MRS.
JYOTHI MARTIN K
ASSOCIATE PROFESSOR
KMCT CON
What is care
bundle??????????
• A care bundle is a set of interventions
that, when used together, significantly
improve patient outcomes
• A bundle is structured way of improving
the processes of care and patient
outcomes
• A bundle is a group of EB care
components for a given disease that,
when executed together, may result in
better outcomes… than implemented
individually.
• Most common
• Accounts for 40% of nosocomial infection
Presence of significant bacterium in a
catheterized or recently catheterized
patient, with or without symptoms or
signs referable to the urinary tract.
• Catheter-associated : bacteriuria
with symptoms or signs referable to
the urinary tract
• Catheter associated asymptomatic
bacteriuria: without symptoms or
signs referable to the urinary tract
EPIDEMIOLOGY
• 15-25% hospitalized patient experience UTI in
hospital stay
• Risk increases with length of stay
• 3-10% per catheter day rise up to 25% at end of
one week
• CDC-NHSN says, CAUTI per 1,000 catheterized
days was 0-5.3% in critical care unit
• 0-3.1% in inpatient wards
• In India, 1.63 to 2.1 per 1,000 catheter days
TYPES OF UTI
CRITERIA UNCOMPLICATE HAI-UTI
D UTI
Age Younger Older
Sex Female, rare in male Both sexes
Major risk Sexual intercourse Presence of catheter
Pathogenesis Fecal commensals Extra luminal and
ascend from urethra intraluminal spread
to bladder of fecal commensals
or cross infection
from HCW
Virulence and More virulent, less Less virulent but
resistance drug resistant more drug resistant
CRITERIA UNCOMPLICATED HAI-UTI
UTI
Microbiology Usually monomicrobial Short-term:
monomicrobial
Clinical spectrum ASB(asymptomatic CA-ASB
bacteria) CAUTI-fever, altered
Cystitis –dysuria, mental status, other
frequency or urgency non-specific
Pyelonephritis -fever and signs/symptoms.
back pain or tenderness Usually no lower
urinary tract
symptoms
Diagnosis ASB: 105 cystitis CA_ASB >105
103 Pyelonephritis CAUTI >103
Treatment Short course 5 to 14 day regimen
Single dose to 5 days Depending on
MICROBIOLOGY
• A broad range of bacteria can cause CAUTI
In short-term catheterized patient
•Monomicrobial
•Gram-negative bacilli
•Enterococci
•E. coli- predominant agent
•Enterobacteriaceae : klebsillea, Serratia, Citrobactor and enterobacter
•Non-fomentors such as pseudomonas and acinetobacter
•Gram positive cocci: coagulase-negative staphylococci and enterococcus
•Fungaria: candiduria
In long term catheterized patient
• Polymicrobial
•Proteus
•Providencia
•Morganella
RISK FACTORS
Device
related
Patient Caregiver
related related
Device related
•Types of catheterization
•Type of catheter material
•* Latex – higher
•* Silicon
TYPE OF
CATHETERIZATION
Patient related
• Female gender
• Fatal underlying conditions
• Older age> 50
• DM
• Elevated serum creatinine
• Poor personal hygiene
• Urethral colonization
• Incomplete emptying of bladder
• Fecal incontinence
Care giver related
• Failure to follow aseptic technique
• Emergency catheter insertion
PATHOGENESIS
• 4 main entry points
› Urethral meatus- catheter junction
› Junction between drainage tube and
bag
› Drainage bag
› Bag outlet valve
• Microorganism ascend to urinary tract via
› Extraluminal surface
› Intraluminal surface
EXTRALUMINAL SPREAD INTRALUMINAL SPREAD
• 2/3 of cases ➢ Improper drainage bad
• Patients own endogenous system
flora ➢ Reflux of contaminated
• Hands of healthcare urine
workers
• Inanimate objects
• Not practicing aseptic
technique while insertion
Others:
• Biofilm: bacteria attach catheter -------- form
biofilm------- insertion of catheter--------
immunocompromized state--------- infection
spread to UT
• Struvite stone: increase in PH by proteus
species of organism---------formation of Struvite
stone in bladder------block catheter flow-------
promote colonization------- recurrent infection
COMPLICATIONS
• BACTERIURIA
• CATHETER OBSTRUCTION
• BLADDER STONE
• LOCAL GENITOURINARY INFECTION
• FISTULA FORMATION
• URINARY INCONTINENCE
• PYELONEPHRITIS
• BLADDER CANCER
DIAGNOSIS
History of catheterization
• Short term- sample from catheter port by
aseptic technique
• Long term – sample from fresh replaced
catheter
• In non catheterized patients, sample taken
through condom catheter, clean catch voided
urine
Significant bacteriuria
Catheterized patients Non-catheterized patients
• Colony count • Colony count
• Symptomatic: > • Symptomatic :
103CFU/mL >103CFU/mL
• Asymptomatic: • Asymptomatic:
>105CFU/mL • Female- >105CFU/mL
in two specimens
• Male- >105CFU/ml
single specimen
Signs and symptoms –any one
should be present
• New onset or worsening of fever
• Altered mental status
• Flank pain
• Costovertebral angle tenderness
• Rigors
• Pelvic discomfort
• New or worsening incontinence, malaise or
lethargy
• Patient with spinal cord injury :
increased spasticity, autonomic
dysreflexia, sense of unease
• After catheter removal : dysuria,
frequency, and urgency
TREATMENT -CAUTI
Empirical therapy:
• It depends upon the local antibiogram.
