Dissertations / Theses on the topic 'Catheter related urinary tract infections'

Bakgrund:Kvarliggande kateter [KAD] är en behandling för akut eller kronisk urinretention och används vid sjukdomar eller vissa operationer. Samtidigt ökar KAD risk för urinvägsinfektion, vilket minskar patientsäkerheten, förlänger återhämtningstid och ökar behandlingskostnad. Förebyggande åtgärder för att minska kateterassocierad urinvägsinfektion [UVI] blir därför allt viktigare. Flera länder i Europa, Nord- och Sydamerika har gjort flertalet studier och hittat effektiva evidensbaserade förebyggande åtgärder mot kateterassocierad UVI. Utifrån säker och evidensbaserad vård skulle evidensbaserade förebyggande åtgärder tas reda på och användas för att minska kateterassocierad UVI.  Syfte:Att beskriva förebyggande åtgärder inom omvårdnad mot kateterassocierad UVI. Metod:Litteraturöversiktutifrån Polit och Becks niostegsmodell användes i urval och datainsamling till att 12 artiklar gick igenom kvalitetsgranskningen och analyserades till resultatet med induktiv ansats.  Resultat:Förebyggande åtgärder sammanställdes i tre huvudkategorier. Första huvudkategorin följ riktlinjer med underkategorierna kateterisering endast utifrån läkarordination och lämpliga indikationer, aseptisk teknik med rätt utrustning, fixering av KAD och uppsamlingspåsen samt borttagning av KAD om inga behov föreligger. Andra huvudkategorin utför kontrollrutiner med underkategorierna utför kateteriserings checklista samt kontrollera, rapportera    och dokumentera kateter dagligen. Tredje huvudkategorin etablera ett systematiskt förbättringsarbete med underkategorierna utse en eller två ansvariga personer, erbjud föreläsning och träning om kateterisering samt arrangera workshop. Slutsatser:Kateterassocierad UVI kan förebyggas om sjuksköterska uppfyller sin kompetens med hjälp av workshop, utför kateterisering enligt riktlinjer, samt hanterar och kontrollerar urinkateter enligt kontrollrutiner såsom kateteriserings checklista.
Background:An indwelling catheter is used as a treatment for acute or chronic urinary retention and is commonly used for diseases or some surgeries. At the same time, indwelling catheters increases the risk of urinary tract infections, which reduces patient safety, prolongs patient’s recovery and increases treatment costs. Several countries in Europe, North- and South America have conducted several studies that found evidence-based, effective preventive measures against catheter associated urinary tract infections. Evidence-based preventative measures should be found out and be used to decrease catheter associated urinary tract infections. Aim: To describe preventive measures in nursing against catheter-associated urinary tract infections. Method:Literature overview with Polit and Beck's nine-way model is used in selection and data collection to ensure that the 12 articles selected to the quality review were analyzed for results with an inductive approach. Results:Prevention measures were compiled into three main categories. First main category follows guidelines with subcategories catheterization only based on medical ordinance and appropriate indications, aseptic technique with proper equipment, fixation of catheter and collection bag and removal of catheter if no needs exists. Second main category performs check routines with subcategories perform catheterization checklist as well as check, report and document catheters daily. Third main category establish a systematic improvement work with subcategories appoint one or two responsible persons, offer lecture and training on catheterization and arrange workshop. Conclusions:Catheter associated urinary tract infections can be prevented if the nurse fulfills her/his competency with help of workshop, performs catheterization according to guidelines, manages and controls the urinary catheter according to control routines such as catheterization checklist.

The Centers for Disease Control and Prevention, the Joint Commission, and the Agency for Healthcare Research and Quality recognized the importance of reducing health-care-associated infections (HAIs) and catheter-associated urinary tract infections (CAUTIs) for the safety of all patients. The U.S Department of Health and Human Services has focused on approving a plan to address HAIs in the health care setting with an emphasis on CAUTIs. The purpose of this project was to decrease CAUTI rates on a long-term care and rehab unit by educating staff about using the CAUTI bundle and CAUTI maintenance tool kit. The theoretical framework that guided this project was Knowles's assumption of adult learning. The practice-focused questions addressed the effects of staff education on CAUTI prevention using a CAUTI bundle approach. Pretest and posttest data were collected from all current primary care nursing staff providers at the study site. CAUTI rates were also obtained from the infection prevention and control nurse at the study facility. Implementation of education related to the CAUTI bundle approach led to 2 consecutive months of no CAUTIs in 2019. Findings from the CAUTI project may bring about positive social change by improving patients' quality of life by ensuring they do not develop HAIs. Use of the CAUTI bundle approach may be implemented in long-term care facilities throughout the United States to ensure patients do not acquire HAIs.

The changes in health care over the past decade have caused hospitals across the nation to focus on improving quality outcomes for the patients they serve. One of the most preventable hospital-acquired infections is catheter-associated urinary tract infections (CAUTIs). Nursing’s role in the prevention of CAUTI spans patients’ entire hospital stay, and quality education to nursing staff is essential for sustained reduction efforts.

The project’s purpose was to evaluate the content and design of the nursing curriculum on CAUTI reduction given to nurses in a pediatric intensive care unit at one healthcare institution. A process evaluation showed that the curriculum had several key strengths and weaknesses and could be improved through application of Knowles’s adult theory of learning. Management and the clinical leadership team could improve patient outcomes by building nursing curriculum with a greater focus on learners’ needs, an understanding of what motivates learners, and more involvement of the nursing staff.

Background: Catheter-associated urinary tract infections (CAUTIs) are a major source of avoidable hospital-acquired infections. The scientific evidence supports utilization of nurse-driven protocols to reduce CAUTIs. Purpose: The purpose of this quality improvement project was to update and implement an evidence-based CAUTI prevention protocol for the nursing staff on a medical-surgical unit in an adult acute care hospital to decrease the utilization of indwelling urinary catheters and CAUTIs. Theoretical Framework: Donabedian’s structures, processes, and outcomes (SPO) model was utilized as the framework for this project. Donabedian’s SPO model focuses on strong healthcare structures and processes to improve nurse, patient, and organizational outcomes. Methods: This project utilized a quantitative design. A convenience sample of 28 nurses from the medical-surgical unit of a South Florida hospital participated in the project. An educational intervention was delivered on CAUTI prevention based on guidelines from regulatory agencies, and the hospital existing protocol was updated and revised to reflect the guidelines. The sample was administered a short demographic survey, and 10-item pretests and posttests on CAUTI prevention before and after implementation of the standardized evidence-based protocol. To determine possible differences in nurses’ knowledge and perceptions of indwelling urinary catheters before and after the implementation, paired t tests were conducted. To determine if the proportions of days with urinary catheters were statistically significantly different 30 days before and after implementation of the standardized evidence-based guideline, a 2-proportion z-test was conducted. Results: On analysis of the pretests and posttests, a statistically significant difference was found in 6 of the 10 questions, indicating that nurses’ knowledge and perceptions of CAUTIs improved after the intervention (p < .001 to p < .043). After the intervention, urinary catheter days relative to patient days also decreased significantly (z = 5.562, p < 0.001). Conclusion: Implementation of an evidence-based nurse-driven protocol in a hospital in South Florida improved nurses’ knowledge and perceptions of CAUTI prevention. Nursing practice and healthcare delivery can benefit from development of such guidelines and educational interventions to empower nurses to better manage patients’ indwelling urinary catheters, and decrease the incidence of CAUTIs in hospitals.

The most important risk factor for developing a catheter-associated urinary tract infection (CAUTI) is the prolonged use of the urinary catheter. To address the CAUTI rate at the project site, which was higher than the national benchmark, a team of healthcare practice leaders developed an evidence-based algorithm addressing the appropriate indications for inserting or discontinuing a patient's Foley catheter. Using the plan-do-study-act model, the purpose of this quality improvement evaluation project was to evaluate the effectiveness of the evidence-based Foley algorithm for decreasing the use of Foley catheters and reducing the CAUTI rate and to explore whether using the Foley algorithm shift assessment tool would reduce the incidence of Foley catheter utilization. Data were compared on the rate of CAUTI and Foley catheter use over 4 months before and 4 months after implementation of the algorithm. There was a statistically significant decrease in the Foley utilization rate after implementing the Foley algorithm; the overall CAUTI rate did not decrease. The outcome of this quality improvement evaluation project could produce social change by highlighting the need for consistent application of the algorithm. In addition, reducing the rate of Foley catheter usage could decrease the incidence of CAUTIs, reduce hospital costs, and improve overall patient health during hospitalization.

