Applying CAUTI Definitions and Protocol to Case Studies. Device-associated Module 5 Events. Objectives. NHSN and CMS

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1 Intermountain APIC Qualis Health present I-APIC HAI Prevention Learning Network Webinar Series : Case Studies with the CDC Catheter-Associated Urinary Tract Infections February 15, 2012 with Angela Bivens Anttila, MSN, RN, FNP C, CIC Applying Definitions Protocol to Case Studies Angela Bivens-Anttila RN, MSN, NP-C, CIC Nurse Epidemiologist Centers for Disease Control Prevention Division of Healthcare Quality Promotion February 2012 Objectives Review requirements for reporting to CMS through NHSN Define key terms Review apply criteria application Define resources methods for catheter-associated urinary tract infection () surveillance Device-associated Module 5 Events Deviceassociated Module CLABSI CLIP VAP DE CLABSI Central line-associated bloodstream infection CLIP Central line insertion practices VAP Ventilator-associated pneumonia Catheter-associated urinary tract infection DE* Dialysis event *For outpatient dialysis only CMS Reporting via NHSN Current Requirements DRAFT (11/14/2011) HAI Event Facility Type Reporting Start Date Acute Care Hospitals CLABSI Adult, Pediatric, Neonatal ICUs January 2011 Acute Care Hospitals Adult Pediatric ICUs January 2012 Acute Care Hospitals SSI January 2012 Colon Abdominal Hysterectomy I.V. antimicrobial start Dialysis Facilities January 2012 Positive blood culture Dialysis Facilities January 2012 Signs of vascular access infection Dialysis Facilities January 2012 CLABSI Long Term Care Hospitals * October 2012 Long Term Care Hospitals * October 2012 Inpatient Rehabilitation Facilities October 2012 MRSA Bacteremia Acute Care Hospitals January 2013 C. difficile LabID Event Acute Care Hospitals January 2013 HCW Influenza Vaccination Acute Care Hospitals January 2013 HCW Influenza Vaccination ASCs October 2014 SSI (TBD) Outpatient Surgery/ASCs TBD * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN NHSN CMS must be included in Monthly Reporting Plans for data to be reported on behalf of the hospital/facility to CMS Must follow the NHSN protocol exactly report complete accurate data in a timely manner. Report each detected or indicate that no occurred for selected reporting locations Report total device days total patient days for selected locations 1

2 CMS Reportable Data Must Be Included in Monthly Reporting Plans Key Terms All s Must be HAI Key Term: Healthcare-associated Infection (HAI) A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that Occurs in a patient in a healthcare setting Was not present or incubating at the time of admission, unless the infection was related to a previous admission Key Term: Indwelling Catheter Key Term: A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, is connected to a closed collection system. Also called a Foley catheter Does not include (among others): Straight in out catheters Suprapubic catheters Nephrostomy tubes A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset. *Note: There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated. 2

3 Location of Attribution s are attributed to inpatient location at time of urine collection or symptom onset, whichever comes first. *Exception: If a develops within 48 hours of transfer from one inpatient location to another in the same facility, or a new facility, the infection is attributed to the transferring location (Transfer Rule). Transfer Rule: Example Mr. Smith is transferred from SICU with a Foley 36 hours after transfer has a fever of 38.2 C. The next day a urine culture collected has >10 5 CFU/ml of E. coli. This is attributed to the SICU. Criteria Application Catheter Associated Urinary Tract Infection Definitions There are two** criteria than can be applied for identifying a Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI) SUTI Overview Symptomatic Urinary Tract Infection SUTI Overview Symptomatic Urinary Tract Infection Must have symptoms AND 4 different criterion groups: Criteria 1 (a & b): Urine culture > 10 5 CFU/ml, no more than 2 species Criteria 2 (a & b): Urine culture > 10 3 <10 5 CFU/ml, no more than 2 species, AND positive U/A a Criteria: catheter at/within 48 hours prior to urine collection or onset of signs or symptoms b Criteria: no catheter at/within 48 hours prior to urine collection or onset of signs or symptoms Criteria 3 & 4: Patients < 1 year of age; have age-specific signs symptoms AND Criterion 3: Urine culture > 10 5 CFU/ml no more than 2 species Criterion 4: Urine culture >10 3 <10 5 CFU/ml no more than 2 species AND positive U/A 3

