1. Infection Prevention: Recognizing and Communicating CAUTI
Onboarding #4 for Long-Term Care Staff
Welcome to today’s onboarding session titled, “Infection Prevention: Recognizing and Communicating CAUTI.” This is the final onboarding module for the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care: HAIs/CAUTI. This brief module is intended for all levels of long-term care staff and will discuss ways to recognize and communicate when a resident is suspected of having a catheter-associated urinary tract infection, or CAUTI.

2. Learning Objectives
Upon completion of this session, long-term care staff will demonstrate a working knowledge of:
how an indwelling urinary catheter increases the risk of CAUTI;
the limitations of urinary diagnostic tests used to diagnose CAUTI;
what to communicate and document when a CAUTI is suspected; and
how to document actions to prevent CAUTI.
At the end of today’s session facility staff will have an understanding of:
how the presence of an indwelling urinary catheter allows bacteria to enter into the bladder and can increase the risk of CAUTI;
the limitations of the diagnostic tests we use to identify a CAUTI;
what to communicate and document when a CAUTI is suspected; and
how to document actions to prevent CAUTIs among residents.

3. How Does an Indwelling Urinary Catheter Increase Risk for a CAUTI?
Bacteria can enter the urinary tract via the urinary catheter
Bacteria can stick to the catheter by forming a biofilm
Once bacteria are included in a biofilm, they are protected from antibiotics given to treat a UTI or CAUTI
Presence of biofilm allows antibiotic-resistant bacteria to develop
When the catheter stops flowing, bacteria in the bladder reflux back into the ureters and kidneys which leads to signs/symptoms of infection
Catheter flow can stop because of sludge/sediment; kinks in the catheter or dislodging of the catheter
The presence of a urinary catheter increases the risk for a urinary tract infection (or UTI) in several ways. First bacteria gain entry to the urinary tract by creeping up the urinary catheter and then they stay in the bladder by forming a sticky coating on top of the catheter called a “biofilm.”
Once the bacteria are covered in the biofilm, they are protected from our bodies’ immune systems and the antibiotics we use to treat infections. Because these bacteria are exposed to an antibiotic but not killed, they often develop resistance, which you’ll learn more about during Training Module 4 on antibiotic stewardship.
Finally, if a urinary catheter stops working, then the bacteria that normally flow out of the bladder in the urine can reflux, or travel backwards, up the ureters into the kidneys. When bacteria get into these upper parts of the urinary tract, that’s often when people develop signs and symptoms of infection. Lots of things can cause the urine flow to become disrupted like sludge or sediment building up in the catheter tubing.
Additional Facilitator Notes
Biofilm: A biofilm is any group of microorganisms in which cells stick to each other on a surface. Most microorganisms that form biofilms are embedded in a matrix/substance called an extracellular polymeric substance (EPS). EPS is produced by the microorganisms and is mostly composed of sugars and proteins. Biofilms can protect microorganisms from antibiotics and speed up the development of antibiotic resistance. Medical devices, like indwelling urinary catheters, provide ideal surfaces for biofilms to develop.

4. Entry Points for Bacteria
Bacteria can gain access to and grow in the bladder in several ways:
Contamination of the tube at the time of placement
Bacteria colonizing the perirectal area and groin can creep up the catheter tube
Contamination of the urine collection bag or other breaks in the tubing
3-10% of people develop bacteria in their urinary tract every day a catheter is in place
Bladder
Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April
There are several places where bacteria can gain access to the bladder. Poor technique during catheter insertion can result in bacteria entering the bladder as the device is placed. Bacteria colonizing the GI tract, often gram-negative organisms like E. coli, can slide along the outside of the catheter tubing into the bladder. Or, bacteria can get placed into other parts of the urine collection system, like the drainage bag, if our hands or gloves are contaminated when we handle the device.
The longer a urinary catheter remains in place, the higher the likelihood the resident will have bacteria in the bladder—up to 10% of people develop bacteria in their urinary tract each day a catheter is in place, and after a few weeks with the device, the bacteria will definitely be there.
Additional Facilitator Notes
Bacteria colonization: Bacterial colonization is the development of bacteria on a surface without causing disease. For example, E. coli live in and around people’s gastrointestinal (GI) tract, yet do not often cause infection. E. coli is said to colonize the GI tract.
Gram-negative bacteria: Gram-staining is a biological test used to identify microorganisms. Bacteria that do not stain using this test are said to be “Gram-negative.” Gram-negative bacteria have fatty-sugars (Lipopolysaccharides, LPS) on the outside of their cell-membrane, which can be toxic, especially in the circulatory system, and provide protection from some antibiotics. Common Gram-negative bacteria include: Klebsiella, Acinetobacter, Pseudomonas aeruginosa and E. Coli.
Collection Bag