Introduction: Urinary catheters provide ideal surfaces for bacterial biofilm formation, being a major factor for hospital-acquired infections. With increased antibiotic resistance, there is a push for non-antibiotic-based measures to prevent catheter-associated urinary tract infections (CAUTI). I pursue the use of polymer-linked, broad-spectrum, host-defense-based antimicrobial peptides (AMPs) as novel catheter coatings. Here, I present the efficacy of tethered AMPs against common uropathogens both in vitro and in vivo. Materials and Methods: Peptides E6, Tet20, Tet26, and Kai13 were linked to surfaces using polymer brushes PDMA, PMPC, and PMPDSAH. All peptides were chosen based on their antimicrobial activity and biocompatibility as suggested by previously published papers. Antimicrobial activity of each coating was determined in vitro via colony counts 6 hours post-exposure to uropathogens. The in vivo efficacy of AMP coatings was also tested using a clinically relevant CAUTI mouse model; bladders of mice were catheterized percutaneously under ultrasound guidance, and 50 μL of 5E+5 CFU/mL P. aeruginosa was instilled. Indwelling polyurethane catheters and urine were collected after 7 days for examination of bacterial adherence and growth. Results: The most effective peptide-brush combination was E6-PDMA, decreasing bacterial adhesion and planktonic growth by up to 94.1% and 63.8%, respectively based on in vitro data. In vivo results look even more promising; the coating decreased bacterial adhesion by up to 99.9958% and planktonic growth by 99.8660% in comparison to untreated mice. Conclusions: Based on our in vitro and in vivo data, E6-PDMA coatings may effectively prevent CAUTI. Further testing of these novel coatings against more common uropathogens as well as tests to confirm the safety of such coatings will be important.
Medicine, Faculty of
Medicine, Department of
Experimental Medicine, Division of
Graduate

En aquesta tesi s’ha desenvolupat un catèter urinari tipus Foley bacteriofòbic. L’efecte bacteriofòbic es basa en un recobriment superhidrofòbic micro- i nanostructurat amb una topografia específica, recobert per una pel·lícula de plata metàl·lica homogènia, que crea un ambient incòmode per a les bactèries, evitant l’adhesió bacteriana a la superfície, però sense provocar cap efecte sobre el creixement bacterià. Per aconseguir-ho, s’ha generat un conjunt de recobriments nanoestructurats superhidrofòbics basats en diferents polímers. S'han utilitzat com a polímers base el metacrilat de pentafluorofenil polimeritzat per plasma (pp-PFM) i la polidopamina (PDA), recoberts amb una fina pel·lícula de plata metàl·lica. Tots ells van a mostrar una reducció en l’adhesió bacteriana d’entre 4 i 6 ordres de magnitud respecte a PDMS sense recobriment, així com la capacitat de repel·lir l’adhesió de proteïnes en assajos in vitro. El recobriment basat en PDA-plata va ser seleccionat per implementar-lo en el catèter urinari. Aquest catèter urinari ha demostrat mantenir l’efecte bacteriofòbic durant 30 dies in vitro, provat amb assajos d’ús simulat en condicions de fluix i estàtiques, utilitzant soques bacterianes uropatògeniques i aïllats clínics. A més, el catèter ha estat validat in vivo mitjançant porcs cateteritzats durant 15 dies. Durant aquest període, el catèter ha pogut mantenir l’adhesió bacteriana 2 ordres de magnitud per debat dels catèters estàndard comercials i els antimicrobians
En esta tesis se ha desarrollado un catéter urinario tipo Foley bacteriofóbico. El efecto bacteriofóbico se basa en un recubrimiento super-hidrofóbico micro- y nanostructurado con una topografía específica, recubierto por una película de plata metálica homogénea, que crea un ambiente incómodo para las bacterias, evitando la adhesión bacteriana a la superficie, pero sin provocar ningún efecto sobre el crecimiento bacteriano. Para conseguirlo, se ha generado un conjunto de recubrimientos nanoestructurados super-hidrofóbicos basados en diferentes polímeros. Se han utilizado como polímeros base el metacrilato de pentafluorofenilo polimerizado por plasma (pp-PFM) y la polidopamina (PDA), recubiertos con una fina película de plata metálica. Todos ellos mostraron una reducción en la adhesión bacteriana de entre 4 y 6 órdenes de magnitud con respecto al PDMS sin recubrir, así como la capacidad de repeler la adhesión de proteínas en ensayos in vitro. El recubrimiento basado en PDA-plata fue seleccionado para ser implementarlo en el catéter urinario. Este catéter urinario ha demostrado mantener el efecto bacteriofóbico durante 30 días in vitro, probado con ensayos de uso simulado en condiciones de flujo y estáticas, utilizando cepas bacterianas uropatógenas y aislados clínicos. Además, el catéter ha sido validado in vivo utilizando cerdos cateterizados como modelo animal durante 15 días. Durante este período, el catéter ha podido mantener la adhesión bacteriana 2 órdenes de magnitud por debajo de los catéteres estándar comerciales y los antimicrobianos.
In this thesis, a bacteriophobic urinary Foley catheter has been developed. The bacteriophobic effect is based on a homogeneous super-hydrophobic coating with a specific micro- and nanostructure covered by a homogeneous metallic silver film, which create an uncomfortable environment for bacteria, avoiding bacterial attachment to the surface but without causing any effect on bacterial growth. To achieve this, a set of super-hydrophobic nanostructured coatings based on different polymers has been developed. Plasma-polymerized pentafluorophenyl methacrylate (pp-PFM) and Polydopamine (PDA) have been used as base polymers, being coated with a thin film of metallic silver. All of them showed a reduction in bacterial adhesion between 4 and 6 orders of magnitude regarding the uncoated PDMS, as well as the ability to repel protein adhesion in in vitro tests. The PDA-silver coating was selected to be implemented on the urinary catheter. This urinary catheter has been shown to maintain the bacteriophobic effect for 30 days in vitro, tested with simulation-use tests in flow and static conditions, using uropathogenic bacterial strains and clinical isolates. Moreover, the catheter has been validated in vivo using catheterized pigs as animal model for 15 days. During this period, the catheter has been able to maintain bacterial adhesion 2 orders of magnitude lower than commercial standard or antimicrobial catheters.

Many inpatients in U.S. hospitals acquire an hospital-acquired infection (HAI), the majority of which can be attributed to an indwelling urinary catheter. The use of urinary catheters is a common practice within the acute care setting although the placement comes with risk. Improper catheter placement or a lack of care and maintenance can increase patient morbidity and mortality, as well as increase financial strain for the hospital. The purpose of this quality improvement (QI) evaluation was to determine if using a safety checklist and a 2-person urinary indwelling catheter-insertion team would reduce the rate of catheter-associated urinary tract infections (CAUTIs). Kotter’s change model informed the project. The evaluation encompassed reviewing the number of CAUTIs in the hospital for the 9-month period starting January 1 and ending October 1, 2018, for pre-QI data (n = 9). Following the implementation of the safety checklist, evaluation occurred for the next 9 months, October 1, 2018, through June 30, 2019 (n = 9), for post-QI data. At the end of the data collection, analysis of CAUTI rates was conducted using a 2-tail paired t-test to evaluate if there was a statistically significant difference in CAUTI rates. After running the paired t-test, it was determined there was a statistically significant difference in pre versus post-CAUTI rates (p = 0.0497). The result of the evaluation demonstrates that through the use of a 2-person safety checklist and leadership support, CAUTIs can significantly decrease in an acute care hospital. This project might support social change by contributing to improved health care outcomes and a reduction in cost of care.