4 Symptomatic UTI SUTI 1a Symptomatic UTI SUTI 2a 1a Patient had an indwelling urinary catheter in place at the time of specimen collection at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), suprapubic tenderness, or costovertebral angle pain or tenderness. a positive urine culture of 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms OR Patient had indwelling urinary catheter removed within the 48 hours prior to specimen collection at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms 2a Patient had an indwelling urinary catheter in place at the time of specimen collection at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), suprapubic tenderness, or costovertebral angle pain or tenderness a positive urinalysis demonstrated by at least 1 of the following findings: a. positive dipstick for leukocyte esterase /or nitrite b. pyuria (urine specimen with 10 white blood cells [WBC]/mm3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine a positive urine culture of 10 3 <10 5 CFU/ml with no more than 2 species of microorganisms OR Patient had indwelling urinary catheter removed within the 48 hours prior to specimen collection at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness a positive urinalysis demonstrated by at least 1 of the following findings: a. positive dipstick for leukocyte esterase /or nitrite b. pyuria (urine specimen with 10 white blood cells [WBC]/mm3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine a positive urine culture of 10 3 <10 5 CFU/ml with no more than 2 species of microorganisms. Asymptomatic Bacteremic UTI (ABUTI) Patient with** or without an indwelling urinary catheter has no signs or symptoms (i.e., for any age patient, no fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR for a patient 1 year of age, no fever (>38 C core), hypothermia (<36 C core), apnea, bradycardia, dysuria, lethargy, or vomiting) a positive urine culture of >10 5 CFU/ml with no more than 2 species of uropathogen microorganisms* a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant. *Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, betahemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, Corynebacterium (urease positive) +. + Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated. **The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release). Note: All ABUTIs will have a secondary bloodstream infection Surveillance Consistency is a Must! Criteria designed to look at a population at risk Identify patients meeting the criteria Consistently i t tl apply the criteria i Ensures the comparability of the data- protects your facility others Strengthens the validity of the data Entering Events into NHSN (Numerator) 4

5 Patient Information The top section of UTI data collection form is used to collect patient demographics. Required fields have an asterisk (*). There are 4 required fields: Facility ID Patient ID Gender Date of Birth Event Information Event Type is UTI Date of Event: Required. The date the signs or symptoms appeared or date the diagnosing urine specimen was collected, whichever comes first. Event Information Event Information Post Procedure UTI: Optional field. Mark YES if this event occurred after an NHSN defined procedure but before discharge from the facility. MDRO Infection: Enter YES only if the pathogen is being followed for Infection Surveillance in the MDRO/CDI Module in that location as part of your Monthly Reporting Plan. Required. Enter location of patient to which the patient was assigned when the UTI was identified. Event Information Risk Factors Required Field: Three options: INPLACE REMOVE - Removed within 48 hours prior NEITHER Not in place nor within 48 hours Required. The date admitted to Inpatient location If the UTI develops in a patient within 48 hours of transfer from a location, indicate the transferring location, not the current location of the patient. Optional: Date indwelling urethral catheter inserted. Optional: Patient location where indwelling urethral catheter inserted. 5

6 Event Details: Specific Event Event Details: Secondary BSI Available selections based on Event Type Secondary BSI: Required. If the patient had a cultureconfirmed bloodstream a related/documented healthcare associated UTI, select Yes. Secondary BSI Event Details For UTI, at least one organism from the positive urine culture must match an organism in the blood culture (antibiograms of the isolates do not have to match). Example: Patient with a urinary catheter grows E. coli in her urine in her blood. The is reported with Secondary BSI = Yes the pathogen is E. coli. Died: Required for completion. If the patient died during this hospitalization, circle Yes. ** The record may be saved without completing this field, but it will be considered incomplete. UTI Contributed to Death: Required only if the patient died. If the UTI caused the death or exacerbated an existing condition which led to death, mark Yes. Event Details Pathogens Identified Collecting Summary Denominator Data S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptibledose dependent N = Not tested Required. Enter up to three pathogens. If multiple pathogens, enter pathogen judged to be most important cause of infection as #1, the next most important as #2 For all locations, count at the same time each day Number of patients on the unit Number of patients with an indwelling urinary catheter 6

