Acquired Urinary Tract Infection Prevention Discussion

Acquired Urinary Tract Infection Prevention Discussion ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Acquired Urinary Tract Infection Prevention Discussion Identify the clinical problem/issue. Formulate perspective considering the limits of position and other points of view. Acquired Urinary Tract Infection Prevention Discussion 2. Explore consequences or possible outcomes using national quality and safety initiatives: (30 points) a. National Patient Safety Goals (NPSG) b. The Joint Commission (TJC) c. Agency for Healthcare Research and Quality (AHRQ) d. Institute for Healthcare Improvement (IHI) e. Institute for Safe Medication Practices (ISMP) f. Quality and Safety Education for Nurses (QSEN) Acquired Urinary Tract Infection Prevention Discussion g. ANA Code of Ethics h. ANA Scopes of Standards and Practice – Nursing i. Quality Improvement Representative or Quality Safety Council member from the local hospital or medical center j. Other. 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Acquired Urinary Tract Infection Prevention Discussion cauti_article.pdf prevent_cauti.pdf cauti_2.pdf Pharmacology Reducing Carbapenem Exposure: Extended-Spectrum `-Lactamase CatheterAssociated Urinary Tract Infection Management Shannon Holt, PharmD, BCPS-AQ ID Mollie Grant, PharmD, BCPS, BCCCP Kelly A. Thompson-Brazill, RN, DNP, ACNP-BC, CCRN-CSC Catheter-associated urinary tract infections are one of the most common sources of infection, accounting for up to 40% of health care–associated infections each year in the United States. Extended-spectrum `-lactamase–producing Enterobacteriaceae are frequent causes of urinary tract infections in health care settings. Prevalent use of carbapenems has led to the emergence of carbapenem-resistant Enterobacteriaceae infections, leaving clinicians with few treatment options. Reducing carbapenem use and investigating alternative options for low-severity extended-spectrum `-lactamase infections is imperative to prevent more cases of carbapenem-resistant Enterobacteriaceae. Although carbapenems are the antibiotics of choice for treating extended-spectrum `-lactamase–producing Enterobacteriaceae catheter-associated urinary tract infections, carbapenem-sparing regimens may be appropriate for treating hemodynamically stable patients with low inoculum levels. Moreover, frontline health care providers can initiate efforts to reduce the development of multidrug-resistant organisms by decresing inappropriate antibiotic use during the treatment of catheter-associated asymptomatic bacteruria, avoiding unnecessary catheterizations, and avoiding culturing urine in asymptomatic patients. (Critical Care Nurse. 2017;37[5]:78-84) atheter-associated urinary tract infections (CAUTIs) are one of the most common sources of infection, accounting for up to 40% of health care–associated infections (HAIs) each year in the United States. Acquired Urinary Tract Infection Prevention Discussion Approximately 95% of urinary tract infections (UTIs) in critically ill patients develop in individuals who have a urinary catheter in place.1 Prolonged duration of catheter placement is the highest risk factor for the development of CAUTI.2 During the time a urinary catheter remains in place, the device alters the body’s natural defense mechanisms and facilitates the ability of pathogens to migrate from the perineum into the bladder.3 Microorganisms commonly C CE 1.0 hour, Pharma 0.5, CERP A This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives: 1. Describe the differences among catheter-associated asymptomatic bacteriuria and uncomplicated and complicated urinary tract infections. 