More than 13,000 deaths and $340 million in health care costs are the result of catheter-associated urinary tract infections (CAUTIs) annually in the United States. CAUTIs can also result in acute patient discomfort and potentially preventable exposure to antibiotics. The hospital for which this quality improvement project was developed was above the National Healthcare Safety Network CAUTI bench mark. Framed within the Iowa model of evidence-based practice, a multidisciplinary team of 8 hospital stakeholders guided the project (n=8). The purpose of the project was to develop an indwelling urinary catheter maintenance checklist using evidence-based practice guidelines related to preexisting inappropriate risk factors for catheterization and appropriate indications for catheterization, as well as evidence-based maintenance practices for care of the indwelling catheter. Each piece of evidence to be included in the checklist was evaluated by 4 content experts using a 10 item 5 point Likert scale ranging from 'strongly disagree' to 'strongly agree'. Descriptive analysis showed an average of 4.8/5 for all items with 'agree' being voiced in two of the items rather than 'strongly agree'. The checklist was completed and presented to hospital senior leadership who recommended that the checklist be incorporated into the hospital CAUTI prevention plan. All project team members (n=8) completed an 8 item 5 point Likert scale summative evaluation of the purpose, goal, objectives, and my leadership which averaged as 5 or 'strongly agree' supporting the development of the project. Implications for social change include improved patient outcomes, mindful stewardship of healthcare dollars, and increased patient and family satisfaction.

Catheter-associated urinary tract infections (CAUTIs) are the most frequently reported hospital-acquired condition, affecting more than 560,000 patients each year. CAUTIs prolong hospital stays and increase health care costs, and they can result in patient morbidity and mortality. Nurses can be empowered by receiving education and knowledge to manage and identify urinary catheters that are not clinically indicated. The purpose of this project was to develop an education program on CAUTI prevention for critical care nurses using the teach-back method. The conceptual framework that guided this project was Knowles's adult learning theory. The theoretical model was based on 4 fundamental assumptions of self-concept development. A total of 32 critical care unit nurses participated in the evaluation of the teach-back method. Demographic data were collected from these 32 participants, and the results of a frequency analysis were obtained. Deidentified CAUTI data were provided by the organization prior to the educational intervention. The postintervention CAUTI rate and increase in nurses' knowledge level were evaluated 1 month after the educational intervention using a 1-sample t test. The finding was statistically significant (p < .001). The incidence of CAUTI was followed, and the outcomes indicated that the overall incidence of CAUTI in these patients was decreased. The education program was effective in improving critical care unit nurses' knowledge of evidence-based practices to prevent CAUTIs. Improving nurses' knowledge to decrease CAUTI rates is a strategy that may be effective in many healthcare settings. This educational intervention may create social change by improving the health of patients and serving as an educational resource for nurses.

In the United States, many hospitalized patients with indwelling urinary catheters acquire catheter-associated urinary tract infections (CAUTI) during their hospital stay. CAUTI negatively affects peoples’ health and quality of life and causes a financial burden to individuals and the nation. The purpose of this quantitative cross-sectional study was to explore the relationship between gender, age, and hospital types and CAUTI incidence in New York and North Carolina over a 3-year period. The theoretical framework of choice was the Donabedian model. Simple logistic regression and hierarchical multivariable logistic regression analysis were performed on archival data that was requested from Healthcare Cost and Utilization Project (HCUP) agency. According to the findings, males (n = 61,040) were at a higher risk of developing CAUTI compared to female (n = 66,792) (p < .001) in New York and North Carolina between 2012 and 2014. The odds of getting CAUTI were much higher among age ≥ 45 compared to the < 17 years. These findings fit in with previous literature identifying age and gender as having a significant relationship with CAUTI occurrence. The outcomes in this study may guide the formulation of policies that are age-appropriate, gender-specific, and facility-tailored to reduce the incidence of CAUTI.

Master of Science
Department of Industrial & Manufacturing Systems Engineering
Malgorzata Rys
Catheter associated urinary tract infections (CAUTIs) are a source of concern in the healthcare industry because they occur more frequently than other healthcare associated infections and the rates of CAUTI have not improved in recent years. The use of urinary catheters is common among patients; between 15 and 25 percent of all hospital patients will use a urinary catheter at some point during their hospitalization (CDC, 2016). The prevalence of urinary catheters in hospitalized patients and high CAUTI occurrence rates led to the application of human factors engineering to develop a tool to help hospitals reduce CAUTI rates. Human reliability analysis techniques are methods used by human factors engineers to quantify the probability of human error in a system. A human error during a catheter insertion has the opportunity to introduce bacteria into the patient’s system and cause a CAUTI; therefore, human reliability analysis techniques can be applied to catheter insertions to determine the likelihood of a human error. A comparison of three human reliability analysis techniques led to the selection of the Cognitive Reliability and Error Analysis Method (CREAM). To predict a patient’s probability of developing a CAUTI, the human error probability found from CREAM is incorporated with several health factors that affect the patient’s risk of developing CAUTI. These health factors include gender, duration, diabetes, and a patient’s use of antibiotics, and were incorporated with the probability of human error using fuzzy logic. Membership functions were developed for each of the health factors and the probability of human error, and the centroid defuzzification method is used to find a crisp value for the probability of a patient developing CAUTI. Hospitals that implement this tool can choose risk levels for CAUTI that places the patient into one of three zones: green, yellow, or red. The placement into the zones depends on the probability of developing a CAUTI. The tool also provides specific best practice interventions for each of the zones.

Catheter associated urinary tract infection (CAUTI) incidence continue to rise despite all prevention efforts. The state of Georgia incidence of CAUTI between 2012 and 2013 showed an increase by 350 cases. The challenge is translating CAUTI prevention knowledge into practice by all physicians. The purpose of this correlational study was to improve the epidemiological understanding of CAUTI. Looking at physicians' perception and practice of CAUTI preventions was necessary. A total of 336 physicians from the state of Georgia completed a 26-item survey. Additionally, a pilot study was conducted on a small sample of participants. The result of the Cronbach alpha for the pilot study analysis of the 26-item survey instrument indicated excellent reliability. The analysis revealed that participants' frequency of training on proper catheterization and their perception of CAUTI risk factors and effective implementation of CAUTI prevention bundle elements, varied significantly. It also resulted that many of the participants were not knowledgeable of certain important CAUTI prevention elements. Only a few made changes in their practice despite knowledge of the Center for Medicare and Medicaid Services reimbursement policy. Results of the Pearson's chi-square test for independence indicated a significant correlation (p < .05) between physicians' perception and practice of CAUTI prevention elements and CAUTI incidence. The results of this study suggest that current CAUTI prevention practice may be inefficient without the effective implementation of proven bundled element. Improved understanding of CAUTI and its relation to effective implementation of bundled prevention elements may result in improved prevention efforts, decreased morbidity, mortality, and overall healthcare cost.

Master of Science
Department of Industrial & Manufacturing Systems Engineering
Malgorzata J. Rys
According to the Centers for Disease Control and Prevention (2015), urinary tract infections (UTIs) are the most commonly reported healthcare-associated infection (HAI), of which approximately 75% of infections are attributed to the presence of a urinary catheter. Urinary catheters are commonplace within hospitals as approximately 15-25% of patients receive a urinary catheter during their hospitalization, introducing the risk of a catheter associated urinary tract infection (CAUTI) during their stay (CDC, 2015). In recent years there have been efforts to reduce CAUTI in U.S. hospitals; however, despite these efforts, CAUTI rates indicate the need to continue prevention efforts. Researchers have investigated the use of human reliability analysis (HRA) techniques to predict and prevent CAUTI (Griebel, 2016), and this research builds on that topic by applying the Human Error Assessment and Reduction Technique (HEART) to develop a model for a patient’s probability of CAUTI. HEART considers 40 different error-producing conditions (EPCs) present while performing a task, and evaluates the extent to which each EPC affects the probability of an error. This research considers the task of inserting a Foley catheter, where an error in the process could potentially lead to a CAUTI. Significant patient factors that increase a patient’s probability of CAUTI (diabetes, female gender, and catheter days) are also considered, along with obesity which is examined from a process reliability perspective. Under the HEART process, human reliability knowledge and the knowledge of eight expert healthcare professionals are combined to evaluate the probability that a patient will acquire a CAUTI. In addition to predicting the probability of CAUTI, HEART also provides a systematic way to prioritize patient safety improvement efforts by examining the most significant EPCs or process steps. The proposed CAUTI model suggests that 7 of the 26 steps in the catheter insertion process contribute to 95% of the unreliability of the process. Three of the steps are related to cleaning the patient prior to inserting the catheter, two of the steps are directly related to actually inserting the catheter, and two steps are related to maintaining the collection bag below the patient’s bladder. An analysis of the EPCs evaluated also revealed that the most significant factors affecting the process are unfamiliarity, or the possibility of novel events, personal psychological factors, shortage of time, and inexperience. By targeting reliability improvements in these steps and factors, healthcare organizations can have the greatest impact on preventing CAUTI.

