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Intermountain APIC and Qualis Health present

I-APIC HAI Prevention Learning Network Webinar Series

CAUTI: Case Studies with the CDCCatheter-Associated Urinary Tract Infections

February 15, 2012

with Angela Bivens‐Anttila, MSN, RN, FNP‐C, CIC

Applying CAUTI Definitions and Protocol to Case Studies

Angela Bivens-Anttila RN, MSN, NP-C, CICNurse Epidemiologist

Centers for Disease Control and PreventionDivision of Healthcare Quality Promotion

February 2012

Objectives

Review requirements for CAUTI reporting to CMS through NHSN

Define CAUTI key terms

Review and apply CAUTI criteria and application

Define resources and methods for catheter-associated urinary tract infection (CAUTI) surveillance

Device-associated Module5 Events

Device-associated

Module

CLABSI CLIP VAP CAUTI DE

CLABSI Central line-associated bloodstream infection

CLIP Central line insertion practicesVAP Ventilator-associated pneumoniaCAUTI Catheter-associated urinary tract

infectionDE* Dialysis event

*For outpatient dialysis only

CMS Reporting via NHSN – Current Requirements DRAFT (11/14/2011)

HAI Event Facility Type Reporting Start Date

CLABSIAcute Care Hospitals

Adult, Pediatric, and Neonatal ICUsJanuary 2011

CAUTIAcute Care Hospitals

Adult and Pediatric ICUsJanuary 2012

SSIAcute Care Hospitals

Colon and Abdominal HysterectomyJanuary 2012

I.V. antimicrobial start Dialysis Facilities January 2012

Positive blood culture Dialysis Facilities January 2012Positive blood culture Dialysis Facilities January 2012

Signs of vascular access infection Dialysis Facilities January 2012

CLABSI Long Term Care Hospitals * October 2012

CAUTI Long Term Care Hospitals * October 2012

CAUTI 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 and CMS

CAUTI must be included in Monthly Reporting Plans for data to be reported on behalf of the hospital/facility to CMS

Must follow the NHSN CAUTI protocol exactly p yand report complete and accurate data in a timely manner. Report each CAUTI detected or indicate that no

CAUTI occurred for selected reporting locations

Report total device days and total patient days for selected locations

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CMS Reportable Data Must Be Included in Monthly Reporting Plans

http://www.cdc.gov/nhsn/PDFs/pscManual/3PSC_MonthlyReportingPlanCurrent.pdf

Key Terms

All CAUTIs 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

O i ti t i•Occurs in a patient in a healthcare setting and•Was not present or incubating at the time of admission, unless the infection was related to a previous admission

Key Term:Indwelling Catheter

A drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system.

•Also called a Foley catheter

•Does not include (among others):

•Straight in and out catheters

•Suprapubic catheters

•Nephrostomy tubes

Key Term:CAUTI

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.

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Location of Attribution

CAUTIs are attributed to inpatient location at time of urine collection or symptom onset, whichever comes first.

*Exception: If a CAUTI 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 and 36 hours after transfer has a fever of 38.2°C. The next day a urine culture collected has >105 CFU/ml of E coli Thiscollected has >105 CFU/ml of E. coli. This CAUTI is attributed to the SICU.

CAUTI Criteria and Application

Catheter Associated Urinary Tract Infection Definitions

There are two** criteria than can be applied for identifying a CAUTIy g

•Symptomatic UTI (SUTI)

•Asymptomatic Bacteremic UTI (ABUTI)

SUTI OverviewSymptomatic Urinary Tract Infection

“a” Criteria: catheter at/within 48 hours prior to urine collection or onset of signs or symptoms

Must have symptoms AND

4 different criterion groups:

Criteria 1 (a & b): Urine culture > 105

CFU/ml no more than 2 or symptoms

“b” Criteria: no 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

CFU/ml, no more than 2 species

Criteria 2 (a & b): Urine culture > 103 and<105 CFU/ml, no more than 2 species, ANDpositive U/A

SUTI Overview Symptomatic Urinary Tract Infection

Criteria 3 & 4: Patients < 1year of age; have age-specific signs and symptoms AND

•Criterion 3: Urine culture > 105 CFU/ml no more> 105 CFU/ml no more than 2 species

•Criterion 4: Urine culture>103 and <105 CFU/ml no more than 2 species ANDpositive U/A

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Symptomatic UTI SUTI 1a

1a Patient had an indwelling urinary catheter in place at the time of specimen collection and 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. and a positive urine culture of ≥105 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 and 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 tendernessand a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms

Symptomatic UTI SUTI 2a

2aPatient had an indwelling urinary catheter in place at the time of specimen collection and 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 and a positive urinalysis demonstrated by at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/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

and a positive urine culture of ≥103 and <105 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 and 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 and a positive urinalysis demonstrated by at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/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

anda positive urine culture of ≥103 and <105 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) and a positive urine culture of >105 CFU/ml with no more than 2 species of uropathogenmicroorganisms* and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or

Note: All ABUTIs will have a secondary bloodstream infection

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, beta-hemolytic Streptococcus spp., Enterococcus spp., G. vaginalis, Aerococcus urinae, and 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).

