Demystifying CAUTI: When to Culture and When to Treat September 18, 2014 Barbara W. Trautner, MD, PhD Baylor College of Medicine Michael E. DeBakey Veterans Affairs Medical Center

Skills Questionnaire Results Two main areas of confusion When to culture a catheterized resident When to treat for CAUTI in a catheterized resident Today’s objective is to clarify these issues

Street Sign of Confusion

Case 1 Mrs. Bell is an 86-year-old resident of your facility. She has an indwelling catheter to assist with healing of a sacral ulcer acquired while hospitalized. Yesterday her urine was clear and yellow. Today her urine is definitely pink and smells bad. What should be done next? Urinalysis Urine culture Urinalysis and antibiotics Culture and antibiotics Nothing N/A – NPT or HRET staff ANIMATION on click for polling Q&A

Remember the C.A.U.T.I. Intervention The Clinical Intervention: Catheter removal Aseptic insertion Use catheters only if indicated Training about catheter care Incontinence care planning ANIMATION on click (CAUTI) There are many areas of uncertainty in CAUTI prevention, but these are the topics that all of us agree on as beneficial.

Remember C.A.U.T.I. to Prevent CAUTI ANIMATION on click (star)

Training About Catheter Care Routine catheter changes, urinalysis, and culture are not required.

Bacteriuria ≠ CAUTI Translation? What is the main difference? Bacteriuria is not the same as catheter-associated urinary tract infection, and vice versa. What is the main difference? Bacteriuria can be symptomatic or asymptomatic. Asymptomatic bacteriuria is abbreviated ASB CAUTI requires presence of symptoms consistent with UTI. ANIMATION on click (4) http://www.idsociety.org/Organ_System/#Genitourinary

Relationship of Bacteriuria to ASB and CAUTI Bacteriuria means a positive urine culture. Bacteriuria ASB CAUTI

Which are the signs and symptoms of a CAUTI? Fever Rigors Malaise/lethargy Flank pain or CVA tenderness Foul-smelling urine Acute hematuria Pelvic discomfort Change in urine color Dysuria, urgency, frequency Cloudy urine Urinary sediment ANIMATION on click (removes incorrect choices)

Common Inappropriate Triggers for Urine Culture Urine color Urine smell Urine sediment Cloudy urine Pyuria (white blood cells or WBC in the urine) Positive dipstick

Why isn’t cloudy urine a symptom of CAUTI? Cloudy urine, a change in urine color, foul odor, and sediment are all non-specific. Many non-urinary causes Medications Certain foods Several possible urinary causes Crystals Bacteria What does non-specific mean? Well it’s like when my husband says I need to go to the grocery store because we don’t have anything to eat. And I say, what would you like for me to get? And he says “food!” Now that does NOT tell me what the desired behavior is. “Food” is a non-specific symptom

Bacteriuria is not CAUTI Bacteriuria does cause Foul smell Cloudy urine Sediment Change in urine color These are not symptoms of CAUTI. 99% of long-term catheterized residents have bacteriuria. Making the diagnosis of CAUTI requires ______________. Answer: symptoms ANIMATION on click (answer)

Case 1 Mrs. Bell is an 86-year-old resident of your facility. She has an indwelling catheter to assist with healing of a sacral ulcer acquired while hospitalized. Yesterday her urine was clear and yellow. Today her urine is definitely pink and smells bad. What should be done next? Urinalysis Urine culture Urinalysis and antibiotics Urine culture and antibiotics Nothing N/A – NPT or HRET staff ANIMATION on click for polling Q&A

Answer to Ms. Bell’s Case Nothing! At least don’t send urine for urinalysis or culture. Definitely don’t start antibiotics! You wouldn’t really do nothing. Ask about what she ate. Look at her medications. Assess for catheter trauma. Assess to ensure she is at her baseline. ANIMATION

Why Knee-Jerk Antibiotic Use Is Bad Reason #1: It’s Bad for the Resident Side effects are common. Nausea, diarrhea Allergic reactions Antibiotic-related infections Clostridium difficile Candida (yeast) Wrong diagnosis will delay treatment.

Why Knee-Jerk Antibiotic Use Is Bad Reason #2: It’s Bad for Everyone Bacteria become resistant. There is a danger of running out of antibiotics that work. Antibiotics won’t work when residents need them. Multi-drug resistance is increasingly common. Overuse of antibiotics can increase MDR organisms in your facility.

