의료관련요로감염의예방 아주대학교의과대학감염내과최영화
목차 도뇨관의역사 도뇨관감염을줄이기위한여러노력 유치도뇨관관리 유치도뇨관삽입시관리 유치도뇨관삽입중관리 유치도뇨관삽입후소변백관리 소변배양검사 포괄적요로감염예방법 (UTI Bundle) SHEA/IDSA 2014 update
도뇨관의역사 Painful urinary retention은기원전 3000년에도있었다. 당시사용한것들 : straw, rolled up palm leaves, hollow tops of onions, as well as, gold, silver, copper, brass, and lead 11세기 : 굽혀지는금속 catheter, 주로굽히기쉬운은제품 18 세기고무로만든 catheter ; 너무열에약함, Debris Latex rubber 제품 : 1935 년 www. URO Today.com
Frederic E.B. Foley(1891-1966) St. Paul urologist introduced the latex balloon catheter at a urologic meeting in 1935 Foley type catheter (0.33 mm = 1 French [Fr]) 초창기에는 male penis, female labia 에묶거나고정
Foley type urinary catheter
bacteriuria!!! Catheter fever Open drainage system The urinary catheter was originally an open system with the urethral tube draining into an open container 96hrs 100%
Closed drainage system 1950 년대이후 closed bag 도입 96hrs 100% bacteriuria!!! 14days 50% bacteriuria!!!
Catheter-associated (CA)-bacteriuria 무증상세균뇨 : 증상없이 10 5 /ml 임산부, urosurgery 의경우에만치료 80 세노인 : 40-50% Catheter-associated (CA)-bacteriuria Asymptomatic bacteriuria : no treatment (CA-ASB) Symptomatic UTI: diagnosis of exclusion (CA-UTI) CA- bacteriuria: 도뇨관삽입후하루 3-8%/d ASB: 치료필요없으나내성균전파의주요병원소 Symptomatic UTI : 세균뇨환자가증상발현하는비율은낮으나워낙많은도뇨관이사용되므로원내패혈증에서차지하는비율 20% 로높음. 입원환자중 12-16% 가도뇨관사용
1,000 기구일당감염율의변화 (2011-2015) CAUTI surveillance data NHSN 2011: 0.2-4.8/1000 catheter-days, 성인병실 NHSN 2011: 1.2-4.5/1000 catheter-days, 성인 ICU
감염부위별감염율의 병원규모별비교
CAUTI pathogen(2006-2013) 100% 90% 80% 70% 60% 50% 40% Fungus G(-) G(+) 30% 20% 10% 0% 2006 2007 2008 2009 2010 2011 2012 2013 G(+) G(-) Fungus % 24.4 40.2 35.2 Trend test p-value 0.0478 0.0027 0.1944
Pathogenesis of CAUTI Biofilm S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
Treatment of CAUTI 1) 유치카테터제거또는교체 (>2weeks); biofilm 2) 새것넣고 urine culture sampling 3) Antibiotics: 7~10~14 Asymptomatic bacteriuria: Do not screen, Do not treat!!
다른방법들 생각해봅시다.
Bladder irrigation: 방광세척 여러가지로씻어보기 Normal saline KMNO4 Antibiotics Povidone iodine Prophylactic bladder irrigations using antibiotics, hydrogen peroxide or povidone-iodine are not helpful. J Hosp Infect. 1992;21:223 9, N Engl J Med. 1978;299:570 3 Colonization or infection with more resistant organisms.
요도구를매일소독해주기 Routine daily meatal care 혼합항생제크림 : Infect Control Hosp Epidemiol. 1991 Mar;12(3):157-62 10% Betadine meatal care vs no care: 간호학회지 1989 chlorhexidine gluconate or povidone iodine: J Hosp Infect 2004 Mar;56(3):236-8 meatal disinfectants and antibacterial urethral lubricants are ineffective no benefits with routine daily periurethral cleaning using normal saline, soap, or an antiseptic or with the addition of antiseptics to the drainage bag
정기적으로교체해주기 7 일 14 일 21 일 28 일 There are no strong recommendations to date as to the time at which routine catheter changes have to be made. Most guidelines agree that catheters should not be changed routinely. Some advocate change if there is presence of obstruction, before urine sampling for culture or before treatment initiation for symptomatic UTI.
특별한카테터 Silver coated catheter Antibiotic coated catheter
Short-term catheterization Silver vs Standard, Outcome : No. of ASB <1 week
Short-term catheterization Antibiotic impregnated vs Standard catheter outcome: No. of ASB(<1week)
특별한카테터 Silver coated catheter Antibiotic coated catheter Antibiotic-coated catheters have been shown to prevent or delay the onset of catheter-associated bacteriuria. However, there is no evidence to suggest that they decrease symptomatic infection or demonstrate any clinical benefit. Nitrofurazone-impregnated catheters had significant effect on biofilm formation and bacterial growth. In the former, this was significant for only the initial 5 days of catheterization.
