Review of 2009 IDSA Clinical Practice GuidelinesCID 2010;50: 625-663.

Nov 09 2011Savitri Aguiar, MD

Diagnosis, Prevention and Treatment of CA-UTI in Adults

MOTIVATION

UTI AS AN EXPLANATION FOR A.M.S IN OLDER ADULT WITH A CATH

UTI IS THE MOST COMMON ILNESS IN ADULTS > 65 YO (1)

Incidence > 80 yo: 10% in women and 5.3% in men.

ASB: 6 to 16% of women in the community and 25-54% in nursing homes (men is about half of those percentages) (2)

with caths: 85-100% of ASBU.S. hospitals have not widely implemented

strategies to reduce H.A. UTI (3)CMS will no longer pay for it

MOTIVATION

HOW DO WE GO FROM UTI TO AMS?-pro inflammatory cytokines (ILs and

TNF alpha) may play a role in pathogenesis of delirium

-hypoperfusion

Do we overdiagnosis CA-UTI?- excessive ATBC’s

Not to do something is a much harder thing to do in our culture

INTRODUCTIONCA-UTI in adults ≥ 18 yoShort-term cath (<30 days)Long-term cath (≥ 30 days)Indwelling / intermittent / condom cath

NOT COVERED: single in/out cath for diagnostic purposes; complicated urologic procedures (i.e., ureteral stents, nephrostomy tubes); or fungal UTI.

INTRODUCTIONCA-Bacteriuria is the most common hospital

acquired infection in the world. Largely due to too many Foley's.

40% of hosp acquired infections in U.S. (NNIS 1992-2004)15% of H.A. bacteremia (mainly Gram Neg) attributable to CA-B;

however only 1-4% of CA-B evolves to bacteremia.Association with increased mortality (NEJM 1982;307:637-642);

confounding?Most of the 900,000 yearly nosocomial bacteriuria have a cath15-25% of patients in a general hosp will have some cath daysIncidence of CA-B: 3%-8% per day; BY ONE MONTH: 100%

bacteriuric< 25% of CA-B develop UTI symptoms.

Catheter literature nomenclature1)CA-ASB2)CA-B (asymp or non):

predominantly CA-ASB

Very few are reports on CA-UTITherefore, most recommendations in these

guidelines refer to CA-B. Because this is the only or predominant outcome measure

DIAGNOSIS (=DEFINITIONS)Cath (indwelling urethral, indwelling

suprapubic or intermittent cath)CA-UTI:

signs / symptoms compatible w/ UTI

no other identifiable source of infection

≥103 CFU/ml of ≥ 1 bacterial species in a single cath-urine specimen or in a midstream voided urine from a patient whose urethral, suprapubic or condom cath was removed within 48 h

not clear the number of CFU for men with condom cath (to diagnose UTI)

DIAGNOSIS (=DEFINITIONS)CA-ASB:

Same caths: ≥ 105 CFU/ml of ≥ 1 bacterial species in a single cath urine specimen in a patient WITHOUT symptoms compatible with UTI

Condom cath (freshly applied): same 105 CFU

SHOULD NOT BE SCREENED FOR, EXCEPT IN RESEARCH AND PREGNANT WOMEN

VERY IMPORTANTPyuria (≥ 10 WBC/mm3 of uncentrifuged urine)

is NOT diagnostic of CA-B or CA-UTI presence, absence or its degree is of NO USE to

differentiate CA-ASB from UTIpyuria plus CA-ASB: NOT and indication for

ATBC'sabsence suggests another diagnosis other than

CA-UTI presence or absence of odorous / cloudy urine

alone should not be used to differentiate CA-ASB from CA-UTI: DO NOT CULTURE; DO NOT RX ATBC'S.

Leukocyte esterase and nitrites: NO VALUE either

CORE OF THE PROBLEMSIGNS / SYMPTOMS OF UTI

flank pain, CVA tenderness, acute hematuria, pelvic discomfort (rare)

and, if cath was removed: dysuria, urgency, frequency, suprapubic pain / tenderness

CORE OF THE PROBLEMSIGNS / SYMPTOMS OF UTI

spinal cord injury: increased spasticity, autonomic dysreflexia, sense of unease (SUBJECTIVE)

new onset fever, rigors, A.M.S, malaise, lethargy WITHOUT OTHER IDENTIFIABLE CAUSE

EXCLUSION DIAGNOSIS!!!!!!!!!!!CLINICAL DILEMA: what defines symptomatic in frail, often

cognitively impaired seniors?

PREVENTION=REDUCE USE OF URIN. CATHETERIZATIONusing clear indications (absent in

up to 50% of the times)

removing cath ASAP

The strategies to do the above have more impact on the incidence of CA-ASB and CA-UTI than anything else!!!

