Surface-expressed EbpA correlates with fibrinogen binding among enterococcal strains. Conservation of EbpA epitopes predicts that an EbpA antisera raised against one strain will recognize EbpA expressed by diverse strains. This prediction was tested using antisera raised against EbpA of E. faecalis OG1RF and a panel of clinical strains isolated from the urinary tract (UT),the bloodstream, and the gastrointestinal tract (GIT), including representatives of E. faecalis, E. faecium, E. gallinarum, and VRE, as well as several unclassified enterococcal isolates (see Table S1 in the supplemental material). Expression of cell surface EbpA was evaluated by enzyme-linked immunosorbent assay (ELISA) following in vitro culture under conditions known to promote Ebp pilus expression in OG1RF (static culture in brain heart infusion [BHI] medium for 18 h at 37°C). It was found that the EbpA antiserum detected surface-expressed EbpA in all strains tested (see Fig. S2A); however, there was a considerable range in the amount of EbpA that was detected across the panel of isolates (see Fig. S2B). To evaluate whether this range reflected differences in the efficiency by which the antiserum recognized EbpA from different strains versus differences in the levels of Ebp pilus ex- pression, the panel of isolates was tested for fibrinogen binding. This analysis also revealed a range of binding efficiencies of the various isolates (see Fig. S2C). However, there was a positive (r ⫽ 0.5385) and significant (P ⬍ 0.0001) correlation between the de- tected levels of surface-expressed EbpA and the levels of fibrino- gen bound (Fig. 5C). Correlation between detection and function suggests that there is heterogeneity in Ebp expression between isolates rather than differential abilities of the anti-EbpA antise- rum to detect heterologous EbpA proteins. Taken together, these data show that EbpA is a ubiquitous factor expressed among en- terococcal strains and species and that it has a conserved antigenic profile.
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infections. This leads to a large economic burden on the patient, provider, and healthcare system. Despite many proposed interventions to alleviate this, CA-UTIs rates have still remained high. When patients are catheterized for more than seven days, 10-50% will develop a CA- UTI.
Domingo et al., 1999). In our study it was also observed that from cases of asymptomatic patients with indwelling urinary catheters (CA-ASB) 2 strains of Enterococcus were isolated. Ubiquitous presence of enterococci, however requires caution in establishing the clinical significance of particular isolate. Enterococcus has become second or third leading cause of Hospital acquired infection (HA-UTI). UTI s are the most common of enterococcal infection (approximately 16% of nosocomial UTI s). Such bacteruria occurs in patients with structural anomalies and those who have undergone urological manipulations eg indwelling catheterization (Patrick et al., 2007). In this study, ESBL production was determined by Phenotypic confirmatory disc diffusion method in E.coli and Klebseilla isolates. 28.57% E.coli and 23.73% were klebseilla spp. showed ESBL production. There is ample literature against use of antimicrobial impregnated catheters. Study by Toshie Tsuchidaa et al. (2008) concludes that use of silver alloy catheters infact have highest CA-UTI rates. Similarly study by Robert Pickard et al. (2012) interprets that silver alloy coated catheters were not effective for reduction of symptomatic CA-UTI. They also observed that the reduction of CA-UTI with Nitrofural impregnated catheters were less than that regarded as clinically important. Use of antimicrobial impregnated catheters may even cause laxity in aseptic care. The guidelines for Diagnosis, Prevention and Management of patient s with CA-UTI by infectious disease society of America, 2009 does not recommend the use of Antimicrobial impregnated catheters (Martin and Bookrajian, 1962). In the present study Antimicrobial impregnated catheters were not used. Reducing the frequency of use of indwelling catheters, avoiding inappropriate insertions, aseptic precautions while inserting the indwelling catheters and reducing the duration of catheterization are some of the recommendations to reduce CA- UTI.
