george allen phd, cic, cnor. no disclosures identify mandates, clinical & regulatory for...
TRANSCRIPT
George Allen PhD CIC CNOR
No Disclosures
Identify mandates clinical amp regulatory for monitoring and preventing CAUTI
Review the surveillance definitions and criteria for CAUTI
Discuss strategies institutions can utilize to reduce the risk for the development of CAUTI
Discomfort to the patient
Limit mobility
Prolonged hospital stay
Increased cost and mortality
Each year 17- 2 million Americans (5-10 of hospitalized patients) acquire at least one infection while hospitalized
90-100 thousand die of those infections
One third of these are believed preventable
Conservatively HAI cost $33 billion each year
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
No Disclosures
Identify mandates clinical amp regulatory for monitoring and preventing CAUTI
Review the surveillance definitions and criteria for CAUTI
Discuss strategies institutions can utilize to reduce the risk for the development of CAUTI
Discomfort to the patient
Limit mobility
Prolonged hospital stay
Increased cost and mortality
Each year 17- 2 million Americans (5-10 of hospitalized patients) acquire at least one infection while hospitalized
90-100 thousand die of those infections
One third of these are believed preventable
Conservatively HAI cost $33 billion each year
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Identify mandates clinical amp regulatory for monitoring and preventing CAUTI
Review the surveillance definitions and criteria for CAUTI
Discuss strategies institutions can utilize to reduce the risk for the development of CAUTI
Discomfort to the patient
Limit mobility
Prolonged hospital stay
Increased cost and mortality
Each year 17- 2 million Americans (5-10 of hospitalized patients) acquire at least one infection while hospitalized
90-100 thousand die of those infections
One third of these are believed preventable
Conservatively HAI cost $33 billion each year
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Discomfort to the patient
Limit mobility
Prolonged hospital stay
Increased cost and mortality
Each year 17- 2 million Americans (5-10 of hospitalized patients) acquire at least one infection while hospitalized
90-100 thousand die of those infections
One third of these are believed preventable
Conservatively HAI cost $33 billion each year
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Each year 17- 2 million Americans (5-10 of hospitalized patients) acquire at least one infection while hospitalized
90-100 thousand die of those infections
One third of these are believed preventable
Conservatively HAI cost $33 billion each year
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Urinary tract ndash most common site of healthcare associated infections most are associated with urinary catheterization 15 - 25 of inpatients are catheterized
80 of hospital associated UTIs caused by a urinary catheter
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
CAUTI cost $500 ndash $1000 - $2800 if bacteremia
Most CAUTIs are asymptomatic bacteriuria 1-5 lead to secondary bacteremia
5 of all deaths from HAI are urinary catheter associated
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
CAUTI are the most common HAI accounting for about 30
Each year more than 13000 deaths are associated with UTI Klevens RM Edwards JR et al Estimating health care-associated infections and deaths in U S hospitals 2002 Public Health Reports 2007 122160-166
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
The good news is that many CAUTIs may be prevented with recommended infection control measures
Up to 380000 infections and 9000 deaths related to CAUTI per year could be prevented
httpwwwcdcgovncidoddhqphaihtmlUmscheid et al Infec Control amp Hospital Epidemiology 2011 Scott 2009
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Proper management and use of catheters could prevent infections
Study in Lansing MI Less than half of urinary catheters in teaching hospital were indicated
Am J Infect Control 2004 Jun32(4)196-9 Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospitalGokula RR Hickner JA Smith MA
Urinary catheters are uncomfortable limit mobility
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Virtually all healthcare associated urinary tract infection are caused by instrumentation of the urinary tract
CAUTI can lead to complications
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Cystitis
Pyelonephritis
Gram-negative bacteremia
Prostatitis
Epididymitis
Orchitis in males
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Endocarditis
Vertebral osteomyelitis
Septic arthritis
Endophthalmitis
Meningitis
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
The Joint Commission NSPG 070601
CMS Value Based Purchasing
CMS Inpatient Quality Reporting Program
Goals
To eliminate and sustain reductions in CAUTI
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Mandatory Reporting through NHSN
Denial of CMS dollar reimbursement Core
Measures
CAUTI must be included in monthly NHSN
NY Partnership for Patients
To reduce unnecessary catheter utilization
To eliminate preventable catheter-associated urinary
tract infections
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
As of Oct 2008 CMS will no longer reimburse hospitals for eight ldquoreasonably preventablerdquo conditions
Included are CAUTI and hospital acquired pressure ulcers
Reimbursement to the hospital for care of these patients will be decreased
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Report by the following facilityinstitution
Acute Care Hospitals Adult and Pediatric ICUs January 2011
Long Term Care Hospitals All inpatient location October 2012
Inpatient Rehabilitation Facilities All inpatient locations
October 2012
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Report CAUTI indentified by surveillance
Indicate NO CAUTI detected for specific location
Report total device days for specific location
Report total patient days in specific location
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
