Catheter-AssociatedUrinary Tract Infection (CAUTI) Moderator : Dr Renuka Sinha Presenter : Dr Rudrika Chandra
• Types of urinary catheters and drainage bag.• Indwelling catheters- indications, complications, technique, maintenance • CAUTI and health burden • CDC Definition UTI • Urine collection and laboratory analysis • Causative organisms • ACOG guidelines
TYPES OF URINARY CATHETERSThere are three main types of catheters:• Indwelling catheter• Condom catheter• Intermittent (short-term) catheter Red rubber Robinson catheter Foley’s catheter Coude tipped Catheter
DRAINAGE BAGSA catheter is usually attached to a drainage bag :-• A leg bag is a smaller drainage device that attaches by elastic bands to the leg. It is usually worn during the day. It is easily emptied into the toilet.• A down drain is a larger drainage device. It may be used during the night. This device is hung on the bed .
Appropriate Indications for Indwelling Urethral Catheter Use• Patient has acute urinary retention or bladder outlet obstruction• Need for accurate measurements of urinary output in critically ill patients.• Perioperative use for selected surgical procedures: • Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract • Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) • Patients anticipated to receive large-volume infusions or diuretics during surgery • Need for intraoperative monitoring of urinary output
• To assist in healing of open sacral or perineal wounds in incontinent patients• Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)• To improve comfort for end of life care if needed.• For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.) HICPAC (Healthcare Infection Control Practices Advisory Committee) and CDC (Centers for Disease Control and Prevention)
Inappropriate Uses of Indwelling Catheters• As a substitute for nursing care of the patient with incontinence• As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void• For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.) HICPAC (Healthcare Infection Control Practices Advisory Committee) and CDC (Centers for Disease Control and Prevention) GUIDELINE FOR PREVENTION OF CATHETER ASSOCIATED
Proper Techniques for Urinary Catheter Insertion• Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site.• Only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility.• In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment.• Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion.• Routine use of antiseptic lubricants is not necessary.• Properly secure indwelling catheters after insertion to prevent movement and urethral traction.
• In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable alternative to sterile technique for patients requiring chronic intermittent catheterization.• Unless otherwise clinically indicated, consider using the smallest bore catheter• If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension.• Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. GUIDELINE FOR PREVENTION OF CATHETERASSOCIATED URINARY TRACT INFECTIONS 2009
Proper Techniques for Urinary Catheter Maintenance• Maintain a closed drainage system• If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment.• Consider using urinary catheter systems with preconnected, sealed catheter tubing junctions.• Maintain unobstructed urine flow.• Keep the catheter and collecting tube free from kinking.• Keep the collecting bag below the level of the bladder at all times.• Do not rest the bag on the floor.
• Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container.• Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system.• Complex urinary drainage systems (such as antiseptic-release cartridges in the drain port) are not necessary for routine use.• Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended.• change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.• Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization.
• Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place.• Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.• Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended.• . Routine irrigation of the bladder with antimicrobials is not recommended.• Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended.• Clamping indwelling catheters prior to removal is not necessary. GUIDELINE FOR PREVENTION OF CATHETERASSOCIATED URINARY TRACT INFECTIONS 2009
CAUTI AND HEALTH BURDEN• Catheter Associated urinary tract infection - are the most common healthcare UTIs with 80% attributed to an indwelling catheter.• CAUTI is the leading cause of secondary nosocomial bloodstream infections• 12%-16% of hospital inpatients will have a urinary catheter at some time during their hospital stay.• 13,000 deaths per year are attributable to UTI (mortality rate 2.3%).• 69% of CAUTI may be preventable which - An estimated 17%translates to 380,000 infections and 9,000 deaths prevented per year.• About 17% of hospital-acquired bacteremias are from a urinary source, with an associated mortality of approximately 10%.
ROUTES OF MICROBIAL ENTRY• There are two main routes for entry of bacteria from external environments into the bladder through an indwelling urethral catheter, ascending intraluminal route and the extraluminal route.• Even when a closed drainage system is used, the intraluminal route is still important.
CDC NHSN Definitions of UTI• CAUTI• Symptomatic Urinary Tract Infection (SUTI)• Asymptomatic Bacteremic Urinary Tract Infection (ABUTI) (created in 2009)• OUTI- Other infections of the urinary tract (kidney, ureter, bladder, urethra, or tissue surrounding the retroperitoneal or perinephric space)NOTE: Asymptomatic Bacteriuria (ASB) is no longer a CDC/NHSN infection type National Healthcare Safety Network (NHSN) Centers for Disease Control and Prevention (CDC)
Definition: CAUTI• UTI that occurs in a patient who had an indwelling urinary catheter in place within the 48hr period before the onset of UTI.• Specifically the date when the first clinical evidence appeared or the date the specimen used to meet the criterion was collected, whichever came first. NOTE: There is no minimum period of time catheter must be in place in order for the UTI to be considered catheter-associated.
