Transcript FIC-Slides-UTI_2015-

URINARY TRACT INFECTIONS
focus on adults
Ruth Anne Rye
October, 2015
OBJECTIVES
• Identify specific symptoms suggestive of
urinary tract infection (UTI)
• Discuss asymptomatic bacteriuria
• Identify prevention strategies and
interventions
WHAT WE KNOW
• UTI most common bacterial infection occurring in
healthcare facilities (HAI); 70 – 8-% attributed to use
of indwelling catheter
• Leading nosocomial complication following joint
prosthesis surgery
• More common in women than men. Estimate 20-35%
females have at least 1 episode in lifetime
• In nursing homes most frequently occurs in those
with functional impairment
• No consensus on clinical definition, presentation and
management
URINARY TRACT
makes, stores urine
• Kidneys: pair of kidney-shaped organs
– Below ribs toward the middle of the back
– Remove excess liquids and wastes from blood in form of urine
• Ureters: narrow tubes that carry urine from kidney to
bladder
• Bladder: sac-like organ in the lower abdomen
– Urine is stored in bladder and emptied through the Urethra (tube
that connects bladder to skin)
• Urethra: tube from bladder to skin
ANATOMY
Excerpted from http://www.neocontrol.com/patients/about_incontinence/urinary_tract_anatomy.htm
DEFINITION
Urinary Tract Infection
• The invasion of disease-causing
microorganisms, which proceed to establish
themselves, multiply, and produce various
symptoms in their host.
Can occur anywhere along the urinary tract –
kidneys, bladder, ureter, or urethra
DEFINITIONs
• Relapse: same organism as originally
isolated
• Recurrence: occurs within 2 weeks
caused by the original uropathogen
• Re-infection: occurs more than 2 weeks
following treatment completion; same or
different organism
ETIOLOGY
• Most likely cause: Escherichia coli
– Also:
•
•
•
•
Proteus species
Klebsiella species
Providentia species
Enterococci species
• Catheter present? Often polymicrobial
SYMPTOMS – when no catheter
• Frequency: frequent urge to urinate
• Urgency: strong persistent urge to urinate; may
pass only small amounts of urine
• Dysuria: painful burning sensation when
urinating
• Fever – more likely if kidneys are affected
• May experience upper back and side pain,
nausea and vomiting
Presentation in the older adult
Atypical presentation of illness
* Over age? – 65, or 85 * Multiple comorbidities
* Multiple medications * Functional or physical
impairments
UTI-specific
• Classic symptoms in independent elderly
• Hospital or N.H – increased lethargy. delirium, blunted fever
response, anorexia
Inf Dis Clinics of NA, 2014: “…generally requires presence
of localized G-U symptoms, etc. “…although – definitions
for surveillance purposes, a universally accepted definition
of symptomatic UTI in older adults does not exist.
DIAGNOSIS
• Based on symptoms (+ lab)
• Urinalysis: urine examined for the
presence of white and red blood cells
Bacteria in urine? 90% have pyuria
No bacteria in urine? 30% have pyuria
Diagnosis (con’t)
 Urine Culture: identifies bacteria (isolate),
when present, and counts colony-forming units
(cfu)
* First morning specimen best
* Obtain specimen by catheterization, in/out
(best practice), or clean catch
 Sensitivity testing identifies the agent most
effective at inhibiting the organism’s growth
SPECIMEN COLLECTION
• Collection method decision: clean
voided/midstream, sterile (catheter)
• Validate competency of collector
• Verify collection method and transport container,
and label with patient identifiers, time and date
collected
• If antibiotic ordered, collect specimen
before first dose
SPECIMEN COLLECTION
• Collect in manner to minimize
contamination
• Transport to lab timely to prevent
bacterial growth
• Refrigerate prior to transport unless
collection container contains preservative
ACCURACY AFFECTED BY
• Urine collection method
• Time delay between collection and
analysis
• Time of void
DIAGNOSITIC EVALUATION
• If patient has fever, hypotension (low blood
pressure), tachycardia (rapid heart rate)
consider urine culture + blood culture
• Additional symptoms of systemic (bodywide)
illness, such as chills, warm skin, malaise –
feeling rotten, mental status changes
DIAGNOSITIC EVALUATION
• Dipstick urine testing: Point-of-care test
useful in detecting the presence or
absence of nitrite and/or esterase
• Nitrites: formed when bacteria changes
nitrate to nitrite
• Leukocyte esterase: intact and lysed
leukocytes produced in inflammation
Urine Dipstick for Diagnosing Urinary
Tract Infection
Q: How accurate is the urine dipstick for diagnosing UTI?
A.. The sensitivity and specificity of the urine dipstick varies
somewhat with the setting and population, as does it’s
interpretation.
–
Women with classic urinary tract infection (UTI) symptoms:
dipstick adds little to the diagnosis.
–
Women with nonspecific urogenital symptoms: positive or
negative dipstick results may require backup urine culture
depending on the clinical situation.
–
Low-risk patients with a low pretest probability of UTI: the urine
dipstick alone is useful to exclude infection if both nitrites and
leukocyte esterase are negative.
Excerpted from http://www.aafp.org/afp/20060101/fpin.html
Asymptomatic Bacteriuria
• Definition: Presence of bacteria in the urine, e.g. positive
urine culture, without signs or symptoms of infection
• Screening for and treatment of asymptomatic bacteriuria
in elderly institutionalized residents of long-term care
facilities is not recommended (A-I).
Reason: Treatment may lead to multidrug resistant
organisms and does not improve safety or care of the
resident
PRESCRIBING terms
• Empiric
– Utilize accepted prescribing standard, and
– Facility antibiogram, and
– Clinician’s experience
• Therapeutic: based on sensitivity results
• Prophylactic: preventive
– Generally not recommended. Role unclear.
ANTIMICROBIAL TREATMENT
• Symptomatic: TREAT
– Clinician document decision in progress note
• Asymptomatic: treatment NOT recommended
– ABS in elderly considered a benign and
transient condition that does not require
antibiotic treatment
– Clinician decision and should document
decision in progress note
APPLICATION OF SCIENCE-BASED
EVIDENCE
Clinical and bacteriological outcomes are improved
when long-term indwelling catheters are replaced
before initiating antimicrobial therapy for
symptomatic urinary tract infection.*
* Chronic Indwelling Catheter Replacement Before
Antimicrobial Therapy for Symptomatic Urinary Tract
Infection: Raul Raz, David Schiller, Lindsay E Nicolle:
Journal of Urology 2000;164;1254-1258
SYSTEM OF DOCUMENTATION
Importance of documentation
• What