• In Indian set up, the recommended agents are:
› Ciprofloxacin
› Ceftazidime or cefepime
› Piperacillin-tazobactam
› Imipenem or meropenem.
Definitive therapy:
• The choice of the agent depends up on the
susceptibility pattern of the organism isolated.
Duration: There is no consensus on optimal
duration of treating CAUTI.
› For mild to moderate, afebrile - duration of treatment
must be for 5 to 7-days and
› For severe illness or febrile or both, duration of
treatment ranges from 5 to 14 days.
Removal of catheter :
Treatment of CA-ASB
• If bacteriuria persists for more than 48 h after
removal of catheter
• In pregnancy, as there is 20-30 fold higher risk of
developing pyelonephritis and risk of premature
delivery with low birth weight
• Duration of treatment is about 3-7 days.
• Prior to traumatic urological procedures with
anticipated bleeding.
Treatment of candiduria
• Flucanozole for 14 days
• Flucytosine - oral
• Parenteral amphotericin B
Prior to catheterization
• Education: regular periodic training on
insertion and maintenance of catheter
• Catheter type:
› Short term- latex catheter (urethritis, stricture
formation, obstruction)
› Silicon catheter - obstruct less, prefer for long-
term
› Teflon coated catheter – medium use(28 days)
• Catheter size: smallest diameter, free flow
allowed, avoid potential trauma to urethra and
sphincter
Larger catheter block urethral gland, and put
pressure on mucosa lead to ischemic necrosis
Inflation of balloon with sterile water, 10ml for
adult and 2.5ml for children
Normal size:
12-16 Fr for men 5-6 Fr for newborn
12-14 Fr for women 5-10 Fr for children
For urology patients larger diameter can be used
• Use only when indicated
Appropriate indication Inappropriate
indications
➢I/O monitoring in CCU •Urinary incontinence unless
➢Acute urinary retention pressure ulcer present
➢Urinary obstruction •Morbid obesity
➢Perioperative use •Use in uncooperative patients
➢Anticipated prolonged surgery •Urine specimen collection when
➢Prolonged immobilization normal voiding possible
➢Improve comfort for end life •Patient or family request when
care not indicated
• Alternatives to indwelling urinary
catheter:
› Suprapubic catheter
› Condom catheter
› Intermittent catheter
• Controversial practices: not recommended
such as antimicrobial coated catheters,
prophylactic systemic antimicrobial therapy,
methenamine salts, cranberry products.
During catheterization
• Minor surgical procedure
• Maintain aseptic field
• Use only sterile equipments
• Prior to procedure, explain the procedure to
patient
• Should follow procedure steps as such with
principles of aseptic manner
1. Gloves – sterile gloves
2. Sterile field – on top of trolley where articles
are placed
3. Periurethral cleaning – clean with sterile water
or saline
4. 2% lignocaine – instill to urethra to minimize
pain
5. Catheter insertion – aseptic non touching
technique
6. Balloon inflammation
7. Dressing
8. Drainage system – closed urinary drainage,
below bladder level
9. Drainage stand
10. Securement - with plastic tape at thigh or
abdomen
11. Gloves removed
After catheterization
Closed drainage system:
● Drainage bad below bladder level, above floor
level
● Leg bags in ambulatory patients
● Emptying
● Drainage tap
● Separate container
● Hand hygiene
● Gloves
● Alcohol swabs
Meatal care:
➢ Periodic care
➢ With soap and water
➢ 2 or 3 time in 24 hrs
➢ Wet first and followed by dry
➢ No use of antiseptic solution or ointments
➢ Maintain personal hygiene
When taking specimens;
• Disinfect site with alcohol, allowed to
dry before sample collection
• Collect from sample port, not from bag
• Aspirate drainage tube with sterile needle
• Silicone catheter not punctured
Removal of catheter
• Inspect daily
• Assess for readiness to removal
• Replace in presence of signs of UTI, obstruction,
or fecal incontinence
• Use bedside ultrasound to assess post voiding
residual volume
• Administer prophylactic antibiotic before catheter
removal or replacement is not recommended.
Documentation
• Proper documentation
• Note indication for catheterization
• Name of staff inserted
• Date and time of catheter insertion
• Daily assessment
• Daily catheter care
• Date of removal
Innovative strategy
• Hydrophilic coating of catheter –
provide improved comfort, decrease microbial
adherence, reduce encrustation
• Nanoparticles – magnesium fluoride inhibit
biofilm formation
• Iontophoresis - application of electrical field
in silicon catheter to enhance efficacy of
antibiotics against biofilm
• Newer antimicrobial coated catheters:
triclosan, gendine(-gentian violet and
chlorhexidine), nitrous oxide impregnated
catheters
• Urease inhibitors: acetohydroxamic acids,
fluorofamide reduce encrustation
• Bacterial interference: colonize catheter
with non-pathogenic bacteria
Care bundle
Insertion bundle Maintenance bundle
Inserted only when appropriate Daily catheter care
Only sterile items used Secure properly
Insert by non-touching Drainage bag above floor and
technique below bladder level
Continuous closed drainage Use closed drainage
used
Use appropriate size Make sure safe sample
collection
Secure catheter in place Daily assessment and readiness
for removal
Urinary catheter care bundle
D D D D D D D D D D
Device day 1 2 3 4 5 6 7 8 9 10
Closed drainage system
Urinary catheter secure
Drainage bag above floor and below bladder
level
Catheter Hand hygiene
care
Meatal care
Single use glove while emptying
No contact between jug and bag
Separate jug for collecting
Assessment to readiness for removal-
documented?