Foley catheters are commonly used to manage urinary incontinence in elderly patients and in those with bladder dysfunction. Besides helping the patients, these also put them at high risk for the development of UTIs. Uropathogens such as Proteus mirabilis, Providencia stuartii, Morganella morganii are strong urease producers and have a capability of forming a unique type of crystalline biofilms on catheters. The production of urease enables them to breakdown the urea in urine (14) and releases ammonia, which raises the urinary pH resulting in calcium and magnesium phosphate crystal formation within the biofilm matrix. Studies have also demonstrated that biofilm is a prerequisite for the crystal formation since the matrix may act as a nucleation site for crystal development. (15) Following this, the production of urease by these colonies, calcium and magnesium phosphate crystals begin to form and the biofilm extends down the luminal surface. The crystal formation in-turn leads to the blockage of catheters due to crystallization and encrustation that ultimately ends in bladder distention, urine leakage and pyelonephritis. Additionally, crystalline biofilms can also cause irritation and trauma of the urethral mucosa. (16)
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Data on patients’ age, sex, disease, and type and place of catheterization, and hospitalization ward were obtained from patient’s medical records. Patients who used con- doms, supra-pubic catheter, and percutaneous nephros- tomy tube and those who used catheter prior to admission to the selected wards were excluded. The plan was to take 3 urine samples from each patient: first, within 12 hours af- ter insertion; second, 48 hours from admission, and third, in day 5 of admission. The urine samples were taken from the bifurcation of Foley’s catheter with aseptic technique and put in a sterile container. The samples were imme- diately taken to microbiology lab for culture preparation.
Alternate voiding management strategies such as inter- mittent catheterization or, for men, external condom cathe- ters, should be used when possible. Institutional policies should also minimize perioperative catheter use by promot- ing early post-procedure catheter removal and monitoring of bladder volume with ultrasound bladder scanners, where available, to limit catheter reinsertion for potential urinary retention. When a catheter is indicated, it should be re- moved promptly once it is no longer required. Patients with indwelling catheters should be identified and reviewed on a continuing basis, preferably at daily rounds, and the catheter removed when no longer indicated. Catheters have been reported to frequently remain in situ beyond necessary, sometimes because health-care personnel are not aware the catheter is present [7,52]. A systematic re- view of catheter discontinuation strategies for hospitalized patients reported that the intervention of a “stop order” to facilitate prompt removal of unnecessary catheters reduced the duration of catheter use by 1.06 days, and use of either catheter reminders or stop orders decreased the CA-UTI rate by 53% .
sterilization, disinfection and hand washing practices, poor catheter care and also irrational antibiotic use against these infections are alarming markers of global menace necessitating continuous hospital surveillance. The antimicrobial drug resistance mechanisms (Lautenbach et al., 2009; Cosgrove et al., 2002; Gaynes, 2005; Luyt et al., 2014; Bassetti et al., 2015) (mutation and methods of gene transfer), biofilm production, improper or over use of 3 rd generation cephalosporins in gram negative bacteria and gram positive bacteria may interfere with multiple facets of antibiotic stewardship guidelines, including the choice of empirical regimen, in hand options for de-escalation and the therapeutic management of clinical failure due to the potential emergence of resistance under therapy. IDSA guidelines to be followed for the medical