1. REDUCING CATHETER ASSOCIATED URINARY TRACT INFECTIONS CLINICAL EXCELLENCE COMMISSION 2015 URINE COLLECTION, CULTURE and CATHETERISATION IN ACUTE SETTINGS

2. 2 “…. Over-testing may lead to overdiagnosis, the circumstance where people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death. This can lead to unnecessary treatment, adding to the risk of patient harm.” - Morgan & Coleman, 2014

3. 3 Advice on unnecessary laboratory testing

4. 4 General principles for rational specimen collection and ordering 1) Only test if there is a clear purpose:  Diagnosis  Treatment  Disease or therapy monitoring  Assessment of adverse event of side event  Exclusion of possible diagnosis  Assessment or management of comorbidity  Disease screening AND 2) Only test if clinically indicated:  Acute/immediate patient care is required  As part of a clinical pathway/standard of care for patients with that condition  Fulfils a public health objective  To assist with good patient flow

5. 5 A rational approach to urine collection and culture

6. In 1993, only 24% of CSUs collected were because of UTI signs and symptoms! In 1993, only 24% of CSUs collected were because of UTI signs and symptoms! 6 See: Rao, G.G. et al. Journal of Hospital Infection, 1993. 25: p. 219-22.

7. 7 Collect urine specimen only if UTI signs and symptoms also are present or if septic workup is also required What if:  Urine is malodorous, cloudy or has blood?  Dipstick +ve for leukocytes, protein, blood or nitrite?  As part of routine admission screening? Identify purpose and clinical indication for specimen collection

8. 8 A urine culture is required from an adult catheterised patient if:  A septic work up is needed OR  The patient has UTI signs and symptoms Adults with a UTI may present with ≥1 of the following symptoms with no other recognised cause: fever, suprapubic tenderness, costovertebral angle pain or tenderness, delirium or hypothermia (<35.5 o C core). Identify purpose and clinical indication for specimen collection

9. 9 NO, a septic work up is not required and NO, the patient doesn’t have UTI symptoms

10. 10 YES, septic work up is required OR YES, the patient has UTI symptoms

11. 11 Identify specimen to collect Q: Does the patient still need their catheter? Is the original indication for catheterisation still present? Has a new indication for catheterisation emerged?

12. 12 No, the IDC is no longer required

13. 13 No, the patient can’t produce a clean MSU

14. 14 Yes, the patient can produce a clean MSU

15. CSU - What’s the difference? 15  Used to identify urinary tract infection (UTI)  Urine sample collected via a urinary catheter  May be known as a ‘catheter urine’  Not the same as a mid stream urine (MSU)

16. 16 Identify specimen to collect Q: Does the patient still need their catheter? Is the original indication for catheterisation still present? Has a new indication for catheterisation emerged?

17. 17 Yes, the IDC is still longer required

18. Handling urine specimens 18  Collect the specimen aseptically  Get the specimen to the lab quickly  Refrigerate (4-10 o C)  Packaging for transport

19. Testing the urine specimen 19  Initial cell count of microorganisms and WBC  Culture for 24 hours  Identify growth and colony count  Each urine specimen costs $22.50 to culture on the MBS Acinetobacter spp. growing on sheep’s blood agar. Image courtesy of CDC/Amanda Moore, Todd Parker, Audra Marsh

20. 20 Documentation of urine specimen collection  Indication for collection  Date and time of collection  Specimen collected -MSU -CSU from current catheter - CSU from newly inserted catheter Medical record Lab order  Indication for collection  Date and time of collection  Specimen collected - MSU - CSU from existing catheter - CSU from newly inserted catheter  Catheter type (and dwell time of catheter) - Indwelling or SPC (at insertion or ≥48hrs) - In/out catheter (at insertion or at catheter change)  Start date and indication for catheterisation  +/- UTI symptoms

21. Thank you 21 For further information: CEC-HAI@health.nsw.gov.au www.cec.health.nsw.gov.au