Surveillance Consistency is a Must!

Criteria designed to look at a population at risk

Identify patients meeting the criteria

C i t tl l th it iConsistently apply the criteria

Ensures the comparability of the data- protects your facility and others

Strengthens the validity of the data

Entering CAUTI Events into NHSN (Numerator)

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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 Gender

Date of Birth

Event InformationCAUTI

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 InformationCAUTI

Post Procedure UTI: Optional field. Mark “YES” if this event occurred after an NHSN defined procedure but before discharge from the facility.

Event InformationCAUTI

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.

Event InformationCAUTI

identified.

Required. Enter location of patient to which the patient was assigned when the UTI was identified.

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.

Required. The date admitted to Inpatient location

Risk FactorsCAUTI

Required Field: Three options:

• INPLACE

• REMOVE - Removed within 48 hours prior

NEITHER Not in place nor within 48

Optional: Patient location where indwelling urethral catheter inserted.

• NEITHER – Not in place nor within 48 hours

Optional: Date indwelling urethral catheter inserted.

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Event Details: Specific Event

Available selections based on Event Type

Event Details: Secondary BSI

Secondary BSI: Required.

If the patient had a culture-confirmed bloodstream and a related/documented healthcare associated UTI, select Yes.

Secondary BSI

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).

http://www.cdc.gov/nhsn/PDFs/SecondaryBSIGuide_06_11.pdf

Example: Patient with a urinary catheter grows E. coli in her urine and in her blood. The CAUTI is reported with Secondary BSI = Yes and the pathogen is E. coli.

Event Details

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 DetailsPathogens Identified

Required Enter up to threeRequired. Enter up to threepathogens. If multiple pathogens, enter pathogen judged to be most important cause of infection as #1, the next most important as #2…S = Susceptible

I = Intermediate

R = Resistant

NS = Non-susceptible

S-DD = Susceptible-dose dependent

N = Not tested

Collecting Summary Denominator Data

For all locations, count at the same time each dayNumber of patients on the unitpNumber of patients with an indwelling urinary catheter

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Case Studies Ground Rules for Case Studies

Purposes:– Training on use of definitions AS THEY

EXIST (dated August, 2011)

– Surveillance ≠ clinical

– Optimize data reliability and 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 and antibiotics only; foley catheter, peripheral IV and nasal cannula inserted

Day 4: patient is febrile to 38.0°C and 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 = 105 CFU/ml E coli Day 7: WBC/mm3 = 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 2aCriterion 2a.

3. Yes, ABUTI.

4. No UTI.

Case 1

– (fever 38°C not high enough for criteria)

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°) and complained of diffuse abdominal pain

WBC increased to 19,000. He had cloudy, foul-smelling urine and urinalysis showed 2+ protein, + nitrite, 2+ leukocyte esterase, wbc –TNTC, and 3+ bacteria. Culture was 10,000 CFU/ml E. coli. The abdominal pain seemed localized to surgical area

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Is this a UTI? If so, what type?

1. No UTI.

2. Yes, SUTI Criterion 1b.

Y SUTI3. Yes, SUTI Criterion 2a.

4. Yes, ABUTI.

Case 2

Case 3

84 year old patient is hospitalized with GI bleed

Day 3: Patient has indwelling catheter in place and no signs or symptoms of infection

Day 9: Patient becomes unresponsive, is intubated and CBC shows WBC of 15 000 Temp 38 0°C Patient isCBC shows WBC of 15,000. Temp 38.0 C. Patient is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine >105 CFU/ml.

Is this a UTI? If so, what type?

1. No. Because the blood seeded the urine and 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.

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Case 3

No. Micrococcus is not on uropathogen list. Therefore this is not an ABUTI.

Case 3

UROPATHOGENS:

• Gram-negative bacilli,

• Staphylococcus spp.,

Yeasts• 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, and core temperature ranges between 37.8°Cand 36.2°C. Baby is lethargic. Straight cath urine culture yields >105 CFU/ml Enterococcus faeciumEnterococcus faecium.

1 blood culture collected same day, also positive for E. faecium. Susceptibilities match.

Is this a UTI?

If so, what type?

If so, is it CAUTI?

Is this a CAUTI? If so, what type?