Biofilm is an increasing problem in the healthcare and have in urinary catheters long been associated with nosocomial urinary tract infections. The infections caused in 2002 alone 13,000 deaths in the US and annual costs have been estimated to over $400 million. These costs are however most likely underestimated. The analysis of biofilm is important to aid the work on increasing patient safety and reducing the financial implications. A literature study was conducted in order to recommend a method for quantification that was fast, accurate and versatile. Methods used for biofilm quantification are primarily based upon light absorption, light scattering and changes in impedance. A few methods utilizing these properties are spectrophotometry, flow cytometry and coulter counters. Samples of biofilm are usually collected via traditional scraping with a sterile blade or with sonication (ultrasound). Flow cytometry was considered the superior method for quantification along with sonication for sample collection. The survey therefore came to the conclusion that biofilm sample collection should be done with sonication and analysis with flow cytometry.
Biofilm är ett ökande problem inom sjukvården och har i urinkatetrar länge varit associerademed sjukvårdsrelaterade urinvägsinfektioner. Infektionerna orsakade under 200213,000 dödsfall i USA och de ekonomiska kostnaderna har uppskattats till över $400miljoner. Kostnaderna antas dock vara underskattade. Analysen av biofilm är viktig förarbetet med att förbättra patientsäkerhet och minska kostnader relaterade till biofilm.En litteraturstudie användes för att rekommendera en metod som var snabb, noggrannoch mångsidig. Mätmetoder som används för kvantifiering är i huvudsak baserade påljusabsorption, ljusspridning samt förändringar i elektrisk impedans. Några metodersom använder detta är t.ex. spektrofotometri, flödescytometri samt coulter counters.Prover av biofilm samlas ofta in via traditionell skrapning med ett sterilt knivblad ellermed hjälp av ultraljud. Flödescytometri ansågs vara den bästa metoden för kvantifieringtillsammans med ultraljud för provtagning. Utifrån undersökningen drogs slutsatsen attprovtagning bör ske med ultraljud och analys med flödescytometri.

Doctor of Medicine
Publications 1-49 represent studies that I have undertaken myself or conjointly over a 34 year period to investigate a variety of issues relating to diseases of the kidney and urinary tract in children. The studies were carried out at the Royal Alexandra Hospital for Children, Camperdown when I was Clinical Superintendent from 1968 - 1970; The Department of Paediatrics, University of Minnesota, Minneapolis, USA when I was Overseas Research Fellow of the Post Graduate Foundation in Medicine, University of Sydney, 1970 - 1972, then as Staff Physician in Nephrology at the Royal Alexandra Hospital for Children, Camperdown, 1972 - 1977, and then Head of that Department at the Hospital until 1995 and then as an Honorary Staff Specialist at that hospital. Some of the studies were done conjointly with members of the Renal Unit of Royal Prince Alfred Hospital where I hold an Honorary appointment and others conjointly with members of the Renal Unit of Prince Henry Hospital, Little Bay. I was appointed Clinical Associate Professor to the Department of Paediatrics and Child Health, University of Sydney in 1993. In 1966 paediatric nephrology was in the early phase of development as a medical subspecialty. There was no definitive textbook, the first was published in 1975 (Pediatric Nephrology, Ed. Mitchell I. Rubin. Williams and Wilkins.). In the preface to the 2nd edition of Renal Disease (Blackwell) in 1967 the editor D.A.K. Black noted that he had included a chapter on paediatric aspects which had been planned for the 1st edition in 1962 but ”it could not be arranged”. In the chapter on Renal Disease in Children the author, D.Macauly, comments that the mortality rate of acute renal failure in children was 50%. When I joined the resident staff of the Royal Alexandra Hospital for Children in 1966, children with renal disease were managed by general paediatricians. There was no active program for the treatment of children with acute or chronic renal failure. A small number of kidney biopsies had been performed by Dr Trefor Morgan who, together with Dr Denis Wade, had taught me the technique while I was a resident medical officer at the Royal Prince Alfred Hospital in the preceding year. With the guidance and support of Dr S.E.J. Robertson and Dr C. Lee, Honorary Medical Officers, and Dr R.D.K. Reye, Head of the Department of Pathology, I began performing kidney biopsies on children at the request of the paediatrician in charge. In the same year, encouraged again by Doctors Robertson and Lee, and by J.C.M. Friend and J. Brown, I introduced peritoneal dialysis for the treatment of children with acute renal failure, a technique which I had also been taught by Dr Trefor Morgan whilst I was a resident at Royal Prince Alfred Hospital. Dr Robertson encouraged me to present my experience in percutaneous renal biopsy in children at the Annual Meeting of the Australian Paediatric Association in 1968 and this study became the first paper I published in relation to disease of the urinary tract in children (1). In 1970 I was granted an Overseas Research Fellowship by the Post Graduate Foundation in Medicine, University of Sydney, to enable me to undertake a fellowship in the Department of Paediatrics at the University of Minnesota. I had the great fortune in undertaking studies in the new discipline of paediatric nephrology and related research under the guidance of Dr A. F. Michael, Dr R.L.Vernier and Dr A. Fish. I acquired the techniques of immunopathology and electron microscopy. On my return to Australia I established a Department of Nephrology at the Royal Alexandra Hospital for Children. I introduced immunofluorescent and electron microscopic studies for the kidney biopsies that I continued to perform and, with the support of Dr R.D.K. Reye, I provided the official reports of these studies until 1990. As a result these studies became part of the histopathologic service provided by the hospital. I continue to be consulted concerning the interpretation of some electron microscopic findings in renal tissue. With the assistance of Dr J.D. Harley I set up a laboratory in the Children’s Medical Research Foundation to continue and expand the studies I had commenced during my Fellowship. Establishing a dialysis and transplant program for children with end stage renal disease (ESRD) was extremely time consuming. At that time most children with ESRD died. The program was initially established jointly with the Renal Unit at Royal Prince Alfred Hospital in 1972 and eventually dialysis facilities were established at the Children’s Hospital using predominantly peritoneal dialysis. By 1978 the existence of the Unit was well known in the general community and articles appeared in the press. One prompted the late Sir Lorimer Dods, the first Professor of Paediatrics in Australia to write to me congratulating me on what I had achieved. He remarked “I have just read with special interest Shaun’s review in the SMH of some of your recent achievements in the field of renal failure in infancy and childhood and want to offer you my personal congratulations on all that you have achieved and are achieving in this area of paediatrics which, in my little world of yesterday, meant nothing more than progressive and unrelenting fatal illness”. Taking part in the development of a relatively new discipline led me to study a number of areas. I encouraged trainees to write reports concerning clinical observations and eventually I was joined by Fellows whom I encouraged and supported to study a number of different areas to ensure that children were being cared for in an environment of strong and open enquiry. This led to studies on investigations of chronic renal failure which Dr Elisabeth Hodson pursued and studies on urinary tract infection in small children for which Dr Jonathon Craig was awarded a PhD. As I had been a contributor and co-author in a number of these studies they have been included in my list of publications. As a result of this diversity I have listed the publications in 9 sections. The overall theme is to study diseases of the renal tract in children and treatments used to understand the processes and ensure the most effective treatment. Some published abstracts of papers presented at scientific meetings have been included to clarify invitations I received to prepare reviews and chapters on various subjects and my involvement in some conjoint studies. I was author or coauthor of several book chapters, reviews, editorials and certain published studies to which I was invited to contribute as a result of my primary studies and these I have included as “Derivative References”numbered 50-76.

Catheter-Associated Urinary Tract Infections are considered a clinical indicator of quality of care. A descriptive research study was conducted to identify the strategies used by hospitals to reduce or eliminate CAUTIs. Infection Control Preventionists were surveyed. In a predominately rural southeastern state, this study demonstrated that about 40% of hospitals surveyed are implementing CAUTI prevention processes.

