There s More Than One Way to Skin a CAuTi:

Transcription

1 There s More Than One Way to Skin a CAuTi: A Multidisciplinary Approach to Prevent Catheter Associated Urinary Tract Infections & Treatment of Asymptomatic Bacteriuria

2 Objectives Identify causes of CAUTI Discuss measures to reduce CAUTI Review the definition of surveillance vs clinical CAUTI Define asymptomatic bacteriuria and consequences of treatment Discuss how to interpret a urinalysis and when to order a urine culture Review steps taken at Seton Healthcare Family to reduce CAUTI rates and treatment of asymptomatic bacteriuria

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4 Causes of CAUTI Indwelling Urinary Catheters! Introduction of bacteria on insertion Migration of bacteria along the catheter External (normal flora of perineal area, stool, etc) Internal (contamination from bag, tubing, broken connections) Unnecessary catheter utilization Figure from: Maki DG, Tambyah PA. Emerg Infect Dis 2001;7:1-6

5 The 3 W s to reducing CAUTIs at UMCB Wait Wash Work with a Partner

6 Wait Recognizing that Foley s Catheters do not need to placed upon arrival in the ED for most emergent patients Changing the culture that Foley s are not part of the ABC s Waiting for a less hectic time to insert Foley s to ensure that the process is done with aseptic technique

7 Wash Prepping the area before insertion Castile soap Soap and water Ensure that bacteria is not present before insertion

8 Work with a Partner Foley placement will now require two associates for insertion This change in practice is to ensure sterility of the procedure

9 Other Interventions Daily Rounding WTF (Why the Foley?) Collect data from rounds with REDCap addressing: Stool, Secure, Green Clips, Dependent Loops, HICPAC reasons, CHG Bathing, Removal?, Separate containers for stool/urine Urinary Catheter Practice Improvement Lack of dependent loop Chart in COMPASS the time/date of Insertion Increase use of the Green Clips Patient/Associate Hygiene Practices Hand Hygiene CHG Bathing

10 Action Items to Achieve CAUTI Reduction Promote the appropriate time/place for placement and follow proper insertion technique of urinary catheters in the ED/ICU. Increase awareness on proper Foley Catheter Practices in the ICU/ED Educate and facilitate proper patient hygiene technique in the ICU/ED Daily rounding (M-F) regarding the need for the Foley and monitoring the use of patient hygiene techniques in the ICU.

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13 Causes of *Pseudo-CAUTI Inappropriate pan culturing Obtaining urine specimens from old catheters Colonization rate 3% -10% per day Inappropriate handling of urine specimens *Not an accepted term if it meets CDC s CAUTI definition, it s a CAUTI! Hooton et al. Clin Infect Dis 2010;50: Garibaldi RA, et al. Infect Control 1982;3: Saint S, et al. Ann Intern Med 2002;137:

14 CAUTI Surveillance Definition Urinary catheter in place for > 2 calendar days PLUS Fever >38 C, urgency*, frequency*, dysuria*, suprapubic tenderness* and/or costovertebral angle tenderness* (* with no other recognized cause) PLUS Positive urine culture with 100,000 or more CFU/ml, with no more than 2 species of organisms (not including yeast) Definition is deliberately broad to capture all CAUTIs, but captures more than we need to or should treat. I.E., all CDC-defined CAUTIS are not UTIs Accessed January, 2015.

15 CAUTI Clinical Definition Presence of symptoms or signs compatible with UTI with no other identified source along with 10 3 cfu/ml of 1 bacterial species in a single catheter urine specimen Hooton et al. Clin Infect Dis 2010;50:

16 Asymptomatic Bacteriuria (ASB) Isolation of a specified quantitative count of bacteria in a collected urine specimen from a person without symptoms or signs referable to urinary infection Often identified in catheterized patients Pyuria plus asymptomatic bacteriuria is not an indication for antibiotic treatment Not an indication for treatment unless Pregnant Traumatic urologic procedure Nicolle LE, et al. Clin Infect Dis 2005;40:643-54