Implementing those should be a priority for all health care facilities

Acceptable Indications for Indwelling Urinary Catheter Use.

Hooton T M et al. Clin Infect Dis. 2010;50:625-663

© 2010 by the Infectious Diseases Society of America

PREVENTION: LIMIT UNNECESSARY CATHS

No cath for urinary incontinence, except per patient request (I’d add informed consent with risks of infection)

Institution must develop a list of appropriate indications

Institution should require a physician order before indwelling cath is placed

Institution should consider portable bladder scanners to determine whether cath is necessary for post-op patients

PREVENTION: DISCONTINUE CATHRemove indwelling cath ASAP

Institution should consider NURSE based or ELECTRONIC based physician reminder systems to reduce inappropriate caths

Institution to consider AUTOMATIC STOP orders to reduce inappropriate urine caths

PREVENTION:INFECTION PREVENTION: develop, maintain

and enforce policies and procedures for recommended cath insertion indications, insertion and maintenance techniques and replacement indications

may consider feedback of CA-B rates to providers on a regular basis to reduce risk of CA-B (unclear if this will drop CA-UTI) 

place patients with urinary caths in different rooms?

PREVENTION:UNCERTAINTIES:

ALTERNATIVES TO INDWELLING CATHS1)Condom / 2)intermittent / 3)suprapubic cath:

insufficient definitive data to support one over another

INSERTION TECHNIQUES:INTERMITTENT: clean is enough; multiple use

caths are okINDWELLING: aseptic technique is required

PREVENTION:TECHNIQUES AFTER INSERTION

CLOSED CATHETER SYSTEM: keep it closed and lowANTIMICROBIAL COATED CATHS (silver alloy or ATBC): may be

considered: insufficient data to support recommendationPROPH ATBCS: NO! NO!PROPH WITH METHENAMINE SALTS: NO! If done, the goal is to

reduce urine pH < 6; consider in women after GYN surgery who are catheterized for no more than 1 week

PROPH WITH CRANBERRY PRODUCTS: NOENHANCED MEATAL CARE: NO PROOF IT WORKS! (povidone-

iodine, silver sulfadiazine, polyatbc ointment or cream, soap / water)

CATHETER IRRIGATION W/ SALINE AND OR ATBCS: may be considered only in selected patients who undergo surgical procedures and short term cath to reduce CA-B.

ATBCS IN THE DRAINAGE BAG: NO! NO!ROUTINE CATH CHANGE: unclear benefit for change Q 2-4

weeks of functional caths, even for patients who experience repeated early cath blockage from encrustation (!!!!)

PROPH ATBC AT TIME OF CATH REMOVAL / REPLACEMENT: NO!

TREATMENTSCREENING FOR AND RX OF CA-ASB AT CATH

REMOVAL TO REDUCE CA-UTI: no strong evidence; consider in CA-ASB that persists 48 h after short-term indwelling cath.

SCREENING FOR AND RX OF CA-ASB IN PATIENTS WITH CATHS TO REDUCE CA-UTI: NO!

EXCEPTION: pregnant women and patients who undergo urologic procedures for which visible mucosal bleeding is anticipated.

TREATMENTU/C and cath replacement before RX:

YES for both: narrow ATBC based on Cx results; change the cath if placed for > 2 weeks => expedites resolution of symptoms and reduces risk of recurrent CA-ASB and UTI.

Cx from new cath or voided urine if old cath can be D/C’d.

Duration of RX: regardless of cath in place or not

Seven days: for CA-UTI w/ prompt resolution of symptoms

10-14 days for those w/ delayed responseFive days levofloxacin may be considered for not

severely illThree days ATBC regimen may be considered for

women ≤ 65 yo (CA-UTI without upper U.T. symptoms) after the cath has been removed.

Possible improvementsDiagnosis

Study our prevalence / incidenceF/U on mortalityMatch with bacteremia

PreventionWhat are our indications? Do we have them clearly

written / available?Powerchart urinary catheter insertion orders/

automatic removal or reminder of removalGive feedback rates to providers / nurses

TreatmentRX duration / ATBC of choice

Quality improvement project5-WInfection control (use their data collection

tool)Implement intervention (Published

indications? Powerplan? Auto-D/C Cath?)Analyze dataPublish paper and try to disseminate to the

medical wards

REFERENCES1)Epidemiology of urinary tract infections: transmission and risk factors, incidence, and costs. Foxman B,

Brown P. Infect Dis Clin North Am. 2003;17(2):227.

2) Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med 2007; 23:585.

3)Saint S et al. Preventing H.A. UTI in the USA: a national study. CID 2008; 46:243-50.

UPTODATE

IDSA Guidelines.