53. Clobbering CAUTI

Catheter-associated UTI: Callum’s nemesis. His white whale. His Sauron. His favourite rant. 

Want to know how favourite? Listen on! 

Useful links (see show notes for more)
RICAT study
Chlorhexidine meatal cleaning

Transcript

Jame: 0:00

Hi everyone, welcome to the Idiots podcast. That's infectious disease insight of two specialists. I'm James, that's Callum, and we're going to tell you everything you need to know about infectious disease. Soon may the ID team come to discontinue the ta-zo-cin. One day, when the CRP's done we'll take our leave and go. Callum, how are you doing?

Callum: 0:24

Oh You, alright. there, buddy, i'm doing good. thank you, how are you? I'm fine, where are you going with this? I had some tea earlier on and someone asked if I wanted some milk in it, and it was just the normal milk From a cow. Yeah, from a cow actually. yeah, i guess that was normal, wasn't it?

Jame: 0:52

Yep.

Callum: 0:53

So I guess it was a sort of cow tea.

Jame: 0:57

I suppose it was Callum, and what a coincidence that is, because what are we discussing today?

Callum: 1:04

Catheter associated urinary tract infection, lovingly or hatingly referred to as CAUTI by many people.

Jame: 1:12

Cow tea, indeed quite just so Good. well, this is your favourite topic, isn't it? We've had a few of my favourite topics lately, and now it's time for you to take the stage.

Callum: 1:26

I definitely feel strongly about this topic.

Jame: 1:29

it comes up a lot, I think we both do really, Callum, have done this for ourselves.

Callum: 1:34

You know, i guess someone and I can't remember who it was now they said it was at the Harvard Digital Education Conference. I went to that Sarah Dong was involved with Shed out a fair amount And it was great. and there was a session on Twitter and how to get the most out of Twitter, and I'm not sure I really listened or follow the advice, whereas you've been doing good work on the idiots Twitter.

Jame: 1:59

If you stick to ID Twitter and just ignore every other bit of Twitter, it's a really great educational research, that's good.

Callum: 2:07

The problem is that I'm like mixed between MedEd and ID and just lots of random cycling stuff. Yeah, well, they said, and that was tweet and make your mission clear. And your mission is what breaks your heart. That's what your mission is, and I think every time I see someone getting a catheter associated UTI or a Baterenia from it, it breaks my heart a bit, because I think it's so common and I think there's more that we could do to stop it. And you see it. And also it breaks my heart that we so often diagnose people with it incorrectly or people get treated for it when they really shouldn't be and all these sort of things, and it's just over and over and over again.

Jame: 3:02

You see, that's what I thought was going to break your heart was people being diagnosed with it when they don't have it?

Callum: 3:09

Yeah, and it's not just like oh well, you know, i think, as we learn more about the microbiome and the harms of antibiotics and the importance of good stewardship, you know these people are getting a lot of antibiotics, god, aren't they just yeah, it's difficult, but yeah, I guess that's why I want to talk about it.

Jame: 3:29

Fine. Well, let's just dive in. So, Kellan, without any further ado. What is a catheter associated UTI infection?

Callum: 3:39

Well, it's when you have a catheter in a urinary catheter. So a bit of plastic going up the urethra into the bladder and you get an infection.

Jame: 3:50

Fine. So if you take a urine sample from anybody with a catheter and it's got bugs in it, that will be a county, will it No?

Callum: 3:59

It's plastic, it's where it shouldn't be. It will get colonized with bacteria And we've got data for that. So the colonization of the catheter. You get an increased risk of what we'd call bacteria urea And that risk increases by about 5% every day that you've got the catheter in. And almost all catheters are colonized by one month of being in. Yeah, so if you've got a patient who's had a catheter in for a month and they present and you're not sure what's going on and you take a urine sample because they might have an infection and it comes back positive, that has no real relation to whether or not they have an infection.

Jame: 4:43

Yeah, and that's why we talk about short versus long term catheterization And with 28 days as the cutoff between the two is that over the long term, essentially everybody is going to be bacteria uric because you've just introduced a highway from the outside world directly into the bladder which is normally considered to be sterile or at least is functionally sterile. There may be a low level urinary microbiome, but it's full of bugs which don't really cause urinary tract infections, i think functionally sterile is a good term.

Callum: 5:19

Yeah, the thing is there is a link, obviously, between bacteria urea and developing an infection, and about 25% of those people that develop a bacteria urea will develop a catheter associated with its UTI, so it's pretty common. So obviously you need the bacteria to be there for them to cause the infection. But what causes you to go from it just being bacteria to it being an infection? there's basically a constant tug of war there. The bacteria are there and a lot of them would like to expand and grow to their heart's content And they don't really care. From a bacteria's perspective, it doesn't care if it's causing an infection. It just wants to multiply and pass on its genes.

Jame: 6:07

Yeah, multiply and be fruitful, or whatever the saying is.

Jame: 6:11

Yeah, i mean that's true of everything. It's true of your skin commentals, it's true of your GI commentals. They're perfectly happy doing what they're doing and they will replicate to the maximum amount possible in whatever environment they find themselves in. And if that's your gut, your normal gut, then that's fine. And if that's the gut of an inflammatory bowel disease patient which has loads of easy access points into the bloodstream, then they'll go and try and replicate there too. And so too with the catheter. Having the catheter changes the equation. It makes the bladder more colonizable than it was before because there's now a highway directly in. But tell me about the scale of the problem now. How common are catheter associated UTIs? Very common. How common are UTIs in terms of healthcare, acquired infection generally? And then talk about Cauties.

Callum: 7:11

So we talk about healthcare associated infections And I think that's where there's always going to be a low level of UTI that is going on in the community and well, people. That just happens to happen, particularly to women because of the difference in anatomy. And if we think about healthcare associated infections, uti make up about 20% of those in total. It's got a huge number And of those, about half of them are catheter associated UTI, bearing in mind that about 20% of people in a hospital will have a urinary catheter at any time. So you know there's a mismatch there. So 20% of hospital inpatients have a catheter. About half of UTIs are due to people, are in people that have a catheter. But we don't have great data on this in the UK. It's not monitored, we don't have reporting, it's not a notifiable disease. It's incredibly common. We see it all the time. So what the actual stats are, i don't think we know.

Jame: 8:16

It's a bit strange, because we do monitor rates of E coli bloodstream infection, don't we?

Callum: 8:21

Yes, a very good marker.

Jame: 8:23

Staffalius, bloodstream infection as well, but we don't specifically focus. You might do that at an individual trust level or your infection prevention team might do it, but we don't do it as a country.

Callum: 8:37

So we look at E coli Batcharimia in the UK as a sort of marker and fill in some information for that. That's pretty poor marker. Just don't take blood cultures. Oh, all the E coli Batcharimia has gone away. Or just get rid of E coli, it's just Klevneumol, we don't care about that.

Callum: 8:57

So I don't think it's very accurate And I think it goes without doubt. If you do any work in infection and you see lots and lots of patients presenting with catheter, so does UTI And it's a huge impact on that individual patient in terms of the discomfort having symptoms, potential hospital admission and some more corobio exposure, increased length of stay. There was a study that estimated that it's about 99 million pounds a year for the NHS, or about 2000 pounds per episode of a catheter associated UTI.