17 Consequences of ASB Treatment Antibiotic Stewardship Appropriate diagnosis and treatment that leads to the best clinical outcome for the treatment or prevention of an infection Consequences of treating of colonization Inappropriate treatment of asymptomatic bacteriuria increases the risk of adverse events & colonization/infection with drug-resistant organisms 3-times as many treatment-related adverse events 8-fold greater incidence of developing C.difficile within 3 months after treatment Hospital-acquired condition CA-UTI penalty Harding G, et al. N Engl J Med 2002;347: Aslam S, et al. Gastroenterol Clin North Am 2006;35:315-35

18 Bacteriuria with Catheter Use Daily bacteriologic monitoring (1140 cases) Bacteriuria at insertion: 99/1140 (8.7%) 1041 had no colonization at insertion, 43 removed within 24 hours Of 608 catheterizations >24 hours, 76 (12.5%) developed bacteriuria Risk of bacteriuria was 3% per catheter-day Garibaldi, et al. Infect Control 1982;3:466-70

19 Bacteriuria with Catheter Use Incidence of bacteriuria associated with an indwelling catheter is 3% -10% per day Duration of catheterization = most important risk factor for development of catheter associated bacteriuria IDSA CAUTI Guidelines. Hooton et al. Clin Infect Dis 2010;50: Trautner BW. Infect Dis Clin N Am. 2014;28:15-31 Garibaldi RA, et al. Infect Control 1982;3: Saint S, et al. Ann Intern Med 2002;137:

20 Signs & Symptoms of CAUTI New onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort Unfortunately, many of these signs & symptoms, including fever, are NOT specific to UTI/CAUTI & have little predictive value for that diagnosis. Can be challenging to sort out! Hooton et al. Clin Infect Dis 2010;50: Chenoweth CE, et al. Infect Dis Clin N Am 2014;28:

21 Pyuria is NOT Diagnostic of CAUTI Pyuria (> 10 WBC/hpf) does not help differentiate asymptomatic bacteriuria Sensitivity of 37% for predicting CA-UTI Absence of pyuria (< 10 WBC/hpf) is a good indicator patient does not have a CA-UTI Negative predictive value = % Pyuria + bacteria CAUTI, BUT the absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI Hooton et al. Clin Infect Dis 2010;50: Semeniuk H. J Clin Microbiol 1999;37: Tambyah PA, et al. Arch Intern Med 2000;160:

22 Pyuria is Common in Patients with Asymptomatic Bacteriuria 32% of young women 30-70% of pregnant women 30-75% of bacteriuric short-term catheterized % of long-term indwelling catheterized 70% of women with diabetes 90% of elderly institutionalized & hemodialysis patients The high rate of asymptomatic bacteriuria with or without pyuria may be associated with misdiagnosis of CAUTI and inappropriate antibiotic use Nicolle LE, et al. IDSA Asymptomatic Bacteriuria Guidelines. Clin Infect Dis 2005;40:

23 CAUTI is Rarely Symptomatic Prospective study: 1497 newly catheterized patients Definitions: CAUTI: new appearance of bacteriuria or funguria with count of > 10 3 CFUs/ml Data collected: Daily urine samples Patients questioned daily by nurse regarding discomfort or other symptoms possibly associated with the catheter (urethral or pelvic pain, sense of urgency) Chart reviewed for fever or other clinical and lab data associated with infection, peripheral WBC recorded Urine WBCs counts measured daily Tambyah et al. Arch Intern Med 2000;160:678-82

24 CAUTI is Rarely Symptomatic Results: 235 new cases of nosocomial CAUTI > 90% of patients were asymptomatic No significant differences between patients with or without CAUTI in signs or symptoms commonly associated with UTI; e.g. fever, urgency, flank pain, or leukocytosis Only 1/ 235 episodes of CAUTI was unequivocally associated with secondary bloodstream infection How many of these patients were treated? How many of them NEEDED to be treated? Tambyah et al. Arch Intern Med 2000;160:678-82

25 Pseudo-CAUTI Prevention Avoid PAN culturing for fever If you must culture, the best practice is to discontinue catheter and obtain specimen from either a clean catch, straight cath, or a new indwelling catheter Is there a clinical reason to suspect the urinary tract as the source of fever?