7 Case Studies Ground Rules for Case Studies Purposes: Training on use of definitions AS THEY EXIST (dated August, 2011) Surveillance clinical Optimize data reliability quality Examples highlight common errors/difficult issues Case 1 50 year old patient with end stage pancreatic cancer with liver & bone mets admitted to hospital with advance directive for comfort care antibiotics only; foley catheter, peripheral IV nasal cannula inserted Day 4: patient is febrile to 38.0 C has suprapubic tenderness; IV ampicillin started after urine obtained for culture Day 5: difficulty breathing; CXR=infiltrate L lung base Day 6: urine culture results = 10 5 CFU/ml E coli Day 7: WBC/mm 3 = 3400; patchy infiltrates in both lung bases; continued episodes of dyspnea; rales noted in LLL Day 11: Patient expired Does this patient have a UTI? If, so what type? 1. Yes. SUTI Criterion 1a. 2. Yes, SUTI Criterion 2a. 3. Yes, ABUTI. 4. No UTI. Case 1 Case 2 POD 3: 66 y.o. patient in the ICU with a Foley catheter s/p exploratory lap; patient noted to be febrile (38.9 ) complained of diffuse abdominal pain WBC increased to 19,000. He had cloudy, foul-smelling urine urinalysis showed 2+ protein, + nitrite, 2+ leukocyte esterase, wbc TNTC, 3+ bacteria. Culture was 10,000 CFU/ml E. coli. The abdominal pain seemed localized to surgical area (fever 38 C not high enough for criteria) 7

8 Is this a UTI? If so, what type? Case 2 1. No UTI. 2. Yes, SUTI Criterion 1b. 3. Yes, SUTI Criterion 2a. 4. Yes, ABUTI. Case 3 84 year old patient is hospitalized with GI bleed Day 3: Patient has indwelling catheter in place no signs or symptoms of infection Day 9: Patient becomes unresponsive, is intubated CBC shows WBC of 15,000. Temp 38.0 C. Patient is pan-cultured. Blood culture urine both grow Streptococcus pyogenes urine >10 5 CFU/ml. Is this a UTI? If so, what type? 1. No. Because the blood seeded the urine therefore there is no UTI. 2. Yes, ABUTI. 3. Yes, SUTI Criterion 1a with secondary BSI. C3:Q1 Case 3 ABUTI: No signs or symptoms (fever not > 38 C) Positive blood culture with at least 1 uropathogen matching to the urine culture What if the organism in both cultures had been Micrococcus? Is it a UTI? 1. Yes. This is an ABUTI. 2. No, This is not an ABUTI. 8

9 Case 3 Case 3 No. Micrococcus is not on uropathogen list. Therefore this is not an ABUTI. UROPATHOGENS: Gram-negative bacilli, Staphylococcus spp., Yeasts, Beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, Corynebacterium (urease positive) Case 4 3 week old infant born at 27 weeks gestation. Umbilical catheter in place. HR 100, RR 32, core temperature ranges between 37.8 C 36.2 C. Baby is lethargic. Straight cath urine culture yields >10 5 CFU/ml Enterococcus faecium. 1 blood culture collected same day, also positive for E. faecium. Susceptibilities match. Is this a UTI? If so, what type? Is this a? If so, what type? 1. Yes, CA-SUTI Criterion Yes, CA-SUTI Cit Criterion i 1a. 3. Yes. CA-SUTI Criterion 2b. 4. No CA-UTI. If so, is it? Case 4 Case 4 This patient has a SUTI 3, however, it is not catheter-associated. 9

10 Does this patient have this a CLABSI? 1. No CLABSI. 2. Yes, CLABSI Criterion 1. Case 4 No. Although there is no CA-UTI, there is a UTI. The blood cultures are related to an infection at another site the UTI- therefore this is not a CLABSI. Case 5 48 year old male involved in motorcycle accident. Closed head injury, multiple fractures. Taken to OR for ORIFs evacuation of subdural hematoma. Foley catheter left subclavian catheter placed in ED. Patient t remains on ventilator t placed in OR. Lungs clear bilaterally. 6 days postop, temp F, rhonchii in left lung base. CXR shows possible infiltrate/atalectasis in this area. Urine draining, clear yellow by foley. Patient remains ventilated, sputum increased, white. Case 5 Post op day 7, temp F vent settings stable. No change to sputum production. Post op day 8, temp F, lungs sounds clear, CXR clear. Patient on vent, with foley, central line. Pan cultures sent. Empiric antibiotic tx begun. Post op day 9: Urine culture: 100,000 CFU/ml of P. aeruginosa. Sputum: P. aeruginosa. Blood culture: No growth. Physical assessment normal. No patient response to suprapubic or costovertebral angle palpation. Does this patient have a UTI? If so, what type? 1. No UTI. 2. Yes, ABUTI. 3. Yes, SUTI 2a. 4. Yes, SUTI 1a. Case 5 Yes, this patient has a SUTI 1a. Fever, positive urine culture > 100,000 with one pathogen. C5:Q1 10

