How Practice and Surveillance Affect Your CAUTI Efforts Mohamad Fakih, MD, MPH Medical Director, Infection Prevention and Control St. John Hospital and Medical Center Professor of Medicine Wayne State University School of Medicine Detroit, MI Tuesday, March 11, 2014

We will discuss Relation between catheter use and bacteriuria Triggers of urine culture The definition of CAUTI When (or not) to obtain urine cultures Bacteriuria and antimicrobial use

For the last year, your hospital Always had zero CAUTIs Reduced CAUTI rates (or SIR) by >20% Reduced CAUTI rates (or SIR) by <20% Had increases in CAUTI rates (or SIR) by <20% Had increases in CAUTI rates (or SIR) by >20% Do not know

Bacteriuria: Risk in catheterized patients (Gould et al, HICPAC guidelines 2009) High quality evidence: prolonged catheterization Moderate quality evidence: female gender, positive meatal cultures, lack of antimicrobial exposure Low quality evidence: “older age, disconnection of the drainage system, diabetes, renal dysfunction, higher severity of illness, impaired immunity, placement of the catheter outside of the operating room, lower professional training of the person inserting the catheter, incontinence, and being on an orthopaedic or neurology service”

Matrix for reducing CAUTI Reduce urinary catheter use Promote aseptic insertion and maintenance Avoid obtaining urine cultures unless clinically indicated Do not treat asymptomatic bacteriuria except for select conditions Matrix for reducing CAUTI

Reducing Urinary Catheter Use Prevent placement (risk of introduction of organisms and bladder colonization are eliminated) Reduce duration of use (risk of bladder colonization is reduced by minimizing indwelling time)

Bacteriuria with Catheter Use (Garibaldi et al, Infect Control 1982; 3: 466-70) Daily bacteriologic monitoring of 1140 cases: Bacteriuria at insertion: 99/1,140 (8.7%) catheterizations 1,041 had no colonization at insertion, 433 removed within 24 hours Of 608 catheterizations >24 hours, 76 (12.5%) developed bacteriuria Risk of bacteriuria was 3% per catheter-day

Picture of Routes of Entry Maki and Tambyah, Emerg Infect Dis 2001; 7: 1-6

Intraluminal and Extraluminal Bacteriuria (Tambyah, Mayo Clin Proc 1999; 74: 131-6) Prospective evaluation of bacteriuria of 1479 newly placed urinary catheters Looked at the integrity of the closed urinary system Daily urine sampling from the sampling port and the urine bag Definitions: Early extraluminal infection: Organisms introduced to bladder at time of UC insertion (organisms +ve after 24 hours of insertion) Late extraluminal infection: Organisms ascending from perineum Intraluminal infection: Access to lumen through failure of closed drainage

Intraluminal and Extraluminal Bacteriuria (Tambyah, Mayo Clin Proc 1999; 74: 131-6) CAUTI defined: >103 CFU/ml of an organism (bacteriuria or funguria) Excluded bacteriuria at insertion time 235 (15%) CAUTIs (23.2% females vs. 8.9% males)

Intraluminal and Extraluminal Bacteriuria (Tambyah, Mayo Clin Proc 1999; 74: 131-6) About a third had an indeterminate source Mean duration of catheterization to infection for late extraluminal, intraluminal and indeterminate was 6-7 days The $1 million question: Can we prevent catheter-associated bacteriuria if all the evidence-based measures are implemented?

Catheter associated Bacteriuria in ICU (Clec’h et al, Infect Control Hosp Epidemiol 2007; 28: 1367-73) 12 ICUs: weekly urine cultures or if symptoms in catheterized patients CAUTI defined as urine culture >103 CFU/ml CAUTI (bacteriuria) rate= 12.9/ 1000 catheter-days Median time to CAUTI 11 days (range 6-19 days) Median ICU LOS longer for those with CAUTI (28 days) vs. those without (7 days)

Then reducing duration of urinary catheter use is critical to… Prevent bacteriuria and CAUTI

Interventions to Reduce Catheter Use (Meddings et al, BMJ Qual Saf Sep 2013) 30 studies: Reminders, stop orders to prompt removal of unnecessary urinary catheters Average 1 day drop for urinary catheter use with interventions Overall reduction in CAUTI was about 53% with such interventions

Reducing Urinary Catheter Use and CAUTI (Meddings et al, BMJ Qual Saf Sep 2013) Success with ~53% reduction in CAUTI rates

