Catheter Associated Urinary Tract Infection

Catheter Associated Urinary Tract Infection

Facts about CAUTI 12% to 16% of adult patients will receive a urinary catheter during hospitalization. 4 th most common HAI Accounts for more than 12% of acute care infections Nearly 100% of CAUTI caused by instrumentation of the urinary tract More than 13,000 deaths associated with UTIs Associated with an excess length of stay of 2-4 days Excess cost per patient approximately $1,000 costing $400 million to $500 million annually Reference: CDC

Infection rates dropped in all categories nationally except CAUTI

In Texas CAUTI is the only HAI to increase

Key Terms Indwelling catheter: A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a drainage bag (including leg bags). Includes indwelling catheters used for intermittent or continuous irrigation. Not Included (Unless Foley also present): Condom Straight in-and-out catheters Nephrostomy tubes Ileoconduits Suprapubic catheters

Risk of developing CAUTI Infection risk increases by 3% to 7% for each day a urinary catheter remains in place Catheter day 7- What is this patients risk for CAUTI? UP TO 49%

Removal Protocols Daily/Shift needs assessments Bedside shift reports Necessity for urinary catheter? Acute urinary retention Accurate measurement in critically ill patient Selected surgeries perioperative Assist with healing stage III or IV perineal and sacral wounds Hospice/Comfort/Palliative care Required immobilization for trauma or surgery Remove catheters not meeting necessity

Caution with Spinal Cord Injuries Reports of Foley catheters discontinued without adequate alternative bladder emptying method Spinal cord injury patients may appear to be voiding voluntarily but actually retaining huge volumes Potentially serious adverse effects include bladder damage, renal damage, autonomic dysreflexia, death, etc Use of Foley should be clinical decision providing appropriate alternatives/care

Key Terms Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar days on the date of event, with day of device placement being Day 1, AND an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheterassociated. Yeast not used to meet CAUTI criteria

No more than 2 species of microorganisms Urine cultures with > 2 organisms are usually contaminated and not used for care or NHSN Urine culture including mixed flora or equivalent cannot be used Organisms of same genus but different species = 2 organisms. Ex: Pseudomonas Aeruginosa and Pseudomonas stutzeri The same organism with different antimicrobial susceptibilities=1 organism. ES MRSA and MSSA

Know Your Lab s Reporting What are the ranges of CFU reported? What minimal CFU are reported i.e. 10,000-100,000 CFU/ml. Can the laboratory tell you this is at least 100,000 CFU/ml? Are positive urine cultures reported for the unit on which they were collected or where the patient is housed at the time of report? Consider the Transfer Rule. Account for positive cultures from the ED which may represent recently discharged patients

Key Terms Present on Admission (POA) The date of event of the NHSN site-specific infection criterion occurs during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1), the 2 days before admission, and the calendar day after admission.

Key Terms Date of Event (DOE) is the date the first element used to meet the site-specific infection criterion occurs for the first time in the infection window period.

Key Terms: Infection Window Period

CAUTI SUTI 1A Patient must meet 1, 2, and 3 below: 1. Patient had an indwelling urinary catheter that had been in place for > 2 days on the date of event (day of device placement = Day 1) AND was either: Present for any portion of the calendar day on the date of event, OR Removed the day before the date of event 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) suprapubic tenderness* costovertebral angle pain or tenderness* Symptoms can t be used with catheter in place Urgency Frequency Dysuria 3. Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of 105 CFU/ml. All elements of the UTI criterion must occur during the Infection Window Period

Criterion Rationale-SUTI 1a Catheter removed

CAUTI SUTI 1B Patient must meet 1, 2, and 3 below: 1. One of the following is true: Patient has/had an indwelling urinary catheter but it has/had not been in place >2 calendar days on the date of event OR Patient did not have a urinary catheter in place on the date of event nor the day before the date of event 2. Patient has at least one of the following signs or symptoms: fever (>38 C) in a patient that is 65 years of age suprapubic tenderness* costovertebral angle pain or tenderness* urinary frequency ^ urinary urgency ^ dysuria ^ 3. Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of 105 CFU/ml. All elements of the SUTI criterion must occur during the Infection Window Period

CAUTI SUIT 2A Patient must meet 1, 2, and 3 below: 1. Patient is 1 year of age (with or without an indwelling urinary catheter) 2. Patient has at least one of the following signs or symptoms: fever (>38.0 C) hypothermia (<36.0 C) apnea* bradycardia* lethargy* vomiting* suprapubic tenderness* 3. Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of 105 CFU/ml. (See Comments) All elements of the SUTI criterion must occur during the Infection Window Period (See Definition Chapter 2 Identifying HAIs in NHSN).