Jame: 9:29

So that's quite a lot of money.

Jame: 9:31

It is And people might be wondering well, where's all the money going? Because the antibiotics that we use to treat them are fairly cheap and they are But the cannula. The nurse's time to administer said antibiotics, the pharmacist's time to check the prescription Just an extra day in hospital would be about 450 quid, with the patient just sitting there getting three meals. So the cost can fairly ramp up pretty easily once you take into account things like staff time and opportunity cost in other areas, That patient being in the bed means that somebody else can get into that bed, etc.

Callum: 10:10

So if we're saying out there on, about a quarter of the people that have got a bachelor's year of urea will develop a catheter associated UTI of those So of all the people that get a catheter associated UTI, about 4% will develop a life-threatening infection such as Bacteremia, in which the mortality is about 10% to 30%. So it's not to be sniffed at. And I think the other way of reading that is that 96% of them are non-life-threatening. So this is more of an inconvenience and mild symptoms perhaps, but that doesn't undermine the cost of it. Still, you need to treat it. And the other thing to say is that you know, often patients have had a capture for a while because you've got this sort of set up environment where organisms can thrive, and this is a very common cause problems. People get given antibiotic courses. They may be even put on an antipocrobial prophylaxis or their UTIs And you very quickly run into problems with resistance, particularly to your first line aurals.

Jame: 11:18

So then you need to give them IVs or second line agents And then all of a sudden, every episode they have to come into an opa or they have to be admitted to the hospital. You know, if they don't know how seriously you want to take it, yeah, you're right.

Callum: 11:32

It's a slippery slope, you know. It just starts with oh it looks like you'll probably need a catheter, and then the next thing is that you've got, you know a carbapenemies producing organism or you've got some you know an ESBL producing pseudomonas that's difficult to eradicate And you end up with complications And obviously I think as we have to acknowledge quite a lot on here that our practice is biased by the area in which we you know our experience is biased by the area in which we practice, which is the complicated end of the spectrum, and there are, you know, a lot of patients that will get catheters to us, the UTIs, and we'll get us, of course, antibiotics and get better. Quite simply, i maybe won't run into those, those issues, but you know there's certainly pretty risky thing to have in. So I guess you know, if you think about it that way, that you know, ultimately catheters are required in some circumstances And although you know we really need to have a high bar to put them in, there's some patients where they just you will need to have that.

Jame: 12:33

So but I guess it's worth pointing out the potential of harms And there's also hundreds of thousands of people that won't come to any harm whatsoever. You know plenty of people wondering about in the world with the catheter and you have a good catheter care. Yeah, exactly.

Callum: 12:46

Yeah, you can have a completely normal life with the catheter. But I guess why we're, why we're stressing this point, is that we want to talk about how we can potentially stop people getting infections. or also, how do we differentiate because and this is really hard Who has an infection and who just has batiruria or who has something else?

Jame: 13:10

Yeah, let's talk a bit now about the path physiology, what, how exactly the catheter predisposes. We cover this a little bit. But tell me a bit about how the the catheterization can sort of promote the formation of a UTI.

Callum: 13:29

Yeah. so I guess the main thing is that you, your anatomy, is evolved in such a way to try and stop organisms getting up your, your reef, from from your sort of perineal flora, gut organisms, skin organisms, and getting into the nice bladder, which is a sort of warm, wet environment, is lovely to grow in. And so some of the main. there's lots of different natural host defenses, but two of the main ones are the urethra itself, so just the structural length, with sort of cilia going down it and various immune cells lining it. And then the other thing is the sort of physical flow of your in the mixturist mixturition. that's going on And because you've got a catheter, suddenly you've got this surface which isn't the, you know, the mucosal surface of your urethra, and your flow is going to be different because instead of having this sort of large flow of urine all at once, you've got this sort of intermittent low level urine trickling down.

Jame: 14:30

Well, yeah, and it will be going through the inside of the catheter as well.

Callum: 14:34

That's the thing, is that?

Jame: 14:36

it's sort of like diverting a river and instead of the the salmon having to swim upstream, they've got a sort of highway that they can, that they can manipulate instead, and the river is being diverted somewhere else. So they can. that, that's one way. So it's in its interrupting flow And, as opposed to the inhospitable urethral epithelium which is packed full of white blood cells ready to murder everything that's got a non self antigen on it, they've got a load of plastic and they can stick to it and they can climb up it. but they can also form biofilm, can they?

Callum: 15:16

Yeah, so biofilms will form pretty readily on a catheter And there's some some organisms which are worse than others. So you know biofilms are incredibly complex part of microbiology, in terms of like how organisms actually behave and the different cellular activity.

Jame: 15:36

Yeah, we're going to cover it separately.

Callum: 15:37

It's too big So we're not going to go into that too big But biofilm, essentially organisms in a sort of extracellular matrix which is usually formed by bacteria and other stuff that's lying around And they are in a sort of different states. So they're sort of sleepy bacteria. They're not replicating as quickly And they're quite difficult to get rid of once they're there And they aren't usually affected by a lot of antibiotics, because the antibiotics depend on the bacteria replicating.

Jame: 16:06

Yeah, and also they have difficulty getting in.

Callum: 16:09

Yes, and the way biofilm is.

Jame: 16:12

There's some antibiotics that are good at it and some are bad.

Callum: 16:15

Yeah, so something like proteas morabolis is particularly bad because it has an enzyme called urease, which I think we talked about briefly when we were talking about expanding intrabacterallis. It's one of the enzymes that is used to identify this in laboratory, and the urease has this function, you know, for the bacteria really, because it can break down urea and it causes the urine to become alkaline, and that is problematic because then that causes certain ions, like calcium and magnesium, for example, to crystallize, and these crystals can be incorporated into the biofilm, which leads to incrustation, and it's not the good crustaceans that you can eat, it's incrustation which is bad. Oh God, that was bad.

Jame: 17:05

That was bad, so give me a by surprise. You know, like there's a pun at the start of the episode, nothing go good. The worst is over. But the worst wasn't over, was it Callum?

Callum: 17:14

No. So, and I think you see that sometimes when you look at capuchers, you see the sort of like crusty Well, when you take them, out.

Jame: 17:22

If you've ever seen I guess quite a lot of our audience will be early years sort of doctors in training And if you have never done it, it is a good idea to if a catheter is coming out because of a UTI and the patient getting their catheter changed, hanging around the nurses they do it And when it comes out you'll see that it's covered in this kind of gunge. It looks like snot really That's the sort of biofilm And sometimes it can be quite, almost hard And actually taking that causes quite a lot of urethral trauma. That's why some people want the antibiotics to be on board first before the catheter comes out, in case the urethral trauma leads to bacterimia, although that's not really a very evidence-based practice. That's what will come on too shortly. So James was talking about this river.