현재까지의요로감염예방지침요점 Closed drainage system 유치기간단축
포괄적요로감염예방법 ( UTI bundle) 이란? 1. 유치도뇨관삽입과사용기간최소화 (Avoid unnecessary urinary catheters) 2. 유치도뇨관삽입시무균술적용 (Insert urinary catheters using aseptic technique) 3. 가이드라인에따른유치도뇨관관리 (Maintain urinary catheters based on recommended guidelines) 4. 매일유치도뇨관유지의필요성평가 (Review urinary catheters necessity daily against criteria)
유치도뇨관을넣어야하는경우 - 급성요정체와요로폐쇄의관리를위한사용 - 중증환자의정확한소변량을측정할필요가있을경우 -다음의수술과정과관련되어사용하려고할때 * 비뇨기수술이나비뇨생식기와인접한구조물에대한수술 * 장시간의수술이예견되는경우 ( 이때는수술후회복실에서바로제거 ) * 수술중많은양의수액또는이뇨제를투여받는환자 * 수술중소변량을감시할필요가있는경우 -요실금환자의천골부위또는회음부위에개방창상이있는경우 -장기부동자세를요구하는환자 ( 예, 흉곽또는척추불안정, 골반골절과같은다발손상 ) -말기환자를편안하게해주기위한사용 Mandell GL ed. Philadelphia: Churchill Livingstone, 2015.
1. 유치도뇨관삽입과사용기간최소화 꼭필요한때에삽입하고필요기간만큼만유지 유치도뇨관을대체할수있는방법검토 Condom catheter Suprapubic catheterization Intermittent catheterization 유치도뇨관을요실금관리를위한목적으로사용하는것은금지 수술환자에게관례적이기보다필요시에만사용 유치도뇨관을삽입한수술환자는지속적으로사용해야하는경 우가아니라면수술후가능한 (24 시간이내 ) 빨리제거
장기사용자에서무엇이더좋은가? 남자 Condom catheter Suprapubic catheter Intermittent catheterization 잔료량이많지않은경우요도협착, 손상감소, 성생활, 카테터제거시기평가용이 여자용? 침습적시술, 교체가불편, 누출 4-6 시간간격, <500mL, 남자, 여자, 척수손상환자의표준 세균뇨, 수신증, 결석등의합병증적음 * 단기사용시유치도뇨관보다세균뇨는감소하나교육, 인력, 환자들비선호 *+ bladder scanner 그런연구는해본적이없다.
2. 유치도뇨관삽입시무균술적용 손위생 멸균기구와멸균수법을이용한유치도뇨관삽입 가능한내경이작은유치도뇨관사용 Rarely is a catheter larger than 18 F required, and 14 or 16 F usually suffices
3. 가이드라인에따른유치도뇨관관리 무균적폐쇄시스템유지소변관류가막히지않도록유지소변백은항상방광보다아래유지하며바닥에닿지않도록각환자마다개별수집용기사용하고주기적으로소변백비움소변이튀지않도록하고수집통에소변백마개가닿아오염되지않도록함소변을비우고난소변백의입구는소독제로소독한후뚜껑을씌움 유치도뇨관과소변백의정기적인교환은권고하지않음. 단, 감염, 관류막힘, 폐쇄시스템이유지되지않을때도뇨관과소변백을교환 유치도뇨관삽입부위는물과비누세척같은일상적인위생으로충분함. 만일폐쇄가예상되는경우가아니라면 ( 예, 방광수술후출혈 ) 방광세척은하지 않음
4. 매일유치도뇨관유지의필요성평가 더이상필요하지않은유치도뇨관을찾아제거하는정책필요 유치도뇨관삽입의적절한적응증이아닌경우즉시제거 유치도뇨관사용이적절하지않은경우 - 요양시설이나거주치료소에서요실금을해결하기위한사용 - 자발적배뇨가가능한환자에서진단적목적또는배양을위한소변채취시사용 - 적절한적응증없이수술후장기간도뇨관을유지하는경우
유치도뇨관관리
1. 유치도뇨관삽입시관리 (1-1) 준비물품 - 도뇨세트 - 유치도뇨관 - 소변백 - 10cc 주사기 - 멸균소공포 - 소독솜 - 멸균증류수 - 일회용윤활제 - 멸균장갑 - 고정장치 ( 반창고 ) - 손소독제
1. 유치도뇨관삽입시관리 (1-2) 손위생실시및개인보호장구착용 Femal e Male 손위생도뇨세트손위생멸균유기물 (+) : 물과비유기물 (+) : 물과비장갑누누유기물 (-) : 알콜젤유기물 (-) : 알콜젤열기착용
1. 유치도뇨관삽입시관리 (1-3) 소공포적용및피부소독 (10% 베타딘 or 1-2% chlorhexidine/ 식염수스폰지 ) Femal e Femal e Male Male 멸균소공포 회음부피부소독 적용여자 : 위에서아래로 ( 왼쪽오른쪽가운데 ) 남자 : 요도구부터둥글게아래쪽으로