Matrix of reducing CAUTI Reduce urinary catheter use Promote aseptic insertion and maintenance Avoid obtaining urine cultures unless clinically indicated Do not treat asymptomatic bacteriuria except for select conditions Matrix of reducing CAUTI

Common inappropriate triggers for urine culture in urinary catheters Urine color, consistency and smell Pyuria

Resident physicians (n=106) and Nurses (n=159): triggers for cultures in catheterized patients (Sibai et al, ID Week 2013, presentation 205 ) Trigger for Urine Culture Resident Physicians (Answered Yes) Nurses (Answered Yes) Foul smelling urine 75 (70.8%) 146 (94.8%) Cloudy urine 84 (79.2%) Sediments in urine 57 (53.8%) 129 (84.3%) Darker urine 39 (36.8%) 72 (47.7%) Chronic UC on admission 46 (43.4%) 115 (74.2%) All of the above should not trigger a urine culture in catheterized patients!

Color or Odor (Hooton, Clin Infect Dis 2010; 50:625–663) IDSA guidelines: “In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy.”

Resident physicians and Pyuria: Obtain a urine culture in catheterized patients (Sibai et al, ID Week 2013, presentation 205 ) Trigger for Urine Culture Answered Yes Urine WBC 25 cells 71 (67%) Urine WBC 100 cells 94 (88.7%) Urine WBC 500 cells 101 (95.3%) Pyuria in an asymptomatic patient with an indwelling urinary catheter should not be a trigger for culture or antimicrobials

Pyuria is not diagnostic of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663) Pyuria does not help differentiate asymptomatic bacteriuria from CAUTI Pyuria + bacteria ≠ CAUTI

Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) 761 patients with newly inserted catheters, 10.8% developed bacteriuria or candiduria Defined bacteriuria as >103 CFUs Women had more bacteriuria (21.2%) than men (7.2%) bacteriuria >103 CFUs.

Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) Pyuria more common with bacteriuria related to gram negatives than gram positives or funguria bacteriuria >103 CFUs.

Pyuria and Bacteriuria (Tambyah, Arch Intern Med. 2000;160:673-677) Pyuria cannot predict bacteriuria Note: Study used nitrofurazone and silver-hydrogel catheters

Absence of Pyuria (Hooton, Clin Infect Dis 2010; 50:625–663) IDSA guidelines: “The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI”

What is CAUTI? Multiple definitions Clinical (IDSA) Clinician (physician’s impression) Surveillance (NHSN)

IDSA Guidelines: Definition of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663) …is defined by the presence of symptoms or signs compatible with UTI with no other identified source along with 103 cfu/mL of 1 bacterial species in a single catheter urine specimen…

IDSA Guidelines for Diagnosis of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663) Signs and symptoms: “New onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort” Many signs and symptoms are not specific for CAUTI!!

IDSA Guidelines for Diagnosis of CAUTI (Hooton, Clin Infect Dis 2010; 50:625–663) If catheter is removed: “Dysuria, urgent or frequent urination, or suprapubic pain or tenderness” Spinal cord injury: “Increased spasticity, autonomic dysreflexia, or sense of unease”

From the IDSA Guidelines… (Hooton, Clin Infect Dis 2010; 50:625–663) “…the greatest impact of an intervention may be to reduce the frequent occurrence of CA-ASB, rather than to directly reduce the number of episodes of CA-UTI, which occur much less often.” CA-ASB: catheter associated asymptomatic bacteriuria CA-ASB: catheter associated asymptomatic bacteriuria

The Clinician’s Practice Bacteriuria or candiduria are common in patients with an indwelling urinary catheter Clinicians tend to treat asymptomatic bacteriuria Reduce inappropriate antibiotic use with obtaining urine cultures only when indicated

Does the Organism and Pyuria Matter? Candiduria (Kauffman, Clin Infect Dis 2000; 30: 14-18): majority treated with antifungals though not usually symptomatic, 55% had U/A with WBC >5 per HPF, clearing of organism occurred in both those given (50%) and not given antifungals (75%) Physicians tend to treat more G-negatives and pyuria (Cope, Clin Infect Dis 2009; 48: 1182-8)

NHSN Symptomatic CAUTI (www. cdc NHSN Symptomatic CAUTI (www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf) Surveillance definition: Depends on having a positive urine culture and clinical/ laboratory findings Heavily dependent on the presence of fever May help evaluate improvement for the same hospital over time for those that are catheterized

