CASE SCENARIO EXERCISE

Transcription

1 påçííáëü=pìêîéáää~ååé=çñ=eé~äíüå~êé ^ëëçåá~íéç=fåñéåíáçå=mêçöê~ããé CASE SCENARIO EXERCISE CATHETER-ASSOCIATED URINARY TRACT INFECTION SURVEILLANCE SCOTTISH SURVEILLANCE OF HEALTHCARE ASSOCIATED INFECTION PROGRAMME (SSHAIP)

2 CASE SCENARIO EXERCISE Four case scenarios for catheter associated UTI are available, it is recommended that this exercise is carried out as group work and that groups spend 20 min evaluating each of the four case scenarios, after which their evaluation should be presented. Five Key Questions are asked of each scenario and the evaluation and answers to the questions are provided. 2

3 CASE SCENARIO 1 Case history: A 68-year-old female patient presents at surgical outpatients with pains in the right lower abdomen region which have worsened over a number of days. A diagnosis is made of suspected acute appendicitis. Abdominal sonography reveals an inflamed, oedematous swelling of the appendix. The patient is prepared for an appendectomy. Laboratory findings: Leukocytosis and an increased erythrocyte sedimentation rate. Urine: bacteria ++, protein and blood ++. Intra-operative diagnosis of a perforated appendix with peritonitis. Case progression: Day 1 Day 2 Day 4 Day 5 Day 6 Day 10 Day Day 21 Admission and operation. Post-operative continuation of antibiotic therapy instituted during the operation. Temperature 38.4 C. Patient complains of problems urinating (post-operative urine retention). Decision to perform a single catheterisation (bladder volume 750ml). Bacteriological examination of catheter urine. Temperature rises to 39.2 C. Chills, headache. Abdominal wall taut. Blood cultures taken. Continued urination problems with dysuria Microbiological findings from the catheter urine: >10 5 CFU/ml Escherichia coli. Acute deterioration in general condition, with tachycardia and hypotension. Temperature 39.5 C. Blood cultures from Day 4: no growth. Adjustment of the antibiotic therapy. Entry in the patient s notes: Change of antibiotics because of clinical sepsis. Stabilisation of general condition. Relief of urination problems. Temperature drops until patient is no longer feverish. Clear improvements in general condition. Patient discharged. Key Questions 3. Was the urine specimen taken? 4. Were there symptoms and signs for CAUTI? 3

4 CASE SCENARIO 2 Case history: A 39-year-old woman is admitted as an inpatient to the surgical unit for a planned haemorrhoidectomy. Case progression: Day 1 Admission. Blood samples taken and urinalysis performed. Findings normal. Preparation for proctological operation in the evening (enema). Day 2 Operation. Day 4 Patient complains of burning pain during urination. No fever. Inspection of the wound: negative. Further diagnostic procedure: urinalysis and examination of urine for pathogens and resistance. Day 5 Urinalysis: large number of bacteria (+++), protein and blood (++). Clinical diagnosis: urinary tract infection. Antibiotics instituted. Day 7 Dysuria ceased. Microbiological findings in the urine from Day 4: evidence of >10 5 CFU/ml Escherichia coli. Day 10 Patient discharged from hospital with wound condition normal. Continuation of antibiotics until Day 12. Monitoring of the infection by the GP. Key Questions 3. Was the urine specimen taken? 4. Were there symptoms and signs for CAUTI? 4

5 CASE SCENARIO 3 Case history: A 52 year-old woman is admitted as an inpatient to the surgical unit for a planned hysterectomy. Case progression: Day 1 Day 2 Day 4 Day 5 Day 7 Operation. Patient complains of problem urinating (post-operative urinary retention) Decision to insert urinary catheter. Catheter removed Temperature 38.3 o C Patient complains of suprapubic tenderness. Bacteriological examination of MSU Microbiological finding >10 5 cfu/ml Escherichia coli. Antibiotic therapy instituted Day 8 Patient discharged with continuation of antibiotics until day 14 Key Questions 5

6 CASE SCENARIO 4 Case history: A 82 year old male is admitted as an inpatient to a Geriatric Medical ward following a CVA. Case progression: Day 1 Day 2 Day 5 Admission Decision to insert urinary catheter for urinary incontinence Temperature 38.4 o C Patient presents with loin tenderness. Physician diagnoses UTI and institutes appropriate antibiotics. CSU sent for microbiological examination Key Questions: 6

7 CASE SCENARIO EVALUATIONS 7

8 Case Scenario 1 Evaluation No. Patients with single in/out catheters are excluded from CAUTI surveillance A single in/out catheter was inserted on day 2 A urine specimen taken on admission and on day 2 Specimen taken on admission has bacteria present ++ Specimen taken on day 2 had >10 5 CFU/ml Escherichia coli Patient presented with fever, headache, chills, dysuria This is NOT case of healthcare acquired CAUTI infection Criteria for CAUTI not met: Patients with single in/out catheters are excluded from CAUTI surveillance 8

9 Case Scenario 2 Evaluation No. There was no urinary catheter inserted No A urine specimen was taken on day 4. Patient presented with dysuria on day 4. Specimen taken had >10 5 CFU/ml Escherichia coli This is a NOT a case of catheter associated urinary tract infection. Criteria for CAUTI are not met: No catheter was in situ or had been in situ during the 3 days previously 9

10 Case Scenario 3 Evaluation Yes Urinary catheter inserted on Day 2 A urine specimen was taken on Day 4 Microbiological findings from the urine specimen >10 5 CFU/ml Escherichia coli. Patient presented with fever and suprapubic tenderness. This is a case of catheter associated urinary tract infection Criteria met: The catheter was removed within the three days before the time of onset of UTI. The first positive specimen was taken more than 48 hours after the catheter was inserted. The patient presented with suprapubic tenderness and fever 10

11 Case Scenario 4 Evaluation Urinary catheter inserted on Day 1 A urine specimen was taken on Day 5 Patient presented with fever and loin tenderness This is a case of catheter associated urinary tract infection Criteria met: The catheter was in situ at the the time of onset of UTI. The physician diagnosed a UTI and institutes appropriate antimicrobial therapy. The patient presented with suprapubic tenderness and fever 11