Bakgrund: Urinvägsinfektioner är en av de vanligaste vårdrelaterade infektionerna inom svensk sjukvård. Varje år drabbas 65 000 personer av en vårdrelaterad infektion, av dessa är 14 % urinvägsrelaterad. Detta medför onödigt lidande för patienten, men ger också upphov till förlängda vårdtider och ökade kostnader för hälso- och sjukvården. Syfte: Syftet var att beskriva hur sjuksköterskan kan arbeta preventivt för att minska förekomsten av vårdrelaterade urinvägsinfektioner. Metod: Studiens design var en litteraturöversikt innehållande 15 vetenskapliga artiklar, varav 13 stycken var kvantitativa och två stycken var kvalitativa. Datainsamlingen har skett via sökningar i databaserna PubMed och Cinahl, valda artiklar granskades med granskningsmallar och sammanställdes sedan i resultatet. Resultat: Resultatet visade att ett förebyggande arbete kring rutiner vid kateterisering innebar minskade risker för att drabbas av urinvägsinfektioner. Utbildning och ökad medvetenhet kring hygien visade sig ha en positiv effekt både hos patienter och bland personal. Det påvisades även ett positivt samband med ett ökat vätskeintag samt kosttillskott i form av tranbärskapslar. Slutsats: För att minska vårdrelaterade urinvägsinfektioner krävs det att sjuksköterskan har en följsamhet i det förebyggande arbetet. Utbildning bland personal och patienter, större medvetenhet kring basala hygienrutiner och korrekt rutiner vid kateterisering har en stor betydelse i det preventiva arbetet.
Background: Urinary tract infection is one of the most common nosocomial infections in Swedish health care. Each year, 65 000 people suffer from a nosocomial infection, of which 14 % are urinary tract related. This problem causes unnecessary suffering for the patient, prolonged waiting times and increased costs for health care. Aim: The aim of this study was to describe how nurses could prevent nosocomial urinary tract infections. Methods: This was a literature review based on 15 articles. Of these, 13 studies had a quantitative approach and two studies had a qualitative approach. The data collection has been done by searching in the databases PubMed and Cinahl. Chosen articles were reviewed by using reviewing templates, analyzed and were compiled in the result. Results: The result showed that proactive work regarding routines when catheterize amounted to less risks for patients suffering from urinary tract infections. Education and increased awareness around hygiene turned out to have a positive effect on patients in decreasing urinary tract infections and on staff behavior. There was also a positive correlation between an increased fluid intake and cranberry capsules as a supplement. Conclusion: To reduce nosocomial urinary tract infections it is required that the nurse is involved in the proactive work. Education for staff and patients, greater awareness around basic hygiene routines and correct routines when catheterizing has a big impact on the proactive work.

SAMMANFATTNING  Bakgrund  Kateterisering av urinblåsan är en vanligt förekommande behandlingsåtgärd inom hälso- och sjukvården som kan vara indicerad vid exempelvis urinretention och residualurin efter miktion. Kateterisering kan orsaka komplikationer, såsom urinvägsinfektioner och urinläckage, vilket kan medföra lidande. Sjuksköterskan har som uppgift att lindra lidande genom bland annat personcentrerad och säker vård. Att förstå hur kateterisering kan påverka den individ som är i behov av den är därför viktigt för sjuksköterskans yrkesutövande.  Syfte  Syftet var att beskriva patienters upplevelser relaterade till kateterisering och att leva med urinkateter.  Metod  En icke systematisk litteraturöversikt genomfördes och baserades på 16 vetenskapliga artiklar av kvalitativ och kvantitativ design. Inkluderade artiklar söktes fram i databaserna PubMed och CINAHL med hjälp av lämpliga sökord. Med Sophiahemmet högskolas bedömningsunderlag kvalitetsgranskades inkluderade artiklar och sedan analyserades innehållet för att sammanställas i tre övergripande kategorier; ‘En vardag med urinkateter’, ‘livskvalitet’ och ‘patientens relation till hälso- och sjukvården’.  Resultat  De övergripande kategorierna är indelade i sju underkategorier där patienters upplevelser relaterat till kateterisering av urinvägarna beskrivs. Komplikationer som urinvägsinfektion, urinläckage och trycksår; bristande bemötande och förhållningssätt hos sjuksköterskan; svårigheter i vardagen; informationsbrist samt påverkan på sexuell aktivitet är aspekter som kan påverka upplevelsen enligt patienter.  Slutsats  Föreliggande litteraturöversikt beskriver hur olika faktorer påverkar upplevelsen av kateterisering och att leva med urinkateter samt vad de olika metoderna för kateterisering har för betydelse i upplevelsen. Faktorer såsom komplikationer med smärta, urinläckage och urinvägsinfektioner; förändrad självbild och påverkad sexuell aktivitet; bristande information och bemötande från vårdgivare samt skattad livskvalitet hade betydelse för patientens upplevelse och eventuella lidande. Utifrån dessa upplevelser kan hälso- och sjukvård identifiera bristfälligt handhavande med personer och medicintekniska vårdmoment samt initiera förbättringsarbete i syfte att stärka patienters upplevda livskvalitet relaterat till urinkateterisering.
ABSTRACT  Background  Urinary catheterization is a common treatment in health care and there are several reasons why catheter is indicated. It is often due to urinary retention and residual urine volume after urination. Urinary catheterization can cause complications, such as urinary tract infections and leakage, which can cause suffering. The nurse's task is to relieve suffering through, among other things, person-centered and safe care. Understanding how catheterization can affect the individuals who are in need of it, and it is therefore important for the nurses’ professional practice.  Aim  The aim of this study was to describe patients experiences related to urinary catheterization and living with urinary catheter.  Method  A non-systematic literature review was conducted and based on 16 scientific articles, with both qualitative and quantitative design. Included articles were searched in the databases PubMed and CINAHL using appropriate keywords. With the Sophiahemmet university's quality framework the articles were quality examined and then the content was analyzed to be grouped into three general categories; 'A daily life with a urinary catheter', 'quality of life' and 'the patient's relationship to health care'.  Results  The general categories are divided into seven subcategories where patients' experiences related to catheterization of the urinary tract are described. Complications such as urinary tract infection, urinary leakage and pressure ulcers; the deficient conduct and approach of nurses; difficulties in everyday life; Lack of information and influence on sexual activity are aspects that can affect the experience according to patients.  Conclusions  This literature review describes how various factors affect the experience of catheterization and living with urinary catheters, and what the different methods of catheterization have for the impact on the experience. Factors such as complications with pain, urinary leakage and urinary tract infections; altered self-image and affected sexual activity; lack of information and response from caregivers as well as estimated quality of life had significance for the patient’s experience and possible suffering. With these experiences, health care can identify inadequate handling with persons and medical devices, and initiate improvement work with the aim of strengthening the patients’ perceived quality of life related to urinary catheterization.

碩士
國立陽明大學
醫務管理研究所
99
Background: The progress of medical technology enables patients’ vital sign to be controlled. But it also induces some other problems, and among which an important one is nosocomial infections. The most common healthcare-associated infection in Taiwan is urinary tract infection. The past study showed catheter-related urinary tract infection (CAUTI) accounted for 29% to 45% of all healthcare-associated infections. And other past study showed 80% of CAUTI is caused by the catheter. The studies hope to understand the CAUTI risk factors and medical utilization. Objectives: Title of thesis is The Utilization of catheter-associated urinary tract infections in Taiwan. This study has two major purposes: First, to understand the risk factors of infection the CAUTI. Second, to understand the utilization of CAUTI in Taiwan. Methods: This thesis is cross-sectional study. We collect declared information from bureau of national health insurance of patient in 2004 to 2006 which is provided by National Health Research Institutes, including underwriting file, CD, DD, OO, DO and HOSB files. We select all use catheter patients in 2005, and then exclude use catheter and UTI in 2004. To analyze sex, age, diagnosis, hospital-level and disease of burden factors how to impact CAUTI patient medical utilization. When patients has CAUTI, they disease burden over 1.9676 than those not has CAUTI. Results: The study shows the incidence rate of CAUTI is 4.6%. The influence CAUTI factors have age-level(0-34, 35-49, 50-64, 65-74 and more than 75), gender, diagnosis, department(medicine, surgery and other),disease of burden and hospital-level, there were statistically significant difference (p-value &lt; 0.001). Then comorbidity (0, 1, 2, more than 3) not statistically significant difference in not ICU group (p-value > 0.05). But comorbidity has more than 3 been statistically significant difference in ICU group (p-value &lt; 0.001). By using generalized linear model, we found that the patient of CAUTI increased the outpatient, inpatient, emergency fee and prolonged the length of stay. The has CAUTI patient's use service (9.1%) and cost (12.5%) more then not has CAUTI patient's in outpatient. The CAUTI patient's use service (21.7%) and cost (22.9%) in emergency, and the inpatient-day (54.7%) and cost (46.1%) in inpatient. Their were statistically significant difference (p-value &lt; 0.001). Conclusions: When the patient has high disease of burden will increase the risk of CAUTI. The infectious diseases, endocrine and metabolism diseases and age of patients have high risk of CAUTI. If patients who has CAUTI or high disease of burden, they utilization of medical resources will rise. Their use the emergency treatment and inpatient costs relatively high.

