Urinary Catheter-Related Infections and Infection Preven：尿导管相关感染和感染的预防

1、Urinary Catheter-Related Infections and Infection Prevention SystemsCarol E. Chenoweth, M.D.Medical Director, Infection Control and EpidemiologyPrevention of Infections:“Bench to BedsideResearch findings “translated into improved clinical care using the resources already in place at the UMHSInfectio

2、n Control and EpidemiologyUMHS Patient Safety CommitteeContinuous Quality ImprovementOffice of Clinical AffairsPrevention of InfectionsPrevention of urinary catheter infectionsPrevention of central venous catheter infectionsNew methods of promoting hand hygieneUrinary Catheter-related Infection: Bac

3、kgroundUrinary 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)

4、Remove the catheter as soon as possible#4) Consider other methods for preventionPrevention of Catheter-related InfectionUTI Prevention Rule #2: Make Sure the Patient Really Needs the Catheter Appropriate indicationsBladder outlet obstructionIncontinence and sacral woundUrine output monitoredPatients

5、 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 ha

6、ve 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

7、 U of M Medical CenterFunding 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

8、 rates Bladder irrigation: NOTAntibacterial agents in collection bag: NOTRigorous meatal cleaning: NOTUse of antiseptic urinary cathetersMethods for Preventing Urinary Catheter-related InfectionPrevention of Catheter-related UTI using Silver Catheters: The Silver Bullet?Silver has in vitro antibacte

9、rial 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 CathetersDecision analytic model comp

10、aring silver catheters with standard non-coated cathetersPatient population: hospitalized patients at high risk for infection requiring catheterization for 2 to 10 daysResults of base-case analysis: Silver catheters prevent morbidity and save money (Saint, Veenstra, Sullivan, Chenoweth, Fendrick. Ar

11、ch Intern Med 2000)Silver Catheters: Policy ImplicationsSilver catheters should be considered in appropriate patients requiring catheterization for 2 to 10 daysEvaluate if silver catheters work at U-MCatheter-related UTI Prevention:Summary RecommendationsUse only a closed drainage system and aseptic

12、 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 daysPrevention of InfectionsPrevention of urinary catheter infection

13、sPrevention of central venous catheter infectionsNew methods of promoting hand hygieneCatheter-related Bloodstream Infection (CR-BSI): BackgroundVascular 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% at

14、tributable mortality rateAnnual cost between $300 million and $2 billionPrevention of Bloodstream InfectionsAseptic placement of CVC catheters Antimicrobial cathetersSite disinfectionFull Barrier Protection for Insertion of CVCsRaad, Infection Control Hosp Epidemiol, 1994Effect of Maximal Barrier Pr

15、ecautions during Insertion on CVC InfectionsRaad et al, Infect Control Hosp Epidemiol, 1994Meta-analysis of Antiseptic Catheters: CR-BSI0.00.51.02.03.0SummaryGeorgeTrazzeraRamsayPembertonCiresiCollinHeardBachHannanMakiTennenbergOdds Ratio OR 0.56, 95% CI (0.37-0.84)(Veenstra, Saint, Saha, et al. JAM

16、A 1999)Economic Evaluation of Antiseptic CathetersIs 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 daysResults: Antiseptic catheters saves money & live

17、s(Veenstra etal, JAMA 1999)Antiseptic Catheters: ImplicationsAntiseptic catheters recommended in critically ill patients requiring central venous access for 2 to 10 daysUM now using these catheters and recently evaluated the resultsintervention“Back of the Envelope Economic Analysis Which Disinfecta

18、nt 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 efficacyChlo

19、rhexidine for Site Disinfection: CR-BSIFavors CHGFavors P-I(Chaiyanupruk et al. Ann Intern Med 2002)Which Disinfectant Should be Used for Catheter Site Care? CaveatsChlorhexidine gluconate costs 2-fold more than povidone-iodine $0.41 vs $0.92 for same amountEffect of CHG in addition to antimicrobial

20、 catheters unclearUM now using this new disinfectant and we plan to evaluate the resultsWashing Hands to Stop Spread of DiseaseIgnaz Semmelweis (1818-1865) Handwashing is still the most important intervention to prevent health-care associated infectionsHandwashing among PhysiciansTibballs, Med J Aus

21、t,1996Barriers to Handwashing ComplianceBoyce, Ann Intern Med, 1999Perceived or real time constraintsSkin irritation and drynessInconvenient locations of sinksLack of personal responsibilityLack of awareness that hand hygiene effects clinical outcomeAntiseptic Hand Rinses60-70% alcohol solutionsEffective against most bacteria, viruses