1. Roadmap to Preventing Catheter- Associated Urinary Tract Infections in the Intensive Care Units Mohamad Fakih, MD, MPH Medical Director, Infection Prevention and Control St John Hospital and Medical Center Professor of Medicine, Wayne State University School of Medicine Detroit, MI 1/16/15

2. Objectives Describe urinary catheter use and CAUTI in the intensive care setting Address how to reduce catheter risk Suggest how different team members may collaborate to reduce CAUTI in ICU Address “culturing stewardship” in catheterized patients and its impact on CAUTI rates and antimicrobial use

3. 56 year old asthmatic lady on mechanical ventilation for the last 2 days. She is starting to wean and is awake. I would… A.Discontinue the urinary catheter when she is extubated B.I will discontinue urinary catheter now C.I will keep the urinary catheter till she is ready to be discharged from unit

4. 64 year old male admitted with severe pneumonia and septic shock. He is day 3 in the ICU and off pressors, extubated, awake, but confused. I will... A.Discontinue the urinary catheter when his confusion resolves B.Discontinue urinary catheter now C.Keep the urinary catheter till he is ready to be discharged from unit

5. 35 year old male S/P GSW to abdomen and exp. laparotomy. Day 3, he is intubated, off pressors, but started on early mobility program. I will… A.Discontinue the urinary catheter when extubated B.Discontinue urinary catheter now C.Keep the urinary catheter till he is ready to be discharged from unit

6. Mean ICU UC use: change over 6 years? (Edwards, Am J Infect Control 2009;37:783-805; Dudeck, Am J Infect Control 2011;39:349-67; Am J Infect Control 2011;39:798-816; Dudeck, Am J Infect Control 2013; 41: 1148-66) 2006-8200920102012 Med-surg ≤15 beds 0.640.670.630.53 Med-surg >15 beds 0.790.720.710.64 Med-surg major teaching 0.780.73 0.68 Neurosurgical0.760.770.740.69 Trauma0.890.830.800.78 This does not adjust for new units reporting to NHSN… Not a dramatic reduction in use

7. Mean ICU CAUTI: change over 6 years? (Edwards, Am J Infect Control 2009;37:783-805; Dudeck, Am J Infect Control 2011;39:349-67; Am J Infect Control 2011;39:798-816; Dudeck, Am J Infect Control 2013; 41: 1148-66) Rates per 1000 catheter-days 2006-8200920102012 Med-surg ≤15 beds 3.41.3 1.2 Med-surg >15 beds 3.11.21.31.6 Med-surg major teaching 3.42.32.22.4 Neurosurgical6.94.44.05.0 Trauma5.43.43.24.1 NHSN definition change (2009) resulted in >50% drop in CAUTI… No change in CAUTI in ICU, more recent data show increase

8. Room for Improvement Utilization CAUTI

9. How to reduce urinary catheter risk

10. Know when you need it (indications) Know how to place it (insertion technique) Know how to care for it (maintenance) Know when it is no longer needed (appropriate continued use) Know your catheter

11. Know when you need it Clearly identify what the indications are and what they mean Have agreement of key leaders on the indications (may even have institutional guidelines) Incorporate appropriate indications into policies, and competencies

12. Indications: CDC HICPAC Guidelines (Gould et al, Infect Control Hosp Epidemiol 2010; 31: 319-326) 12

13. More Recent- SHEA 2014 Update (Infect Control Hosp Epidemiol 2014; 35 (5): 464-479) “Perioperative use for selected surgical procedures, such as urologic surgery or surgery on contiguous structures of the genitourinary tract; prolonged surgery; large volume infusions or diuretics during surgery; intraoperative monitoring of urine output needed. Hourly assessment of urine output in ICU patients. Management of acute urinary retention and urinary obstruction. Assistance in healing of open pressure ulcers or skin grafts for selected patients with urinary incontinence. As an exception, at patient request to improve comfort (e.g., end-of-life care).”