Indications for catheter insertion

Date and time of insertion

Name of individual who inserted

Date and time of catheter change/removal

Routine catheter maintenance
• Where (e.g. patient’s medical record)
• When (how often)
PREVENTION STRATEGIES
If NO urinary catheter:
–
–
–
–
–
Drink plenty of fluids
Don’t delay urination, and don’t rush
Wipe front to back
Urinate after sexual intercourse
Consider estrogen replacement for women after
menopause.
– No conclusive evidence to advise supplemental
vitamin C, cranberry pills or juice, or blueberry
– Encourage activities of daily living (ADL’s)
– Avoid potentially irritating feminine products
PATHOGENESIS OF CAUTI
Urinary Cath. Use
Hospital = 25%
LTCF = 5%
Most
UTIs in
hospitals
are
catheter
associated
Figure 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 2001. http://www.cdc.gov/ncidod/eid/vol7no2/makiG1.htm
PREVENTING CATHETERASSOCIATED UTI’S (CAUTI)
CORE STRATEGIES
 Insert catheters only for appropriate indications
Examples of appropriate indications for use
* Acute urinary retention or bladder outlet
obstruction
* Need for accurate measurement of output in
critically ill patients
Appropriate indications, continued
• Perioperative use in selected surgical
procedures such as G-U, anticipated
prolonged duration of surgery, large-volume
infusions, intraoperative monitoring of urinary
output
• To assist in healing of open sacral or perineal
wounds in incontinent patients
• Patient requires prolonged immobilization
• To improve comfort for end of life care if
needed
Core prevention strategies, continued
 Insert catheters using aseptic technique and
sterile equipment (acute care)
 Ensure that only properly trained persons
insert and maintain catheters
 Following aseptic insertion maintain a closed
drainage system
 Maintain unobstructed urine flow
 Practice hand hygiene and standard
precautions according to CDC/HICPAC
guidelines, World Health Organization
selected additional CATHETER-RELATED
PREVENTION STRATEGIES
• Maintain closed drainage system. If break occurs replace catheter and collecting system
• Consider using alternatives to indwelling urethral
catheterization in selected patients when appropriate.
Examples: external/condom catheters, intermittent
catheterization
• Use Standard Precautions during manipulation of
catheter or collecting system
• Do not change catheter at fixed intervals
• Portable ultrasound device to assess urine volume for
patients using intermittent catheterization
• Properly secure catheter after insertion to prevent
movement and traction
Implement strategies to enhance appropriate
use of indwelling catheters to assure
appropriate utilization of catheters
 System of alerts or reminders to remove unnecessary
catheters
 Stop orders for urinary catheters
 Protocols for nurse-directed removal of unnecessary
catheters
 Guidelines/algorithms for appropriate perioperative
management
Additional strategies:
• Develop, implement and assess organizational
prevention protocol
• Education
• Surveillance
* Infection - consider when indicated by a
facility-based risk assessment,
* Process – measure adherence to protocol
Are there new technologies that can help prevent?
Catheter material
• If CAUTI rate not decreasing after implementing
comprehensive strategy, consider using
antimicrobial/antiseptic-impregnated catheters, such as
silver alloy
• Hydrophilic catheters might be preferable for persons
requiring intermittent catheterization
• Silicone - might be preferable to reduce the risk of
encrustation in long-term catheterized patients who have
frequent obstructions
What is a bundle?
A bundle is a structured way of improving
the processes of care and patient
outcomes: a small straightforward set of