2. Verbalize 5 best practices for urinary catheter insertion and maintenance during acute care. 3. List noncarbapenem antibiotics to treat carbapenem-resistant Enterobacteriaceae in patients with low-severity catheter-associated urinary tract infection. To complete evaluation for CE contact hour(s) for activity C1752, visit www.ccnonline.org and click the “CE Articles” button. No CE fee for AACN members. This activity expires on October 1, 2020. The American Association of Critical-Care Nurses is an accredited provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Registered Nursing of California (#01036) and Louisiana (#LSBN12). ©2017 American Association of Critical-Care Nurses doi: https://doi.org/10.4037/ccn2017648 78 CriticalCareNurse Vol 37, No. 5, OCTOBER 2017 www.ccnonline.org found in the perineum and gastrointestinal tract, such as Escherichia coli and other Enterobacteriaceae (Table 1),3 often cause CAUTI.Acquired Urinary Tract Infection Prevention Discussion Extended-spectrum `-lactamase (ESBL)– producing Enterobacteriaceae are frequent causes of UTI in health care settings.5 The Centers for Disease Control and Prevention cites ESBL-producing Enterobacteriaceae as a serious health care threat.3 Because these organisms are resistant to many antibiotics, carbapenems have emerged as the drugs of choice for invasive infections due to ESBLproducing organisms.6 However, this prevalent use of carbapenems for more than 10 years has led to the emergence of carbapenem-resistant Enterobacteriaceae (CRE) infections, leaving clinicians with few treatment options.7 Reducing use of carbapenems and investigating alternative options for low-severity ESBL infections is imperative to prevent more cases of CRE. In addition to reducing carbapenem use, a reduction in inappropriate antibiotic prescribing overall is necessary. The Centers for Disease Control and Prevention has reported that inappropriate antibiotic prescribing occurs for 30% to 50% of hospitalized patients receiving antibiotics.8,9 This inappropriate use of antibiotics not only leads to increased risk for the development of resistant organisms but also to adverse events including Clostridium dif?cile–associated diarrhea.10 The purpose of this article is to describe the criteria for an active ESBL CAUTI and to examine the evidence regarding the currently available ESBL CAUTI treatment options for patients with active infections. De?nitions Catheter-associated asymptomatic bacteriuria (CAASB) is de?ned as the presence of signi?cant bacteria in the Authors Shannon Holt is an assistant professor of clinical education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and a clinical pharmacist specialist, infectious disease, Department of Pharmacy, WakeMed Health & Hospitals, Raleigh, North Carolina. Mollie Grant is a critical care pharmacy specialist, WakeMed Health & Hospitals, Raleigh, North Carolina. Kelly A. Thompson-Brazill is an assistant professor, Georgetown University School of Nursing and Health Studies, Washington, DC. Corresponding author: Kelly A. Thompson-Brazill, RN, DNP, ACNP-BC, CCRN-CSC, FCCM, Georgetown University School of Nursing and Health Studies, 3700 Reservoir Rd NW, Washington, DC 20057 (email: [email protected]). Acquired Urinary Tract Infection Prevention Discussion To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected]. www.ccnonline.org Table 1 Enterobacteriaceae involved in catheter-associated urinary tract infections Enterobacter aerogenes Enterobacter cloacae Escherichia coli Klebsiella pneumoniae Klebsiella oxytoca Morganella morganii Proteus mirabilis Serratia marcescens Adapted from Hooton et al2 and Murray PR et al.4 urine culture of a patient without signs or symptoms of a urinary infection.11 Uncomplicated UTI is de?ned as a symptomatic bladder infection characterized by frequency, urgency, dysuria, or suprapubic pain in a woman with a normal genitourinary tract, and is associated with both genetic and behavioral determinants. A complicated UTI is de?ned in the Infectious Diseases Society of America guidelines as a symptomatic urinary infection in individuals with functional or structural abnormalities of the genitourinary tract. Assessing Patients With Bacteriuria The ?rst step toward effective antimicrobial stewardship is decreasing unnecessary exposure to antibiotics, including carbapenems. The risk of developing multidrugresistant organisms (MDROs) increases with the inappropriate treatment of urinary catheter colonization or CAASB. Therefore, determining if the patient is colonized or actively infected is imperative.2 This determination may be dif?cult in patients with indwelling urinary catheters. Acquired Urinary Tract Infection Prevention Discussion They