14. Accurate Measurement of Urinary Output in the Critically Ill Need to clearly define where it is applicable for the critically ill population If hourly assessment, check if the information is affecting management Accurate measurement in critically ill: 82% of labeled indications in the ICU (Greene, Infect Control Hosp Epidemiol 2014; 35(S3): S99-S106) Urinary catheter labeled as appropriate use: >95% in ICU

15. Accurate Measurement of Urinary Output in the Critically Ill Consider removing the catheter in those on mechanical ventilation who are hemodynamically stable, those part of early mobility programs, and patients able to communicate

16. Know how to place it (Proper Insertion Technique) Perform hand hygiene before and after placement. Maintain aseptic technique and use of sterile equipment. Use sterile gloves, drape, an antiseptic solution for periurethral cleaning, and a single packet of lubricant for insertion. Use the appropriate catheter size. Have all the elements needed for procedure in one kit 16

17. Know how to care for it (Maintenance of Urinary Catheters) Closed urinary drainage system Unobstructed urinary flow (no kinks, urinary bag below bladder, regular emptying of bag) Securement device Seal not broken 17

18. What about urine meters? Kits may come with or without urine meters Increased cost associated if in all kits Have a mechanism to use kits with urine meters in areas of need (OR to intensive care units and ED resuscitation area) to avoid breaking the seal of the system

19. Insertion and Maintenance Dominant nursing component Evaluate competencies for insertion and care Consider periodic audits Provide support to prevent unnecessary placement (bladder scans, urinals, condom catheters), and skin care

20. Know when it is no longer needed ICUs have a high prevalence of urinary catheter utilization. Utilization may be significantly reduced in ICU with daily assessment for need, and in the non-ICU at time of transferred out from the ICUs. 20 Transfer from ICU ICU Non-ICU

21. Collaboration in ICU 1.Champion(s): promote best practices, provide performance feedback, promote accountability 2.Supporters: facilitate the champion’s work, point out any barriers or concerns, help build capacity to sustain effort Goal alignment is critical for support

22. 22 Urinary Catheter Harm CAUTI Increased Length of Stay Patient discomfort Trauma Immobility Pressure ulcers Falls Partnership for Patients Venous thrombo- embolism Potential morbidities/ harm events related to the catheter Adverse drug events

23. The Champion(s) and Supporters Fakih, Preventing Device Associated Infections, Ascension health, Nov 2012

24. Considerations for ICUs: Closed vs. Open

25. Intensivist (faculty) Other physicians Nurses Other supporting services Infection Prevention Midlevel providers Hospital epidemiologist, urologists Respiratory care, IV team, wound care, physical therapy Resident Physicians

26. Building capacity: bundling it as a device safety issue, incorporating it into the work on other devices

27. Physician Supporters: Reasons to Support the Champion Infectious Disease SpecialistsUrologists Reduce CAUTI. Reduce antibiotic use. Reduce potential of increased resistance and Clostridium difficile disease. Reduce trauma (mechanical complications): 1.Meatal and urethral injury 2.Hematuria HospitalistsGeriatricians Infectious and mechanical complications. Potential catheter complications prolonging length of stay. Hospitalists care for a large number of patients. Their support may help significantly improve the appropriate use of the urinary catheter. Many elderly are frail. Urinary catheters are placed more commonly in elderly inappropriately. Urinary catheters increase immobility and deconditioning risk, in addition to infection and trauma.

28. Physician Supporters: Reasons Support the Champion Rehabilitation SpecialistsSurgeons The urinary catheter reduces mobility in patients: one point restraint. Rapid recovery (improvement in ambulation) may be hampered by the catheter (in addition to the other associated risks). Surgical Care Improvement Project: Remove catheters by postop day 1 or 2. Inappropriate urinary catheter use postoperatively will negatively affect the surgeon’s profile. Risk of infection and trauma related to the catheter. IntensivistsEmergency Medicine physicians Discontinue no longer needed devices upon transfer from the ICU to floor, including urinary catheters. Intensivists can support the DAILY evaluation of catheter need to reduce harm risk. EARLY MOBILITY? Up to half of the patients are admitted through the emergency department (ED). Inappropriate urinary catheter placement is common in the ED. Promoting appropriate placement of urinary catheters in the ED will reduce inappropriate use hospital-wide.

29. How many disciplines do you think would support your work at your hospital? A.One B.Two C.Three D.Four or more E.None

30. Culturing Stewardship Bacteriuria and duration of catheter use Relation of fever and bacteriuria Pyuria Urine color Appropriate urine cultures

31. Catheter associated Bacteriuria in ICU (Clec’h et al, Infect Control Hosp Epidemiol 2007; 28: 1367-73) 12 ICUs: weekly urine cultures or if symptoms in catheterized patients CAUTI defined as urine culture >10 3 CFU/ml CAUTI (bacteriuria) rate= 12.9/ 1000 catheter-days Median time to CAUTI 11 days (range 6-19 days) Median ICU LOS longer for those with CAUTI (28 days) vs. those without (7 days)

32. Fever, Leukocytosis and Relation to CAUTI (Golob et al, Surg Infect 2008; 9: 49-56) Retrospective evaluation of 510 patients in a surg- trauma ICU within the 1 st 14 days of hospital stay over 18 months Definitions: fever= T ≥38.5°C; leukocytosis WBC ≥12,000; UTI= urine culture ≥10 5 CFU/ml Fever was in 29% of patient-days, and leukocytosis in 41% of patient-days Mean length of stay 15.8 ±1.2 days for UTI (bacteriuria) vs. 9.4 ±0.5 days for no UTI; p = 0.003.