Why do we have different CAUTI rate changes over the last few years depending on ICU type? Surveillance definition: Depends on having a positive urine culture and clinical/ laboratory findings Heavily dependent on the presence of fever >90% of cases fitting the NHSN definition have fever, used regardless of source Some ICUs have longer LOS (higher bacteriuria risk)

NHSN CAUTI Note: NHSN CAUTI requires the patient to have a catheter for at least 2 days prior to symptom onset

NHSN CAUTI

Does NHSN CAUTI Definition Correlate with Physician’s Practice Does NHSN CAUTI Definition Correlate with Physician’s Practice? (Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77 ) NHSN definition had a poor positive predictive value of physician practice and Infectious Diseases consultant impression

NHSN CAUTI vs. CAUTI Treated by Clinicians (Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77 ) 90.8% of those diagnosed with NHSN CAUTI had a temperature >38°C Only 18/ 387 (4.7%) of patients had one or more focal signs or symptoms documented 91.4% of patients with NHSN CAUTI fit criterion 1 T >38°C + positive urine culture=NHSN CAUTI; important to obtain urine cultures when clinically indicated

NHSN Symptomatic CAUTI Caution: If practice of obtaining urine cultures changes, the NHSN rate may be influenced without a change in clinical CAUTI Changing the frequency of obtaining urine cultures will affect the number of NHSN symptomatic CAUTI

NHSN CAUTI Definition Depends on Frequency of Obtaining Urine Cultures and Fever Prevalence (Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77)

NHSN CAUTI Definition Depends on Frequency of Obtaining Urine Cultures and Fever Prevalence (Al Qas-Hanna, Am J Infect Control 2013;41 (12): 1173-77) An increase in fever prevalence (keeping bacteriuria and urine culture use constant) will reflect in a higher NHSN-CAUTI rate (eg, patients in neuro-ICUs with an increased incidence of central fevers, or a respiratory unit during influenza season). An increase in frequency of urine culture collection (keeping bacteriuria and fever prevalence constant) will also lead to an increase in the number of NHSN-CAUTIs (e.g., a change in practice by clinicians or the implementation of automatic triggers/protocols to obtain urine cultures based on fever or Pyuria without clinical evaluation).

Fever, Leukocytosis and Relation to CAUTI (Golob et al, Surg Infect 2008; 9: 49-56) Retrospective evaluation of 510 patients in a surg-trauma ICU within the 1st 14 days of hospital stay over 18 months Definitions: Fever= T ≥38.5°C; leukocytosis WBC ≥12,000; UTI= urine culture ≥105 CFU/ml Fever was in 29% of patient-days, and leukocytosis in 41% of patient-days Mean length of stay 15.8 ±1.2 days for UTI (bacteriuria) vs. 9.4 ±0.5 days for no UTI; p = 0.003

Fever, Leukocytosis and Relation to CAUTI (Golob et al, Surg Infect 2008; 9: 49-56)

Fever was not associated with bacteriuria!!!!! Fever, Leukocytosis and Relation to CAUTI (Golob et al, Surg Infect 2008; 9: 49-56) Fever was not associated with bacteriuria!!!!! If we try to apply the NHSN definition (fever and bacteriuria), then in that study, the rate would at least be 1,000 x (60 x 0.29) /3,839= 4.5/ 1,000 patient-days

When to Obtain a Urine Culture? Focal symptoms suggestive of urinary tract infection (e.g., lower abdominal tenderness, flank pain, lower abdominal discomfort) Signs and symptoms of sepsis in patients with no clear source

Do you have triggers to obtain a urine culture based on either a urine analysis result or fever without the need for physician evaluation? Yes No Do not know

Screening Urine Cultures Screening on admission Screening prior to non-urologic surgery Automatic triggers for cultures (temperature or WBCs on urinalysis) They’re all bad!

Preoperative urine cultures in Veterans (Drekonja, JAMA Intern Med Evaluated 1934 procedures, mostly orthopedic, cardiothoracic and vascular Males (96%), mean age 62 years old 25% had screening urine cultures (mainly cardiothoratic and vascular) 11% of urine cultures were positive with asymptomatic patients, 30% of whom received antibiotics for asymptomatic bacteriuria Postoperative UTI was more frequent among treated than untreated patients (18% vs. 7%) for bacteriuria

Screening Urine Cultures The practice: “screening culture on admission”, “standing orders” or “reflex orders” for urine cultures based on urinalysis results May not help the hospital avoid non-reimbursement May increase utilization of additional resources (testing, antibiotics, consults) May adversely affect patients exposing them to inappropriate testing and treatments