11 Case 5 What if the patient had been afebrile, but had an elevated WBC for which they sent the cultures as reported? Would the patient t have a UTI? Would the patient have a UTI? 1. No UTI. 2. Yes, SUTI 1a. 3. Yes, ABUTI. Case 5 No. Patient without symptoms no matching blood culture. Does not meet any of UTI criteria. Case 5 Surveillance definitions work better in some patient populations than others. Patients should be thoroughly assessed for UTI symptoms, including S/P CVA pain. Dialogue/education with clinicians may be warranted. Clinical diagnosis may differ from surveillance determination. Definitions must still be applied consistently. Case 6 9/1: 73 y.o. patient in neurosurgical ICU. Admitted 7 days ago following cerebrovascular accident. Ventilated, subclavian catheter foley catheter in place since admission. i Patient t reacts only to painful stimuli. 9/2: WBCs slightly elevated, at 12,000/mm 3, temp 37.4 C, urine cloudy. Lungs clear to auscultation. Case 6 9/3: WBC 15,800/mm 3, Temperature: 37.6 C. Breath sounds slightly coarse, minimal clear sputum. Urine unchanged. Blood, endotracheal urine cultures collected. No suprapubic p or CVA pain noted. 9/4: Blood endotracheal cultures no growth. Urine + 100,000 E. faecium. 11

12 Does this patient have a UTI? If so, what type? 1. Yes, ABUTI. 2. Yes, SUTI Criterion 1a. 3. Yes, SUTI Criterion 1b. 4. No UTI. Case 6 Because there are no urinary symptoms, nor fever > 38 C, nor blood culture matching the urine culture, there is no UTI. Case 6 What if the patient s temp. was 38.1 C the patient also met the criteria for a PNU including a bronchoalveolar lavage for E. faecium? Does this patient have a UTI? 1. No. The patient s fever is due to pneumonia. Therefore patient is symptomless. 2. Yes. Fever is a non-specific symptom may be due to more than one cause at once. Case 6 This patient has a SUTI 1a: indwelling catheter present, fever, urine culture 100,000 CFU/ml with 2 organisms. Case 7 8/16: 4-year-old girl admitted following MVA. Taken to OR for open-reduction internal fixation of multiple upper lower extremity fractures. Admit to pediatric surgical care unit with Foley catheter draining yellow urine, right femur to traction. IV in right antecubital vein. 12

13 Case 7 8/18: Foley removed. Patient voiding without problems. Afebrile, taking clear liquid diet beginning oral pain medication. BM in a.m. Using incentive e spirometer. 8/19: Tolerating solid diet. IV converted to saline lock. Voiding without trouble on bedpan. 8/20: Patient has slight cough of clear phlegm. BM in a.m. Case 7 8/21: Temp: 37.5 C. Cough continues, phelgm slightly yellow. Using incentive spirometer. ORIF incisions traction sites clean. Bacitracin to traction sites. 8/22: Patient requesting bedpan frequently, crying with urination. Temp C. Cough unchanged. Straight cath urine culture collected. Urine cloudy. U/A + for leukocyte esterase, nitrites negative, 5 WBC by HPF of spun urine. Later that evening, Gram stain of urine shows many gram-negative rods. Empiric co-trimoxazole is ordered. Case 7 8/23: Urine culture + 50,000 CFU/ml of E. coli. Does this patient have a UTI? 1. No. 2. Yes, SUTI 1b. 3. Yes, SUTI 2a. 4. Yes, SUTI 2b. Case 7 This patient meets the criteria for SUTI 2b: Case 8 9/1: 68-year-old female admitted to 6E from OR, status post left KPRO. Foley draining pink urine, PACU nurse reports difficulty with Foley placement. Bulb suction to left knee via stab wound ddraining i small amount tblood ddrainage. IV in left forearm, site without redness dressing dry. Patient controlled analgesia via pump. 9/2: Drain removed. Patient up to bathroom with help of physical therapist. Foley removed. IV continues. Taking full liquids for lunch. Afebrile. 13

