URINARY TRACT INFECTIONSfocus 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 TRACTmakes, 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

Excerpted from http://www.neocontrol.com/patients/about_incontinence/urinary_tract_anatomy.htm

ANATOMY

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 adultAtypical presentation of illness * Over age? – 65, or 85 * Multiple comorbidities* Multiple medications * Functional or physical

impairmentsUTI-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 presenceof localized G-U symptoms, etc. “…although – definitionsfor surveillance purposes, a universally accepted definitionof 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

• 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

Asymptomatic Bacteriuria

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

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

Urinary Cath. Use

Hospital = 25%

LTCF = 5%Most UTIs in hospitals are catheterassociated

PREVENTING CATHETER-ASSOCIATED 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 appropriateuse of indwelling catheters to assureappropriate 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. 2009September, 35(9):449-455

Performance Measures

Internal Reporting Reporting both process and outcomemeasures to senior administrative, medical,and nursing leadership and clinicians whocare for patients with indwelling urinarycatheters.

PERFORMANCE MEASURESExamples 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 MEASURES2. Compliance with documentation of catheter

insertion and removal datesRandom 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 MEASURES3. 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 MEASURESRecommended outcome measures:

1. Rates of CAUTI - use definitions

# of patients (each location)______________________________ total # of

urinary-catheter days

• 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 Catheter-

Associated Urinary Tract Infections 2009• CDC. HAI Elimination. Catheter-associated Urinary Tract

Infection (CAUTI) Toolkit• IDSA. Diagnosis, Prevention, and Treatment of Catheter-

Associated 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