Dr Eleri Davies. Consultant Microbiologist and Infection Control Doctor, Public Health Wales NHS Trust

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1 Dr Eleri Davies Consultant Microbiologist and Infection Control Doctor, Public Health Wales NHS Trust

2 Antimicrobial stewardship What is it? Why is it important? Treatment and management of catheter-associated urinary tract infections Antimicrobial stewardship and catheter-associated urinary tract infections Antimicrobial coated urinary catheters

3 Antimicrobial Stewardship Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Infectious Disease Society of America (IDSA)

4 Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. (Association of Professionals in Infection Control & Epidemiology APIC USA)

5 From Practical Guide to Antimicrobial Stewardship in Hospitals - BSAC

6 The right antibiotic for the right patient, At the right time, With the right dose, and the right route, Causing the least harm to the patient and future patients

7 Right Drug, Right Dose, Right Time, Right Duration, Every Patient

8 The overarching goal of the Strategy is to slow the development and spread of AMR. It focusses activities around 3 strategic aims: improve the knowledge and understanding of AMR, conserve and steward the effectiveness of existing treatments, stimulate the development of new antibiotics, diagnostics and novel therapies.

9 Why is Antimicrobial Stewardship Important? The success of antibiotics / antimicrobials has meant that many lives have been saved through the successful treatment of infection... BUT Over use / Misuse is a problem Antimicrobial resistance has been identified as a MAJOR threat by the WHO. Clostridium difficile disease a significant problem related to antimicrobial use. There is a lack of new antibiotics in development

10 BALANCE Effective Rapid Empirical Treatment of Infection Sepsis Six Broad spectrum antibiotics Driving Resistance Clostridium difficile

11 Published 18 th November 2013 to coincide with European Antibiotic Awareness Day.

12 E. coli (the commonest cause of blood stream infections in Wales) Resistance to most antimicrobials has increased in the last year o Co-amoxiclav resistance increased to 42% o Ciprofloxacin resistance increased to 23% o 3rd generation cephalosporin resistance increased to 15% o Gentamicin resistance increased to 10%

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14 Linking antimicrobial stewardship

15 CAUTI the burden Urinary tract infections are one of the commonest healthcare associated infections across the developed world: Prevalence survey 2011 Wales 21% of HCAI were UTI A significant amount is urinary catheter associated 60% of Healthcare associated UTI in the acute sector in Wales were associated with urinary catheters 33% of the UTIs in the non-acute hospitals were CAUTI.

16 Defining CAUTI Bacterial colonisation of urinary catheters is inevitable. Estimated risk of 5% per day with almost 100% colonisation at day 7 10 of catheterisation. Simply basing treatment of CAUTI on the culture of organisms from the urine is therefore flawed. From Health Protection Scotland CAUTI surveillance protocol

17 Guidelines Prevention E.g. Epic 2, SHEA / IDSA practice recommendation 2008 Reducing duration of catheterisation Reducing unnecessary catheterisation Insertion and maintenance care bundles Do not treat asymptomatic bacteriuria in catheterised patients. Over use of antimicrobials drives resistance.

18 CAUTI Management Principles Treat an INFECTION symptoms + positive urine Send urine for culture if infection suspected Blood culture also if hospitalised and septic Empirical treatment should take account of local resistance information START SMART Review with culture results THEN FOCUS the antimicrobial therapy

19 Treatment Duration Generally 7 days treat as complicated UTI Some consider shorter courses in females <65 years with short term catheter. If there are signs of sepsis / positive blood culture / pyelonephritis 7-14 days therapy with monitoring of inflammatory markers and resolution of symptoms.

20 Antibiotic prophylaxis NICE guidance March 2012 When changing catheters in patients with a longterm indwelling urinary catheter: do not offer antibiotic prophylaxis routinely consider antibiotic prophylaxis for patients who: have a history of symptomatic urinary tract infection after catheter change or experience trauma during catheterisation. [new 2012]

21 The Aberdeen Study

22 Antimicrobial Catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial (Pickard et al) Published the Lancet December 1 st 2012 Aim: To establish whether short term routine use of antimicrobial catheters reduced risk of CAUTI compared with standard polytetrafluoroethylene (PTFE) catheterisation Silver alloy coated catheters and nitrofural impregnated catheters were compared with PTFE standard.

23 Large multi-centre study 6394 patients in total 2144 in control group 2097 in silver alloy catheter group 2153 in nitrofural impregnate catheter group Primary outcome: Incidence of symptomatic CAUTI Presence of participant reported symptoms of UTI and clinician prescription of antibiotic for UTI up to 6 weeks post randomisation to one of the catheters.

24 Conclusion Silver alloy-coated catheters were not effective for reduction of incidence of symptomatic CAUTI. The reduction noted in CAUTI associated with nitrofural impregnated catheters was less than that regarded as clinically important. Routine use of antimicrobial impregnated catheters is not supported by this trial.

25 Summary Antimicrobial stewardship is key to protecting the antimicrobials we have for use in the future. Right Drug, Dose, Time and Duration for every antimicrobial for every patient! Bacteriuria is to be expected following catheterisation Asymptomatic bacteriuria does not require antimicrobial therapy. Focus antimicrobial treatment based on culture results Routine use of antimicrobial impregnated catheters is not recommended.