Case 2: Just Don’t Dip (the Urine) Mr. Parker is a 91-year-old man with an indwelling catheter who stayed in bed today rather than going to breakfast. The dipstick (urinalysis) is positive for nitrites (bacteria) and leukocyte esterase (WBC). What should be done next? Urine culture Antibiotics Urine culture and antibiotics Re-assess the situation N/A – NPT or HRET staff ANIMATION on click for polling Q&A

Pyuria is not diagnostic of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663) Pyuria does not help differentiate asymptomatic bacteriuria from CAUTI Pyuria + bacteria ≠ CAUTI Why? Pyuria is also non-specific Can be from catheter itself, bladder distension, or ASB Bacteriuria causes pyuria I cited the guidelines reference above. OK, I can tell you are still not believing me on this point, so I am going to show you the science.

Pyuria Does NOT Predict Bacteriuria or Funguria Relationship between levels of bacteriuria or candiduria and quantitative pyuria in 761 catheterized patients. Data are depicted on a log-log scale, for clarity; colony counts between 1 and 103 colony-forming units per milliliter are not shown. Each point represents 1 catheter-day. It can be seen (curvilinear regression line) that the relationship between urine microbial counts and pyuria in the catheterized patient is weak until very high levels of bacteriuria or candiduria are reached. Tambyah, P. A. et al. Arch Intern Med 2000;160:673-677. Copyright restrictions may apply.

Answer to Just Don’t Dip Re-assess Mr. Parker. There may be many reasons for behavioral change. Mild diarrhea Slept poorly Mild dehydration Offering fluids is often a better initial step. Dipstick or urinalysis cannot rule in a CAUTI. These can only tell you that WBC and bacteria are present. Generally avoid in catheterized residents. Insert picture of dipstick and also dipping tobacco

Communicating with Residents and Families You are now convinced that most urinalyses, urine cultures, and antibiotics are unnecessary in residents with indwelling catheters. What are you going to tell the family members? Highlight side effects of antibiotics. Discuss alternatives. Promote shared decision making.

Antibiotic Stewardship Antibiotic brochure available in the tools section of website

Sample Dialogues: With Families My Bobby always looks like this when he has a UTI. We are going to watch him closely. Let’s help him drink more fluids. Dehydration and UTI are often confused. Let’s just give him some antibiotics just in case. Antibiotics won’t help if he doesn’t have a UTI. Antibiotics could hurt him (diarrhea). We don’t want to miss the real cause.

Sample Dialogues: With Physicians Mutual understanding is key to communication. Recognize pressures on physicians that drive antibiotic overuse. Fear of missing urosepsis Fear of not doing what everyone else is doing Pressure to come up with a diagnosis Lack of awareness of the guidelines covered today Acknowledge these pressures; point out your own. Emphasize shared mission: patient care. First of all, this is scary. Yes, I think it is scary, and this is my field and these are my colleagues

Sample Dialogues: With Physicians I know you don’t want to miss anything with Mrs. Lacy. We are doing a campaign to decrease CAUTI. We learned that cloudy urine is not a symptom of CAUTI. Almost everyone with a catheter gets cloudy urine eventually. I’m not sure we need a urine culture yet. She might just be tired. Extra urine cultures lead to extra antibiotics—and that’s not good for anyone.

Rosy Picture versus Reality These dialogues aren’t easy, and they don’t make anyone comfortable. But emphasizing your mutual interest in improving patient care is going to help.

Is Everything Clear Now?

Thank You and Questions

Your Feedback Is Important Please take a moment to complete the evaluation of today’s event. The evaluation will open automatically when you close out of the WebEx session.

Upcoming Content Webinars Date* Topic Oct. 16 Overcoming Barriers: How to Stay Engaged and Engage Others (Working Title) Nov. 20 Avoiding Unnecessary Catheter Placement: Working With Families and Residents Dec. 18 Care Transitions and Handoffs: How Hospital and LTC Staff Can Reduce CAUTI Together *Every third Thursday of the month at 12:15-1:00pm ET/11:15am-12:00pm CT/10:15-11:00am MT/9:15-10:00am PT