therapy of patients with CAUTI (Warren, 1997; Saint et al., 2009; Platt et al., 1982). The major complications of CAUTI are cystitis, pyelonephritis, gram negative bacteremia, prostatitis, epididymitis, and orchitis in males which in turn causes discomfort to the patient by prolonging the hospital stay, increased cost and mortality. Prevention of CAUTI can be accomplished by the following (Bassetti et al., 2015; Platt et al., 1982; Saint et al., 2008; Garibaldi et al., 1974; Esclarin De Ruz et al., 2000; Kunin and McCormack, 1966; Tambyah et al., 2002; Loet al., 2008) a) Health care workers (HCWs) must follow Standard Precautions when caring for the patients with an urinary catheter in-situ; b) A closed drainage system to be used for all the patients with an indwelling catheter; c) to use a pre-connected urinary catheter and drainage bag may decrease CAUTI; d) Use sterile single- Table 2. Bacteriological profile of Catheter Associated Urinary Tract Infections (CAUTI)
Background: In 2008, the catheter associated urinary tract infection (CAUTI) rate at King Fahad Medical City (KFMC) was 3.8/1000 urinary catheter days with some variability between depart- ments. KFMC is the newest tertiary, referral and teaching hospital with 1100 beds in Riyadh, Saudi Arabia. The Infection Control Department at KFMC decided to implement a quality improvement project by applying the bladder bundle in our general ward (Non-ICU) using the model of National Health Service (NHS) hospitals in England even though there was good evidence supporting this in- fection control practice only in ICU patients  . Our objective was to decrease CAUTI in two non-ICU units by at least 50% in one year. Study design: This was a prospective interventional qual- ity improvement project aiming to decrease CAUTI in two non-ICU inpatient units with a total of 193 beds including children and adult patients. Our intervention includes insertion and maintenance components. Results: CAUTI decreased significantly in both departments from 23 infections in 2008 (Rate: 5.03/1000 CDs) to 12 infections in 2009 (Rate: 1.92/1000 CDs) (P = 0.0001); in RH (Rehabili- tation hospital) from 18 in 2008 (Rate: 4/1000 CDs) to 11 infections in 2009 (Rate: 0.36/1000 CDs) (P < 0.0001) and in NSI (National Neuroscience Institute) from 5 in 2008 (Rate: 5.42/1000 CDs) to 1 infections in 2009 (Rate: 3.16/1000 CDs) (P < 0.0001). Conclusion: Implementation of urinary ca- theter insertion and daily care bundles, and creation of a competitive spirit among employees were associated with a significant reduction in catheter associated urinary tract infections.
After conducting a root cause analysis and process and practice audits of CAUTIs, it was determined that there were several contributors to the high CAUTI rate. Some of these reasons included antiquated indwelling urinary catheter (IUC) insertion kits, lack of a nurse driven protocol for IUC removal, and lack of front-line RN knowledge on basic insertion practice. The CNLs on the HAI workgroup were integral in selecting an updated IUC insertion kit that was organized in segments to support sterile process during IUC insertion. The workgroup also advocated and gained support from senior leaders and supply chain representatives to add IUC alternatives into the supply chain. One of these additions was a female urinal. Having female urinals on hand could help decrease the need for an IUC at all or decrease the duration of an IUC. The CNLs created a series of huddle messages to educate RNs on best IUC insertion practices management of IUCs, and alternative urinary management tools to avoid use of IUCs. An example of a huddle message is in Appendix V. Additionally, all RN staff were retrained in IUC insertion using the new kits at the annual nursing skills fair. The CAUTI interventions resulted in a 25% reduction of CAUTIs through the year and cost avoidance of $5,000 (Appendix T). The rate of CAUTIs was below benchmark in the fourth quarter of 2017 (Appendix W).
