Post on 17-Jan-2016
URINARY TRACT INFECTIONSfocus on adults
Ruth Anne Rye
October, 2015
OBJECTIVES
• Identify specific symptoms suggestive of urinary tract infection (UTI)
• Discuss asymptomatic bacteriuria
• Identify prevention strategies and interventions
WHAT WE KNOW• UTI most common bacterial infection occurring in
healthcare facilities (HAI); 70 – 8-% attributed to use of indwelling catheter
• Leading nosocomial complication following joint prosthesis surgery
• More common in women than men. Estimate 20-35% females have at least 1 episode in lifetime
• In nursing homes most frequently occurs in those with functional impairment
• No consensus on clinical definition, presentation and management
URINARY TRACTmakes, stores urine
• Kidneys: pair of kidney-shaped organs– Below ribs toward the middle of the back– Remove excess liquids and wastes from blood in form of urine
• Ureters: narrow tubes that carry urine from kidney to bladder
• Bladder: sac-like organ in the lower abdomen– Urine is stored in bladder and emptied through the Urethra (tube
that connects bladder to skin)
• Urethra: tube from bladder to skin
Excerpted from http://www.neocontrol.com/patients/about_incontinence/urinary_tract_anatomy.htm
ANATOMY
DEFINITION
Urinary Tract Infection
• The invasion of disease-causing microorganisms, which proceed to establish themselves, multiply, and produce various symptoms in their host.
Can occur anywhere along the urinary tract –
kidneys, bladder, ureter, or urethra
DEFINITIONs
• Relapse: same organism as originally isolated
• Recurrence: occurs within 2 weeks caused by the original uropathogen
• Re-infection: occurs more than 2 weeks following treatment completion; same or different organism
ETIOLOGY
• Most likely cause: Escherichia coli– Also:
• Proteus species• Klebsiella species • Providentia species • Enterococci species
• Catheter present? Often polymicrobial
SYMPTOMS – when no catheter
• Frequency: frequent urge to urinate• Urgency: strong persistent urge to urinate; may
pass only small amounts of urine• Dysuria: painful burning sensation when
urinating• Fever – more likely if kidneys are affected• May experience upper back and side pain,
nausea and vomiting
Presentation in the older adultAtypical presentation of illness * Over age? – 65, or 85 * Multiple comorbidities* Multiple medications * Functional or physical
impairmentsUTI-specific• Classic symptoms in independent elderly• Hospital or N.H – increased lethargy. delirium, blunted fever
response, anorexia
Inf Dis Clinics of NA, 2014: “…generally requires presenceof localized G-U symptoms, etc. “…although – definitionsfor surveillance purposes, a universally accepted definitionof symptomatic UTI in older adults does not exist.
DIAGNOSIS
• Based on symptoms (+ lab)
• Urinalysis: urine examined for the presence of white and red blood cells
Bacteria in urine? 90% have pyuria
No bacteria in urine? 30% have pyuria
Diagnosis (con’t)
Urine Culture: identifies bacteria (isolate), when present, and counts colony-forming units (cfu) * First morning specimen best * Obtain specimen by catheterization, in/out (best practice), or clean catch
Sensitivity testing identifies the agent most effective at inhibiting the organism’s growth
SPECIMEN COLLECTION
• Collection method decision: clean voided/midstream, sterile (catheter)
• Validate competency of collector• Verify collection method and transport container,
and label with patient identifiers, time and date collected
• If antibiotic ordered, collect specimen before first dose
SPECIMEN COLLECTION
• Collect in manner to minimize contamination
• Transport to lab timely to prevent bacterial growth
• Refrigerate prior to transport unless collection container contains preservative
ACCURACY AFFECTED BY
• Urine collection method
• Time delay between collection and analysis
• Time of void
DIAGNOSITIC EVALUATION
• If patient has fever, hypotension (low blood
pressure), tachycardia (rapid heart rate)
consider urine culture + blood culture
• Additional symptoms of systemic (bodywide)
illness, such as chills, warm skin, malaise –feeling rotten, mental status changes
DIAGNOSITIC EVALUATION
• Dipstick urine testing: Point-of-care test useful in detecting the presence or absence of nitrite and/or esterase
• Nitrites: formed when bacteria changes nitrate to nitrite
• Leukocyte esterase: intact and lysed leukocytes produced in inflammation
Urine Dipstick for Diagnosing Urinary Tract Infection
Q: How accurate is the urine dipstick for diagnosing UTI?