Callum: 18:23

And I guess when we talk about the catheter there's two real roots. When they're going upstream, so organisms can get into the bladder either going through the catheter, lumen itself, so that's usually reflux from the contaminated drainage bag. So again, if you think about what's a nice place for organisms to grow, a nice warm bag of urine with plastic in it, stuck to someone's leg, yeah, lovely. Or it can go extra lumen, which is what we're talking about, and that is coming basically from your perineal flora and then tracking up between the catheter and the mucosa and getting in that way And I don't know if I've ever really thought about it like that before It kind of makes sense as two main roots. I don't think you would ever clinically think trying to differentiate them. That's not really any value to that. But I think it's worth thinking about how does the infection happen, because that maybe works into how do we stop it.

Jame: 19:24

Yeah, and also what bugs are involved. So I mean, we all know the kind of bugs that are involved with standard ETI. So how does it differ with with county?

Callum: 19:38

It does differ. That's a great point. So in normal ETI we've got our entrobacter. rallies are going to be the main culprits. We've got our E Coli is the public enemy number one. Klebsiella species, proteus species, entrobacter for the main ones.

Jame: 19:57

And as a reminder for the listener, it's about 70% E Coli, 10 to 15% Klebsiella and 10 to 15% every other entrobacter. All is. That's the sort of rough breakdown. So E Coli and Klebs are your main culprits. They're definitely important.

Callum: 20:12

The additional things to think about are pseudomonas, our genosa in particularly intra cocci, and staphococcus aureus and Candida can be involved, and then there'll be differences on these are depending on your patient group. You know, for example, if it's a suprapubic catheter or if it's a urethral catheter.

Jame: 20:37

Yeah, so I guess the take home there is that your stuff that you would expect to find on the skin or particularly in the skin of the groin. So your staph aureus and your intra cocci and Candida's, they can sort of feature more prominently in your, your epidemiology of, of of CAUTI, whereas they would be considered quite not, maybe not intra coccus, but you know, would be reasonably odd for a standard GTI. In fact, usually when you find staph aureus and urine it's hematogenous spread, so it's descending from the kidneys, it's not ascending from the, from the vagina or the or the penis.

Callum: 21:20

Yeah, i do. I do think there's something worth saying about intra coccus though, because we do grow a lot in urine samples, particularly catheter urines, and we work it up and identify it. But my understanding from the literature is really that this isn't, actually is not, it's not that pathogen in an organism. So, you know, i saw someone the other day with like intra cocco infective endocrinitis, loads of vegetations, disseminated disease. They were fine, like they didn't have fever. It's not, you know, that's staph aureus. You know, obviously they weren't fine.

Callum: 21:49

It was like a really serious infection and had big implications. But I'm being a bit flippant there. But you know, it doesn't make people septic. You know everyone was like Oh well, they're not that unwell from the end of the bed, they don't have particular fevers. You know, they're not unwell. And intra coccus just and as part of the reason why it's such a pain is it just sort of sits along and is slightly annoying, and so, you know, i guess with with it in capiturs, it colonizes, we grow it. Is it really that much of a pathogen? If it's a normal urine cultures like an MSU, is it really causing UTI? Is it just a contaminant? I don't know. I think there's a bit of an unanswered question there.

Jame: 22:29

If you, if you have the answer, please, please, inform us more, because I mean, luckily it's pretty easy to kill in the urine, as we'll be talking about in the next episode. But yes, you're right, I mean it's certainly less pathogen. It's some of the other things on this on this list.

Callum: 22:45

Yeah, pseudomonas is worth, you know, thinking that's an. I think one of the important things is that pseudomonas is something that we worry about.

Jame: 22:53

Well, pseudomonas UTI is the bane of my life, cal, because I you know, when I'm on in the duty room I'm getting if I'm doing a shift in the micro lab, you know, a lot of the time we'll get calls from a GP and the GP will say, hey, this guy's got urinary tract infection symptoms, they've got pseudomonas in the urine, it says it's SIPROR and I think everything else is IV. What can I do? And I have to answer nothing. You got to send them in if you want to be the person to be treated, because if Quin loans are out, then that's your only order option. Or is it, callum? That's a little bit of sizzle for the next episode.

Callum: 23:37

Also. Also, what's pseudomonas? Well, we're going to go back to the bug episodes, because we've not done one in a while. It's been a while, hasn't it? It's been sitting there just looking at us and we've been thinking uh, it's standing out from the sink at me right now, callum, it's looking at me, but yeah like you know so if they're, you know, wanting to treat it, they've got to send the patient in.

Jame: 24:05

And luckily enough down here our rolepads got polyfusors, so we've got. You know, if we want to give a day's worth of PIP-Tazzo, we can do. We can stat amygdalaic sites if we need to. You know we've got our options. But you know there are other places where you know they may not have no pat or the rolepad doesn't do polyfusors, and then it's kind of toss up between admitting the patient.

Callum: 24:35

Yeah, yeah, really difficult. So that's the organisms different in cafeteria, associated UTI or county. So what you know we were talking out there on about it's not just you've got a positive urine culture. What is it, james? How do you diagnose this? like you and the patient comes in, you know, what is it that makes you think, james? what makes you think that this is a county and not just a casp? So what's CASP? Caffeotra-associated asymptomatic bacteria.

Jame: 25:15

Okay, a, c, a, a, S, b, yeah, okay. So the I mean making the diagnosis definitively on symptoms. You know we tell people for UTI you need to diagnose this on symptoms and the tests so tell you whether or not those bacteria present, but not whether or not they're the cause of organism of. You know of what's going on. You know the issue is complicated with catheter-associated UTI in that basically every patient is going to be bacteriotic and you need to determine whether or not that's the. You know that's the diagnosis or not, based on the symptoms.

Jame: 25:54

The symptoms aren't really sort of typical. You can't ask people if they've got urinary frequency because they're not peeing on their own, and similarly dysiudia, pain-on-mituration. They won't have that either because they're not peeing on their own, and so you've not got those kind of diagnostic weapons to rely upon. So the main symptoms that we tell people to look for are sort of fever, obviously, so systemic sort of SIRS kind of symptoms, suprapubic pain, loin pain if it's ascending up urinary tract, or you know we talk about new confusion in a catheterized patient, but then I think people say look at that and they sort of say, oh, new confusion in this.

Jame: 26:42

Person has a catheter, it must be a county, i must treat it. And they go ahead with treatment and what they failed to do is to look for alternative sources or causes of that confusion or sources of infection. So you know a newly confused patient with a catheter fine, they may have a county. They may also have a chest infection or cellulitis or something else that's going on with them, and you need to try and exclude all that stuff as well in your history and clinical before you go on to selecting your antibiotics. I tell you what you don't look for Calum is. You don't look at the urine to see if it's cloudy, because it might be cloudy, smelly because it might be smelly, sedimented because it might be sedimented, and all of those things are present in the asymptomatic bacteria. They don't. The smelliness of a urine or cloudiness of the urine doesn't correlate with its propensity for causing infection. There are plenty of people with a county that don't have any of those features, that have a county.