What about if increased bacteriuria prevalence is related to increased catheter duration of use? ICUs based on type may have different CAUTI rates Clec’h et al: Median time to bacteriuria 11 days (range 6-19 days) Tambyah et al: mean duration to bacteriuria 6-7 days

ICU CAUTI: Large variation between units (Edwards, Am J Infect Control 2009;37:783-805; Dudeck, Am J Infect Control 2011;39:349-67; Am J Infect Control 2011;39:798-816; Dudeck, Am J Infect Control 2013; 41: 1148-66) Rates per 1000 catheter-days 2006-8 2009 2010 2012 Med-surg ≤15 beds 3.4 1.3 1.2 Med-surg >15 beds 3.1 1.6 Med-surg major teaching 2.3 2.2 2.4 Neurosurgical 6.9 4.4 4.0 5.0 Trauma 5.4 3.2 4.1 NHSN definition change (2009) resulted in >50% drop in CAUTI… No change in CAUTI in ICU, more recent data show increase

Culturing Stewardship Fakih, Improving the Culture of Culturing

Pre-Printed Orders Foley Catheter Protocol

Can we get to zero CAUTI? We can greatly reduce CAUTI (may be get close to zero for a period of time) especially in areas where fever prevalence is low (e.g., non-ICU med-surg) and units with shorter LOS For units with high fever prevalence and longer duration of stay, this goal is unlikely to be achievable at this point

Matrix for reducing CAUTI Reduce urinary catheter use Promote aseptic insertion and maintenance Avoid obtaining urine cultures unless clinically indicated Do not treat asymptomatic bacteriuria except for select conditions Matrix for reducing CAUTI

Bacteriuria and Antimicrobial Use So we have a positive urine culture: When should we use antibiotics? Understand the prevalence of asymptomatic bacteriuria in patients with indwelling urinary catheters Understand the risks associated with inappropriate antimicrobial use

Table 2 Nicolle et al, Clin Infect Dis 2005; 40:643–54

IDSA Guidelines for Asymptomatic Bacteriuria (Nicolle et al, Clin Infect Dis 2005; 40:643–54) Screening and treatment of bacteriuria recommended for: Pregnancy Before transurethral resection of the prostate Urologic procedures for which mucosal bleeding is anticipated

IDSA Guidelines for Asymptomatic Bacteriuria (Nicolle et al, Clin Infect Dis 2005; 40:643–54) Screening and treatment of asymptomatic bacteriuria not recommended for: Non-pregnant women Diabetic women Elderly in the community or institutionalized Persons with spinal cord injury Patients with indwelling catheter

Risk of Obtaining Cultures with no Symptoms Urinary catheter present in an asymptomatic patient Cloudy, odorous urine, sediments Inappropriate use of urine culture Inappropriate antimicrobial use More resistant organisms, Clostridium difficile, increased cost, Patient harm

Best solution: Focus on avoiding the catheter No catheter No unnecessary urine cultures No CAUTI

Matrix for reducing CAUTI Reduce urinary catheter use Promote aseptic insertion and maintenance Avoid obtaining urine cultures unless clinically indicated Do not treat asymptomatic bacteriuria except for select conditions Matrix for reducing CAUTI

In your opinion, the most important intervention to reduce CAUTI is… Proper insertion and maintenance of catheter Prevention of placement and minimizing duration of use Avoid obtaining unnecessary urine cultures

Questions for our presenters? Thank you! Questions for our presenters?

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Upcoming National Content Calls Date(s) Time/Duration Topic 4/8/14 12 ET/11 CT/10 MT/9 PT (60 minutes) April National Content Call Apply CUSP, Just Culture and TeamSTEPPS 5/13/14 May National Content Call Preventing CAUTI in Specialized Patient Populations: The ICU and Bariatric Patients 6/10/14 June National Content Call Mindfulness Component: Antimicrobial Prescribing 7/8/14 July National Content Call Preventing CAUTI in Specialized Patient Populations: Procedural-Related Catheter Use

April Content Call Preview Presenters: Barb Edson, HRET This call will focus on the “Apply CUSP” module and “Just Culture” principles highlighted in the CUSP Toolkit. Call participants will understand where CUSP aligns with other safety and quality improvement frameworks in addition to the specific “Just Culture” principles that will help units instill a culture of shared accountability and insert TeamSTEPPS concepts/tools.