidly fatal underlying diseases Nonsurgical diseases Faulty aseptic management of the indwelling catheter Bacterial colonization of drainage bag Azotemia (serum creatinine concentration > 2 mg/dl Catheter not connected to a urine meter Periurethral colonization with uropathogens

11 Asymptomatic Bacteriuria

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20 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

21 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.

22 Community-Acquired UTI E. coli Proteus S.saprophyticus K.pneumoniae S.epidermidis & gram neg enterics Enterococcus

23 Nosocomial UTI catheter associated Short Term E.coli Long Term Enterobacter E.coli Enterococcus Proteus Candida Proteus Pseudomonas S.aureus Pseudomonas Providencia Morganella

24 By patient age FQ resistance By patient sex With time

25 Smithson A EJCMID 2011

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28 Prevalence (%) of ESBL producing isolates by species in Assistance Publique Hopitaux de Paris long-term-care facilities ( ). Nicolas-Chanoine et al. CMI 2008

29 Risk factors for ESBL-producing Escherichia coli and Klebsiella pneumoniae Mendelson et al EJCMID 2005

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31 Multivariate logistic regression analyses: Fluoroquinolone use days: OR 1.33 ( ) P=0.02 History of UTI: OR 2.56 ( ) P=0.003

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33 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

34 Acquisition of Multidrug-Resistant Gram- Negative Bacteria within a LTCF Population O Fallon E et al ICHE 2010

35 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

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38 Appropriateness by Site of Infection 50 Appropriate Inappropriate 40 p= Urinary Respiratory Gastrointestinal Skin/Soft Tissue Ear/Nose/Throat Genital Tract Other Lautenbach, Arch Intern Med 2003;163:601

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40 What factors or conditions are likely to have determined UTI?

41 What measures should have been put in place to prevent it?

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