1. Yes, CA-SUTI Criterion 3.

2. Yes, CA-SUTI C it i 1Criterion 1a.

3. Yes. CA-SUTI Criterion 2b.

4. No CA-UTI.

Case 4

This patient has a SUTI 3, however, it is not catheter-associated.

Case 4

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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- and 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 and evacuation of subdural hematoma. Foley catheter and left subclavian catheter placed i ED P ti t i til t l din ED. Patient remains on ventilator placed in OR. Lungs clear bilaterally.

6 days postop, temp. 99.8° 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. 100.3° F vent settings

stable. No change to sputum production.

Post op day 8, temp 101.9° F, lungs sounds clear, CXR clear. Patient on vent, with foley, and 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.

C5:Q1

Case 5

Yes, this patient has a SUTI 1a. Fever, positive urine culture > 100,000 with one pathogen.

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Case 5

What if the patient had been afebrile, but had an elevated WBC for which they sent the cultures as reported? W ld th ti t h UTI?Would the patient 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 and no matching blood culture. Does not meet any of UTI criteria.

Case 5Surveillance definitions work better in some patient

populations than others.

Patients should be thoroughly assessed for UTI symptoms, including S/P and CVA pain. Dialogue/education with clinicians may be warranted. g y

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 and foley catheter in l i d i i P ti t t lplace since admission. Patient reacts only

to painful stimuli.

9/2: WBCs slightly elevated, at 12,000/mm3, temp 37.4° C, urine cloudy. Lungs clear to auscultation.

Case 6

9/3: WBC 15,800/mm3, Temperature: 37.6 ° C. Breath sounds slightly coarse, minimal clear sputum. Urine unchanged. Blood, endotracheal and urine cultures collected. No suprapubic or CVA pain noted.p p p

9/4: Blood and endotracheal cultures no growth. Urine + 100,000 E. faecium.

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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 UTIis no UTI.

Case 6

What if the patient’s temp. was 38.1 ° C and the patient also met the criteria for a PNU including a bronchoalveolar lavage for E. g gfaecium?

Does this patient have a UTI?1. No. The patient’s

fever is due to pneumonia. Therefore patient is symptomless.is symptomless.

2. Yes. Fever is a non-specific symptom and may be due to more than one cause at once.

Case 6

This patient has a SUTI 1a: indwelling catheter present, fever, and urine culture ≥ 100,000 CFU/ml with ≤ 2 organismsorganisms.

Case 7

8/16: 4-year-old girl admitted following MVA. Taken to OR for open-reduction and internal fixation of multiple upper and lower extremity fractures. Admit to pediatric surgical care unit with Foley catheter draining yellow urine, and right femur to traction. IV in right antecubital vein.

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Case 7

8/18: Foley removed. Patient voiding without problems. Afebrile, taking clear liquid diet and beginning oral pain medication. BM in a.m. Using incentive ed ca o a Us g ce espirometer.

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 and traction sites clean. Bacitracin to traction sites.

8/22: Patient requesting bedpan frequently 8/22: Patient requesting bedpan frequently, crying with urination. Temp. 37.9°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

d d i i ll t bl d d iwound draining small amount blood drainage. IV in left forearm, site without redness and 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.

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Case 8

9/3: Patient to physical therapy. Complains of burning with urination and urgency. Suprapubic pain upon palpation. Temp 37.8°C. Urine

ll t d d t f lt d U/A fcollected and sent for culture and U/A. + for 10+ WBCs by HPF of unspun urine, + leukocyte esterase. Empiric antiobiotics begun.

9/4: Urine culture + >100,000 S. epidermidis.

Does this patient have a UTI attributable to 6E?

1. Yes. Patient has a SUTI 1a attributable to 6E.

2 No Patient’s SUTI 1a is attributable2. No. Patient s SUTI 1a is attributable to the OR.

3. No. Patient does not have a UTI.

Case 8

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.

Case 9

How many indwelling

catheter days?

A. 6

B

Patient ADT Urinary Status

101 Black Day2 Indwelling foley to DD

102 White Day 3 Bedpan – cath spec to labB. 5

C. 4

D. 3

E. 2

F. 1

spec to lab

103 Gray D/C home 1.p.m

Voiding

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 rehab @ 11 a.m.

Straight cath Q3 hours

Catheter Day Count at 12 noon

Case 10

How many indwelling

catheter days?

A. 6

B

Patient ADT Urinary Status

101 Washington Adm. @ 4 p.m. Condom cath to DD

102 Dallas Day 2 Indwelling foleyto DDB. 5

C. 4

D. 3

E. 2

F. 1

to DD

103 St. Charles D/C @ 11 a.m. Voiding

104 London Day 3 Incontinent using diaper

105 Orlando Day 2 Suprapubic to direct drainage

106 Denver D/C to ECF @ 4 .pm.

Indwelling foleyto DD

107 England Adm @ 1 p.m. VoidingCatheter Day Count at 11 p.m.

Great Job!!!