Callum: 27:51

And you see that all the time and I think you get that as a medic from nurses, and nurses will get that from the patient And it's, you know it can be a bit of a distressing thing for people, particularly because you know the general public awareness of this is, you know, non-existent. So you know, if you you're like smelling of urine, like that's not pleasant for you as a patient, is it? Or if your urine is cloudy and it's very visible, it looks wrong that your urine shouldn't be cloudy. When you do have a catheter, when you do have a catheter, you know there's bacteria there, they will smell, they will the urinary be cloudy. The bag might have like gunk and sediment in it, but it's really down to those symptoms, you know, the key thing being fever, although actually that might be absent in older patients. So it's, i think it's quite. Maybe we talk about, like you know, positive and negative things like positive predictive value, negative predictive values and so on. I don't have the data for that, but I guess the way to think about it perhaps is it's quite hard to say for definite that someone doesn't have a catheter associated with the EGI when they come in with a fever, because those findings are so nonspecific. Yeah, true, but really the key thing is and I think this is where we get it wrong a lot is to not just stop and think, oh, it's going to be a catheter infection, and to really have a think and look for other causes, because if you don't look you won't find And you know that's what happens. Is you know? they come in, they've got a new fever, maybe they're a bit confused because they're elderly and they have maybe cloudy urine or smelly urine, or and maybe you've even done a urinalysis for what it's worth and it's positive I'm going to come onto that in a second And you say it's a urinary tract infection and they've got a catheter, a catheter associated with UTI, and then you stop and that's it. No more other investigations, no more searching. The patient's confused. So it's tricky And I'm not saying this is easy, but I would implore people to keep looking because none of that stuff is saying this is a UTI And I think the way I would approach it is, say possible catheter associated with UTI, because it's hard to rule out.

Callum: 30:10

But you know the way that we phrase our diagnoses are really important, because then what otherwise ends up happening, even if you think all that stuff and you know all this. If you write in the notes, you know, catheter associated with UTI, the diagnostic momentum kicks in And then the next person to see them on the busy acute medical wardrobe is saying oh, it was catheter associated with UTI. That diagnosis made, brain doesn't need to engage. I'll just continue the plan. You know we're giving them antibiotics And then you're four or five days in the line And then it's like they're not better.

Callum: 30:43

Oh, actually there's something else going on Which isn't uncommon.

Jame: 30:48

Yeah, it's a big problem that most of the diagnosing is made within the first 24 hours of admission. You know that's always going to be the case. But particularly as you get to be more senior, you know, as you're being the senior reg and as you're being the consultant, part of your job is almost, as a sense, check for the rest of the healthcare system, the. You know the average F1, f2, you know your early years doctor can make an accurate diagnosis, like 90% of the time. You don't need 20 to 25 years of experience to make most of the diagnoses. What you're there for is for the 10% when the diagnosis hasn't been made Or when there's uncertainty, and, as a sense, check against the diagnosis already made to make sure that it's the right diagnosis and that the patient is going to benefit from the interventions that have been put into place.

Callum: 31:50

Two things about that. One is that when we look at, like and study and review what medical error or diagnostic error in particular it's about 30% of hospital diagnoses are, wrong, so it's not 10%, it's actually a lot more than you would think.

Callum: 32:06

Yeah, it's pretty common And you know, maybe that was fine. Maybe actually you thought it was Gaptor's was UTI and actually they had diverticulitis and he gave them antibiotics and they got better. But he's still, you know, like we quite often get it wrong And that's just. It's not that people are incompetent, It's just that it's really freaking hard to get diagnoses right. And then the other thing is that I think part of the issue is that because there's such a hierarchy in medicine that that diagnosed momentum kicks in, even more so when someone senior has reviewed them, because you know you might see them as a consultant and everything you've got there at that time is saying like well, you know you don't have another source possible UTI.

Callum: 32:48

But when later on and you know I really like great consultant I used to work with, really hammered, this to me was like you know what you saw three days ago. You know there's always new information coming up. Your colleague, when they saw it three days ago, they made one impression but you need to think about things again because new information comes up and things, things change over time. And so if you're not, if you're quite junior and you know, say I'm nasty, free and you're the consultant and you have, three days ago, said it's like after social UTI. Right, who am I to challenge you? Like, you know how am I going to say I don't think that's the case, even if it's like, well, actually, you know, the urm is mixed growth or maybe the urm is negative weirdly, or you know, actually they've now got auction requirement And you know, those diagnosis stick And you know, like Staffel Caucasus, they're very sticky And it's hard to like D label a new end up with a situation where something that isn't supportive of a CAUTI is recognized And then it's putting the notes that they've got a CAUTI.

Callum: 34:00

and then you're, you know it's really hard to walk that back and say actually, maybe they never had a catheter, so CTI. And I think it's quite difficult for patients to understand as well, because they kind of just want someone to be very clear and say this is what you've got. Yeah, and that's, i think, how people understand medicine. No, i mean, you do a test or the test is positive. That's the answer You're now rearing into diagnostic stewardship here.

Jame: 34:24

But you, i mean you're absolutely right And I mean everybody wants a concrete answer. And people get very frustrated when you walk back a diagnosis or say I don't have the answer. You know like, oh so I had this and now you're saying I don't have it. But the guy last week you know said that I did have it. Now I don't have it. And you know you're going to have to phone my life and tell her that you've made a mistake here and blah, blah, blah, and it's very difficult to say, look, we've not made a mistake.

Jame: 34:53

New information has come to light and people you know don't understand Bayesian inference about this.

Jame: 35:01

So, like people you know, when I try and explain it to people patients you know early years and doctors I talk about sort of competing horses And with every diagnostic test you're sort of giving an advantage to kind of one horse over the other and so now this is more likely and this is less likely.

Jame: 35:23

And you're doing that with new information and every test is a sort of like a kick up the backside of you know one horse rather than the other And then all of a sudden you've got a, got a winner. But the race never ends and you have to be prepared to sort of change your opinion with every new piece of information that comes to light and you need to be able to kind of wait it according to you know the likelihood ratio, as best you understand it, of that diagnostic test or that clinical examination finding or that point in the history. You know ID physicians are famously obsessed with taking points in the history I think for a good reason And that kind of factors into the diagnostics. But that is, you know, really difficult to explain to people. But it's also kind of the job, particularly for infection physicians. Everybody's a diagnostician.

Callum: 36:22

I love that analogy for essentially when you've got a differential diagnosis, and so I guess, to sum up, the bit about diagnosis of a catheter associated with UTI is it's really difficult, but the key thing is to remember that it's quite hard to rule out. So it's probably if the person's got a catheter it's often going to be on the list. but don't call the race finished when it's still going on.

Jame: 36:47

So, cal, i'm going to make your blood pressure go through the roof now. I'm going to do it with one sentence. It smelled really bad, so I dipped it and sent it away for the culture.

Callum: 37:01

That's really dirty, James.