CAUTI ExamplePatient has a Foley catheter in place on an inpatient unit. It is discontinued, and 4 days later patient meets the criteria for a UTI.This is not reported as a CAUTI because the time since Foley discontinuation exceeds 48 hours.
UTI Specific Infection Types• Symptomatic UTI (SUTI) • Criterion 1 –– a: (catheter in place 48 hours prior to onset) b: (no catheter in place 48 hours prior to onset) • Criterion 2 –– a: (catheter in place 48 hours prior to onset) b: (no catheter in place 48 hours prior to onset) • Criterion 3 (with or without catheter in place 48 hours prior to specimen collection) • Criterion 4 (with or without catheter in place 48 hours prior to specimen collection)• Asymptomatic Bacteremic UTI (ABUTI)• Other Urinary Tract Infection (OUTI)
• Catheter associated UTI (CAUTI) must by definition involve an indwelling catheter.• Only the following specific event types can be CAUTI: • SUTI Criteria: –– • 1a • 2a •3 •4 • ABUTI
Catheter Associated SUTI• Patients of any age:Criterion 1a ( > or= 10 5 CFU/ml)Criterion 2a (> or= 10 3 and 10 5 CFU/ml)• Patients ≤ 1 year of age (only where a catheter is involved):Criterion 3 ( > or= 10 5CFU/ml)Criterion 4 (> or= 10 3 and 10 5CFU/ml)Urine culture must have no more than 2 microorganism species.
Example• Post op day 3: • 40yr patient in the ICU with Foley catheter noted to be febrile (38.9 C) and complained of diffuse abdominal pain. • WBC increased to 19,000. • She had cloudy, foul, smelling urine and urinalysis showed 2+ proteins and 3+ bacteria. • Culture was 10,000 CFU/ml E. coli. Is this a CAUTI??
Recurrent UTI’s—culture-confirmed UTI’s * >3 in 1 year or * > 2 in 6 monthsRelapse UTI — occurs within 2 weeks of Rx of an earlier UTI same pathogenRe-infection UTI— occurs >4 weeks after earlier UTI different pathogen Swart, Soler & Holman, 2004
Asymptomatic Bacteriuria (ASB)At least 1 of the following criteria:1. Patient has had an indwelling urinary catheter within 7 days before the culture and positive urine culture, that is, >or=10 5 microorganisms per cc of urine with no more than 2 species of microorganisms and no fever , urgency, frequency, dysuria, or suprapubic tenderness.2. Patient has not had an indwelling urinary catheter within 7 days before the ﬁrst positive culture And positive urine culture, that is, >or=10 5 microorganisms per cc of urine with no more than 2 species of microorganisms and no fever , urgency, frequency, dysuria, or suprapubic tenderness.
• The daily risk of bacteriuria with catheterization is 3% to 10% approaching 100% after 30 days (which is considered the delineation between short and longterm catheterization.)• Less than 5% of bacteriuric cases develop bacteremia• ASB does not present an increased risk of progression to UTI unless other conditions that predispose the patient to UTI are present.• Monitoring and treatment of ASB is not an effective prevention measure for SUTI, as most cases of SUTI are not preceded by bacteriuria for more than a day.• Treatment of ASB has not been shown to be clinically beneficial and is associated with the selection of antimicrobial-resistant organisms.