The Logic Behind SUTI Definitions Symptoms of true UTI will vary depending on if device is present or not Cannot use the following symptoms to identify UTI in patients with a urinary catheter Frequency Urgency Dysuria Infants will exhibit infection differently from patients of other ages For infants, the following additional symptoms may indicate a UTI Apnea Bradycardia Lethargy Vomiting Hypothermia <36.0 C

ABUTI (Asymptomatic Bacteremic UTI) Patient must meet 1, 2, and 3 below: 1. Patient with or without an indwelling urinary catheter has no signs or symptoms of SUTI 1 or 2 according to age (Note: Patients > 65 years of age with a non-catheter-associated ABUTI may have a fever and still meet the ABUTI criterion) 2. Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of 105 CFU/ml (see Comment section below) 3. Patient has organism identified from blood specimen with at least one matching bacterium to the bacterium identified in the urine specimen, or meets LCBI criterion 2 (without fever) and matching common commensal(s) in the urine. All elements of the ABUTI criterion must occur during the Infection Window Period

Discontinuation & Reinsertions Indwelling urinary catheters that are removed and reinserted: If, after indwelling urinary catheter removal, the patient is without an indwelling urinary catheter for at least 1 full calendar day, then the urinary catheter day count will start anew. If instead, a new indwelling urinary catheter is inserted before a full calendar day has passed without an indwelling urinary catheter being present, the urinary catheter day count will continue. 1. When is patient A eligible for CAUTI? 2. When is patient B eligible for CAUTI? March 31 through April 6 March 31 April 3 then April 6

UTI Repeat Infection Timeframe (RIT) 14-day timeframe No new infections of the same type are reported Day 1 is Date of Event (starts 14 day) Any additional pathogens in this time are added to event

UTI Repeat Infection Timeframe (RIT)

Where did the infection happen? The inpatient location where the patient was assigned on the date of event is the location of attribution Exception to Location of Attribution: Transfer Rule: If the date of event is on the date of transfer or discharge, or the next day, the infection is attributed to the transferring/discharging location.

Transfer Rule Examples

Which of the following is most accurate? Grandpa does not have an NHSN CAUTI. Grandpa has a CAUTI attributed to the new hospital. Grandpa has a CAUTI attributed to the Rehab facility and POA to the hospital.

Which of the following is most accurate? Grandpa does not have an NHSN CAUTI. Grandpa has a CAUTI attributed to the new hospital. Grandpa has a CAUTI attributed to the Rehab facility and POA to the hospital.

Is this a SUTI catheter associated? YES or NO

Does the patient have a CAUTI? Yes or No This is a healthcare-associated UTI which is non-catheterassociated by NHSN Definitions. Date of event is 1/9 Foley was not in place >2 calendar days on 1/9

Is this a CAUTI? Yes or NO

This patient has a CAUTI with date of event February 1 True or False

Case Study 1 This patient meets criteria for CAUTI on February 1 because Fever Positive urine > 100,000 CFU/ML No more than 2 organisms Foley in place > 2 days NOTE: Do not total # organsims from multiple urine cultures.

Is this a CAUTI? If so, what type? 1. No UTI 2. Yes, catheter-associated SUTI criterion 1A 3. Yes, catheter-associated SUTI criterion 2A 4. Yes, catheter-associated ABUTI

Is this an HAI? If so, what type? 1. Yes, healthcare-associated UTI but not CAUTI 2. No, it is a UTI that is POA 3. Yes, CAUTI criterion 1A

Should another CAUTI be reported? YES or NO