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the care of catheterized patients receives less attention than patients in acute care settings. Three studies explored whether implementing a complete clinical guideline (all the individual elements) can prevent CAUTI or improve overall quality of long-term urinary catheter care in nursing homes. All implemented complex, multifaceted interventions which were developed by undertaking in- house systematic reviews rather than based on published clinical guidelines. All but one of the publications 40 was a short report with limited detail thus reducing
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Obritsch et al., demonstrated the significant increases in resistance to single antipseudomonal agents, multidrug resistance, and dual resistance to commonly prescribed combination therapies among P. aeruginosa isolates during the 10-year period from 1993 to 2002 by using the intensive care unit surveillance study database. Nosocomial infections caused by Pseudomonas aeruginosa in critically ill patients were often difficult to treat due to resistance to multiple antimicrobials. The selection of appropriate antimicrobial therapy requires active surveillance of emerging resistance trends and continuing education among the health care providers and institution involved. They also suggested that susceptibility of antipseudomonal agents against ICU isolates decreased while multidrug resistance and dual resistance rates increased from 1993 to 2002. Significant reduction in susceptibilities of P. aeruginosa isolates may compromise the ability to choose efficacious empirical regimens for treatment of this formidable pathogen in critically ill patients. This study also provided valuable information related to emerging trends in resistance, and dual resistance rates which were vital to clinicians in the selection of reliable empirical therapy for P. aeruginosa infections in ICU. 25
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Contrary to clinical dogma that healthy urine is sterile; these results suggest that the state of healthy urine is, in fact, one of ‘ asymptomatic bacteriuria ’ . Utilizing high throughput sequencing and metaproteomics, we have described the healthy urine microbiome of a number of populations: male and female healthy controls and healthy subjects with NB. Differing urinary microbiomes for males and females were described. We have demonstrated that NB and/or urinary catheterization impacts the healthy urine microbiome in both genders and this varies by type of bladder management and duration of NB. Furthermore, the presence of a variety of urine microbiomes differing on key, clinical characteristics suggests the benefit of a more personalized approach to UTI care. Clearly, DNA sequencing techniques allow for more specific assessment of the contributing microorganisms than do current clin- ical diagnostic standards, offering the potential for signifi- cant clinical advancement of diagnostic methods for UTI, which have otherwise remained relatively unchanged for decades. Longitudinal differentiation of the urine micro- biome at the time of, prior to, and after infection also will be necessary to fully describe the course of disease and its antecedents. These findings advance clinical translational science toward improved diagnostics and more targeted use of therapeutics.
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thromboembolism (VTE), catheter- associated urinary tract infection (CAUTI), and pressure ulcer (PU) cause signiﬁcant harm to hospitalized children. 1–3 The reduction in the occurrence of these serious conditions improves quality and safety, but in pediatric care less is known about the extent to which hospital-acquired conditions increase the cost of care. Estimating cost savings associated with reduction in harm will help hospital administrators and quality leaders estimate up-front cost and bene ﬁ ts of improvement work, both locally and through participation in improvement networks, and create evidence to evaluate if investment in quality improvement infrastructure improves health care value. In hospitalized adults, a number of authors have found substantial excess length of stay (LOS), costs, and/or resource use associated with hospital- acquired conditions. For example, Saleh et al 4 estimated 77% to 92%
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significant effect on enterococci, yeasts, or enterobacteriaceae (Schierholz et al., 2002). These catheters have therefore not been widely adopted and are no longer available. Both norfloxacin and gentamicin impregnated catheters have been investigated in vitro. Where Gentamicin-coated catheters had demonstrated efficacy against Proteus vulgaris, Staphylococcus aureus and Staphylococcus epidermidis over a short time period (Cho et al., 2003), the Norfloxacin catheters conveyed considerable inhibitory effects against Escherichia coli, Klebsiella pneumoniae and Proteus vulgaris over a 30 day period (Park et al., 2003). In vivo trials however have not been pursued. Nitrofurazone catheters have been studied more extensively, have been marketed and are more widely accepted. In vitro studies have demonstrated the efficacy of nitrofurazone impregnated catheters against common as well as multi-resistant uropathogens (Johnson et al., 1999, 1993). Nitrofurazone-coated catheters have been extensively studied in comparison to uncoated or silver-alloy-coated catheters and have almost unanimously been demonstrated to have a significant influence on reducing catheter associated bacteriuria (Desai et al., 2010; Pickard et al., 2012; Regev-Shoshani et al., 2011; Stensballe et al., 2007). Hachem et al recently researched the activity of an antiseptic coating based on chlorhexidine and gentian violet: Gendine (Hachem et al., 2009). The gendine-coated catheters appeared to prevent both biofilm formation and CAUTI. No human trials have been conducted to date.