碩士
美和科技大學
護理系健康照護碩士班
105
Purpose Several factors will cause Healthcare-associated urinary tract infections. The main purpose of this research is to elucidate the density variation of catheter-associated urinary tract infections whether patients in intensive care units were introduced the care bundle beyond controlling the patient factors (sex, age and illness severity) and catheter factors (material and diameter of catheter). Method Data collection is retrospective and longitudinal follow-up. A total of 2461 catheter possessed cases were aimed at adult intensive care units (included internal Medical, surgical and neurological department) in specific medical center located in the south of Taiwan from Jan. 1 2012 to Dec. 31 2015. The detailed data were collected by patient information sheets and catheter care information sheets from healthcare records, inquiring healthcare nursing people and medical records. We compared the density variation of catheter-associated urinary tract infections among years whether patients in intensive care units were introduced the bundle care beyond controlling the patient factors (sex, age and illness severity) and catheter factors (material and diameter of catheter). Descriptive statistics, ANOVA, Chi-square and Cox regression were employed to test the hypothesis. Results Significant variation of the density of catheter-associated urinary tract infections after patients in intensive care units introduced the care bundles were found among years. After executing the care bundle to patients in various adult intensive care units from 2013, the density of catheter-associated urinary tract infections significantly decreased in 2014 and 2015, the values reduced from 15.9‰ in 2013 to 8.4‰ in 2014 (HR=0.53, 95% confident interval 0.37-0.76, p=.001) and to 8.6‰ in 2015 (HR=0.57, 95% confident interval 0.39-0.83, p=.003); The decline rates for 2014 and 2015 were about 47.2% and 45.9%, respectively. The risk of catheter-associated urinary tract infections before introducing care bundle was higher 1.76-1.89 time than the one after executing care bundle. Conclusion and Suggestion Most catheter possessed patients in intensive care units were severe and not stable in haemodynamics. Thus, more invasive medical facilities were necessary to utility and cure for them. Once they got infection and the time infection extended, the days they stayed in hospital will increase. Therefore, it is more important to exactly assess the indication and care for catheter possessed patient. We found the density of catheter-associated urinary tract infections after introducing the care bundle was much lower. However, after health care removed the catheter from our objects according to the assessment for indication of catheter possessed patient, 24% patients were essential to be reset the catheter (but only 15% patients were really necessary to be reset) because of lack of objective equipment to measure the residual urine volume. Therefore, we suggest that introduction of objective equipment, like as Bladder ultrasound machine is essential to lower the reset rate of catheter to reduce the density of catheter-associated urinary tract infections. Keywords: urinary tract infections, care bundle, catheter -associated urinary tract infections