26 What Triggers Urine Cultures? Presence of pyuria or bacteriuria Urine odor Urine color Urine turbidity RN calls about the above; resident or hospitalist orders culture in otherwise asymptomatic patient or a patient with some other known cause of fever None of these are by themselves an indication for ordering a urine culture. Hooton et al. Clin Infect Dis 2010;50: Trautner BW. Infect Dis Clin N Am. 2014;28:15-31

27 When to Order a Urine Culture? Not an easy decision Should not be an automatic response to evaluation of fever Carefully consider other potential sources of fever or altered mental status (AMS) Consider that typically, most patients with urinary catheters have their bladder emptied continuously; therefore, in the absence of obstruction, development of a clinical CAUTI is unlikely Appropriate for patients with signs and symptoms of sepsis with no clear source Tambyah et al. Arch Intern Med 2000;160:

28 Differential for Fever or AMS Fever Post-operative < 10% of fevers within first 4 days are due to infection 20% of patients have Tmax > 39 C (102.2 F) Drug-related Antibiotics, anti-epileptics, antiarrhythmics, antihypertensives CNS injury AMS Traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, neurosurgery Medication-related (pain medications, sleep aids, anxiolytic) Neurologic (dementia, seizures) Cerebrovascular (stroke) Other (alcohol withdrawal, hypo/hyperglycemia) Shaw JA, et al. Clin Orthop Relat Res 1999;367:181-9 Wortel CH, et al. Surgery 1993;114:564-70

29 2 Key Opportunities Identified at Seton Healthcare Family Urinary catheter insertion & maintenance Avoid collecting unnecessary urine cultures

30 Too Many Urinary Catheters We should avoid placing urinary catheters reflexively (ER?) We should be conscious of and remove unnecessary urinary catheters ASAP We should document lines and tubes and justify their presence in our daily notes Nurses may have a bias toward retaining urinary catheters, especially if the patient is incontinent Incontinence by itself is not a reason to keep a urinary catheter in place3

31 Too Many Urine Cultures Unnecessary urine cultures? (are we really finding asymptomatic bacteriuria/pyuria instead of a true CAUTI? If a patient is catheterized, they are more likely to have pyuria and bacteriuria even if they are asymptomatic (as in the ICU). The longer they are catheterized, the more likely this will be the case. The practice of obtaining urine cultures without appropriate indications may falsely increase CAUTI rates! Are we reflexively ordering urine cultures for patients that have other obvious causes for their fevers? Trautner BW. Infect Dis Clin N Am. 2014;28:15-31

32 Seton Healthcare Family Multi-disciplinary Team Multi-disciplinary team Infection Preventionists Infectious Diseases physicians Clinical Nurse Specialists Infectious Diseases & Critical Care pharmacists Quality Determined project goals Reduce foley catheter days Reduce CA-UTIs Reduce unnecessary urine culturing

33 What are the gains if we do this right? Safer Happier Patients Reduced risk of UTI Reduced risk of Sepsis Reduced exposure to antibiotics Reduced antibiotic resistance Reduced risk of adverse drug events Reduced risk of C. difficile infection Fewer avoidable days Savings on cost of treatment Fewer CAUTIs Better reimbursement Better public image Better financial health

34 Urine Culturing Practices CME approved physician education at all sites Collaboration with Informatics to include recommendations in UA/UC orders Collaboration with Lab to implement process to narrow broad surveillance definition Interim review of urine cultures at academic hospital (07/22/14-11/30/14) Pending urine cultures reviewed & intervened by clinical pharmacy specialists &/or clinical nurse specialist 34

35 Seton Healthcare Family

36 Interim Review (07/22-11/30/14) 3.50 UMCB ICU CA-UTI Standardized Infection Ratio (SIR) Sterile Catheter Insertion Techniques Reinforced Clinical Pharmacy And Nursing Review of UCx & 1:1 Education (55% reduction) July12-Dec12 Jan13-June13 July13-Dec13 Jan14-June14 July14-Dec14 SIR Equation: (Actual # CA-UTIs) (Expected # CA-UTIs)

37 Results! Process: FY15 Statistically Improved FY15 Average: 2.1 Baseline Average: 3.3 Difference: -1.2 P-Value: Phase Start: Jul 2014 # of Periods: 8 UMCB ICU reduced their CAUTI SIR from to 1.255; a 65% reduction and now not significantly higher than the average!