Antibiotic Prophylaxis for Short-term Catheter Bladder Drainage in adults. A Systematic Review (Cochrane database August 2013)

Transcription

1 Antibiotic Prophylaxis for Short-term Catheter Bladder Drainage in adults A Systematic Review (Cochrane database August 2013) Gail Lusardi, Senior Lecturer Dr Allyson Lipp, Principal Lecturer, Dr Chris Shaw, Reader University of South Wales, Pontypridd, S. Wales University of South Wales

2 Background Updated Review ' Urinary catheter policies for short-term bladder drainage in adults' (Neil-Weise & J van den Broek, 2005) Specialist Interest in Infection Prevention and Control University of South Wales

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4 HOUDINI Nurse led catheter removal H Haematuria O Obstruction U Urology surgery D Decibitus ulcer I Input/output measurement N Nursing end of life care I Immobility Where none of these exist remove the catheter (Adams 2012) 4

5 Entry points for bacteria Via meatal junction Via urethra along outside of catheter Faecal Flora Via the sampling port At catheter junction with bag Bacteria Via the drainage tap Via the jug Staff Hands 5

6 Objective to determine if one type of antibiotic prophylaxis is better than another or none in terms of prevention of UTI University of South Wales

7 Included Studies Where antibiotic prophylaxis was given for short term catheterisation in hospitalised adults Six parallel-group randomised control studies dated 1977 to 2006 with 789 participants 4 studies - urethral catheter for post operative bladder drainage 2 studies - urethral catheter for non postoperative bladder drainage Patients had a catheter insitu from at least 24hrs to 18 days! 7

8 Excluded Studies 1 study that was previously included All studies involving bladder drainage post Urological surgery Non randomised studies 8

9 Types of Interventions There were 6 different types of antibiotics with different doses used including: Levofloxacin 250mg, ciprofloxacin 250 or 500mg, cefazolin 500mg, ampicillin 1 or 3g, aztreonam 2g, co-trimoxazole 1.2g/240mg. By: single dose, three doses over eight hours or eight hourly for seven days, nine doses over 3 days, once or twice a day 9

10 Outcome Timing/Measures Varied time points at which outcomes were measured Primary outcome bacteriuria 10 5 colony forming units accompanied by urinary symptoms including febrile morbidity (1 trial) bacteriuria 10 3 or 10 5 (5 trials) Secondary outcomes pyuria, febrile morbidity, organisms isolated, adverse reaction to antibiotics, length of stay, costs 10

11 InfDef_current.pdf ational_evidence- Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf 11

12 URINARY TRACT INFECTION FLOW DIAGRAM How many of the following signs & symptoms does the patient have with no other recognised cause? Fever (>38 o C) Urgency Frequency Dysuria Suprapubic tenderness Patient with 0 signs/ symptoms Patient with at least 1 sign/symptom Patient with at least 2 signs/symptoms AND AND AND AND Patient has had indwelling urinary catheter (a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system; also called a Foley catheter. Do not include intermittent catheterisation) within 7 days before positive culture. AND At least 1 positive urine culture, > 10 5 micro-organisms/ cm 3 urine with no more than 2 species of micro-organisms. NB If patient is not on therapy for a UTI on day of survey, then the most recent positive culture must be from a urine Patient has not had indwelling urinary catheter within 7 days of first positive culture. AND At least 2 positive urine cultures, > 10 5 micro-organisms/ cm 3 urine, with repeated isolation of the same micro-organism, and no more than 2 species of micro-organisms. NB If patient is not on therapy for a UTI on day of survey, then the most recent positive culture must be from a urine sample taken within 72h of day of survey. At least 1 positive urine culture, > 10 5 micro-organisms / cm 3 urine with no more than 2 species of micro-organism. At least 1 of the following: Positive dipstick for leukocyte esterase and/o Pyuria (urine specimen with > 10 WBC/mm 3 WBC/high power field of unspun urine) Organisms seen on Gram stain of unspun ur At least 2 urine cultures with repeated isolati same uropathogen (gram-negative bacteria o saprophyticus) with > 10 2 colonies/ml in nonv specimens <10 5 colonies/ml of a single uropathogen (gr bacteria or S. saprophyticus) in a patient bein an effective antimicrobial agent for a UTI Physician diagnosis of a UTI Physician institutes appropriate therapy for a 12

13 Analyses Undertaken Comparisons: Antibiotic prophylaxis versus no prophylaxis Antibiotic prophylaxis with antibiotic A versus antibiotic B Antibiotic prophylaxis at catheterisation only versus antibiotic prophylaxis throughout catheterisation period 13

14 Results Data on bacteriuria was available on all 6 trials. The data from the 6 trials could not be combined in a metaanalysis because of clinical heterogeneity. Asymptomatic bacteriuria was reported in 5 trials Three surgical studies showed significantly fewer cases of bacteriuria in those receiving antibiotics. 14

15 Results -Antibiotic prophylaxis versus no prophylaxis Three surgical studies showed significantly fewer cases of bacteriuria in those receiving antibiotics when data was combined in a meta-analysis (I 2 = 0% risk ratio (RR) 0.20; 95% confidence interval (CI) 0.13 to 0.31) One surgical study showed significantly fewer cases of symptomatic bacteriuria/uti in those receiving antibiotic prophylaxis versus no prophylaxis (risk ratio (RR) 0.20; 95% confidence interval (CI) 0.06 to 0.66) 15

16 Results -Antibiotic prophylaxis with antibiotic A versus antibiotic B In two trials that compared one type of prophylaxis to another neither study showed a significant difference in cases of bacteriuria. (risk ratio (RR) 4.23; 95% confidence interval (CI) 0.21 to 83.53) (risk ratio (RR) 1.37; 95% confidence interval (CI) 0.58 to 3.21) 16

17 Results -Antibiotic prophylaxis at catheterisation only versus antibiotic prophylaxis throughout catheterisation In one study Antibiotic prophylaxis at catheterisation only, resulted in significantly fewer cases of bacteriuria than giving antibiotic prophylaxis throughout catheterisation. (risk ratio (RR) 0.29; 95% confidence interval (CI) 0.09 to 0.91) 17

18 Results Pyuria, Febrile Morbidity In two surgical studies, pooled data showed pyuria occurred in significantly fewer cases in the prophylactic group. In two surgical studies febrile morbidity showed significantly reduced febrile morbidity. In the meta analysis I 2 = 53% 18

19 Results - Organisms All studies assessed micro-organisms but data was to heterogenous to pool. Adverse reactions Length of stay Costs 19

20 Discussion Broad consistency that prophylactic antibiotics reduced the frequency of bacteriuria and other markers of UTI. Definitions of infection are not consistent with surveillance Variations in protocols in organisms tested Resistance to antibiotics not acknowledged Alternative strategies 20

21 Implications Further research needed in high risk groups Selecting Abx that do not increase risk of complications or future resistance Consistency in - period of catheterisation, type & dose of Abx, point in time of measuring bacteriuria CAUTI should be defined according to standardised definitions 21

22 What next! Next update planned within 2 years. Include trials of prophylaxis on removal of catheter. 22

23 And Finally!! Review available at : / CD pub2/abstr act Also available as a podcast and summarised in Cochrane Nursing corner! 23