1. 유치도뇨관삽입시관리 (1-4) 무균법적용삽입 소공포제거및유치도뇨관과소변백연결 Femal e Male 유치도뇨관 소공포제거 소변 백삽입연결
1. 유치도뇨관삽입시관리 (1-5) 유치도뇨관고정및소변백고정 유치도뇨관고정 삽입후움직임을최소화하도록적절하게고정 소변백고정 소변백이바닥에끌리거나방광보다위에위치하지않도록고정
2. 유치도뇨관삽입중관리 (2-1) 폐쇄도뇨시스템 (Closed drainage system) 유지 관류가막히지않도록유지
2. 유치도뇨관삽입중관리 (2-2) 소변백바닥에끌리지않도록고정 유치도뇨관배액관이꺾이지않도록관리 소변백이방광보다위에위치하지않도록관리
3. 유치도뇨관삽입후소변백관리 (3-1) 준비물품 - 일회용장갑 - 환자별수집용기 - 소독제 - 손소독제
3. 유치도뇨관삽입후소변백관리 (3-2) 장갑착용및개별수집용기사용 일회용장갑착용 환자별수집용기사용
3. 유치도뇨관삽입후소변백관리 (3-3) 소변비우기, 소변백끝을알콜솜으로닦고포트에끼움 소변비우기소변백의입구를소변백의입구소변백의입구가수집용기에에닿지않도록주의하며비움소독제로닦음뚜껑을씌움
3. 유치도뇨관삽입후소변백관리 (3-4) 장갑제거후손위생 장갑제거 손위생 유기물 (+) : 물과비누유기물 (-) : 알콜젤
4. 소변배양검사 (4-1) 적은양의검체채취 유치도뇨관검체채취포트 (Sampling port) 이용 포트표면을소독제로닦은후 멸균주사기를사용하여무균적으로채취 많은양의검체채취 소변백에서무균적으로채취 증상이없는환자에서정기적인소변배양검사자제
4. 소변배양검사 (4-2) 준비물품 - 멸균장갑 ( 비닐또는라텍스 ) - 멸균주사기 - 검체용기 - 소독제 - 손소독제
4. 소변배양검사 (4-3) 손위생및멸균장갑착용 손위생 유기물 (+) : 물과비누유기물 (-) : 알콜젤 멸균장갑착용
4. 소변배양검사 (4-4) 검체채취과정 검체채취포트가있는도뇨관 독 포트소독포트에서검체채취포트소 검체채취포트가없는도뇨관 연결접합부 연결접합부에서 연결접 합부소독 검체채취 소독
4. 소변배양검사 (4-5) 검체용기에담고장갑제거후손위생 검체용기에멸균장갑손위생유기물 (+) : 물과비누검체담기제거유기물 (-) : 알콜젤
가장많은오답 문항? 13. 유치도뇨관을삽입한환자는정기적으로소변배양검사를해야한다. ( O, X) 16. 유치도뇨관삽입부위에국소항생제연고나크림을일상적으로사용하면감염예방에도움이된다. ( O, X)
Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update SHEA\IDSA Education, implementation of common CAUTI prevention practices, outcomes and process measures, and feedback of CAUTI outcomes 도뇨관제한정책, 필요성검토 : 사용율감소 17.5 6.6% 적응증교육, 유치필요성간호회진검토 : 사용률 18.1 13.8%, 적정사용률 44%-58% 교육과 active surveillance: 사용률감소 : 18.5 9.2% UTI bundle: 사용률감소, 13.3 4.0 CAUTI/1,000 catheter day 도관사용율, 유치기간감소 Infection Control and Hospital Epidemiol... Vol. 35, No. 5, May 2014
Basic practices for preventing CAUTI: recommended for all acute care hospitals A. Provide appropriate infrastructure for preventing CAUTI : 예 ) 지침서 B. Perform surveillance for CAUTI if indicated on the basis of facility risk assessment or regulatory requirements : Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations C. Provide education and training D. Use appropriate technique for catheter insertion Infection Control and Hospital Epidemiol...