Callum: 37:03

I really hate you And this is it Podcast over. Why is that a bad sentence? Oh, i just everything. Everything about it is bad. So you know, obviously the reason we just talked about the reasoning for doing the test in the first place was was, you know, essentially misinformed, because cloudy smell urine isn't indicating to do it. But the main sin there is that urinalysis on a catheter, as you might expect, given that we've just said that almost all catheters a month will be colonized, if you dip it, you're going to pick up leukocyte estuary. You know, leukocyte estuary will be positive, i try, will probably be positive as well, because there's organisms there that are going to, they're going to react to those tests And it's just saying if there's organisms there or not. So you know, maybe there's some value in it If you just put the catheter in and you're you're, you're not colonized and maybe, you know, i don't know- Maybe.

Jame: 38:04

I mean if you literally, if you literally shoved in six hours ago and then they've wriggered though like, think of that situation, you have that story. Do you really need the urinalysis to tell you that you've put plastic into a non-sternal site? It's not helpful is it?

Callum: 38:26

Go back and listen to urinalysis paralysis Maybe that's a good name, because at the end of the day, i don't think we really gave a clear advice on when to do urinalysis, because I'm so certain.

Jame: 38:38

Well no I think we're fairly clear. But yeah, i mean fine. So, like urinalysis is, you know, worse than useless, because it communicates no useful information, but also potentially harmful information, because it biases you towards treatment. Because it's going to be positive Yeah, so it was going to be positive. Yeah, you know well the urinalysis was positive.

Callum: 39:01

The urinalysis was positive. Oh, you know, and it's really hard to be like I wish you had never done that I've got something to do with your blood boil. So ask me how I took the urine sample, jim.

Jame: 39:15

Callum, how do you take a catheter-specific urine? Well, I just went to the bag.

Callum: 39:20

And then there's this, that like lever at the bottom. I just opened it up and took the sample right at the bottom and I send that off. But the last fan are already gone, so I just left it overnight. So I sent it in the morning. Send you in the morning if you leave it at that, was that not?

Jame: 39:36

right. Was that not right? No, it's not right. You know full well it's not right. Just tell me how to do it properly.

Callum: 39:42

So that happens all the time and is completely meaningless. test to do it like that Absolutely no relevance to anything, Even if they do have a catheter associated. yeah, it's an absolute nonsensical way to do it.

Jame: 39:56

No, the lawyer listeners should consider the catheter bag to be completely set up organ. It's like like if you've got something with a chest infection, just taking a nose swab and saying, oh, all the stuff is going with the nose swab. This must be the.

Callum: 40:10

So far removed. It's absolutely relevant And often, you know, even if the catheter doesn't have organisms on it, the urine bag almost certainly will. You know it's trailing along the floor, it's not. It's not a clean site, so don't do that. So catheters Yeah, so catheters should have an access point.

Callum: 40:28

So it's usually like a port. On a lot of the like catheters that we use There's a little red port that's quite near the point where it's going to go into the urethra. It might be a different color, but there should be an access port And essentially what you need is a needle. There's a special syringe that you can get that will be able to access that port. Or you can, if you don't have that, you can use a sort of needle, sort of non-sharp needle. You can use a blunt head. Yeah, it depends. It depends on the specific catheter, but each catheter will have like a specific out port and you access it there And the key thing is to clean it, usually with 70% alcohol, and then take the urine from there, discard the first few milliliters.

Callum: 41:14

So you know, take a syringe, take some urine out, get rid of that syringe, get another syringe, take some urine, send that for the culture and try and get it to the lab quickly, so ideally within four hours, because the longer it's sitting out in a warm environment, the more likely you are to get whatever contaminants you know skin organisms and so on that were on the catheter growing up. If it's going to take more than four hours, you can use something called boric acid. I think this might be the thing that I get the most passionate about at work This whole scenario that we've did, this fictional scenario, which I'm saying is fictional. It happens all the time, all the time, but everywhere, all you know, it's so ingrained in practice.

Jame: 42:03

This is the most agitated I've ever seen. You come.

Callum: 42:07

It's. You know, people that have symptoms or signs that don't actually suggest a urinary tract infection, who then get a urinalysis when they shouldn't get one, and then they get a catheter specimen of urine sent and it's collected from the collection bag And what you end up with is a load of tests that have no reflection on someone who doesn't actually have an infection, and even if the organisms are, there have no relation to what might be actually in the catheter. And then they you know, maybe you grow something resistant and then they get antibiotics and then they come to harm, and that's, i guess that's why I care about it is because, at the end of the day, like that's not good for the person who's got the catheter, is it?

Jame: 42:48

No, no, no and the lawyer may be wondering, like you know, say you grow an organism for the bag that's more likely to be the cause than you know anything else. So why don't you just use that as your, as your kind of loadstone for treatment? Well, what if you don't grow one thing? What if you grow five things? What if you get mixed growth? Do you then follow that up? You know, sometimes that can be five or six different organisms growing on the same plate. Do you? do you seed them to five separate plates and grow them up and do anti biograms on all five organisms? to try and compare anti biograms and then get an antibiotic that will treat them all Like this is a massive uptick in work if you do that. So you're much better off getting port catheter specimens of urine and sending that off. Bag urine is worse than useless for the reasons that we've just stated.

Callum: 43:45

It's also a quite expensive test. You know quite a lot of lab time is a bit of a waste of time.

Jame: 43:50

Well, what's the? isn't your analysis? urine culture the commonest culture that we get? So, kallin, how do you stop people getting catheter associated UTI?

Callum: 44:01

Well, the easy answer is don't have a catheter, but that is as ready outlined they're on wishful thinking in a lot of situations.

Jame: 44:11

Well, no, it's not. because, like quite a lot of the time, particularly if somebody doesn't have a long term castor in, the solution is to pull the catheter, because sometimes people leave them in for comfort and convenience and things like you know, in the post-op page, where people are immobile, they'll have it in at the operation and then it'll stay in because they, you know, they don't want to get up and emulate the toilet. So, yes, if you can remove it, then please do consider doing so. You know that requires a discussion with the patient and whatnot, but you know there's no reason that you can't have that discussion.

Callum: 44:47

Yeah, that's true. There was actually a study in the Netherlands called I think they called it the Rye Cat Study. wherever that stands for, i can't actually. I'm looking at the title of the study and I'm not quite sure what. Rye Cat Study Reduce Inappropriate Caffeater AT I don't know. Anyway, we'll put the link in the show notes And they I'm sure they've dodged it so hilarious.

Callum: 45:11

They looked at sort of a group of interventions to try and reduce the inappropriate and they had a sort of they outlined how they defined that Both intravenous catheters and urinary catheters And they found that about 30% of the urinary catheters were inappropriate And they managed to reduce the an absolute reduction of 6%. So their intervention was successful. But it was just interesting to say that, like when they, when they looked at it and went to every catheter and say do you really need this catheter?

Jame: 45:48

on hospitalized patients Three and 10 were like no.

Callum: 45:52

Yeah, that's quite a lot. Yeah, and I think that's one of the things that I look at on a on a wardrobe is, you know? you know, part of my assessment is always what? what intravenous cannulas are there? Are we using them or they needed? Can we get them out? I always remember the person who had came into A&E had an intravenous cannula. It was never used, not once. Went home, came back. Staff always better in me to be commissioned, you know, like that's just that should never happen, really, shouldn't it? And then the urinary catheter is the same. You know that it's in for the convenience or low level things, and I think when you speak to patients you're like, well, you know one, do you really need it? Maybe it's got some sort of quality of life improvements, but actually probably wanting to get up to the toilet because that's part of your physio And like you don't want to get an infection and potentially die. Like a small risk.