NPSG070601 Implement evidence based practices to prevent CAUTI (2012 = Planning year by January 2013 = full implementation)
httpwwwjointcommissionorgassets16NPSGs_CAUTI-VAP_HAP_20101119pdf
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
EPI 2 Insert indwelling urinary catheters according to established-evidence based guidelines that address the following Limiting use amp duration to situation necessary for patient care Using aseptic techniques for site preparation equipment amp supplies
EPI 3 Manage indwelling urinary catheters according to established evidence-based guidelines that address the following Securing catheters for unobstructed urine flow amp drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
EPI 4 Measure amp monitor catheter associated urinary tract infection prevention processes amp outcomes in high-volume areas by doing the following
Selecting measures using evidence based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V Gould MD MSCR 1 Craig A Umscheid MD MSCE 2 Rajender K Agarwal MD MPH 2 Gretchen Kuntz MSW MSLIS 2 David A Pegues MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (eg aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation unresolved issue
Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1A1 Use urinary catheters in operative patients only as necessary rather than routinely (Category IB)
1A2 Avoid use of urinary catheters in patients and nursing home residents for management of incontinence (Category IB)
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1A2a Further research is needed on periodic (eg nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown (No recommendationunresolved issue)
1A3 Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction (No recommendationunresolved issue)
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1A4 Consider alternatives to chronic indwelling catheters such as intermittent catheterization in spinal cord injury patients (Category II)
1A5 Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration (Category II)
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1B2 Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
1B3 Minimize urinary catheter use and duration of use in all patients particularly those at higher risk for CAUTI such as women the elderly and patients with impaired immunity (Category IB)
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1B4 Ensure that only properly trained persons (eg hospital personnel family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility (Category IB)
1B5 Maintain unobstructed urine flow (Category IB)
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1C1 Minimize urinary catheter use and duration in all patients particularly those who may be at higher risk for mortality due to catheterization such as the elderly and patients with severe illness (Category IB)
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2A1 Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction (Category II)
2A2 Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction (Category II)
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2A3 If intermittent catheterization is used perform it at regular intervals to prevent bladder over-distension (Category IB)
2A4 For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2A5 Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization particularly with respect to complications related to catheter insertion or the catheter site
(No recommendationunresolved issue)
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2A6 In the non-acute care setting clean (ie non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization (Category IA)
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2B1 If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI consider using antimicrobialantiseptic-impregnated catheters The comprehensive strategy should include at a minimum the high priority recommendations for urinary catheter use aseptic insertion and maintenance (Category IB)
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2B1a Further research is needed on the effect of antimicrobialantiseptic-impregnated catheters in reducing the risk of symptomatic UTI their inclusion among the primary interventions and the patient populations most likely to benefit from these catheters
(No recommendationunresolved issue)
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2B2 Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization (Category II)
2B3 Following aseptic insertion of the urinary catheter maintain a closed drainage system (Category IB)
2B4 Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use (Category II)
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2B5 Urinary catheter systems with pre-connected sealed catheter-tubing junctions are suggested for use (Category II)
2B6 Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications
(No recommendationunresolved issue)
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C1 Unless clinical indications exist (eg in patients with bacteriuria upon catheter removal post urologic surgery) do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization (Category IB)
2C2a Further research is needed on the use of urinary antiseptics (eg methanamine) to prevent UTI in patients requiring short-term catheterization (No
recommendationunresolved issue)
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C2b Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction (No recommendationunresolved issue)
2C3a Unless obstruction is anticipated (eg as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended (Category II)
2C3b Routine irrigation of the bladder with antimicrobials is not recommended (Category II)
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C4 Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended (Category II)
2C5a Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place Routine hygiene (eg cleansing of the meatal surface during daily bathing)