ASB Dx based on results of a culture from clean-catch specimen (* important to minimize contamination) Women: bacteriuria = 2 consecutive voided urine samples w/isolation of same strain in cfu/mL >100,000 Men: bacteria = single, clean-catch specimen with 1 bacterial species isolated in > 100,000 cfu/mL Both: single catheterized urine specimen with 1 bacterial species isolated in a count of > 1,000 cfu/mL
Screening & Diagnosis Guideline Criteria for TreatmentIndwelling catheter present: Catheter is not present:two of the following must be met three of the following must be met•Fever (>38°C/100.4°F) or increase of 1.5°C •Acute dysuria alone (key indicator) or fever (2.4°F) above baseline temperature. (>38°C/100.4°F) or increase of 1.5°C (2.4°F)•Chills above baseline temperature•New costovertebral angle tenderness •Chills•New suprapubic pain, flank pain or •Frequency tenderness •Urgency•Decreased mental or functional status •New costovertebral angle tenderness (delirium) •Decreased mental or functional status (may be•New-onset hematuria, foul-smelling urine, or new or increased incontinence related) * amount of sediment •New-onset hematuria, foul-smelling urine or (+) sediment •New suprapubic pain, flank pain or tenderness McGeer (1991) and Loeb et al. (2001
Methods of urine collection in UTI• Supra-pubic aspiration (SPA):• Catheter-specimen urine (CSU) • intermittent catheterisation ( in & out) • indwelling catheter- from sampling port or aseptic aspiration of the tubing.• Bag specimen urine (BSU): in infants and children.• Mid-stream urine (MSU): recommended routinely. After periurethral cleaning, the first part of voided urine is discarded and without interrupting the flow ~10ml is collected in a sterile container• Clean-catch urine (CCU): After periurethral cleaning, the whole specimen of voided urine is collected. Not to collect from the collection bag
Routine Urinalysis—Key Indicators of InfectionUrine collection 1st morning specimen is best Straight catherization for those incontinent, functionally or cognitively impairedSpecific gravity Measure of kidney’s abiltiy to concentrate urine Range of SG depends on state of hydrationAppearance Cloudy, may not indicate WBC’s Could indicate a change in urine pH → causes precipitation Alkaline urine → phosphates → cloudy Acid urine → urates → cloudyColor Pale yellow to amberOdor normal → faint odor when freshly voided Foul-smelling—often presence of bacteria which splits urea to form ammonia Fischbach, 2004
pH Acid or base—measures free H+ ion concentration in urine 7.0— neutral. Indicates kidney function Determines if systemic acid-base disorders of metabolic/resp. origin • control of pH → manages bacteriuria, renal calculi & drug Rx • bacteria from a UTI → produce alkaline urineBlood or Always an indicator of kidney/UT damageHemoglobinProtein Single most important indication of renal disease(Albumin)Microalbuminuri Below dipstick range of detectiona Detects deteriorating renal function in diabetic patients (standard screener) Fischbach, 2004
*Nitrite Dipstick - rapid, indirect method to detect bacteria(Bacteria) • common gram- negative organisms contain enzymes → reduce nitrate in urine to nitrite • some UTI’s are caused by organisms that do not convert nitrate to nitrite (e.g., staphylococcus, streptococci)*Leukocyte Esterase is released by leukocytes (WBC’s) in urine Esterase Microscopic exam & chemical test
Urine Culture and Sensitivity• Traditional gold standard for significant bacteriuria >100,000 cfu/mL of urine.• Some argue criteria for bacteriuria is only 100 cfu/mL of a uropathogen in symptomatic females or 1,000 in symptomatic males.• Bacterial identification from urine C&S, key in males and females with complicated UTI’s.• A positive culture of a urinary catheter tip is not an acceptable laboratory test to diagnose a urinary tract infection.
Other Laboratory TestsComplete Blood Count with DifferentialElectrolytes • R/O dehydration & if IV fluids replacement neededBUN, Creatinine • Determine ↓ renal function for nephrotoxic medicationsBlood Culture • Identify bacteremic organism in suspected urosepsis
Prevention of CAUTI• Follow Proper Techniques for Urinary Catheter Insertion and Maintainence.• Short-term silver alloy catheters may reduce incidence of CAUTI and bacteremia.• Silicone or hydrogel catheters are recommended for people using catheters greater than 14 days.• Increasing fluid intake.
APIC Guidelines• Maintain drainage bag below level of bladder at all times• Do not change indwelling catheters or urinary drainage bags atarbitrary fixed intervals• Document indication for urinary catheter on each day of use• Use reminder systems to target opportunities to remove catheter• Use portable ultrasound bladder scans to detect residual urine amounts• Consider alternatives to indwelling urethral catheters, such asintermittent catheterization APIC Guide to Elimination of CAUTI 2008 Association for Professionals in Infection Control and Epidemiology
Biofilms• A biofilm is a surface accumulation of microorganisms in which large amounts of organic polymers of microbial origin bind the cells and other organic or inorganic materials together and to the substratum.• Formation of biofilms by urinary pathogens on the surface of the catheter and drainage system occurs universally with prolonged duration of catheterization.• Microorganisms living in a sessile state within the biofilm, are resistant to antimicrobials and host defenses and virtually impossible to eradicate without removing the catheter.
Causative Organisms• The most frequent pathogens associated with CAUTI are Escherichia coli (21.4%) and Candida spp (21.0%)• followed by Enterococcus spp (14.9%),• Pseudomonas aeruginosa (10.0%),• Klebsiella pneumoniae (7.7%),• and Enterobacter spp (4.1%).•• smaller proportion: by other gram-negative bacteria and Staphylococcus spp .