may not have the classic UTI symptoms of dysuria, urinary frequency, or urgency. When assessing for symptoms, include nonspeci?c signs such as new onset of fever, chills, altered mental status, lethargy, or fatigue. In addition, patients may complain of ?ank or suprapubic pain or discomfort.2,12 Next, if the patient is symptomatic, a urinalysis and urine culture should be assessed before administering antibiotics. When reviewing the urinalysis, the presence of 10 or more white blood cells per cubic millimeter is referred to as pyuria. Pyuria indicates in?ammation in the genitourinary tract.13 Pyuria and the appearance of the urine should not be used to differentiate between CriticalCareNurse Vol 37, No. 5, OCTOBER 2017 79 CAASB and CAUTI.2 Although the lack of pyuria is helpful for ruling out a CAUTI, this ?nding should not be used as the only diagnostic tool for this infection. The urine culture is also important for determining CAUTI, and ideally should be obtained from a freshly placed urinary catheter.2 However, such timing for the culture is not always feasible in practice. The 2010 Infectious Diseases Society of America guidelines state signi?cant bacteriuria is present when cultures report 10 000 cfu/mL or more. If the urinary catheter was placed just before the culture, then lower colony counts may re?ect bladder bacteriuria.2 The completion of a detailed patient assessment can assist with decreasing inappropriate carbapenem use and overall antibiotic use. If CAASB is suspected, then ESBL therapy would not be recommended in most patients. Treatment of CAASB may be considered in women with catheter-acquired bacteriuria 48 hours after indwelling catheter removal or in men with CAASB identi?ed before transurethral resection of the prostate.11 If the patient is symptomatic and does not have pyuria, then another source of the patient’s symptoms should be suspected and investigated.2 Treatment Carbapenem Treatment Options Patients with symptomatic ESBL CAUTI require antibiotic administration; however, treatment options are limited because Enterobacteriaceae that produce the ESBL enzymes are typically resistant to all other penicillins and extended-spectrum cephalosporins.Acquired Urinary Tract Infection Prevention Discussion Fortunately, several agents may still retain in vitro susceptibility to ESBLproducing Noncarbapenem agents with the most organisms. impressive data are `-lactam/ Carbapen`-lactamase inhibitors and fosfomycin. ems have been the mainstay of ESBL therapy since the early 2000s. In early studies, patients treated with carbapenems for invasive ESBL bloodstream infections had improved outcomes compared with patients treated with other agents, despite reported in vitro susceptibility.14,15 Paterson et al16 reported a lower all-cause 14-day mortality in patients with nosocomial ESBL Klebsiella pneumoniae bacteremia with carbapenems (1/27, 3.7%) compared with noncarbapenem agents. The noncarbapenem group included quinolones (4/11, 36.3%) and other `-lactam agents (4/9, 44%). 80 CriticalCareNurse Vol 37, No. 5, OCTOBER 2017 In a retrospective study of 85 patients with nosocomial ESBL-producing bacteremia, patients treated with imipenem versus cephalosporins were more likely to survive (12/13 [92%] vs 5/7 [71%]; P = .023).17 This therapeutic advantage of carbapenems has been attributed to the inoculum effect, as well as high minimum inhibitory concentrations (MICs) of other agents that are close to the susceptibility breakpoints. The inoculum effect is de?ned as the increase of a drug’s MIC of up to 100-fold in the presence of a high bacterial load. This inoculum effect has been observed with cephalosporins.18 To date, there has not been a single prospective randomized control trial (RCT) to determine the most effective regimen for ESBL infections. Conversely, new literature suggests that noncarbapenems with in vitro activity against ESBL microbes may be an alternative option in patients with low levels of inoculum and less invasive ESBL infections such as CAUTIs. Noncarbapenem Treatment Options Several agents have reported in vitro activity to ESBL-producing Enterobacteriaceae. Acquired Urinary Tract Infection Prevention Discussion The