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C5b Further research is needed on the use of antiseptic solutions vs sterile water or saline for periurethral cleaning prior to catheter insertion (No recommendationunresolved issue)
2C6 Changing indwelling catheters or drainage bags at routine fixed intervals is not recommended Rather catheters and drainage bags should be changed based on clinical indications such as infection obstruction or when the closed system is compromised (Category II)
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C7a Use a sterile single-use packet of lubricant jelly for catheter insertion(Category IB)
2C7b Routine use of antiseptic lubricants is
not necessary (Category II)
2C8 Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization
(No recommendationunresolved issue)
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C9 Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization (No recommendationunresolved issue)
2C10a Clamping indwelling catheters prior to removal is not necessary (Category II)
2C10b Insert catheters only for appropriate indications and leave in place only as long as needed (Category IB)
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C10c For operative patients who have an indication for an indwelling catheter remove the catheter as soon as possible postoperatively preferably within 24 hours unless there are appropriate indications for continued use (Category IB)
2C11a Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions (Category II)
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2C11b Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output
(No recommendationunresolved issue)
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2D1a Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion maintenance and removal (Category IB)
2D1b Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment (Category IB)
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2D2 Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended (Category II)
2D3 Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device (Category IB)
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2D5 Maintain unobstructed urine flow (Category IB)
2D6 Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems (No recommendationunresolved issue)
2D7 When performing surveillance for CAUTI consider providing regular (eg quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff (Category II)
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Urinary Tract Obstruction and Neurogenic Bladder
Urologic StudySurgery
Urine monitoring in critically ill patients
Assistance in pressure ulcer management for incontinent patients
Exception ndash Patient request to improve comfort
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Incontinence
Immobility
PatientStaff Convenience
Obtaining Periodic Urine Specimens
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Sterile gloves Sterile drapes Site cleaning supplies Sterile lubricant Sterile catheter attached to drainage
bag (seal)Hand Hygiene amp Aseptic Technique
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Avoid unnecessary urinary catheters insert urinary catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients Managing acute urinary retention and urinary
obstruction Assisting with pressure ulcer healing for
incontinent patients As an exception at patient request to improve
comfort
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Maintain urinary catheters based on recommended guidelines
Tamper-evident seal is intact Collection bag is not on the floor Collection bag is secured to the leg Every patient with a catheter has a labeled
urine collection container at the bedside
Review urinary catheter necessity daily and remove promptly
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Risk of CAUTI is 5 per day catheter is in situ
Increases to 25 after 1 week in situ
Increases to 100 after 1 month in situ
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Point Prevalence = of patients with urinary catheters ------------------------------------------- of patients at a point in time
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Nursing Care Unit Total PatientsFoley Catheters
IndwellingFoley Catheter Utilization Rate
MICU` 10 5 50LampD 1 1 100NS72 12 1 8CTICU 4 2 50CCU 6 1 17PACU 2 2 100NS62 33 4 12NS61 34 2 6NS81 21 3 14CPCU 38 1 3TOTAL 161 22 14
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
UNIT CENSUS WITH DEVICE PREVELANCE RATEED ADULT 17 0 0ED PED 4 0 0NS31 13 2 154NS32 20 0 0NS24 9 4 444NS26 6 2 333NS33 10 6 60NS42 9 0 0NS43 4 0 0NS61 28 2 71NS62 33 4 121NS7173 21 1 48708 4 0 0715 4 1 25NS72 14 1 71NS74 13 0 0NS81 41 2 49TOTAL 250 25 10
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Unit Observations
with Securemen
t
Seal Intac
t
Below level of bladder
Not touching floor
MSICU
5 60 0 100 100
L ampD 1 100 0 100 100
NS72 1 0 100 100 100
CTICU 2 50 50 100 100
CCU 1 100 0 100 100
PACU 2 100 0 100 100
NS62 4 75 50 100 100
NS61 2 100 100 1005 100
Ns81 3 67 67 100 100
CPCU 1 100 100 100 100
Overall
22 73 41 100 100
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
National Healthcare Safety Network
(NHSN)
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Healthcare ndash Associated Infection (HAI)A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that
Occur in a patient in a healthcare setting and
Was not present or incubating at the time of admission unless the infection was related to a previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Indwelling Catheter
A drainage tube that is inserted into the urinary bladder through the urethra is left connected to a closed collection system
Also called a Foley catheter Does not include (among others)
Straight in and out catheters Suprapubic catheters Nephrostomy tubes
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
A UTI in a patient who had an indwelling urinary catheter is in place at the time of or within 48 hours prior to infection onset
NOTE There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter-associated