Antimicrobial resistance• About a quarter of E. coli isolates and one third of P.aeruginosa isolates from CAUTI cases were fluoroquinolone-resistant.• Resistance of gram-negative pathogens to other agents, including third-generation cephalosporins and carbapenems, was also substantial .• The proportion of organisms that were multidrug resistant is: 4% of P. aeruginosa, 9% of K. pneumoniae, 21% of Acinetobacter baumannii.
Alternative Therapies in UTI Prevention Old adage: “An ounce of prevention is worth a pound of cure.”Cranberry (Vaccinium macrocarpon, fruit) Central in folk medicine beneficial effects on urinaryLeading cranberry juice cocktail: juice tract health.sweetener, water & added Vit. C Longstanding Rx for UTI prophylaxis Well-tolerated, key factor with older adultsMechanism Cranberry prevents bacterial (E. coli & other gram- negative uropathogens) binding to host cell surface membranes 1984—Sobota demonstrated a mode of action in cranberry juice that interferes with the adherence of E. coli and other bacteria to uroepithelial cellsScientific Rationale E. coli & other bacteria have different types of adhesins on their fimbriae that allow the organism to adhere to epithelial cells & proliferate. Cranberries unique compound, proanthocyanidins (PAC’s) adhesins inhibit this process
American College of Obstetricians and Gynecologists (ACOG) Guidelines•In nonpregnant, premenopausal women, screening for andtreatment of asymptomatic bacteriuria is not recommended (level ofevidence, A).•Antibiotic class should be changed when resistance rates are higherthan 15% to 20% (level of evidence, A).•Patients with acute pyelonephritis should complete 14 days of totalantimicrobial therapy, regardless of whether treatment is on aninpatient or outpatient basis (level of evidence, A).•For uncomplicated acute bacterial cystitis in women, includingwomen 65 years and older, antibiotics should be administered for 3 days (level of evidence, A).
• Urine culture is not required for the initial treatment of a symptomatic lower UTI with pyuria or bacteriuria, or both (level of evidence, B).• For the treatment of acute uncomplicated cystitis, beta-lactams, including first-generation cephalosporins and amoxicillin, are less effective than the preferred antimicrobials listed as treatment regimens (level of evidence, C).• For the diagnosis of bacteriuria in symptomatic patients, decreasing the colony count to 1000 to 10,000 bacteria per milliliter will improve sensitivity without significantly reducing specificity (level of evidence, C).
• For uncomplicated acute bacterial cystitis, recommended treatment regimens are as follows:• Trimethoprim–sulfamethoxazole: 1 tablet (160 mg trimethoprim–800 mg sulfamethoxazole) twice daily for 3 days. Adverse effects may include fever, rash, photosensitivity, neutropenia, thrombocytopenia, anorexia, nausea and vomiting, pruritus, headache, urticaria, Stevens-Johnson syndrome, and toxic epidermal necrosis.• Trimethoprim :100 mg twice daily for 3 days.• Ciprofloxacin : 250 mg twice daily for 3 days,• Levofloxacin: 250 mg once daily for 3 days,• norfloxacin : 400 mg twice daily for 3 days,• gatifloxacin : 200 mg, once daily for 3 days. Adverse effects may include rash, confusion, seizures, restlessness, headache, severe hypersensitivity, hypoglycemia, hyperglycemia, and Achilles tendon rupture (in patients older than 60 years).
• Nitrofurantoin macrocrystals :50 to 100 mg 4 times daily for 7 days,• nitrofurantoin monohydrate :100 mg twice daily for 7 days. Adverse effects may include anorexia, nausea, vomiting, hypersensitivity, peripheral neuropathy, hepatitis, hemolytic anemia, and pulmonary reactions.• Fosfomycin tromethamine, 3-g dose (powder) single dose. Adverse effects may include diarrhea, nausea, vomiting, rash, and hypersensitivity.
• For women with frequent recurrences of lower UTI, continuous prophylaxis has been shown to decrease the risk for recurrence by 95%.• Suitable prophylactic regimens include once-daily treatment with nitrofurantoin, norfloxacin, ciprofloxacin, trimethoprim, trimethoprim– sulfamethoxazole.• The need for continued therapy can be re-evaluated after 6 to 12 months.• Acute pyelonephritis traditionally has been treated with hospitalization and parenteral antibiotics.• However, cost-savings measures have prompted a recent shift to outpatient management, whenever feasible