Jame: 46:51

But you know they say, well, i mean definitely, cal, but then sometimes the alternative is that the patients is going to piss their pants And that's really that's a real hard sell to the patient. So, like you can understand from their point of view that the having the plastic in if the risks have not been explained to them appears to be a no brainer. Yeah, do you know, we'll put this thing in, it'll take care of the urine business for you. Now you have to just worry about poos and you can just ask us and we'll bring a bed pan. You know, no problem, you know, and there's there are some patients where getting better and getting up and out of bed and getting mobile maybe isn't a viable, you know long term strategy.

Callum: 47:36

Sometimes, as an infection doctor, you can view the primary endpoint, as you know, not having an infection. That's the most important thing, which clearly it isn't. The holistic approach is, you know. So you have to discuss this with people. I think you, you have to be very clear of people what the risk is having a capital is and that there are significant risks associated. And if they say, actually I'd rather keep the capital, and then you know fair enough As long as they know the risks.

Jame: 48:01

I don't really care what decision the patient makes, as long as they know the risks and benefits they're of. And if they say thanks for your opinion, dr McCray, piss off, that's perfectly fine by me.

Callum: 48:13

Well, I'd rather didn't say that. Does that keep it civil?

Jame: 48:20

So what else can we talk about? The catheter itself. Okay, so what can we do to reduce and what, in particular, what doesn't work?

Callum: 48:28

Well, what about latex versus silicon?

Jame: 48:31

Well, what about latex versus silicon Calamine?

Callum: 48:32

D. No, it doesn't make a difference Antibiotic quoted versus non quoted. Any difference.

Jame: 48:40

Nope, right. Well, antibiotics are good They use, by the way, i don't know.

Callum: 48:43

I've got a list of these. I just looked at the and we've got a list of this many guidelines And I can't remember which one that was from. I think it was from the Epic Free Guidance, which is the English infection control ones. Yep, Yep.

Callum: 48:58

But essentially some people very meticulously went through all the evidence and came up with a recommendation And, to be honest, i just have gone with what they've said. So what about smaller catheters? Well, one thing that's potentially supportive in the type of catheter is silver. So silver quoted And we see that in central, like venous catheters as well, silver can potentially be. So I don't think it's a strong.

Jame: 49:25

So, by way of explanation, silver has some antibacterial properties. So you know quite a lot of deodorants contain silver as a way of inhibiting bacterial growth in the armpit, and you can infuse a catheter with silver as well as an antibacterial.

Callum: 49:44

So that might help. I don't think. I think the jury's still out on whether that is something that we should be doing a lot, and I feel like I read a study where they looked at cost and benefit analysis and they were saying that potentially, because you know a lot of these things, where you make things more complicated, they become more expensive, and that has to be a consideration, particularly in something this common, you know, is it, is it worth the money?

Jame: 50:11

And I think you don't So, but it's been in every bottle of links Africa since the year dawn, so I don't think adding silver to something is necessarily that expensive.

Callum: 50:21

That's true, but the manufacturing process is more complex. Yeah, so, other than the type of catheter, what about the size of catheter? Is it bigger or smaller? This better.

Jame: 50:33

You tell me Cal, and this is your episode, clearly Okay it's smaller.

Callum: 50:37

So, in terms of now, there's other reasons to choose different sizes of catheters. Smaller catheters are thought to be associated with less urine infection, because you get less trauma when you're inserting it and you get less of a urine residual. Other things to think about, so meatal cleaning.

Jame: 50:55

So now you're talking about insertion of the catheter itself?

Callum: 50:57

Yes, yes, moving on to the insertion of the catheter, so the urethral myatus, so the opening of the urethra, you would always you clean that And essentially there's some debate in the literature about what the best thing to clean with is And I think standard UK practices to clean with sort of sterile saline or sterile water. With a little bit of cause And essentially the evidence had been quite mixed and suggesting that maybe there's some benefit to cleaning with some sort of antiseptic solutions such as chlorhexidine, and the Epic Free Guidance, which is, i think, probably the sort of the go-to resource in the UK, suggested there's not enough evidence so they didn't recommend it. Interestingly, the infectious diseases Society of America, the IDSA joint guidance of Shia, do recommend meatal cleaning of chlorhexidine. So I think that's a point of divergence between UK and US practice That will link to this newer randomized controlled trial.

Callum: 52:05

But I read it and went through it for a journal couple of you while ago and it was in 2019. And I found it pretty convincing. They had a really large, statistically significant reduction in both asymptomatic bacteria urea and a 94% decrease in incidence of catheter associated with UTI. So it wasn't a small effect and it's a low cost intervention. It was in Australia And I sometimes wonder, when you get evidence like this and we talked about this before read that and I'm like so why do we not do it? And I find that a bit difficult, but I guess other people are thinking about it and there must be a reason not to. There's potential risk of chlorhexidine, but they're pretty low. Some people will have allergy and you have to ask about that, but I think it's quite a big effect size. So I think that's maybe an area for practice to evolve and change And I hope to see that coming through in guidance as they get.

Jame: 53:12

And just to be clear, the Epic Three guidance came out before that Yeah.

Callum: 53:17

So when that gets updated, hopefully they might. I guess they'll look at that evidence as part of their evidence review and maybe they'll change the recommendation. Well, else can reduce infection risk.

Callum: 53:29

Yeah, run through these very quickly So well I don't think this is a bit of a no brainer, isn't it? Wash your hands. So hand to high team before handling the cafeteria, before inserting it, before doing catheter care. It's not just enough to put gloves and gown on. We know that when people put gloves and gown on they often don't wash their hands And sometimes that's associated with harm. Caffeine care bundles. So that's just the very simple stuff of like making sure the cafeteria is cleaned, making sure that it's hanging, it's not dangling. You've got a strap on the leg to make sure that the cafeteria isn't causing trauma. And catheter care bundles have got evidence basis suggests they reduce infections. Sure, the system is closed, so make sure that there's not like openings. You know you're not leaving the valve open and stuff like that Regularly the empty in the cafeteria bag.

Callum: 54:19

So we talked about the roots of infection getting in and one of them is going up the lumen And so a common problem there is. You say you've got your bag full of urine and that bag is a great place for organisms to grow and hang out. If you raise that bag above the cafeteria, all that urine can easily reflux up the up the cafeteria. There's nothing to stop it. There's no valves in that system. So you just kind of, you just basically washing a bladder in dirty urine, so don't do that. Empty it regularly, regularly to washing. So again thinking about it coming from the outside of the cafeteria in. So if you wash you might reduce the battery load.