14 Case 8 Does this patient have a UTI attributable to 6E? 9/3: Patient to physical therapy. Complains of burning with urination urgency. Suprapubic pain upon palpation. Temp 37.8 C. Urine collected sent for culture U/A. + for 10+ WBCs by HPF of unspun urine, + leukocyte esterase. Empiric antiobiotics begun. 9/4: Urine culture + >100,000 S. epidermidis. 1. Yes. Patient has a SUTI 1a attributable to 6E. 2. No. Patient s SUTI 1a is attributable to the OR. 3. No. Patient does not have a UTI. Case 8 Case 9 This patient does have a SUTI 1a. However, since the OR is not a bedded location, no device-associated events can be attributed to it. If necessary, utilize custom event feature of NHSN to monitor such events. How many indwelling catheter days? A. 6 B. 5 C. 4 D. 3 E. 2 F. 1 Catheter Day Count at 12 noon Patient ADT Urinary Status 101 Black Day2 Indwelling foley to DD 102 White Day 3 Bedpan cath spec to lab 103 Gray D/C home Voiding 1.p.m 104 Salmon Adm 2 p.m. Foley to DD 105 Green Adm 9 a.m. Suprapubic to direct drainage 106 Berry Day 5 Indwelling foley to DD 107 Brown D/C to 11 a.m. Straight cath Q3 hours Case 10 Great Job!!! How many indwelling catheter days? A. 6 B. 5 C. 4 D. 3 E. 2 F. 1 Catheter Day Count at 11 p.m. Patient ADT Urinary Status 101 Washington 4 p.m. Condom cath to DD 102 Dallas Day 2 Indwelling foley to DD 103 St. Charles 11 a.m. Voiding 104 London Day 3 Incontinent using diaper 105 Orlo Day 2 Suprapubic to direct drainage 106 Denver D/C to 4.pm. Indwelling foley to DD 107 Engl 1 p.m. Voiding 14

15 Resources for Surveillance Resources for Surveillance NHSN Patient Safety Component Manual, June 2011 Ch 3: Monthly Reporting Plan Ch 7: Protocol (August 2011) Ch 14: Tables of Instructions, Tables 2a, 5, 6, 7 Ch 16: Key Terms Ch 17: Criteria for Specific Infections Resources for Surveillance NHSN Forms (June 2011) : Monthly Reporting Plan : Urinary Tract Infection : Denominator for SCA : Denominator for ICU/Other Resources for Surveillance Operational guidance document for Acute Care Hospitals to report s for CMS -Guidance.pdf Save-the-Date: I-APIC HAI Series Contact Information Surgical Site Infections (SSI): Case Studies with the CDC Wednesday, March 14, 1pm MT/12pm PT Katherine Allen-Bridson, RN, BSN, MScPH, CIC Nurse Consultant Division of Healthcare Quality Promotion National Center for Emerging Zoonotic Infectious Disease Centers for Disease Control Prevention Clostridium difficile Update Wednesday, April 11, 1pm MT/12pm PT Ruth M. Carrico, PhD, RN, FSHEA, CIC University of Louisville School of Public Health Information Sciences Healthcare Infection Control Practices Advisory Committee (HICPAC) Robert Wood Johnson Foundation Executive Nurse Fellow Angela Bivens-Anttila NHSN@cdc.gov Intermountain APIC Trish Heath, Education Lead trishh@slhs.org Quality Improvement Organizations Jennifer Palagi Qualis Health, Idaho QIO jenniferp@qualishealth.org Tina Schwien Qualis Health, Washington QIO tinas@qualishealth.org Laurie Murray-Snyder Acumentra Health, Oregon QIO lmurraysnyder@acumentra.org This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C7-QH

16 Device-associated Module Table 1: Urinary Tract Infection Criteria Criterion 1a Urinary Tract Infection (UTI) Symptomatic Urinary Tract Infection (SUTI) Must meet at least 1 of the following criteria Patient had an indwelling urinary catheter in place at the time of specimen collection or onset of signs or symptoms at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms (see Comments section below) OR b 2a Patient had indwelling urinary catheter removed within the 48 hours prior to specimen collection or onset of signs or symptoms at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms(see Comments section below).. Patient did not have an indwelling urinary catheter in place at the time of, or within 48 hours prior to, specimen collection or onset of signs or symptoms has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C) in a patient that is 65 years of age, urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of 10 5 CFU/ml with no more than 2 species of microorganisms(see Comments section below). Patient had an indwelling urinary catheter in place at the time of specimen collection or onset of signs or symptoms at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), suprapubic tenderness, or costovertebral angle pain or tenderness at least 1 of the following findings: a. positive dipstick for leukocyte esterase /or nitrite b. pyuria (urine specimen with 10 white blood cells [WBC]/mm 3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine January