5. Understanding Asymptomatic Bacteriuria
Almost all residents with a catheter will have bacteria grow in a urine culture
Asymptomatic bacteriuria (ASB) = Presence of bacteria detected in the urine culture when the resident doesn’t have any localizing signs/symptoms of a CAUTI
Amount of bacteria growing in the culture does not help differentiate ASB from CAUTI
The positive urine culture by itself is not enough to diagnose a CAUTI
Treating residents with antibiotics who have ASB does not improve their clinical outcomes or prevent them from developing a symptomatic CAUTI
Antibiotic use for ASB can cause higher rates of antibiotic resistance, Clostridium difficile infection and other adverse events
Since almost all residents with an indwelling urinary catheter have bacteria growing in their urine, one of the main challenges with diagnosing CAUTI is understanding the significance of a positive urine culture.
Asymptomatic bacteriuria, or ASB, is defined as the detection of bacterial growth in a urine culture from an individual who does not have localizing signs/symptoms of a urinary tract infection or CAUTI. Since cultures in people with ASB often grow greater than 100,000 colonies, the amount of bacteria in a culture does not differentiate ASB from a true CAUTI. And, since we know that 100% of residents with catheters have some level of bacteriuria, the culture by itself is NOT ENOUGH to diagnose a CAUTI.
It is also important to note that exposing residents with ASB to antibiotics has no clinical benefits and may actually cause unnecessary harm. Unnecessary treatment with antibiotics can drive up rates of antibiotic resistance, lead to Clostridium. Difficile (or C. Diff) infections and cause other adverse events. You will learn more about the importance of avoiding unnecessary antibiotic use in Training Module 4.
Additional Facilitator Notes
Bacteriuria (pronounced bak-teer-ee-yoo r-ee-uh): Bacteriuria is the presence of bacteria in a person’s urine that is not caused by contamination. Bacteriuria is detected by performing a urine dip stick test or by looking at the urine under the microscope.
Clostridium difficile (pronounced klo-strid-ee-uhm dif·fi·cile) : Clostridium difficile, better known as C. Diff, is a common Gram-positive bacteria that lives in the soil. It is has a high degree of antibiotic resistance and can cause diarrhea and inflammation if it infects the human GI tract.
Nicolle LE Drugs Aging (2014) 31:1–10

6. Interpreting Pyuria When a Catheter is Present
Pyuria is detection of white blood cells, by a urinalysis, dip stick or urine microscopic exam.
The presence of the indwelling urinary catheter can cause local irritation of the bladder wall, resulting in WBCs in the urine.
Presence of pyuria cannot help you tell the difference between ASB and CAUTI.
Pyuria is the detection of inflammatory cells, white blood cells, or products of white blood cells in the urine. Pyuria can be detected by urinalysis, dip stick or urine microscopic exam.
Pyuria, like bacteriuria, is also extremely common among residents with indwelling urinary catheters. The presence of the catheter alone can irritate the lining of the bladder enough to cause the shedding of WBCs. 100% of people with indwelling urinary catheters have pyuria and 90% of residents with Asymptomatic Bacteriuria–or ASB–without a catheter have pyuria.
Therefore, this test cannot help us differentiate symptomatic CAUTI from ASB related to the indwelling catheter either.
Additional Facilitator Notes
Pyuria (pronounced pi-ur-ee -uh): Pyuria is the presence of white blood cells in the urine. Specifically, pyuria is the presence of white blood cells called a neutrophils. Pyuria is often used to indicate the presence of infection, however, indwelling urinary catheters can irritate the inside of the bladder causing pyuria that is not associated with an infection.
Nicolle LE Drugs Aging (2014) 31:1–10