Tese de mestrado, Ciências Biofarmacêuticas, Universidade de Lisboa, Faculdade de Farmácia, 2017
Catheter-associated urinary-tract infection (CAUTI) is a nosocomial infection that represents huge financial burdens to health care facilities as well as increased mortality and morbidity. For these reasons, many protocols have been implemented aiming to reduce the CAUTI rates. However, these preventive measures have not been enough. Uropathogenic Escherichia coli (UPECs) are known as the most preponderant microorganisms in CAUTI. UPECs harbour several virulence factors that allow them to colonize and establish infections into the urinary-tract, overcoming the host defences and, currently, they are winning a high resistance to antimicrobials, reducing the effectiveness of the antibiotics used to prevent and to treat these infections. Therefore, it is urgent to find a well-tolerated therapeutic complement or alternative to avoid and combat urinary-tract infections acquired by the presence of an indwelling urinary catheter, and bacteriophages are good candidates to fulfil these requirements. The main goal of this work was to select bacteriophages aiming the design of a phage cocktail to prevent CAUTI caused by UPEC. At the same time, it was intended to characterize the E. coli bacteria used in this work, most isolated from patients with urinary-tract infections, in order to ensure phage diversity. The final phages selected in this work to be part of a therapeutic cocktail demonstrated to be different from each other and were able to infect bacteria with different antibiotic susceptibility profiles and virulence patterns. The characterized clinical E. coli strains showed to be resistance to the most commonly used antibiotics against urinary-tract infections (UTIs): penicillins and quinolones and, at a minor level, to cephalosporines; but also to be susceptible to carbapenems. Furthermore, they showed to carry some of the most spread virulence genes among UPECs, mainly that codifying to type 1 pili. The results corroborate the necessity of finding a new agent to combat UTIs, including CAUTI, and that bacteriophages are good therapeutic candidates.
A infeção do trato urinário associada aos cateteres (CAUTI) é uma infeção nosocomial que pode afetar todo o trato urinário devido ao comprometimento do mesmo e das defesas imunológicas do hospedeiro. As CAUTIs representam cerca de 36% de todas as infeções associadas aos cuidados de saúde nos Estados Unidos da América e, atualmente, são conhecidos mais de 1 milhão de casos por ano nos Estados Unidos da América e Europa, sendo responsáveis por uma elevada mortalidade e morbidade. Uma vez que só nos Estados Unidos da América são gastos mais de $400 milhões todos os anos para tratar estas infeções, as CAUTIs representam também enormes encargos financeiros para as instituições de saúde. Com o objetivo de reduzir a incidência das CAUTIs, os centros Centers of Medicare and Medicaid Services (CMS) e Centers of Disease Control and Prevention (CDC) têm implementado uma série de programas e protocolos que visam educar os profissionais de saúde a evitar a colonização do trato urinário por microrganismos e, consequentemente, o estabelecimento de infeções. Contudo, estas medidas preventivas não têm sido suficientes para diminuir as taxas de CAUTI. Embora as CAUTIs possam ser causadas quer por bactérias de Gram-negativo e Gram-positivo quer por fungos ou leveduras, as bactérias de Gram-negativo são os organismos mais frequentemente isolados destas infeções, sendo Escherichia coli (E. coli) a mais predominante. E. coli são bactérias comensais do trato gastrointestinal dos mamíferos, mas podem tornar-se uropatogénicas por aquisição de fatores de virulência que lhes permitem colonizar o trato urinário do hospedeiro e aí permanecer, estabelecendo infeções por superação das defesas do mesmo. Para além disso, Escherichia coli uropatogénicas (UPECs) têm também vindo a adquirir, por mecanismos de transferência horizontal de genes, uma elevada resistência aos antibióticos mais comumente utilizados para prevenir e tratar estas infeções, o que representa a principal dificuldade na erradicação destes organismos e, mais uma vez, na redução das taxas de CAUTI. Deste modo, torna-se imperativo encontrar uma alternativa terapêutica ou um complemento aos antibióticos de modo a evitar e combater as infeções do trato urinário adquiridas pela presença de um cateter interno. A capacidade que os bacteriófagos têm de infetar e matar as bactérias e a sua utilização como agentes terapêuticos para as infeções bacterianas foram descobertas há aproximadamente um século por Felix d’Herelle. Contudo, com a descoberta dos antibióticos, o pouco conhecimento que existia na altura sobre a biologia destes vírus conduziu a um desinteresse na sua aplicação como agentes terapêuticos, e só muito recentemente se começou a olhar para a terapia fágica como um meio promissor para o combate às infeções bacterianas. Atualmente, os bacteriófagos apresentam uma série de vantagens relativamente aos antibióticos e, como tal, começam a ser vistos como uma boa alternativa ou ajuda aos mesmos. Uma vez que são as entidades mais abundantes na Terra, os fagos são relativamente fáceis de isolar, e, devido à sua abundância, a sua produção e utilização poderão ser mais baratas do que as dos antibióticos. A especificidade que os bacteriófagos apresentam para as bactérias hospedeiras é tão elevada que os riscos de infetarem a flora microbiana do organismo humano se tornam muito baixos, representando uma segurança para a sua utilização nos seres humanos. Essa mesma segurança é mais uma vez apontada como consequência de os bacteriófagos serem entidades que habitam na natureza e aos quais o organismo humano já está habituado. Os fagos são autorreplicativos no interior das suas hospedeiras, o que permite a aplicação de poucas quantidades nos doentes e, após erradicação dessas bactérias, eles são rapidamente eliminados do organismo humano. Uma vez que levam à libertação de menos endotoxinas aquando da lise de E. coli patogénicas do que os antibióticos β-lactâmicos, os fagos representam, mais uma vez, uma menor probabilidade de ocorrência de reações secundárias do que os antibióticos. A sua capacidade disruptiva e erradicativa sobre os biofilmes constitui outra vantagem sobre os antibióticos, uma vez que estes não têm esta capacidade. A adicionar a tudo isto, tem vindo a ser comprovada a eficácia dos bacteriófagos na prevenção e eliminação das bactérias causadoras de infeções em humanos, incluindo as que provocam CAUTIs, assim como o aumento da mesma através da utilização de mais do que um fago, cocktail fágico, devido ao alargamento da sua gama de bactérias hospedeiras, quando comparado com a utilização de um único bacteriófago. O principal objetivo deste trabalho consistiu em selecionar bacteriófagos capazes de lisar E. coli para constituir um cocktail fágico de modo a prevenir CAUTIs provocadas por UPECs. Para tal, procedeu-se ao isolamento de fagos a partir de diferentes origens e a vários ensaios de eficácia contra E. coli de modo a permitir a seleção dos bacteriófagos mais eficientes e diferentes. Ao mesmo tempo, como forma de garantir a diversidade das bactérias utilizadas no trabalho, foram analisados os seus perfis de suscetibilidade aos antibióticos mais utilizados na prevenção e tratamento das infeções do trato urinário e a presença de alguns dos fatores de virulência mais expressos pelas UPECs. A maioria das E. coli incluídas nestes ensaios foram isoladas de doentes com infeções urinárias. Durante a caracterização das bactérias utilizadas para isolar, propagar e selecionar os bacteriófagos, foram obtidos diversos perfis de suscetibilidade aos antibióticos e padrões de virulência, o que permitiu assegurar a diversidade bacteriana neste estudo. Foi ainda possível verificar que as bactérias isoladas apresentavam resistência aos antibióticos mais utilizados contra as UTIs, nomeadamente às penicilinas e às quinolonas e, a um menor nível, às cefalosporinas, mostrando suscetibilidade aos carbapenemos. A análise da presença dos genes de virulência levou a crer que as bactérias de E. coli estudadas contêm alguns dos genes mais dispersos entre as UPECs, possibilitando a colonização da bexiga, dos ureteres e dos rins, o estabelecimento de infeções no trato urinário e o crescimento das bactérias no interior das células do mesmo. O gene fimH, que codifica para os pili de tipo 1, foi amplificado em praticamente todas as bactérias (38 de 39), seguido dos genes afa e aer que codificam para uma adesina afimbrial e para um sideróforo, respetivamente, e permitem o crescimento bacteriano no trato urinário devido à ligação às células da bexiga e a eritrócitos humanos assim como ao consumo de iões férricos. Porém muito poucas mostraram conter o gene que codifica para os pili S, sfa, e todos os restantes 6 genes foram amplificados em menos de metade das bactérias. Através do isolamento de diferentes bacteriófagos e de ensaios que visaram determinar a eficácia e diversidade dos mesmos, foram selecionados os 6 fagos mais promissores para constituírem um cocktail terapêutico. Estes provaram ser capazes de infetar estirpes de E. coli com diferentes perfis de suscetibilidade aos antibióticos e padrões de virulência. A realização deste trabalho permitiu, corroborar a necessidade de encontrar uma ajuda terapêutica para o tratamento das UTIs. A produção de um cocktail utilizando todos ou alguns dos 6 fagos selecionados e 2 fagos já patenteados pela TechnoPhage, também incluídos neste projeto, deverá ser uma opção promissora, pois estes fagos demonstraram ser eficazes contra estirpes de E. coli com resistência a alguns dos antibióticos mais utilizados no tratamento das infeções do trato urinário e que contêm alguns dos genes mais dispersos entre as UPECs.
This work was developed at TechnoPhage SA. (http://www.technophage.pt), at Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal, and at iMed.ULisboa, Research Institute of Medicines (http://imed.ulisboa.pt/), Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal.

碩士
國立臺灣大學
公共衛生碩士學位學程
99
Purpose The purpose of this thesis is to describe the trends of incidence of healthcare-associated urinary tract infection (HA-UTI) and catheter-associated urinary tract infection(CA-UTI) in adult intensive care units (ICUs ) at National Taiwan University Hospital, from 2002 to 2010. In addition, time series analysis was used to investigate the impacts of various infection control programs on the incidences of HA-UTI and CA-UTI in adult ICUs. Method This is a retrospective study. The study population was patients developing HA-UTI, includind CA-UTI while staying in adult ICUs at NTUH from 2002 to 2010. To identified the independent factors associated with HA-UTI and/or CA-UTI, environmental factors (catheter utilization, severe acute respiratory syndrome, seasonal effects), and infection control interventions (hand hygiene, the project of reducing catheter- associated urinary tract infection, Bundle care) were treated as independent variables; incidence densities of HA-UTI and CA-UTI were treated as the dependent variable. Time series analysis using Poisson regression model was used to evaluate the potential effects of independent variables on dependent variable. A p value less than 0.05 were considered as statistically significantly. Result Because the baselin incidence rates of HA-UTI and CA-UTI were different in surgical and medical ICU, and also the infection control interventions as well as the adherence of healthcare workers to these interventons, the impact of the results are different. Since April 2004, hand hygiene campaign were implemented. It reduced the HA-UTI and CA-UTI significantly (p&lt; 0.0183). For adult surgical intensive care unit, promotion of the "Bundle care" intervention reduced the HA-UTI and CA-UTI significantly (p&lt; 0.002) . Both HA-UTI and CA-UTI decrease in adult medical and surgical ICUs with time. Conclusion This study showed that the impact of various projects on reducing CA-UTI is significant, In addition, self-improvement project and infection control interventions were also helpful for decreasing HA-UTI and CA-UTI.

This dissertation aims to explore the role of patient and family engagement in the context of two current health issues: catheter-associated urinary tract infections (CAUTI) and antibiotic resistance. Chapter One contains an introduction to patient and family engagement, CAUTI, and antibiotic resistance, followed by gaps in the science, a description of the theoretical framework, and specific aims addressed in this dissertation. Chapter Two is a systematic review of existing CAUTI prevention interventions that involve patient and family engagement. Chapter Three is a study designed to meet the learning needs of parents by developing a graphically-enhanced CAUTI-prevention educational resource using participatory design methods. Chapter Four is an environmental scan that summarizes the content and format of existing resources about antibiotic resistance and antibiotic use available from children’s hospital websites across the United States. Finally, Chapter Five contains an overall summary of the findings of this dissertation, a discussion of results within the guiding theoretical framework, practice and policy implications, and suggestions for future research.