Callum: 55:00

And generally, prophylaxis antimicrobial prophylaxis is not recommended in any of the guidance. I think there's always going to be certain cases where you can consider it, but I think overall it's just you just end up with resistant organisms and you know further ahead and actually it's more difficult to treat infections. And then one thing that that was emerging in literature and I think has been talked about a lot but hasn't really made it into established practice yet because it's not, there's not maybe enough evidence is is ultrasound use. So essentially trying to use ultrasound to stop the organisms connecting and sticking onto the cafeteria, and I think that could be quite promising. All just sounds one of these things that seems to come up a lot, particularly in infection control situations. There's lots of, lots of areas of practice as a potential mechanical way, without you know, avoiding the problems of drug therapy to stop infection and the stop other problems.

Callum: 55:59

So you know, fingers crossed it works, because you know, I guess, overall of all these different ways of prevention. And so you know, stopping captors, putting in different types, different sizes, clean the neatus and good infection, because control, precautions, care, bundles, you know, washing all these things. You know we just want something that works and reduces infections. So the more, the more, the better. I guess you know we've done everything we can to stop the person getting a catheter associated with you, but we've not been successful And we've avoided all the pitfall diagnosis and we're confident that the patient has a coffee to capture to the UTI. Maybe they don't have anything else. So what are we going?

Jame: 56:47

to do about it. The first thing we tell everybody about infections that you need to get source control, and at the moment we've got a biofilm laden vehicle for bacterial infection in there. So I think we need to get rid of that. So the thing about catheter associated UTIs is usually there's not actually a lot of urine in the bladder to be to be infected The bladder is. If the catheter is doing its job, the bladder is flaccid and collapsed down, so there won't be a lot of infected urine in the system, but there will be the catheter, and so one of the things that you could do should do maybe is remove the catheter if you can, or exchange the catheter if you can't keep it out.

Jame: 57:47

Now, usually I ask people to do this at the beginning as antibiotics are going on board, but that's not really evidence based in the guidelines as far as I can see. So I looked at this for a talk that I was given to a bunch of urology registrars And I looked at the nice guidance. I looked at the urology European Urology Society guidance. I tried to look at IDSA. I couldn't see anybody actually advising to exchange the catheter with antibiotics already on board. They just sort of said that you could do it at any point, did you?

Callum: 58:31

find anything? Helen, No, I think there's limited evidence. So the theory is change the catheter once the antibiotics are in your system. It kind of depends on the context. A lot of the time, logistically this can be challenging if the patient's not in hospital. or if the patient's in hospital, maybe they're quite sick. So I don't think you should delay therapy starting.

Callum: 58:54

So if you're like we're going to change the catheter but we can't do it right now because there's nobody around to do it, then just start the antibiotics and you can worry about changing the catheter later on. Ideally it makes sense to have antibiotics in the system, because if you imagine you give your antibiotic, we'll come on to which one in a second, and then it's sitting there and it's in your ephra, it's in your urine, and then you put the new catheter in. because what you want to avoid is taking a dirty catheter in out and then immediately putting a new catheter in to a field which is covered in organisms, And then that catheter is immediately going to get colonized, And it will eventually get colonized anyway. But something about the organisms that are there, or the situation, has led that progressing from just bacteria area into infection.

Jame: 59:42

And so I think the issue is more that you want to prevent batoremia during the exchange process. That's what I think.

Callum: 59:49

Right.

Jame: 59:50

The main issue is because I think if you, then if you put in, if you take out the catheter and you put in a new one, a new plastic goes into, you know infected urine and then you promptly sterilize the urine with whatever antibiotic you use, there probably won't be enough time for biofilm to form and all that kind of stuff. So I think you will. The antibiotics will be able to do their thing because, as we're going to come on to in the next episode, the levels of antibiotic that you get in the urine with almost every antibiotic are phenomenal. You know, to the point where, if the organism is sensitive, you can basically use just about anything you like and you'll get antimicrobial sorry, you'll get microbial clearance With it.

Callum: 1:00:37

Well, that's not spoiled the next episode too much, James, because we've teased it so much now. So so change the catheter, What?

Jame: 1:00:43

antibiotics. Well, let's say how long you're going to give them for.

Callum: 1:00:47

Yeah, so all the guidance I've read say seven days, which is versus sort of usual management free days for women.

Jame: 1:00:58

And this is based on the Roman emperor, constantine's, decision to include seven days in a week, because the legendary Brant Spellberg would say so. this is not really based on anything And in fact, if you think about treatment for pylonephritis, a much more significant infection, i would say I would usually be defaulting to five days for that, you know, regardless of the sex of the patient.

Callum: 1:01:30

Yeah, that's true. So I'm sure it's better Brant Spellberg's website, which I just loaded up there. He said, you know, looking at shorter duration for complex UTI or pylonephritis is five or seven days compared to 10 or 14 and of equal. And you know, i guess it does seem seven days doesn't seem quite a long time for catheter-associated UTI.

Jame: 1:01:52

And actually these days because, like, we're defaulting shorter for everything, or at least I am. I think that's the evidence-based approach, really, Yeah. And so if you're, you know you're doing five days for pneumonia now, five days for cellulitis, three days for UTI in women. it's still seven days for UTI in men. I don't really think that you can justify that anymore. So I think if you've got a lower urinary tract infection in the male, you would give seven days. Oh no, it's climbed above the VUJ and all of a sudden they've got a pylonephritis.

Callum: 1:02:29

Oh well, now it's okay to give five days, Yeah well, I think you know, like how are you just Portable diagnoses with intended durations usually go for the longer one out of them. It's not like you say like they've got cellulitis and they've got infected with ectochitis.

Jame: 1:02:41

No, but I'm talking about the default for a lower UTI in a male seven days. But the default for a pylonephritis is, you know, five to seven days And you know, with a pylone I'm usually defaulting five if I can. Yeah, i guess men are worried about prostatitis.

Callum: 1:03:01

But you know and I guess that's something to actually just very briefly say here treatment is that the diagnosis is key. So, as James was saying, you know, do they actually have a higher UTI? Another thing to think about in people with catheters is that often these patients are more mobile, they're frail. So if they've got an AKI, think about, you know, your Turk Calculi is another potential source or sort of structural abnormalities and prostatitis. So you know your catheter is sitting right up against that prostate. And if the organisms are coming outside the outside the catheter and they're sitting on the prostate, you know it's not uncommon for people to get prostatitis in relation to it or epididymorokitis. Even So, make sure you get the diagnosis right. Short duration of therapy if it's just a simple catheter, so it's a UTI, but if there's something else going on you might need to give a bit longer. What about? you know we talked about the organisms that might be involved. Does that affect your empirical treatment for choices? general principles.

Jame: 1:04:06

Well, normally I would just default to what the nice antimicrobial guidance or the local antimicrobial guidance say to do, but I guess that has influenced what they have recommended, although there's not a huge amount of anti-seudomonal coverage in the nice guidance really. So their initial recommendation is Neutrophil and Toan, with the caveat that there's no upper UTI symptoms and that EGFR is acceptable as in grade 45 for that. And Fifth, miscellanam is their second line. So we cover that in our Weird Lactams podcast episodes. This is used exclusively for your Neutrophil infections but has a pretty broad range and is pretty good at this job. And then if you've got, if either you know it's sensitive to Tromethoprim or Amoxicillin or you are in a part of the country which has low to no risk factors for Tromethoprim resistance, then you can use them as options.