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
LocationCAUTIs are attributed to inpatient location at time of urine collection or symptom onset whichever comes first
Exception If a CAUTI develops within 48 hours of transfer from one inpatient location to another in the same facility or a new facility the infection is attributed to the transferring location (Transfer Rule)
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Transfer Rule
Mr Smith is transferred from SICU with aFoley and 36 hours after transfer has a
fever of3820C The next day a urine culture
collectedhas gt105 CFUml of E coli
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
There are two criteria than can be applied for
identifying a CAUTI
Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
NOTE The specific site ldquoOther Urinary Tract Infectionrdquo (OUTI) can also be used to identify an infection in the urinary tract however OUTI are not associated with urinary catheters and therefore cannot be CAUTI events
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge 105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
---------------------OR------------------------------------------
Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urine culture of ge105 colony-forming units (CFU)ml with no more than 2 species of microorganisms
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
2a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 2 of the following signs or symptoms with no other recognized cause fever (gt380C) suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated by at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
-------------------------------OR-------------------------------------------Patient had indwelling urinary catheter removed within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness and a positive urinalysis demonstrated at least 1 of the following findings
a Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
3 Patient le 1 year of age with or without an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urine culture of ge 105 CFUml with no more than 2 species of microorganisms
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
4 Patient le 1 year of age with or with an indwelling urinary catheter has at least 1 of the following signs or symptoms with no other recognized cause fever (gt380C core) hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting and a positive urinalysis demonstrated by at least one of the following findingsa Positive dipstick for leukocyte esterase andor nitriteb Pyuria (urine specimen with ge 10 white blood
[WBC]mm3 of unspun urine or ge3 WBChigh power field of spun urine)
c Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ge103 and lt105 CFUml with no more than 2 species of microorganisms
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
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- Slide 60
-
Patient with or without an indwelling urinary catheter with no signs or symptoms (ie for any age patient no fever (gt380C ) urgency frequency dysuria suprapubic tenderness or costovertebral angle pain or tenderness OR hypothermia (lt360C core) apnea bradycardia dysuria lethargy or vomiting) and a positive urine culture of gt 105 CFUml with no more than 2 species of uropathogen microorganisms and a positive blood culture with at least 1 matching uropathogen microorganism to the urine culture or at least 2 matching blood cultures drawn on separate occasions if the matching pathogen is a common skin contaminant
Note All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
Uropathogen microorganisms are Gram-negative bacilli Staphylococcus spp yeasts beta hemolytic Streptococcus spp Enterococcus spp G Vaginalis Aerococcus urinae and Corynebacterium (urease positive)
Report Corynebacterium (urease positive) as either Corynebacterium species unspecified (COS) or as C urealyticum (CORUR) if so speciated
The indwelling urinary catheter was in place within 48 hours prior to specimen collection (January 2012 Release)
Note All ABUTIs will have a secondary bloodstream infection
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
50 year old end stage pancreatic cancer liver amp bone mets admitted with advance directive for comfort care amp antibiotics only foley catheter peripheral IV amp nasal cannula inserted
Day 4 patient is febrile to 380degC amp has suprapubic tenderness IV ampicillin started after urine obtained for culture
Day 5 difficulty breathing CXR = infiltrate L lung base
Day 6 urine culture results = 105 CFUml E coli
Day 7 WBCmm3 = 3400 patchy infiltrates in both lung bases continued episodes of dyspnea rales noted in LLL
Day 11 Patient expired
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
ndash(fever 38degC not high enough for criteria)
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
POD 3 66 yo patient in the ICU with a Foley catheter sp exploratory lap patient noted to be febrile (389deg) and complained of diffuse abdominal pain
WBC increased to 19000 He had cloudy foul-smelling urine and urinalysis showed 2+ protein + nitrite 2+ leukocyte esterase WBC ndash TNTC and 3+ bacteria Culture was 10000 CFUml E coli The abdominal pain seemed localized to surgical area
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
84 year old patient is hospitalized with GI bleed
Day 3 Patient has indwelling catheter in place and no signs or symptoms of infection
Day 9 Patient becomes unresponsive is intubated and CBC shows WBC of 15000 Temp 380degC Patient is pan-cultured Blood culture and urine both grow Streptococcus pyogenes ndash urine gt105 CFUml
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
ABUTI
ndashNo signs or symptoms (fever not gt 38degC)
ndashPositive blood culture with at least 1 uropathogen matching to the urine culture
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-
For any questions or inquires about
NHSN Criteria and Definitions
Email nhsncdcgov
Website wwwcdcgovnhsn
- Slide 22
- Slide 55
- Slide 60
-