7. Diagnostic Tests – Urinalysis
Urinalysis considerations
Abnormal findings on a urinalysis in a resident with an indwelling urinary catheter are common and non- specific
A completely negative (normal) urinalysis is very helpful to rule out a CAUTI
The negative test rules out CAUTI, but the positive test does not confirm CAUTI
The take away point is that abnormal urine test results are extremely common, and they may not be due to an infection. That means the abnormal test or positive results are not very helpful. However, if you have a completely normal urine test (everything is negative) then you can rule out the presence of a CAUTI.
Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:

8. Diagnostic Tests – Urine Culture
Positive urine culture
≥ 100,000 colony forming units per ml of urine (105 CFU/ml) when a catheter is present
≥ 100 colony forming units per ml (102 CFU/ml) from an in/out catheter specimen
Common Pathogens
As you may recall from the onboarding module on the NHSN CAUTI definition, confirming the presence of bacteria in a urine culture is part of the surveillance criteria for a symptomatic CAUTI. However, the way a specimen is collected determines the amount of growth required to meet the definition for a CAUTI. Listed on the bottom of the slide are some of the more common bacterial organisms which can cause CAUTI in long-term care residents.
Additional Facilitator Notes
Escherichia coli (pronounced esh-uh-rik-ee-uh koh-lahy): E. coli is a Gram-negative bacteria that lives in the human lower intestines.
Klebsiella pneumoniae (pronounced kleb-zee-el-uh new-moan’ –ee-ay): is a Gram-negative bacteria that colonizes human mouth, skin and intestines.
Pseudomonas aeruginosa (pronounced sue-dough-moan’ –ass aye-rue’-jin-oh-sa): is a Gram-negative bacteria that lives in the soil and the environment.
Proteus mirabilis (pronounced proh’ –tee-us mir-rab’-i-lis): is a Gram-negative bacteria that lives in the soil and water.
Morganella morganii (pronounced mōr′gan-el′-ăh mōr-gan-eye): is a Gram-negative bacteria that lives in the human intestinal tract.
Enterococci (pronounced en·tair-o-cock-si): are a family of Gram-positive bacteria that live in the human intestinal tract.
Escherichia coli
Proteus mirabilis
Klebsiella pneumoniae
Morganella morganii
Pseudomonas aeruginosa
Enterococci

9. When Should a UA and Culture be Sent?
Urine testing should only be performed when a resident has local signs and/or symptoms of CAUTI (suprapubic or costovertebral angle tenderness, fever, etc.).
Odorous or cloudy urine are not indications for urine culture or analysis. These non-specific changes in urine character are not considered signs of CAUTI.
This clinical practice guideline recommendations released in 2009 from the Infectious Disease Society of America are that urine diagnostic testing should only be performed when a resident has local signs or symptoms of infection. They go on to say “the presence or absence of odorous or cloudy urine should not be used as an indication for urine culture.” You should recall from Onboarding 2 that acceptable signs and symptoms of a CAUTI include:
Fever;
Rigors;
New onset confusion or functional decline with leukocytosis;
New onset of suprapubic pain or costovertebral angle pain or tenderness;
New onset hypotension with no other site of infection;
Acute pain, swelling or tenderness of the testes, epididymis or prostate gland; and/or
Purulent discharge or pus from around the catheter.
These recommendations are very important because we know that often the decision to start antibiotics may be influenced by the results of the urine culture. Therefore, we have to be careful about when and why we send urine studies. This caution will help to prevent unnecessary use of antibiotics among residents with ASB.
Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:

10. Identifying CAUTI Signs and Symptoms
Complete documentation of resident signs/symptoms is important for accurate diagnosis and infection reporting
You can help by reporting changes that you observe in residents
Who should be communicating with whom?
Nurse
Physician
Other Staff
Therapy
Nurse-aide
Front-line staff play an important role in the early identification of residents with a CAUTI. When you suspect an infection may be present, you have to document and communicate the findings of your assessment to other members of the care team. Often, it’s your initial impression that starts the evaluation process.
All staff are key to early identification and notification of infections

