NHSN N ATIONAL H EALTHCARE S AFETY N ETWORK Catheter-Associated Urinary Tract Infection (CAUTI) ELSA SANTOS-CRUZ, CIC MOUNT SINAI MEDICAL CENTER (INFECTION CONTROL)

TOPICS DISCUSSED 1. CMS Reporting 2. Definition and Protocol 3. Clean-up Issue regarding definition 4. Attendees partake in Case Studies 5. Data Entry & Analysis 6. Preventive Measures of different infection

P ATIENT S AFETY COMPONENT 1. Device – Associated Module 2. Procedure-Associated Module 3. Medication Associated Module 4. MDRO and C. difficile Infection Module 5. Vaccination Module

DEVICE-ASSOCIATED MODULE 1. CLABSI – Central line-associated Bloodstream Infection 2. CAUTI – Catheter-Associated Urinary Tract Infection 3. VAP – Ventilator Associated Pneumonia 4. CLIP – Central Line Insertion Practices 5. DE – Dialysis Event

METHODS OF SURVEILLANCE LABORATORY BASSED Case – finding based on positive laboratory results PATIENT – BASED Monitoring patients for events, risk factors, procedures and practices related to patient care. ― Review patient charts ― Visit patient care areas ― Discuss with caregivers

M ETHODS OF SURVEILLANCE PROSPECTIVE Monitoring patients while still in the facility, hospital; includes post-discharge period for SSI RETROSPECTIVE Case-finding based solely on chart review after patient discharge.

W HY CAUTI SURVEILLANCE ? History: Most common Healthcare Associated Infection (HAI) Most of UTIs are associated with indwelling catheter Other reasons: Mandatory Reporting Denial of CMS dollar reimbursement

MONTHLY REPORT CAUTI must be included in monthly NHSN Report by the following facility/institution; Acute Care Hospitals: Adult and Pediatric ICUs Long Term Care Hospitals: All inpatient location Inpatient Rehabilitation Facilities: All inpatient locations

MONTHLY REPORT Report complete and accurate data in a timely manner. Report each CAUTI indentified Indicate NO CAUTI detected for specific location Report total device days for specific location Report total patient days in specific location

DEFINITION 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 Occur 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

DEFINITION Indwelling Catheter A drainage tube that is inserted into the urinary bladder through the urethra, is left 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

DEFINITION 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

D EFINITION Location 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).

DEFINITION Transfer Rule: Mr. Smith is transferred from SICU with a Foley and 36 hours after transfer has a fever of C. The next day a urine culture collected has >10 5 CFU/ml of E. coli. This CAUTI is attributed to the SICU

D EFINITION Urinary Tract Infection Definition There are two criteria than can be applied for identifying a CAUTI Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI) NOTE: The specific site “Other Urinary Tract Infection” (OUTI) can also be used to identify an infection in the urinary tract, however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events.

CRITERIA Symptomatic UTI SUTI 1a 1a. Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause: fever (>38 0 C), suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥ 10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms OR Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 0 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urine culture of ≥10 5 colony-forming units (CFU)/ml with no more than 2 species of microorganisms

C ASE 1  50 year old patient with end stage pancreatic cancer with liver and 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 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 = 10 5 CFU/ml E. coli.  Day 7: WBC/mm 3 = 3400; patchy infiltrates in both lung bases; continued episodes of dyspnea; rales noted in LLL.  Day 11: Patient expired Q : Does this patient have a UTI? If, so what type? 1. Yes, SUTI Criterion 1a. 2. Yes, SUTI Criterion 2a. 3. Yes, ABUTI 4. No UTI

CRITERIA Symptomatic UTI SUTI 2a 2a. Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause: fever (>38 0 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 [WBC]/mm 3 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 ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms OR Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 0 C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings: a. Positive dipstick for leukocyte esterase and/or nitrite b. Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 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 ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms.