A.. The sensitivity and specificity of the urine dipstick varies somewhat with the setting and population, as does it’s interpretation.
– Women with classic urinary tract infection (UTI) symptoms: dipstick adds little to the diagnosis.
– Women with nonspecific urogenital symptoms: positive or negative dipstick results may require backup urine culture depending on the clinical situation.
– Low-risk patients with a low pretest probability of UTI: the urine dipstick alone is useful to exclude infection if both nitrites and leukocyte esterase are negative.
Excerpted from http://www.aafp.org/afp/20060101/fpin.html
• Definition: Presence of bacteria in the urine, e.g. positive urine culture, without signs or symptoms of infection
• Screening for and treatment of asymptomatic bacteriuria in elderly institutionalized residents of long-term care facilities is not recommended (A-I).
Reason: Treatment may lead to multidrug resistant organisms and does not improve safety or care of the resident
Asymptomatic Bacteriuria
PRESCRIBING terms
• Empiric– Utilize accepted prescribing standard, and– Facility antibiogram, and– Clinician’s experience
• Therapeutic: based on sensitivity results
• Prophylactic: preventive – Generally not recommended. Role unclear.
ANTIMICROBIAL TREATMENT
• Symptomatic: TREAT– Clinician document decision in progress note
• Asymptomatic: treatment NOT recommended– ABS in elderly considered a benign and
transient condition that does not require antibiotic treatment
– Clinician decision and should document decision in progress note
APPLICATION OF SCIENCE-BASED EVIDENCE
Clinical and bacteriological outcomes are improved when long-term indwelling catheters are replaced before initiating antimicrobial therapy for symptomatic urinary tract infection.*
* Chronic Indwelling Catheter Replacement Before Antimicrobial Therapy for Symptomatic Urinary Tract Infection: Raul Raz, David Schiller, Lindsay E Nicolle: Journal of Urology 2000;164;1254-1258
SYSTEM OF DOCUMENTATION
Importance of documentation• What Indications for catheter insertion Date and time of insertion Name of individual who inserted Date and time of catheter change/removal Routine catheter maintenance• Where (e.g. patient’s medical record)• When (how often)
PREVENTION STRATEGIES
If NO urinary catheter:– Drink plenty of fluids– Don’t delay urination, and don’t rush– Wipe front to back– Urinate after sexual intercourse– Consider estrogen replacement for women after
menopause. – No conclusive evidence to advise supplemental
vitamin C, cranberry pills or juice, or blueberry– Encourage activities of daily living (ADL’s)– Avoid potentially irritating feminine products
PATHOGENESIS OF CAUTI
Figure 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
Urinary Cath. Use
Hospital = 25%
LTCF = 5%Most UTIs in hospitals are catheterassociated
PREVENTING CATHETER-ASSOCIATED UTI’S (CAUTI)
CORE STRATEGIES
Insert catheters only for appropriate indications Examples of appropriate indications for use
* Acute urinary retention or bladder outlet obstruction* Need for accurate measurement of output in
critically ill patients
Appropriate indications, continued
• Perioperative use in selected surgical procedures such as G-U, anticipated prolonged duration of surgery, large-volume infusions, intraoperative monitoring of urinary output
• To assist in healing of open sacral or perineal wounds in incontinent patients
• Patient requires prolonged immobilization• To improve comfort for end of life care if needed
Core prevention strategies, continued Insert catheters using aseptic technique and
sterile equipment (acute care) Ensure that only properly trained persons
insert and maintain catheters Following aseptic insertion maintain a closed
drainage system Maintain unobstructed urine flow Practice hand hygiene and standard
precautions according to CDC/HICPAC guidelines, World Health Organization
selected additional CATHETER-RELATED PREVENTION STRATEGIES
• Maintain closed drainage system. If break occurs - replace catheter and collecting system
• Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate.