11. What to Assess When You Suspect a CAUTI
Current and recent vital signs
Recent change in mental status for onset of confusion
MDS confusion assessment tool
Recent change in Activities of Daily Living
Physical exam findings
Lower abdominal/suprapubic tenderness, flank/low back pain
Fever
Rigors (chills and sweats)
Catheter findings:
Purulent discharge at the insertion site
Change in urine output, evidence of sediment which could be obstructing flow
Here are examples of the key clinical data to obtain when a resident is suspected of having a CAUTI. They include:
obtaining vital signs,
evaluating changes in mental status for new onset of confusion,
evaluating changes in functional status,
performing a physical exam, and
evaluating the catheter.
In addition to performing the assessment, the results of your evaluation need to be clearly documented and communicated.

12. Monitoring: Who is at Risk for CAUTI?
You can’t have a CAUTI if you don’t have a catheter
Document date of insertion and indication for every resident with an indwelling urinary catheter
Review and document the urine output and quality of flow for residents with indwelling catheters every day
To ensure catheters are working properly and detect malfunctions early
Assess and document the ongoing need for the catheter on a daily basis
Keep a daily log of residents with an indwelling urinary catheter
It’s helpful to keep track of the residents who have indwelling urinary catheters as part of your CAUTI monitoring program. Remember, you can’t have a CAUTI if you don’t have a catheter.
Important information to document when a catheter is placed includes the date of insertion and the indication for the device. Once a resident has a catheter, check every day that the urine output and urine flow is adequate (this ensures that the catheter is working properly). Also, your facility should have a process for re-assessing and documenting the ongoing need for a catheter for each resident on a regular basis. It may be helpful to maintain a daily log of the residents on your unit with an indwelling catheter.

13. Documenting Efforts to Prevent CAUTI
Proper care and handling of the indwelling catheter can reduce risk of CAUTI.
Use checklists to ensure consistency and that everyone follows best- practices.
Tools can help to document and verify if a process needs to be reviewed and if staff need more training and education.
There are other tools that can be used to assess and document the correct steps have been taken during placement and/or handling of a urinary catheter. These checklists can also be used to verify and document that a staff member has appropriate training and skills to safely manage these devices. If your facility does not currently use checklists to help staff with insertion and maintenance of catheters, there are examples of these resources in the supplemental materials.

14. Case Scenario: Mrs. Smith
It’s time to practice!
Break into small groups of 2-3
Each group should have the following materials:
Case scenario and discussion guide
CAUTI surveillance worksheet
Indwelling urinary catheter insertion checklist
Indwelling urinary catheter maintenance checklists
Work together on Mrs. Smith’s case
Now it’s time to practice! Mastering CAUTI surveillance, like mastering a musical instrument, requires practice. Break into small groups of two to three people. Make sure each group has a copy of the case scenario discussion guide, CAUTI surveillance worksheet and indwelling urinary catheter insertion and maintenance checklists. Use the case scenario discussion guide to learn about Mrs. Smith, an 85-year-old woman transferred from the hospital 5 days ago following a fall and broken hip. Work together on Mrs. Smith’s case and practice using the different surveillance tools.

15. Stay Updated with Useful Resources
Long-term Care: Indwelling Urinary Catheter Insertion Checklist and Instructions for Use
Long-Term Care: Indwelling Urinary Maintenance Checklist and Instructions for Use
CAUTI Surveillance Worksheet
As we wrap up today’s discussion, I’d like to thank you for viewing this presentation. We need all staff’s input to reduce HAIs and CAUTIs in long-term care facilities. The following resources are available to you as participants in the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI project. We hope that these resources will be helpful on your journey to reduce CAUTIs and HAIs and improve your facility’s culture of safety.
Resources:
The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety.
The second resource is a link to the TeamSTEPPS for Long-Term Care web page. TeamSTEPPS is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment.
The third and fourth set of resources are links to checklist for catheter insertion and maintenance and instructions for using each of these checklists.
The fifth and final resource is a link to the CAUTI surveillance worksheet, designed to assist teams in reviewing a resident’s chart for a suspected CAUTI.