CASE 2  POD 3: 66 y.o. patient in the ICU with a Foley catheter s/p exploratory lap; patient noted to be febrile ( C) and complained of diffuse abdominal pain.  WBC increased to 19,000. He had cloudy, foul-smelling urine and urinalysis showed 2+ leukocyte esterase, WBC – TNTC, and 3+ bacteria. Culture was 10,000 CFU/ml E. Coli. The abdominal pain seemed localized to surgical area. Q: Is this a UTI? If so, what type? 1. No UTI. 2. Yes, SUTI Criterion 1b. 3. Yes, SUTI Criterion 2a. 4. Yes, ABUTI

CRITERIA Symptomatic UTI Criteria 3 & 4 (≤ 1 year old) 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 0 C core), hypothermia (<36 0 C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urine culture of ≥ 10 5 CFU/ml with no more than 2 species of microorganisms. ………………………………………………………………………………………………………… Patient ≤ 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38 0 C core), hypothermia (<36 0 C core), apnea, bradycardia, dysuria, lethargy, or vomiting and a positive urinalysis demonstrated by at least one of the following findings: a. Positive dipstick for leukocyte esterase and/or nitrite b. Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm 3 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 ≥10 3 and <10 5 CFU/ml with no more than 2 species of microorganisms.

C ASE 3  3 week old infant born at 27 weeks gestation. Umbilical catheter in place. HR 100, RR 32, and core temperature ranges between C and C. Baby is lethargic. Straight cath urine culture yields >10 5 CFU/ml Enterococcus faecium.  1 blood culture collected same day, also positive for E. faecium. Susceptibilities match. Is this a UTI? If so what type?

CRITERIA Is this a CAUTI? If so, what type? 1. Yes, CA-SUTI Criterion Yes, CA-SUTI Criterion 1a. 3. Yes, CA-SUTI Criterion 2b 4. Not a CAUTI.

CRITERIA Asymptomatic Bacteremic UTI (ABUTI) Patient with or without an indwelling urinary catheter ahs no signs or symptoms(i.e., for any age patient, no fever (>38 0 C ), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness, OR hypothermia (<36 0 C core), apnea, bradycardia, dysuria, lethargy, or vomiting) and a positive urine culture of > 10 5 CFU/ml with no more than 2 species of uropathogen microorganisms 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 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) Note: All ABUTIs will have a secondary bloodstream infection

C ASE 4  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 is pan-cultured. Blood culture and urine both grow Streptococcus pyogenes – urine > 10 5 CFU/ml

CRITERIA 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 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

Q UESTION & A NSWER Q: Are asymtomatic bacteremic urinary tract infections (ABUTIs) in patients in adult and pediatric intensive are units( ICUs) included in the reporting requirements for CMS’s HIQRP beginning January 2012? A: YES, if a patient in the ICUs has an indwelling urinary catheter at the time of or within 48 hours prior to specimen collection or the onset of symptoms ( whichever comes first) and meets the NHSN criteria for ABUTI, this infection is a CAUTI and is reportable to CMS.

C AUTI N HSN N UMERATOR PATIENT INFORMATION Four (4) Required Fields;  Facility ID  Patient ID  Gender  Date of Birth

C AUTI NUMERATOR EVENT INFORMATION  EVENT TYPE : UTI  DATE OF EVENT : Date of Specimen collected OR Date of signs/symptoms (whichever comes first)  POST-PROCEDURE : Mark YES if UTI occurred after an NHSN defined Procedure.  LOCATION :Enter patient location when UTI was identified. See TRANSFER RULE  DATE ADMITTED : Date of Admission to Facility

C AUTI NUMERATOR Risk Factors : Urinary Catheter: In place remove within 48hrs neither. EVENT DETAIL : SPECIFIC EVENT: Symptomatic UTI Signs & Symptoms  Fever  Urgency  Frequency  Dysuria Lab Diagnostic Test  Positive Culture w/>10 5 CFU  Positive leuko esterase/nitrite  Pyuria  1 positive culture w/ >10 3 and <10 5

E VENT DETAIL Secondary BSI ABUTI Secondary BSI:YES One organism from positive urine culture match the blood culture. DIED:YES If patient died during this hospitalization. UTI contributed to Death: Yes

E VENT DETAILS PATHOGEN: If multiple pathogens, enter the most important first #1 -E.coli # 2-Enterococcus faecium SENSITIVITY TEST RESULT:  S – Susceptible  I – Intermediate  R – Resistant  N – Not tested

D ENOMINATOR Count at the same time each day  Number of patients in ICU  Number of patient with an individually urinary catheter  Location code: ICU  Month: January  Year: 2012  Total pt. day:  Urinary Cath day:  CAUTI

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