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Having established the discriminatory power of the NotI PFGE-based method, we went on to examine for the first time the molecular epidemiology of P. mirabilis catheter-associated urinary tract infections. The results confirmed that the organ- isms present on the crystalline biofilms encrusting catheters were identical to those isolated from the same patient’s urine (Fig. 3). In several instances, Dienes analysis corroborated the epidemiological observations made by PFGE. For example, both methods confirmed that isolates (NP1 to NP4) from the catheter biofilms and urine samples of two catheterized patents residing in a nursing home were identical (Fig. 3 and Table 3). Isolates NP5 and NP6, from the catheter and urine, respec- tively, of a third patient at the nursing home, possessed differ- ent Dienes types, which was also confirmed by PFGE finger- printing (Fig. 3 and Table 3).
committee(Roc.No.AS/11/IEC/SVIMS/2017).A total number of patients who underwent renal transplantation from the year 2000 including men and women with all age groups and patients with urinary tract infections are included in the study.Non-Renal Transplant recipients with urinary tract infections are excluded in this study. Adverse drug reactions associated with past medication, Induction therapy, Immunosuppressive therapy and antibiotic therapy were studied. The nature of adverse drug reactions was collected and recorded in suspected adverse drug reaction reporting form designed by Indian pharmacopoeia commission under Pharmacovigilance
used considering a prevalence rate of 50% since the actual prevalence was unknown. Assuming a response rate of 50%, HCP approached were twice as many as the required sample size. HCP were selected using the random number generator of the computer system. The only tool for data collection was an interviewer- administered questionnaire. The study questionnaire was validated by two epidemiologists. The questionnaire consisted of structured 33items (Knowledge 25-items, Attitude 8-Items), and was distributed among house- officers, residents, specialists and nurses to assess their knowledge of indications for urinary catheterisation, measures to be taken to prevent CAUTI, and attitude regarding urinary catheterisation. Demographic details,
16. Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM, Pollock DA, et al. NHSN annual update:antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006 – 2007. Infect Control Hosp Epidemiol. 2008;29:996 – 1011. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18947320. 17. Inan D, Saba R, Yalcin AN, Yilmaz M, Ongut G, Ramazanoglu A, et al. Device-
Results: There was a high statistical significant increase in knowledge of resident physicians and nurses about guidelines for prevention of catheter associated urinary tract infection in the studied intensive care units after intervention (P ˂0.01). There was high statistical significant improvement in urinary catheterization practice in the studied intensive care units after intervention (P ˂0.01). Regarding incidence of CAUTI, before intervention, CAUTI incidence was 10.6 per 1000 urinary catheter days. After intervention, CAUTI incidence significantly dropped to 5.4 per 1000 urinary catheter days. Risk of CAUTI before intervention was approximately twice that after intervention. The intervention reduced risk of CAUTI by 49.1%. Regarding isolated pathogens associated with reported CAUTI, the most frequent isolated pathogens were Klebsiella spp. (31.4%), followed by Candida albicans (21.4%), Pseudomonas spp. (14.3%) and E. coli (12.9%)
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The Prevent CAUTI leadership team was formed in July 2010 and consisted of stakeholders with complementary ex- pertise and spheres of in ﬂ uence (Ta- ble 1) in response to the recognized gap between our institution ’ s perfor- mance and that of other pediatric institutions. Senior hospital leaders sponsored this initiative after recog- nizing an opportunity to build on other improvement work being done at CHOP to prevent central line – associated bloodstream infections and ventilator- associated pneumonia. The Prevent CAUTI project was a component of a newly initiated hospital-wide effort to adopt a pervasive “ culture of safety ” in which all members of the hospital community (including nonclinical sup- port staff, frontline clinicians, and administrators) were expected to pri- oritize local and institution-wide safety. Each member of the Prevent CAUTI team agreed to take ownership for the initiative and to assume accountability for the institution ’ s ability to achieve both desired outcomes and sustain- able results. The team also had re- sponsibility for establishing the scope and direction of the project.
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