noncarbapenem agents with the most clinical data are `-lactam/ `-lactamase inhibitors (BLBLIs) and fosfomycin.19-24 Cefepime has reported in vitro activity against ESBLproducing organisms; however, evidence is con?icting in the treatment of ESBL-producing organisms.25-28 Therefore, use of cefepime is not discussed in this article. Aminoglycosides, quinolones, and trimethoprim/sulfamethoxazole have in vitro activity against ESBL organisms and concentrate in the urine. However, these agents typically cannot be used in practice as the plasmid carrying the genes for ESBL frequently also carries the genes encoding resistance to these agents.29-32 `-Lactamase Inhibitors. ESBLs are inhibited by `-lactamase inhibitors (BLIs). BLBLIs remain active against a large portion of ESBL-producing organisms despite other resistance mechanisms.31 Tazobactam, clavulanate, and avibactam are all BLIs that retain activity against ESBLs.20,31,33-36 The ef?cacy of BLIs can vary among the classes of `-lactamases.37 Tazobactam and clavulanate are considered irreversible “suicide inhibitors” that will permanently inactivate `-lactamase. They also both share a structural similarity to penicillin.35,37 Avibactam is a new non–`-lactam BLI, which means that it has a chemical structure different from older BLIs. The unique structure of avibactam ensures www.ccnonline.org the molecule is less likely to undergo degradation by resistant bacteria.33 BLIs have no antimicrobial activity when used as monotherapy, but when combined with `-lactam antibiotics, BLIs have activity against multidrugresistant gram-negative organisms, including ESBLs.35,37 Combinations that contain these BLIs include piperacillintazobactam, amoxicillin-clavulanate, ceftolozanetazobactam, and ceftazidime-avibactam.33,34,38,39 Although no prospective trials have evaluated the ef?cacy of BLBLIs for the treatment of ESBL-producing UTIs, retrospective observational studies have reported them to be effective.19-22 Piperacillin-Tazobactam. Piperacillin-tazobactam may be an option in low inoculum, less-invasive infections with reported in vitro susceptibility. The effectiveness of this combination is likely because piperacillin is relatively resistant to hydrolysis by plasmid-mediated `-lactams compared with other `-lactams and because tazobactam has relatively more potent inhibition than clavulanate or sulbactam.37 Piperacillin-tazobactam was evaluated in a retrospective study of ESBL-producing E coli bacteremia (n = 39) that included 11 patients who had a urinary source.19 All 11 patients treated with piperacillin-tazobactam were alive at 30 days, regardless of the MIC value reported. Acquired Urinary Tract Infection Prevention Discussion This small study demonstrated that piperacillin-tazobactam can be used effectively for treating ESBL bacteremia from a urinary source, regardless of MIC. However, for patients with other sources of infection, such as intraabdominal infections, piperacillin-tazobactam was more effective in isolates with low MIC values (MIC ?2 ?g/mL).19 Amoxicillin-Clavulanate. In a 2006 retrospective study, BLBLI or carbapenem was compared with quinolones or cephalosporins for the treatment of ESBL E coli bacteremia infections (n = 43) predominantly from a urinary source (46%).22 Piperacillintazobactam, amoxicillin-clavulanate (intravenous), or carbapenem empiric therapy had a reported lower mortality rate than cephalosporins or quinolones (9 vs 35%; P = .05). Another small study evaluated the use of BLBLIs (piperacillin-tazobactam [n = 18] and amoxicillin-clavulanate [n = 36]) compared with carbapenems (n = 120) for the treatment of ESBL E coli bacteremia, with 69% from a urinary or biliary source.20 The authors reported no increase in 30-day mortality when comparing de?nitive therapy of BLBLIs versus carbapenems (9.3% vs 16.7%; P > .2). As seen in these 2 small studies, amoxicillin-clavulanate is another www.ccnonline.org potential noncarbapenem option for immunocompetent, hemodynamically stable patients who are able to take the drug either orally or via feeding tube. The ef?cacy of amoxicillin-clavulanate, while not altered by an inoculum effect, may vary depending on MIC value.20,21,31,36 In addition to the previously cited studies, the efficacy of amoxicillin-clavulanate oral therapy for ESBL-producing E coli cystitis (n = 122) was evaluated in a retrospective case-control study.21 The clinical cure rate with amoxicillin-clavulanate was 84% overall, but varied by MIC. For patients with MIC less than 8 ?g/ mL, over- Newly approved BLBLI combinations all clinical show promise as an alternative option to cure was treat ESBL-producing infections. 