Callum: 1:05:21

Yeah, i think that's rare and I think you often do see those being used empirically And it's problematic because I think the resistance rates to Tromethoprim or Amoxicillin is very high and I'd argue that once a person's got a capiture it's kind of a risk factor for resistance In another setting.

Jame: 1:05:38

No, they've already had some healthcare contact.

Jame: 1:05:41

It does vary in different bits of the country and so depending on where you're practicing, I've got no idea what the situation is internationally. But you know there are. In the place where I'm working at the moment it's in England and we're being amalgamated into a big integrated health board which has three kind of areas that are being amalgamated. In one of those areas Their first line for UTIs and for counties is Nicevieranto, and the reason is that they've got high intrinsic levels of Tromethoprim resistance in their urine bugs, whereas that's not true where I'm currently working and in the place next to me, And so we have Tromethoprim as our first line.

Jame: 1:06:31

So it will vary according to where you are in the country, And in the North there's a creeping increase in Tromethoprim resistance in our gram negative population, which is a problem because quite a lot of our follow-up and antimicrobial stewardship relies on the use of the COTROMOXASOL as sort of a rescue broad spectrum but doesn't cause a lot of C diff, can be taken overly 100% by available functionally, And that I think is a really good argument for not having Tromethoprim as your first line antibiotic if you're creating a microguide.

Callum: 1:07:14

Yeah, nitro is great in a way because you don't really use it for anything else.

Jame: 1:07:18

It's not related to anything else. Yeah, and so too with Pibmasilinam. And so I think that when you're creating a microguide, i also think this about the Quinoleons you know I've got. there are plenty of reasons to hate Quinoleons, but I think one of the really convincing driving factors not to use it straight up, you know, for treatment of basic UTIs or even pylonephritis, is that you kind of want to hold in reserve as your only anti-pseudomonal oral treatment.

Callum: 1:07:50

Yeah, i don't think we can say hate any antibiotics, no, i hate, no, i can.

Jame: 1:07:56

Callum.

Callum: 1:07:57

I hate Cipro.

Jame: 1:07:59

Cipro. If you're listening, come at me Anyway. So yeah, and then for UTI symptoms present.

Jame: 1:08:11

So if there's up UTI symptoms there's, you know there's a few. There's the much maligned, in the UK at least, kefalixin, which I think the US listeners will think that we are crazy for not using in greater amounts. But as a reminder for the loyal listeners who are not familiar, kefalixin is a first generation Kefalisporan. It is 90% bioavailable and has excellent urine levels. It is sensitive sorry, it is active against your staff and your strep. It doesn't have enterococcal coverage. None of the Kefalisporans do. But it is also sensitive against your pec organisms, that's, proteus E coli and Clebsiola, and they just so happen to be the top three caused of organisms of your nutritive infections. You can also use things like you know comoxiclav, cotrimoxazole. There is in the guidance, the nice guidance or recommendation, that if you know what's the sense of you can use tri-methoprim I can say I've ever done it, but I suppose it's there, so it's as an option And quinolones as well. They're recommending Ciprofloxacin by name, but Cipro and Levo will both get you excellent urine levels and also cover pseudomonas.

Callum: 1:09:38

So that's the orals. In an IV's nice give guidance about using a Kefalisporan, kefroxim, kefraxon. You can use comoxiclav, say, if it's non-susceptible, gentamycin absolutely amazing drug or amacacin is another. Basically, you know glycosides are very good for the situation.

Jame: 1:09:58

Yeah, and in fact it's the default. In Nadosch North It's the default. Therapy for pylonephritis is Gentamycin, based on the idea that it covers almost everything except entracoccus And cover staph aureus up in Scotland. I know that's not true in other parts of the world, but if you think about Gentamycin plus amoxicillin that will cover just about every urinary or.

Callum: 1:10:29

And actually most of the time now, if you think they've got a catheterous dose of UTI, you give a dose of Gent it should probably be in your system for killing for 24 hours or so, maybe 48 hours, and then you've got your post-antibodic effect And then that's it. You just give a Gent dose and change the catheter and you're done.

Jame: 1:10:45

Yeah, what I mean, the idea, say, a difficult treat, gram negative guidance includes for UTIs and counties would be part of this, a recommendation that you can single shot Gentamycin with curative intent. So if you think about a patient coming in to, you know, an amylatory assessment unit or an acute medical unit and they've got a county and you know it's a county and you excluded everything else, blah, blah, blah, blah all the good practice stuff that we've talked about. You could exchange the catheter, you could give them a shot of Gentamycin. exchange the catheter, what? an hour later, when enough Gent is in the system and enough of it has gotten into the renal system, and then you're done. you can send the patient home.

Callum: 1:11:34

I've got a question, and maybe it's just a question that we don't answer now and we talk about in a future episode. I'm interested in James pharmacology had opinion on intramuscular antibiotics because I feel like we talk about it quite a lot. We use it in some situations like intramuscular penicillin and syphilis.

Jame: 1:11:51

Yeah, and you can give Gentamycin, i am as well. Yeah.

Callum: 1:11:54

Maybe we should be using more intramuscular antibiotics. Maybe that's.

Jame: 1:11:57

Well, it depends on how tightly you want to avoid the cannula, because I mean, certainly when I'm working at the moment, there's an amylatory assessment which is kind of almost functions as the front door. So the default will be that you get seen in AAU and you will, whenever possible, be sent home, with or without the support of hospital at home or with follow-up appointments and things like that. And as part of that kind of part of the workflow of the department is that you get cannulated. basically the second you walk in the door and blood is taken off that cannula and sent away. And so by the time that you see them, there's no advantage to giving I am, gentamycin or whatever, because the cannula is in.

Callum: 1:12:45

I sigh because there's good evidence that unnecessary cannulation One from my infection hat is you're introducing risk of infections. But I think the actual, more convincing argument is the sort of plastic waste site. So environmental sustainability should be included in everything we think about And I think it's part of capitals as well. But giving cannulas when you don't need to is a ripe target for a quality improvement project.

Jame: 1:13:18

Well, all I'll say, Kellan, is don't move south.

Callum: 1:13:23

I'll go further north. I'm coming for you, iceland, yeah. So I think that's all we had to cover. I think we've teased enough at the next episode on the antibiotics for your new check infection that we'll definitely have to record it now.

Jame: 1:13:42

So we do Questions, comments, suggestions. Why don't you send them into idiotspodcastingcom? Have a five star review in your pocket, callum, and I would love to have it. Please drop it in your podcast player of choice. We tweet at idiots underscore pod, and if you want to donate to support the show, you may now do so. There's a link in the description. But until next time, i'm James, i'm Callum. See you then.

Callum: 1:14:07

Now that the episode's done.

Jame: 1:14:09

We hope you learned and had lots of fun. So go forth and treat people with some of what you now know This is the beginning.

Callum: 1:14:18

James is opening a beer which he tells me is dark and cloudy, just like his urine.

Jame: 1:14:25

You're in trouble if you include that in the podcast episode Callum.