AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

Infection Prevention: Recognizing and Communicating CAUTI

Onboarding #4 for Long-Term Care Staff

Insert Headshot

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Upon completion of this session, long-term care staff will demonstrate a working knowledge of:

• how an indwelling urinary catheter increases the risk of CAUTI;

• the limitations of urinary diagnostic tests used to diagnose CAUTI;

• what to communicate and document when a CAUTI is suspected; and

• how to document actions to prevent CAUTI.

Learning Objectives

How Does an Indwelling Urinary CatheterIncrease Risk for a CAUTI?

• Bacteria can enter the urinary tract via the urinary catheter

• Bacteria can stick to the catheter by forming a biofilm• Once bacteria are included in a biofilm, they are

protected from antibiotics given to treat a UTI or CAUTI• Presence of biofilm allows antibiotic-resistant bacteria

to develop

• When the catheter stops flowing, bacteria in the bladder reflux back into the ureters and kidneys which leads to signs/symptoms of infection• Catheter flow can stop because of sludge/sediment;

kinks in the catheter or dislodging of the catheter 3

Entry Points for Bacteria

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Bladder

Source: Dennis G. Maki and Paul A. Tambyah. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis, Vol. 7, No. 2, March-April 2001. http://www.cdc.gov/ncidod/eid/vol7no2/makiG1.htm

Collection Bag

Bacteria can gain access to and grow in the bladder in several ways:

• Contamination of the tube at the time of placement

• Bacteria colonizing the perirectal area and groin can creep up the catheter tube

• Contamination of the urine collection bag or other breaks in the tubing

3-10% of people develop bacteria in their urinary tract every day a catheter is in place

Understanding Asymptomatic Bacteriuria

Almost all residents with a catheter will have bacteria grow in a urine culture

Asymptomatic bacteriuria (ASB) = Presence of bacteria detected in the urine culture when the resident doesn’t have any localizing signs/symptoms of a CAUTI

• Amount of bacteria growing in the culture does not help differentiate ASB from CAUTI

• The positive urine culture by itself is not enough to diagnose a CAUTI

Treating residents with antibiotics who have ASB does not improve their clinical outcomes or prevent them from developing a symptomatic CAUTI

• Antibiotic use for ASB can cause higher rates of antibiotic resistance, Clostridium difficile infection and other adverse events

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Nicolle LE Drugs Aging (2014) 31:1–10

Interpreting Pyuria When a Catheter is Present

Pyuria is detection of white blood cells, by a urinalysis, dip stick or urine microscopic exam.

The presence of the indwelling urinary catheter can cause local irritation of the bladder wall, resulting in WBCs in the urine.

Presence of pyuria cannot help you tell the difference between ASB and CAUTI.

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Nicolle LE Drugs Aging (2014) 31:1–10

Diagnostic Tests – Urinalysis

Urinalysis considerations

• Abnormal findings on a urinalysis in a resident with an indwelling urinary catheter are common and non-specific

• A completely negative (normal) urinalysis is very helpful to rule out a CAUTI• The negative test rules out CAUTI, but the positive test

does not confirm CAUTI

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Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625-663

Diagnostic Tests – Urine Culture

Positive urine culture• ≥ 100,000 colony forming units per ml of urine (105 CFU/ml)

when a catheter is present

• ≥ 100 colony forming units per ml (102 CFU/ml) from an in/out catheter specimen

Common Pathogens• Escherichia coli

• Klebsiella pneumoniae

• Pseudomonas aeruginosa

• Proteus mirabilis

• Morganella morganii

• Enterococci

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When Should a UA and Culture be Sent?

• Urine testing should only be performed when a resident has local signs and/or symptoms of CAUTI (suprapubic or costovertebral angle tenderness, fever, etc.).

• Odorous or cloudy urine are not indications for urine culture or analysis. These non-specific changes in urine character are not considered signs of CAUTI.

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Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625-663

• Complete documentation of resident signs/symptoms is important for accurate diagnosis and infection reporting

• You can help by reporting changes that you observe in residents

Who should be communicating with whom?

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Nurse

Physician

Other StaffTherapy

Nurse-aide

Identifying CAUTI Signs and Symptoms

All staff are key to early identification and notification of infections

What to Assess When You Suspect a CAUTI

• Current and recent vital signs

• Recent change in mental status for onset of confusion• MDS confusion assessment tool

• Recent change in Activities of Daily Living

• Physical exam findings• Lower abdominal/suprapubic tenderness, flank/low back pain• Fever• Rigors (chills and sweats)

• Catheter findings:• Purulent discharge at the insertion site • Change in urine output, evidence of sediment which could be

obstructing flow11

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Monitoring: Who is at Risk for CAUTI?

You can’t have a CAUTI if you don’t have a catheter

• Document date of insertion and indication for every resident with an indwelling urinary catheter

• Review and document the urine output and quality of flow for residents with indwelling catheters every day• To ensure catheters are working properly and detect malfunctions

early

• Assess and document the ongoing need for the catheter on a daily basis

• Keep a daily log of residents with an indwelling urinary catheter

Documenting Efforts to Prevent CAUTI

Proper care and handling of the indwelling catheter can reduce risk of CAUTI.

• Use checklists to ensure consistency and that everyone follows best-practices.

• Tools can help to document and verify if a process needs to be reviewed and if staff need more training and education.

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Case Scenario: Mrs. Smith

It’s time to practice!

• Break into small groups of 2-3

• Each group should have the following materials:• Case scenario and discussion guide

• CAUTI surveillance worksheet

• Indwelling urinary catheter insertion checklist

• Indwelling urinary catheter maintenance checklists

• Work together on Mrs. Smith’s case

Stay Updated with Useful Resources

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1. AHRQ Safety Program for Long-Term Care: HAIs/CAUTI websiteLogin information

Username: ltcsafetyPassword: ltcsafety

2. TeamSTEPPS® for Long-Term Care

Stay Updated with Useful Resources

3. Long-term Care: Indwelling Urinary Catheter Insertion Checklist and Instructions for Use

4. Long-Term Care: Indwelling Urinary Maintenance Checklist and Instructions for Use

5. CAUTI Surveillance Worksheet