AHRQ Safety Program for LongTerm Care CAUTI Demystifying

AHRQ Safety Program for Long-Term Care: CAUTI Demystifying CAUTI: When to Culture and When to Treat September 18, 2014 Barbara W. Trautner, MD, Ph. D Baylor College of Medicine Michael E. De. Bakey Veterans Affairs Medical Center

Skills Questionnaire Results • Two main areas of confusion – When to culture a catheterized resident – When to treat for CAUTI in a catheterized resident • Today’s objective is to clarify these issues 2

POLL Case 1 Mrs. Bell is an 86 -year-old resident of your facility. She has an indwelling catheter to assist with healing of a sacral ulcer acquired while hospitalized. Yesterday her urine was clear and yellow. Today her urine is definitely pink and smells bad. What should be done next? a. b. c. d. e. f. Urinalysis Urine culture Urinalysis and antibiotics Culture and antibiotics Nothing N/A – NPT or HRET staff 4

Remember the C. A. U. T. I. Intervention The Clinical Intervention: • Catheter removal • Aseptic insertion • Use catheters only if indicated • Training about catheter care • Incontinence care planning 5

Remember C. A. U. T. I. to Prevent CAUTI 6

Training About Catheter Care Routine catheter changes, urinalysis, and culture are not required. 7

Bacteriuria ≠ CAUTI • Translation? – Bacteriuria is not the same as catheter-associated urinary tract infection, and vice versa. • What is the main difference? – Bacteriuria can be symptomatic or asymptomatic. • Asymptomatic bacteriuria is abbreviated ASB – CAUTI requires presence of symptoms consistent with UTI. http: //www. idsociety. org/Organ_System/#Genitourinary 8

Relationship of Bacteriuria to ASB and CAUTI Bacteriuria means a positive urine culture. Bacteriuria ASB CAUTI 9

Which are the signs and symptoms of a CAUTI? • • Fever • Dysuria, urgency, Rigors frequency Malaise/lethargy • Cloudy urine Flank pain or CVA • Urinary sediment tenderness Foul-smelling urine Acute hematuria Pelvic discomfort Change in urine color 10

Common Inappropriate Triggers for Urine Culture • • • Urine color Urine smell Urine sediment Cloudy urine Pyuria (white blood cells or WBC in the urine) Positive dipstick 11

Why isn’t cloudy urine a symptom of CAUTI? • Cloudy urine, a change in urine color, foul odor, and sediment are all non-specific. • Many non-urinary causes – Medications – Certain foods • Several possible urinary causes – Crystals – Bacteria 12

Bacteriuria is not CAUTI • Bacteriuria does cause – – Foul smell Cloudy urine Sediment Change in urine color • These are not symptoms of CAUTI. • 99% of long-term catheterized residents have bacteriuria. • Making the diagnosis of CAUTI requires _______. • Answer: symptoms 13

POLL Case 1 Mrs. Bell is an 86 -year-old resident of your facility. She has an indwelling catheter to assist with healing of a sacral ulcer acquired while hospitalized. Yesterday her urine was clear and yellow. Today her urine is definitely pink and smells bad. What should be done next? a. b. c. d. e. f. Urinalysis Urine culture Urinalysis and antibiotics Urine culture and antibiotics Nothing N/A – NPT or HRET staff 14

Answer to Ms. Bell’s Case Nothing! – At least don’t send urine for urinalysis or culture. – Definitely don’t start antibiotics! You wouldn’t really do nothing. – – Ask about what she ate. Look at her medications. Assess for catheter trauma. Assess to ensure she is at her baseline. 15

Why Knee-Jerk Antibiotic Use Is Bad Reason #1: It’s Bad for the Resident • Side effects are common. – Nausea, diarrhea – Allergic reactions – Antibiotic-related infections • Clostridium difficile • Candida (yeast) • Wrong diagnosis will delay treatment. 16

Why Knee-Jerk Antibiotic Use Is Bad Reason #2: It’s Bad for Everyone • Bacteria become resistant. – There is a danger of running out of antibiotics that work. – Antibiotics won’t work when residents need them. – Multi-drug resistance is increasingly common. • Overuse of antibiotics can increase MDR organisms in your facility. 17

POLL Case 2: Just Don’t Dip (the Urine) Mr. Parker is a 91 -year-old man with an indwelling catheter who stayed in bed today rather than going to breakfast. The dipstick (urinalysis) is positive for nitrites (bacteria) and leukocyte esterase (WBC). What should be done next? a. b. c. d. e. Urine culture Antibiotics Urine culture and antibiotics Re-assess the situation N/A – NPT or HRET staff 18

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 • Why? – Pyuria is also non-specific • Can be from catheter itself, bladder distension, or ASB • Bacteriuria causes pyuria 19

Pyuria Does NOT Predict Bacteriuria or Funguria Tambyah, P. A. et al. Arch Intern Med 2000; 160: 673 -677. Copyright restrictions may apply.

Answer to Just Don’t Dip • Re-assess Mr. Parker. • There may be many reasons for behavioral change. – Mild diarrhea – Slept poorly – Mild dehydration • Offering fluids is often a better initial step. • Dipstick or urinalysis cannot rule in a CAUTI. – These can only tell you that WBC and bacteria are present. – Generally avoid in catheterized residents. 21

Communicating with Residents and Families • You are now convinced that most urinalyses, urine cultures, and antibiotics are unnecessary in residents with indwelling catheters. • What are you going to tell the family members? – Highlight side effects of antibiotics. – Discuss alternatives. – Promote shared decision making. 22

Antibiotic brochure available in the tools section of website 23

Sample Dialogues: With Families • My Bobby always looks like this when he has a UTI. – We are going to watch him closely. – Let’s help him drink more fluids. Dehydration and UTI are often confused. • Let’s just give him some antibiotics just in case. – Antibiotics won’t help if he doesn’t have a UTI. – Antibiotics could hurt him (diarrhea). – We don’t want to miss the real cause. 24

Sample Dialogues: With Physicians • Mutual understanding is key to communication. • Recognize pressures on physicians that drive antibiotic overuse. – Fear of missing urosepsis – Fear of not doing what everyone else is doing – Pressure to come up with a diagnosis – Lack of awareness of the guidelines covered today • Acknowledge these pressures; point out your own. • Emphasize shared mission: patient care. 25

Sample Dialogues: With Physicians • I know you don’t want to miss anything with Mrs. Lacy. • We are doing a campaign to decrease CAUTI. • We learned that cloudy urine is not a symptom of CAUTI. Almost everyone with a catheter gets cloudy urine eventually. • I’m not sure we need a urine culture yet. She might just be tired. • Extra urine cultures lead to extra antibiotics—and that’s not good for anyone. 26

Rosy Picture versus Reality 27

Is Everything Clear Now? 28

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Upcoming Content Webinars Date* Topic Oct. 16 Overcoming Barriers: How to Stay Engaged and Engage Others (Working Title) Nov. 20 Avoiding Unnecessary Catheter Placement: Working With Families and Residents Dec. 18 Care Transitions and Handoffs: How Hospital and LTC Staff Can Reduce CAUTI Together *Every third Thursday of the month at 12: 15 -1: 00 pm ET/11: 15 am-12: 00 pm CT/10: 15 -11: 00 am MT/9: 15 -10: 00 am PT 31