evidenced-based practices – generally
three to five – that, when performed
collectively and reliably, have been proven
to improve patient outcomes.
Institute for Healthcare Improvement (IHI) 4/16/2011
Keystone Bladder Bundle
1. Nurse-initiated urinary catheter
discontinuation protocol
2. Urinary catheter reminders and removal
prompts
3. Portable bladder ultrasound monitoring
4. Insertion care and maintenance
Concise Summary of Guideline
Recommendations
• Adherence to general infection control principles
• Bladder ultrasound may avoid indwelling catheterization
• Condom catheters or other alternatives should be
considers
• Do not use indwelling catheters unless you must!
• Early removal using a reminder or nurse-initiated
protocol
Jt Comm J Qual Patient Saf. 2009
September, 35(9):449-455
Performance Measures
Internal Reporting
Reporting both process and outcome
measures to senior administrative, medical,
and nursing leadership and clinicians who
care for patients with indwelling urinary
catheters.
PERFORMANCE MEASURES
Examples of process measures:
1) Compliance with educational program:
calculate percent of personnel who have
proper training
# persons who insert catheters and are trained
__________________________________
# personnel who insert urinary catheters
Multiply by 100 to express as percent
PERFORMANCE MEASURES
2. Compliance with documentation of
catheter insertion and removal dates
Random measurement and calculation of
compliance rate
# patients on unit with catheter with proper
dates (insertion and removal)
______________________________________
_
total # of patients with catheters
Express measurement as percentage
PERFORMANCE MEASURES
3. Compliance with documentation of
indication for catheter placement
# number of patients on unit with catheter & proper
documentation of indication
____________________________________
# of patients on unit with catheter
•
Multiply by 100 to express as percent
PERFORMANCE MEASURES
Recommended outcome measures:
1. Rates of CAUTI - use definitions
# of patients (each location)
______________________________
of urinary-catheter days
•
total #
Multiply by 1000 to express as # infections
per 1000 catheter days
PERFORMANCE MEASURES
2. Rate of bloodstream infections
secondary to CAUTI - use definitions
# episodes bloodstream infections secondary to
CAUTI
_______________________________
total number of catheter-days
Multiply by 1000 - cases per 1000 patient days
FOR CONSIDERATION
• Drainage bag covers
• Barrier under collection receptacle: risk
reduction strategy – IP or Safety?
• Change and/or cleaning interval: drainage
bag, bedpans, urinals, collection graduate
(disposable or reusable?)
• Drainage system for patients in low-beds
TAKE HOME MESSAGES
• Assess patient and recognize symptoms to
justify further analysis
• Communicate with clinician
• Importance of documentation (nursing + clinician)
• Consider an organizational protocol - Prevention of
Catheter-Associated Urinary Tract Infection.


Include indications for catheter use, insertion,
maintenance, education.
Include surveillance/measurement activities, and
feedback, and action plan.
REFERENCES
•
•
•
•
•
HICPAC. Guideline for Prevention of CatheterAssociated Urinary Tract Infections 2009
CDC. HAI Elimination. Catheter-associated Urinary Tract
Infection (CAUTI) Toolkit
IDSA. Diagnosis, Prevention, and Treatment of CatheterAssociated Urinary Tract Infection in Adults: 2009
International Clinical Practice Guidelines
www.journals.uchicago.edu/doi/pdf/10.1086/650482
Association for Professionals in Infection Control and
Epidemiology (APIC).
Nicolle L, Catheter associated urinary tract infection.
Antimicrobial Resistance and INFECION CONTROL. 2014