Approaches that should not be considered a routine part of CAUTI prevention 1. Do not routinely use antimicrobial/antisepticimpregnated catheters (quality of evidence: I). 2. Do not screen for asymptomatic bacteriuria in catheterized patients (quality of evidence: II). 3. Do not treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (quality of evidence: I). 4. Avoid catheter irrigation (quality of evidence: II). a. Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure. b. If continuous irrigation is being used to prevent obstruction, maintain a closed system. 5. Do not use systemic antimicrobials routinely as prophylaxis (quality of evidence: III). 6. Do not change catheters routinely (quality of evidence: III). Infection Control and Hospital Epidemiol... Vol. 35, No. 5, May 2014
Unresolved issues 1. Use of antiseptic solution versus sterile saline for meatal cleaning before catheter insertion. 2. Use of urinary antiseptics (eg, methenamine) to prevent UTI. 3. Use of catheters with valves. 4. Spatial separation of patients with urinary catheters in place to prevent transmission of pathogens that could colonize urinary drainage systems. 5. Antimicrobial prophylaxis at catheter removal to prevent symptomatic Infection Control and infection. Hospital Epidemiol...
현장적용 1) Engage 여러부서를모아팀을만든다. Physician-led team, Nursing-led team 네트워크이용, champions 2) Educate 교육시간마련 : 도관관리, 적응증, 삽입법, 손위생, 대체안 교육자료제공 : 부서별, online, bedside binder 3) Execute 실행 4) Evaluate Compliance Feedback to staff: UTI rate, hand hygiene rate, costs of UTI
Execute 1. Provide daily nursing reminders to physicians to remove unnecessary catheters 2. Standardize indications for urinary catheter placement 3. Utilize bladder bundle 4. Develop a nurse-driven protocol to discontinue catheter if no longer meeting criteria 5. Employ computerized order entry a. Admitting physician alert requiring confirmation of continued indication for previously placed catheters b. Change of physician order set from insert Foley catheter to patient-initiated void on call for appropriate procedures c. Mandatory order to remove catheter at 5 days d. Best-practice order sets 6. Use prewritten stop orders 7. Utilize bladder scanners to measure urine volume 8. Standardize products 9. Increase availability of bedside commodes 10. Conduct individual case reviews 11. Create redundancy of educational materials
경청해주셔서감사합니다.
여러용어들 bacteriuria asymptomatic bacteriuria catheter-associated asymptomatic bacteriuria (CA-ASB) catheter-associated urinary tract infection (CA-UTI) Catheter-associated funguria (CAfunguria) Presence of significant bacteriuria in a catheterized or recently catheterized patient without regard to the presence or absence of urinary symptoms Presence of significant bacteriuria in a catheterized or recently catheterized patient with symptoms or signs referable to the urinary tract Presence of funguria in a catheterized or recently catheterized patient. asymptomatic or symptomatic
14 일이내사용하는경우 Types of indwelling urethral catheters for short-term catheterization in hospitalized adults. Cochrane Database Syst Rev. 2014 Silver alloy-coated catheters were not associated with a statistically significant reduction in symptomatic CAUTI, and are considerably more expensive. Nitrofurazone-impregnated catheters reduced the risk of symptomatic CAUTI and bacteriuria, although the magnitude of reduction was low and hence may not be clinically important. However, they are more expensive than standard catheters. They are also more likely to cause discomfort than standard catheters.
Take home message Even though treatment of ASB is not recommended, it is possible that prevention of CA-ASB might lead to fewer episodes of CA-UTI, bacteremia, fever episodes, cross-infection, and inappropriate antimicrobial use.
Asymptomatic bacteriuria: Do not screen, Do not treat!! ( 예외 : 산모, 비뇨기시술 )
Risk factors for CAUTI Modifiable Risk Factors Duration of catheterization Nonadherence to aseptic catheter care (ie, opening closed system) Nonmodifiable Risk Factors Female sex Severe underlying illness Lower professional training of inserter Nonsurgical disease Catheter insertion outside operating room Aged >50 y Diabetes mellitus Serum creatinine >2 mg/dl
Burden of CAUTI UTI: MC hospital acquired infection 70-80% 가유치도뇨관사용자입원중 12-16% 가유치도뇨관사용유치도뇨관사용자중 3-7%/d 세균뇨발생세균뇨발생자중일부가유증상 CAUTI rate: NHSN 2011: 0.2-4.8/1000 catheter-days, 성인병실 NHSN 2011: 1.2-4.5/1000 catheter-days, 성인 ICU KONIS 2011 2015: 3.87 0.91/1000 catheter-days, 성인 ICU 기타도뇨관사용의단점 : 요도염증, 협착, 손상, 이동장애무증상세균뇨로인한부적절한항생제사용증가