17 Device-associated Module Criterion Urinary Tract Infection (UTI) a positive urine culture of 10 3 <10 5 CFU/ml with no more than 2 species of microorganisms(see Comments section below) OR Patient had indwelling urinary catheter removed within the 48 hours prior to specimen collection or onset of signs or symptoms at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness at least 1 of the following findings: a. positive dipstick for leukocyte esterase /or nitrite 2b b. pyuria (urine specimen with 10 white blood cells [WBC]/mm 3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine a positive urine culture of 10 3 <10 5 CFU/ml with no more than 2 species of microorganisms(see Comments section below). Patient did not have an indwelling urinary catheter in place at the time of, or within 48 hours prior to, specimen collection or onset of signs or symptoms has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C) in a patient that is 65 years of age, urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness at least 1 of the following findings: a. positive dipstick for leukocyte esterase /or nitriteb. pyuria (urine specimen with 10 WBC/mm 3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram stain of unspun urine a positive urine culture of 10 3 <10 5 CFU/ml with no more than 2 species of microorganisms(see Comments section below). 3 Patient 1 year of age with* or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C core), hypothermia (<36 C core), apnea, bradycardia, dysuria, lethargy, or vomiting a positive urine culture of 10 5 CFU/ml with no more than 2 species of January

18 Device-associated Module Criterion Urinary Tract Infection (UTI) microorganisms(see Comments section below).. *The indwelling urinary catheter was in place within 48 hours prior to specimen collection or onset of signs or symptoms. 4 Patient 1 year of age with* or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 C core), hypothermia (<36 C core), apnea, bradycardia, dysuria, lethargy, or vomiting at least one of the following findings: Criterion b. positive dipstick for leukocyte esterase /or nitritepyuria (urine specimen with 10 WBC/mm 3 of unspun urine or 3 WBC/high power field of spun urine) c. microorganisms seen on Gram s stain of unspun urine a positive urine culture of between 10 3 <10 5 CFU/ml with no more than two species of microorganisms(see Comments section below).. *The indwelling urinary catheter was in place within 48 hours prior to specimen collection or onset of signs or symptoms. Asymptomatic Bacteremic Urinary Tract Infection (ABUTI) Patient with* or without an indwelling urinary catheter has no signs or symptoms (i.e., for any age patient, no fever (>38 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR for a patient 1 year of age, no fever (>38 C core), hypothermia (<36 C core), apnea, bradycardia, dysuria, lethargy, or vomiting) a positive urine culture of >10 5 CFU/ml with no more than 2 species of uropathogen microorganisms** (see Comments section below). a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture, or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin commensal. *The indwelling urinary catheter was in place within 48 hours prior to specimen collection. **Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, Corynebacterium (urease positive) +. + Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated. Comments Laboratory cultures reported as mixed flora represent at least 2 species of organisms. Therefore an additional organism recovered from the same culture, would represent > 2 species of microorganisms. Such a specimen cannot be used to meet the UTI criteria. Urinary catheter tips should not be cultured are not acceptable for the January

19 Device-associated Module Criterion Urinary Tract Infection (UTI) diagnosis of a urinary tract infection. Urine cultures must be obtained using appropriate technique, such as clean catch collection or catheterization. Specimens from indwelling catheters should be aspirated through the disinfected sampling ports. In infants, urine cultures should be obtained by bladder catheterization or suprapubic aspiration; positive urine cultures from bag specimens are unreliable should be confirmed by specimens aseptically obtained by catheterization or suprapubic aspiration. Urine specimens for culture should be processed as soon as possible, preferably within 1 to 2 hours. If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated, or inoculated into primary isolation medium before transport, or transported in an appropriate urine preservative. Refrigerated specimens should be cultured within 24 hours. Urine specimen labels should indicate whether or not the patient is symptomatic. Report secondary bloodstream infection = Yes for all cases of Asymptomatic Bacteremic Urinary Tract Infection (ABUTI). Report only pathogens in both blood urine specimens for ABUTI. Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C. urealyticum (CORUR) if so speciated. January

20 SIGN-IN SHEET Title: : Case Studies with the CDC Presenter(s): Angela Bivens-Anttila, MSN, RN, FNP-C, CIC Presented on: Wednesday, February 15, 2012 CEC Hours: 1.0 FAX TO: Jennifer Palagi, or scanned version to jenniferp@qualishealth.org Printed Name Signature Nursing License Number(s) Address