93%, but clinical cure fell to 40% for patient with MIC greater than or equal to 32 ?g/mL. This retrospective study demonstrated that oral amoxicillin-clavulanate can be a useful option for patients with ESBL E coli cystitis, particularly in isolates with low MIC values less than or equal to 8 ?g/mL.21 Newly approved BLBLI combinations show promise as an alternative option to treat ESBL-producing infections. Ceftolozane-tazobactam was also recently approved by the Food and Drug Administration for complicated UTIs and intra-abdominal infections.34,35 Ceftolozanetazobactam was found to be noninferior to levo?oxacin in the treatment of complicated lower UTIs or pyelonephritis in a large RCT (n = 800; clinical cure 95.0% vs 93.2%; 95% CI, -0.8 to 6.2).40 A subgroup analysis was completed of patients with ESBL-producing uropathogens (n = 118/800, 14.8%) and reported a signi?cantly higher clinical cure rate in the ceftolozane-tazobactam group than in the levo?oxacin group (90.2% vs 73.7%; 95% CI, 2.6-30.2).35,40 Ceftazidime-Avibactam. Acquired Urinary Tract Infection Prevention Discussion Ceftazidime-avibactam is another newly approved cephalosporin/BLI combination antibiotic. The addition of avibactam has expanded the spectrum of activity for traditional ceftazidime to include many ceftazidime-resistant gram-negative organisms, including ESBLs.33 A large RCT found ceftazidime-avibactam to be noninferior to imipenemcilastatin in the treatment of complicated UTIs and pyelonephritis.41 In this trial, for patients with isolated pathogens that were resistant to traditional ceftazidime (n = 18), ceftazidime-avibactam had a slightly higher CriticalCareNurse Vol 37, No. 5, OCTOBER 2017 81 microbiologic response than imipenem-cilastatin (85.7% vs 81.8%). These new BLBLI combination agents represent a feasible noncarbapenem option for the coverage of ESBL CAUTIs. However, given that they are signi?cantly more expensive than other alternative agents and ceftazidime-avibactam has in vitro activity against CRE, providers may want to reserve use of this agent for more invasive gram-negative infections. As with all `-lactams, patients should undergo close monitoring for serious adverse effects, including hypersensitivity reactions and C dif?cile–associated diarrhea. The patient’s creatinine clearance should be closely monitored as all of these agents require dose adjustments in renal dysfunction.33,34,38,39,41 Although the data supporting use of BLBLIs for treatment of ESBL infections are currently limited, BLBLIs can be considered an alternative for patients with a low burden of disease, such as patients with a CAUTI. Fosfomycin. Fosfomycin has in vitro activity against ESBL-producing organisms and is currently available in the United States only as an oral formulation.Acquired Urinary Tract Infection Prevention Discussion Fosfomycin is a bactericidal antibiotic that works to inhibit cell wall biosynthesis. It is approved by the Food and Drug Administration for uncomplicated cystitis in a single 3-g oral dose; however, fosfomycin has also been used for complicated UTIs in a 3-g every-other-day, 3-dose regimen.23,42,43 Fosfomycin has primarily concentration-dependent activity with a postantibiotic effect of 30 to 40 hours, making the antibiotic an efficacious treatment option for singledose administration.44 Observational clinical literature support use of fosfomycin for complicated UTIs.23,24 In one observational study, fosfomycin 3 g every other day for 3 doses was given to patients with complicated and uncomplicated E coli UTIs Nurses should focus on preventing the (n = 52; n = 7 spread of ESBL and other MDROs by with CAUTIs).23 Cliniperforming hand hygiene before and cal suc … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10