33. Fever, Leukocytosis and Relation to CAUTI (Golob et al, Surg Infect 2008; 9: 49-56) Fever did not predict having bacteriuria

34. Does the organism and pyuria matter? Candiduria (Kauffman, Clin Infect Dis 2000; 30: 14-18) : majority treated with antifungals though not usually symptomatic, 55% had U/A with WBC >5 per HPF, clearing of organism occurred in both those given (50%) and not given antifungals (75%) Physicians tend to treat more G- negatives and pyuria (Cope, Clin Infect Dis 2009; 48: 1182-8)

35. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) 761 patients with newly inserted catheters, 10.8% developed bacteriuria or candiduria Defined bacteriuria as >10 3 CFUs. Women had more bacteriuria (21.2%) than men (7.2%)

36. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) Pyuria more common with bacteriuria related to gram negatives than gram positives or funguria

37. Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) Pyuria cannot predict bacteriuria

38. Color or Odor (Hooton, Clin Infect Dis 2010; 50:625–663) IDSA guidelines: “In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy.”

39. NHSN definition for CAUTI Surveillance definition: depends on having a positive urine culture and clinical/ laboratory findings. Heavily dependent on the presence of fever >90% of cases fitting the NHSN definition have fever, used regardless of source Some ICUs have longer LOS

40. 2015: OUT: yeast, urine analysis, and lower colony counts

41. Does NHSN CAUTI Definition Correlate with Physician’s Practice? (Al Qas-Hanna, Am J Infect Control 2013; 41: 1173-1177 ) NHSN definition had a poor positive predictive value of physician practice and Infectious Diseases consultant impression

42. NHSN CAUTI vs. CAUTI Treated by Clinicians (Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77 ) 90.8% of those diagnosed with NHSN CAUTI had a temperature >38°C Only 18/ 387 (4.7%) of patients had one or more focal signs or symptoms documented 91.4% of patients with NHSN CAUTI fit criterion 1. T >38°C + positive urine culture= NHSN CAUTI; important to obtain urine cultures when clinically indicated

43. How Can We See the NHSN definition? May consider NHSN CAUTI as a marker of infectious events associated with the urinary catheter (analogous to IVAC with ventilators) It is a publicly reported measure tied into value based purchasing and seen by patients Potentially a marker for culturing and antimicrobial stewardship

44. Screening Urine Cultures The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results 1.May not help the hospital avoid non- reimbursement 2.May increase utilization of additional resources (testing, antibiotics, consults) 3.May adversely affect patients by exposing them to inappropriate testing and treatments

46. Nicolle et al, Clin Infect Dis 2005; 40:643–54

47. IDSA Guidelines for Asymptomatic Bacteriuria (Nicolle et al, Clin Infect Dis 2005; 40:643–54) Screening and treatment of asymptomatic bacteriuria not recommended for 1.Non-pregnant women 2.Diabetic women 3.Elderly in the community or institutionalized 4.Persons with spinal cord injury 5.Patients with indwelling catheter

48. How to Reduce Unnecessary Urine Cultures 1.Evaluate current processes for obtaining urine cultures (avoid automatic triggers or screening cultures with no appropriate indications) 2.Evaluate practice patterns (avoid PAN culturing) 3.Provide education on when it is appropriate to obtain urine cultures

49. How to Reduce Unnecessary Urine Cultures 4.Have periodic audits on urine culture use in the intensive care units to look for trends 5.Promote appropriate urinary catheter use to reduce risk of bacteriuria/funguria 6.Use urinary catheters only based on appropriate indications

50. 50 http://www.onthecuspstophai.org/on-the-cuspstop-cauti/toolkits-and-resources/additional-resources/

51. Culturing Stewardship and Other Preventative Measures: Large hospital ICUs Influenza epidemic (more fever, more cultures) ICU team only responsible for urine culture ordering

52. Steps to Success Know your catheter (4 elements) Collaborate between disciplines, and have champions for accountability Incorporate catheter evaluation into work routine (e.g., multidisciplinary rounds) Use the data to help you focus your efforts on areas that require attention Promote “Culturing Stewardship”