Examples: external/condom catheters, intermittent catheterization
• Use Standard Precautions during manipulation of catheter or collecting system
• Do not change catheter at fixed intervals• Portable ultrasound device to assess urine volume for patients
using intermittent catheterization• Properly secure catheter after insertion to prevent movement
and traction
Implement strategies to enhance appropriateuse of indwelling catheters to assureappropriate utilization of catheters
System of alerts or reminders to remove unnecessary catheters
Stop orders for urinary catheters Protocols for nurse-directed removal of unnecessary
catheters Guidelines/algorithms for appropriate perioperative
management
Additional strategies:
• Develop, implement and assess organizational prevention protocol
• Education• Surveillance
* Infection - consider when indicated by a
facility-based risk assessment,
* Process – measure adherence to protocol
Are there new technologies that can help prevent?
Catheter material • If CAUTI rate not decreasing after implementing
comprehensive strategy, consider using antimicrobial/antiseptic-impregnated catheters, such as silver alloy
• Hydrophilic catheters might be preferable for persons requiring intermittent catheterization
• Silicone - might be preferable to reduce the risk of encrustation in long-term catheterized patients who have frequent obstructions
What is a bundle?
A bundle is a structured way of improving the processes of care and patient outcomes: a small straightforward set of evidenced-based practices – generally three to five – that, when performed collectively and reliably, have been proven to improve patient outcomes.
Institute for Healthcare Improvement (IHI) 4/16/2011
Keystone Bladder Bundle
1. Nurse-initiated urinary catheter discontinuation protocol
2. Urinary catheter reminders and removal prompts
3. Portable bladder ultrasound monitoring
4. Insertion care and maintenance
Concise Summary of Guideline Recommendations
• Adherence to general infection control principles• Bladder ultrasound may avoid indwelling catheterization• Condom catheters or other alternatives should be
considers• Do not use indwelling catheters unless you must!• Early removal using a reminder or nurse-initiated
protocol
Jt Comm J Qual Patient Saf. 2009September, 35(9):449-455
Performance Measures
Internal Reporting Reporting both process and outcomemeasures to senior administrative, medical,and nursing leadership and clinicians whocare for patients with indwelling urinarycatheters.
PERFORMANCE MEASURESExamples of process measures:
1) Compliance with educational program: calculate percent of personnel who have proper training
# persons who insert catheters and are trained __________________________________ # personnel who insert urinary catheters Multiply by 100 to express as percent
PERFORMANCE MEASURES2. Compliance with documentation of catheter
insertion and removal datesRandom measurement and calculation of compliance rate
# patients on unit with catheter with proper dates (insertion and removal)
_______________________________________total # of patients with catheters
Express measurement as percentage
PERFORMANCE MEASURES3. Compliance with documentation of
indication for catheter placement
# number of patients on unit with catheter & proper documentation of indication
____________________________________# of patients on unit with catheter
• Multiply by 100 to express as percent
PERFORMANCE MEASURESRecommended outcome measures:
1. Rates of CAUTI - use definitions
# of patients (each location)______________________________ total # of
urinary-catheter days
• Multiply by 1000 to express as # infections per 1000 catheter days
PERFORMANCE MEASURES
2. Rate of bloodstream infections secondary to CAUTI - use definitions
# episodes bloodstream infections secondary to CAUTI
_______________________________total number of catheter-days
Multiply by 1000 - cases per 1000 patient days
FOR CONSIDERATION
• Drainage bag covers
• Barrier under collection receptacle: risk reduction strategy – IP or Safety?
• Change and/or cleaning interval: drainage bag, bedpans, urinals, collection graduate
(disposable or reusable?)
• Drainage system for patients in low-beds
TAKE HOME MESSAGES• Assess patient and recognize symptoms to
justify further analysis• Communicate with clinician • Importance of documentation (nursing + clinician)• Consider an organizational protocol - Prevention of
Catheter-Associated Urinary Tract Infection. Include indications for catheter use, insertion,
maintenance, education. Include surveillance/measurement activities, and
feedback, and action plan.
REFERENCES• HICPAC. Guideline for Prevention of Catheter-
Associated Urinary Tract Infections 2009• CDC. HAI Elimination. Catheter-associated Urinary Tract
Infection (CAUTI) Toolkit• IDSA. Diagnosis, Prevention, and Treatment of Catheter-
Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines www.journals.uchicago.edu/doi/pdf/10.1086/650482
• Association for Professionals in Infection Control and Epidemiology (APIC).
• Nicolle L, Catheter associated urinary tract infection. Antimicrobial Resistance and INFECION CONTROL. 2014