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Resources for CAUTI Surveillance

http://www.cdc.gov/nhsn/index.html

Resources for CAUTI Surveillance

NHSN Patient Safety Component Manual, June 2011– Ch 3: Monthly Reporting Plan

– Ch 7: CAUTI Protocol (August 2011)

– Ch 14: Tables of Instructions, Tables 2a, 5, 6, and 7

– Ch 16: Key Terms

– Ch 17: Criteria for Specific Infections

http://www.cdc.gov/nhsn/TOC_PSCManual.html

Resources for CAUTI Surveillance

NHSN Forms (June 2011)

– 57.106: Monthly Reporting Plan

– 57.114: Urinary Tract Infection

– 57.117: Denominator for SCA

– 57.118: Denominator for ICU/Other

http://www.cdc.gov/nhsn/forms/Patient-Safety-forms.html

Resources for CAUTI Surveillance

Operational guidance document for Acute Care Hospitals to report CAUTIs for CMS

http://www.cdc.gov/nhsn/PDFs/FINAL-ACH-CAUTI-Guidance.pdf

Save-the-Date: I-APIC HAI Series

Surgical Site Infections (SSI): Case Studies with the CDCWednesday, March 14, 1pm MT/12pm PTKatherine Allen-Bridson, RN, BSN, MScPH, CICNurse ConsultantDivision of Healthcare Quality PromotionNational Center for Emerging and Zoonotic Infectious Disease

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Centers for Disease Control and Prevention

Clostridium difficile UpdateWednesday, April 11, 1pm MT/12pm PTRuth M. Carrico, PhD, RN, FSHEA, CIC University of Louisville School of Public Health and Information SciencesHealthcare Infection Control Practices Advisory Committee (HICPAC) Robert Wood Johnson Foundation Executive Nurse Fellow

Contact Information

Quality Improvement Organizations

Jennifer PalagiQualis Health, Idaho QIO

jenniferp@qualishealth.org208.383.5944

Angela Bivens-AnttilaNHSN@cdc.gov

Intermountain APIChttp://apicintermountain.com/Trish Heath, Education Lead

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Tina SchwienQualis Health, Washington QIO

tinas@qualishealth.org206.288.2466

Laurie Murray-SnyderAcumentra Health, Oregon QIOlmurraysnyder@acumentra.org

503.382.3927

Trish Heath, Education Leadtrishh@slhs.org

This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C7-QH-709-02-12

January 2012 7-5

Device-associated Module CAUTI

Table 1: Urinary Tract Infection Criteria Criterion Urinary Tract Infection (UTI) Symptomatic Urinary Tract Infection (SUTI)

Must meet at least 1 of the following criteria 1a Patient had an indwelling urinary catheter in place at the time of specimen

collection or onset of signs or symptoms and 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 and a positive urine culture of ≥105 colony-forming units (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 and 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 and a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms(see Comments section below). .

1b 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 and 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 and a positive urine culture of ≥105 CFU/ml with no more than 2 species of microorganisms(see Comments section below).

2a Patient had an indwelling urinary catheter in place at the time of specimen collection or onset of signs or symptoms and 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 and at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/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

January 2012 7-6

Device-associated Module CAUTI

Criterion Urinary Tract Infection (UTI) and a positive urine culture of ≥103 and <105 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 and 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 and at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/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 and a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms(see Comments section below).

2b 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 and 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 and at least 1 of the following findings:

a. positive dipstick for leukocyte esterase and/or nitriteb. pyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or ≥3 WBC/high power field of spun urine)

c. microorganisms seen on Gram stain of unspun urine and a positive urine culture of ≥103 and <105 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 and a positive urine culture of ≥105 CFU/ml with no more than 2 species of

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Device-associated Module CAUTI

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 and at least one of the following findings:

b. positive dipstick for leukocyte esterase and/or nitritepyuria (urine specimen with ≥10 WBC/mm3 of unspun urine or ≥3 WBC/high power field of spun urine)

c. microorganisms seen on Gram’s stain of unspun urine and a positive urine culture of between ≥103 and <105 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.

Criterion 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) and a positive urine culture of >105 CFU/ml with no more than 2 species of uropathogen microorganisms** (see Comments section below). and 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, and 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 and are not acceptable for the

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Device-associated Module CAUTI

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 and 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 and urine specimens for ABUTI. • Report Corynebacterium (urease positive) as either Corynebacterium species

unspecified (COS) or as C. urealyticum (CORUR) if so speciated.

SIGN-IN SHEET

Title: ___CAUTI: 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______________________

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FAX TO: Jennifer Palagi, 208-343-4705 or email scanned version to jenniferp@qualishealth.org

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