urinary catheter-related infections and infection preven：尿导管相关感染和感染的预防

Urinary Catheter-Related Infections and Infection Prevention Systems,Carol E. Chenoweth, M.D.Medical Director, Infection Control and Epidemiology,Prevention of Infections:“Bench to Bedside”,Research findings “translated” into improved clinical care using the resources already in place at the UMHSInfection Control and EpidemiologyUMHS Patient Safety CommitteeContinuous Quality ImprovementOffice of Clinical Affairs,Prevention of Infections,Prevention of urinary catheter infectionsPrevention of central venous catheter infectionsNew methods of promoting hand hygiene,Urinary Catheter-related Infection: Background,Urinary tract infection (UTI) causes over 40% of hospital-acquired infectionsMost infections due to urinary catheters25% of inpatients are catheterizedLeads to increased morbidity and costs,#1) Use a closed drainage system, aseptic placement and care #2) Make sure the catheter is indicated#3) Remove the catheter as soon as possible#4) Consider other methods for prevention,Prevention of Catheter-related Infection,UTI Prevention Rule #2: Make Sure the Patient Really Needs the Catheter,Appropriate indicationsBladder outlet obstructionIncontinence and sacral woundUrine output monitoredPatients request (end-of-life) During or just after surgery (Wong and Hooton - CDC 1983),(Jain, Arch Int Med 1995),Why are Catheters Used Inappropriately?,Perhaps physicians “forget” that their patient has a urinary catheterStudy to determine the extent to which physicians are aware which of their inpatients have urinary cathetersSurveyed 56 medical teams at 4 sites; 256 providers completed the survey (response rate = 89%) (Saint S, Wiese J, Amory J, et al. Am J Med 2000),Urethral Catheters: Lost in Place?,(Saint S, Wiese J, Amory J, et al. Am J Med 2000),Systems Approach to Reducing Urethral Catheterization U of M Medical Center,Funding provided by the Blue Cross Blue Shield of Michigan FoundationWritten reminder placed on the chart by a research nurse after 48 hours of catheter useBefore-and-after study on 2 hospital wards with 2 concurrent control wardsData collection underway; also will evaluate UTI rates,Bladder irrigation: NOTAntibacterial agents in collection bag: NOTRigorous meatal cleaning: NOTUse of antiseptic urinary catheters,Methods for Preventing Urinary Catheter-related Infection,Prevention of Catheter-related UTI using Silver Catheters: The Silver Bullet?,Silver has in vitro antibacterial activityEfficacy of silver catheters shown in meta-analysis of randomized trials (Saint, et al. Am J Med, 1998)Additional cost of $5.30 per silver catheter trayIs the reduction in catheter-related infection worth the extra cost?,Economic Evaluation of Silver Catheters,Decision analytic model comparing silver catheters with standard non-coated cathetersPatient population: hospitalized patients at high risk for infection requiring catheterization for 2 to 10 days,Results of base-case analysis: Silver catheters prevent morbidity and save money,(Saint, Veenstra, Sullivan, Chenoweth, Fendrick. Arch Intern Med 2000),Silver Catheters: Policy Implications,Silver catheters should be considered in appropriate patients requiring catheterization for 2 to 10 daysEvaluate if silver catheters work at U-M,Catheter-related UTI Prevention:Summary Recommendations,Use only a closed drainage system and aseptic techniqueUse urethral catheters only when necessaryConsider using an administrative catheter “stop order” to limit inappropriate catheterizationConsider silver catheters in high-risk patients who require catheterization for 2 to 10 days,Prevention of Infections,Prevention of urinary catheter infectionsPrevention of central venous catheter infectionsNew methods of promoting hand hygiene,Catheter-related Bloodstream Infection (CR-BSI): Background,Vascular catheters are the leading cause of nosocomial bacteremia; most due to central venous catheters150,000 cases of CR-BSI annually in U.S.4% to 25% attributable mortality rateAnnual cost between $300 million and $2 billion,Prevention of Bloodstream Infections,Aseptic placement of CVC catheters Antimicrobial cathetersSite disinfection,Full Barrier Protection for Insertion of CVCsRaad, Infection Control Hosp Epidemiol, 1994,Effect of Maximal Barrier Precautions during Insertion on CVC InfectionsRaad et al, Infect Control Hosp Epidemiol, 1994,Meta-analysis of Antiseptic Catheters: CR-BSI,0.0,0.5,1.0,2.0,3.0,Summary,George,Trazzera,Ramsay,Pemberton,Ciresi,Collin,Heard,Bach,Hannan,Maki,Tennenberg,Odds Ratio,OR 0.56, 95% CI (0.37-0.84),(Veenstra, Saint, Saha, et al. JAMA 1999),Economic Evaluation of Antiseptic Catheters,Is the benefit worth the extra $25 per catheter?Decision model comparing antiseptic with standard catheters in patients at high-risk for CR-BSI (e.g. critically ill) using central lines for 2 to 10 days,Results: Antiseptic catheters saves money & lives,(Veenstra etal, JAMA 1999),Antiseptic Catheters: Implications,Antiseptic catheters recommended in critically ill patients requiring central venous access for 2 to 10 daysUM now using these catheters and recently evaluated the results,“Back of the Envelope” Economic Analysis,Which Disinfectant Should be Used for Catheter Site Care?,Povidone-iodine (PI) is currently the most widely used agent for site disinfectionChlorhexidine gluconate (CHG) has been compared to PI with mixed resultsWe performed a formal meta-analysis of published and unpublished studies to clarify relative efficacy,Chlorhexidine for Site Disinfection: CR-BSI,Favors CHG,Favors P-I,(Chaiyanupruk et al. Ann Intern Med 2002),Which Disinfectant Should be Used for Catheter Site Care? Caveats,Chlorhexidine gluconate costs 2-fold more than povidone-iodine $0.41 vs $0.92 for same amountEffect of CHG in addition to antimicrobial catheters unclearUM now using this new disinfectant and we plan to evaluate the results,Washing Hands to Stop Spread of DiseaseIgnaz Semmelweis (1818-1865),Handwashing is still the most important intervention to prevent health-care associated infections,Handwashing among PhysiciansTibballs, Med J Aust,1996,Barriers to Handwashing ComplianceBoyce, Ann Intern Med, 1999,Perceived or real time constraintsSkin irritation and drynessInconvenient locations of sinksLack of personal responsibilityLack of awareness that hand hygiene effects clinical outcome,Antiseptic Hand Rinses,60-70% alcohol solutionsEffective against most bacteria, viruses