In the United States, home health care (HHC) is the most frequently used form of post-acute care services. Majority of the HHC patients are elderly and have known activities of daily living (ADL) dependencies. The role of HHC as a post-acute care provider has been emphasized under the Affordable Care Act (ACA) as it is expected that HHC services will help patients stay in the community and reduce acute care hospitalization. Urinary tract infection (UTI) -related hospitalization is an adverse patient outcome that affects elderly patients in the HHC setting. Studies examining the ADLs of HHC patients are limited. Although dependence in ADLs is a known risk factor for hospitalization, no study has assessed the relationship between ADL dependency and UTI-related hospitalization among HHC patients. This dissertation describes the ADLs of elderly patients receiving HHC services, and examines risk of UTI-related hospitalization among this population, specifically the potential risk of ADL dependency. In Chapter One, the problems of UTI-related hospitalization and ADL dependency are introduced and their significance is described. In Chapter Two, an integrative review of the literature describing methods of assessing ADLs in skilled nursing facilities (SNF) and HHC are described. In Chapter Three, a cross-sectional study elucidating the risk factors for severe ADL dependency and predictors of ADL improvement among HHC patients is reported. In Chapter Four, the risk factors for UTI-related hospitalization among HHC patients is reported. In Chapter Five, findings of the three studies are summarized and conclusions are provided including strengths, limitations, and implications for practice and policy. Andersen’s Behavioral Model was the theoretical framework used for this study. The Andersen model posits that health care utilization is a function of patients predisposing (e.g. age, gender, race/ethnicity), enabling (e.g. living alone, insurance status, living condition, primary care giver) and need factors (e.g. ADL dependency level, comorbidity, impaired decision making). This model fits this dissertation because evidence shows that health care utilization (UTI-related hospitalizations) depends on predisposing, enabling and need factors. This was a retrospective cohort research design study based on secondary analysis of the Outcome and Assessment Information Set (OASIS) data set of 154,801 beneficiaries who received home health care services in 2013. Descriptive statistics, bivariate analysis, and multivariable logistic regression analyses were conducted to examine the effect of each individual variable on the outcomes of interest (severe ADL dependency, ADL improvement and UTI-related hospitalizations). The study population was elderly (mean age 77 years), mostly female (65%) and white (79.8%). Key findings indicated that, (a) over 60% of patients had severe ADL dependency, and impaired decision making is a strong predictor of severe ADL dependency, (b) Overall, patients experienced ADL improvement from admission to discharge. However, blacks experienced significantly less ADL improvement compared to Whites. Longer HHC length of stay was also associated with ADL improvement, and (c) For the UTI-related hospitalization outcome model, multivariable analysis showed that Medicaid insurance, severe ADL dependency and impaired decision making was associated with increased risk for UTI-related hospitalization

碩士
中臺科技大學
醫療暨健康產業管理系碩士班
107
Purpose:This study mainly discussed the trend and risk factors of catheter- associate urinary tract infection among patients using urinary catheters in the intensive care units of a district hospital in Nantou County from 2015 to 2018. It also discussed the catheter-associate urinary tract infection rate in different "catheter associated care bundle" stages, which can then provide a safe medical environment and quality of care for patients.Methods:This is a longitudinal study which patients was placed catheters in the intensive care unit from May 2015 to December 2018 were collected by the sensory control room. A total of 2,132 cases were collected. Descriptive statistics, Chi-square test and multiple logistic regression analysis were used to identify whether demographic data, hospitalization data and catheter usage data of the cases were related to catheter-associate urinary tract infection. The trend of catheter-related urinary tract infection rate in different stages of implementing "catheter associated care bundle" was also analyzed.Results:Chi-square test and multiple logistic regression analysis showed that the longer hospitalization days and the more days in the intensive care unit, as well as the use of over size 18 catheters were significantly related to catheter-associated urinary tract infection in the intensive care units. After the implementation of "catheter associated care bundle", the average infection rate decreased from 3.17‰(SD=2.61) in the preparation period to 2.33‰(SD=0.35) and 2.43‰(SD=0.54) in the execution period and the autonomous period, respectively. The average and standard deviation of infection rate decreased showed a decreasing trend of infection rate and its variability. Conclusions: The results showed that the longer the hospitalization days, the longer days in the intensive care units, the longer indwelling days of the catheter, and the larger the catheter diameter, the higher the chance of catheter-associated urinary tract infection. Therefore, reducing the hospitalization days and the days in the intensive care unit, and using catheter with a smaller diameter can decrease the risk of catheter-associated urinary tract infection. Implementing "catheter associated care bundle" has a tendency of reducing urinary tract infection rate and its variability, which is helpful to decrease catheter-associated urinary tract infection in the intensive care units.

RESUMO - Introdução: As infecções associadas aos cuidados de saúde são um importante problema de saúde pública. Entre elas, as infecções urinárias são as mais frequentes associando‐se a elevados custos e morbilidade. Pretende‐se caracterizar as ITU adquiridas no Hospital (ITUaH) ocorridas num serviço de Medicina Interna de um hospital português. Métodos: Efectuou‐se um estudo de coorte (histórica) para determinação da incidência da ITUaH e da bacteriúria assintomática. Analisaram-se os dados correspondentes a uma amostra aleatória sistemática de 388 doentes, representativa dos 3492 admissões ocorridas, em 2014, nesse Serviço. Resultados: A taxa de incidência global de ITUaH foi de 6,2% (24/388; IC 95%:[3,8--‐8,6%]). Ocorreram 19,76 ITU por mil dias de cateter vesical (ITUaCV) e 4,17 ITUaCV por mil dias de internamento. A taxa de incidência de ITUaCV foi de 4% (15/388; IC 95%:[2%--‐6%]). Oitenta por cento destas infecções ocorreram em doentes sem indicação para a algaliação. Um quarto dos doentes desta coorte foram algaliados (24,7%; IC 95%: [20%--‐29%]), não se verificando indicação para o procedimento em 36,5% dos casos. Os principais factores de risco para a algaliação identificados foram a dependência total (OR: 24,47; IC 95%: [5,50--‐ 108,87]; p<0,001) a dependência grave (OR:11,43; IC 95% [2,56--‐50,93]; p=0,001) (escala de Barthel) e a carga de doença (OR: 1,19; IC 95% [1,03--‐1,38]; p=0,017) (índice de comorbilidade de Charlson). Foram utilizados CV em 759 dias dos 3591 dias de internamento quantificados neste estudo (21%). A Taxa de incidência de Bacteriúria Assintomática (BA) foi de 4,4% (IC 95%:[2--‐6%]). Cerca de 60% (10/17) desses doentes foram submetidos a tratamento contrariamente às recomendações clínicas actuais. Conclusões: Este estudo evidencia a necessidade de implementação de estratégias de prevenção, das quais se destaca a redução do número de algaliações. O tratamento da BA deve ser evitado.
ABSTRACT - Introduction: Healthcare associated infections associated are an important public health problem. Among them, the urinary tract infections are the most common, being associated to high costs and morbidity. We intend to characterize hospital-acquired urinary tract infections (HaUTI) occurred in an internal medicine department of a Portuguese hospital. Methods: An historical cohort study was carried out to determine both HaUTI and asymptomatic bacteriuria incidence. A systematic random sample of 388 patients, representative of the 3492 admissions occurred in that department in 2014, was analyzed. Results: The overall incidence rate of HaUTI was 6.2% (24/388; 95% CI:[3,8%--‐8,6%]). There were 19,76 urinary tract infections per thousand urinary catheter days (CAUTI) and 4,17 CAUTI per thousand days of hospitalization. The incidence rate of CAUTI was 4% (15/388; 95% CI:[2%--‐6%]). Eighty percent of these infections occurred in patients without indication for urinary catheterization. A quarter of the patients of this cohort had a urinary catheter (24,7%; 95% CI:[20--‐29%]), although there were no indications for the procedure in 36.5 % of cases. The main risk factors for urinary catheterization were the total dependence (OR: 24,47; 95% CI [5,50--‐108,87]; p < 0.001) and the severe dependency (OR: 11,43, 95% CI: [2,56 to 50,93]; p = 0.001) (Barthel Index) and the burden of disease (OR: 1,19; 95% CI: [1,03--‐1,38]; p=0,017) (Charlson Comorbidity Index). Urinary catheters were used in 759 days of the 3591 hospitalization days quantified in this study (21%). The incidence rate of asymptomatic bacteriuria (AB) was 4,4 % (95% CI: [2--‐6%]). Approximately 60 % (10/17) of these patients were treated contrarily to current clinical recommendations. Conclusions: This study highlights the need to implement prevention strategies, which stands to reduce the number of bladder catheterizations. The AB treatment should be avoided.