Catheter-Associated Urinary Tract Infection (CAUTI) Case Studies

Catheter-Associated Urinary Tract Infection (CAUTI) Case Studies


>>Alright. Well let’s first
just real quick go over the purpose of
our case studies. First of all, it just gives
you good training on the use of the definitions, and these
are all based on the new, January 13 definitions. Try to learn to accurately
apply these definitions and to realize these are
surveillance definitions. And can be very consistent
in our application and improve our data quality. And I was just speaking with
someone during the break, and I think when we roll out
all these new definitions and we’ve been talking
a lot about validation of denominator data, I
think it’s really good when you move this many
kind of new definitions, it’s good to get
with someone when — with your numerator as well. And when you’re starting to
write up these [inaudible], you know, based on
new definitions, just have someone you can sit
with and validate, say, “Mike, have I got this right?” [Chuckles], you know. But hopefully going
through this will help you. Alright, let’s start
with case one. Day 1, we have a
50-year-old patient with end-stage pancreatic
cancer, with liver and bone meds admitted to the
hospital with advanced directive for comfort care and antibiotics
only, a Foley catheter, a peripheral IV and
nasal canula inserted. On day four now, the
Foley is still in place. The patient is febrile
to 38.0 centigrade. Has suprapubic tenderness. IV ampicillin was started after a urine was
obtained for culture. Day five the patient’s
having difficulty breathing. The chest x-ray shows
an infiltrate in the left lung base. On day six those urine culture
results are back that were taken on the fourth, and it shows
10 to the 5th of e coli. Day seven, you’ve got WBC’s
of 3,400, patchy infiltrates in both lung bases, continued
episodes of dyspnea [inaudible] in the left lower lobe. And on day 11 the
patient expired [pause]. Does this patient have a UTI? And if so, what type? Yes, a SUTI Criterion 1A. You can get your definitions
there, kind of in front of you. There was a — the SUTI page
was cut and pasted on there. Yes, SUTI, Criterion 2A. Yes, and ABUTI, or no UTI. Go ahead and use your clickers. This is to vote. [ Background conversations ]>>All of mine are voting
questions except the last two I think [pause]. Alright. [ Background conversations ]>>We’re getting there. I need a few more
responses we’re waiting for. [ Background conversations ]>>I can see there’s some group
consensus going on at tables; good discussion [pause]. Alright. I’m going to give
you about 10 more seconds. I don’t use the little
timer, but I’m going to close the poling
in about 10 seconds. So go ahead and get
those responses in. [ Background conversations ]>>See I can see how
many of you have voted. I have a little magic
screen here. [ Background conversations ]>>Alrighty. [ Background conversations ]>>And the answer is
yes, they have a SUTI 1a. Okay? And we’re going
to go through and show you the rationale. You all did great on that
[background conversations]. So I have that page right
in front of me there. The catheter had been in
place in place for greater than two calendar days. Suprapubic tenderness,
and greater than 10 to the 5th colony-forming units. See, that wasn’t so hard, right? But that fever that she had? That was only 38. It was not greater than 38. So you had to use that
suprapubic tenderness. [ Pause ]>>Alright. Case 2. On 8/2 a
66-year-old went to the OR for an exploratory lab and
Foley was inserted in the OR, and they were transferred
to ICU post-op. On 8/3 the patient was
stable; Foley’s still in place. On 8/4 the patient was
noted to be febrile to 38.9 and complained of
diffuse abdominal pain. The WBC’s were increased
to 19,000. He had cloudy, foul-smelling
urine, and the urinalysis showed
2+ protein, 1+ nitrites, 2+ leukocyte esterase, WBC’s
of 10,000 and 3+ bacteria. And the culture was 10 to the 4th colony-forming
units of e coli. The abdominal pain seemed to be
localized to the surgical area. Is this a UTI? And if so, what type? Was there no UTI? Yes, it was a SUTI criterion 1b. Yes, a SUTI criterion
2a, or yes, an ABUTI. [ Pause ]>>Place your votes. [ Background conversations ]>>Alright I’m going to give
you about 10 more seconds. Make a decision;
place your vote. [ Background conversations ]>>Okay. [ Background conversations ]>>Yes. Look how well
you all are doing; 90% of you got that one right. Yes. This is a SUTI,
criterion 2a. And we’ll go over that. So remember, 2a is where you
have the little bit lower colony-forming counts, but
the patient has had a Foley in for two days, had the fever
that was greater than 38. Had the leukocyte esterase
and the nitrite positive. Remember the leukocyte
esterase points to the fact that there may be some
WBC’s in the urine. And the nitrite points to the fact there may be
some bacteria in the urine. If you — that’s fallen off
your radar of what that means. Pyuria was present and also
we then had a urine culture that was 10 to the 4th,
so that’s why we went to the criterion 2a and why we
needed a little more evidence that was found there in
that urinalysis, okay? Alright. Case 3. Day 1 you have a 58-year-old
patient who’s admitted to the ED with GI bleed and a
Foley is inserted. Day two the patient
spikes a temp of 38.6, the indwelling catheter
remains in place and a urine specimen is sent. On day 3 the culture results
are back and it’s 10 to the 5th of pseudomonas aeruginosa
in that urine culture. Is this an HAI? And if so, what type? Yes it’s a UTI but not a CAUTI because the catheter had not
been in for two calendar days. No, it meets the definition
for present on admission. Or yes, it’s a SUTI,
criterion 1a. Go ahead and place your votes. [ Background conversations ]>>This first table’s
having lots of discussion. I’m enjoying this over here. Alright, I’m going to give
you about 10 more seconds. It looks like almost everybody
has voted except this one trouble-making table over here. [ Background conversations ]>>Okay, closing it off here. [ Background conversations ]>>No. This meets the definition
for POA or Present on Admission. Very good. Let’s go over that
[background conversations]. An infection is considered
present on admission if it occurs on the day of hospital admission
or the next day. The infection must fully
meet a CDC/NHSN criterion on the third hospital
day to be — prior to the third
hospital day to be POA. And this one definitely
occurred. They’d only been in house
just that second day and they had the symptoms. Okay? Alright. Case 4 — you guys
are doing great. Day 1, an 84-year-old
patient is admitted to an LTAC with a diabetic foot ulcer and
a indwelling catheter in place. On day 8 — so now
we’re 8 days later — indwelling catheter is still
in place and there are no signs and symptoms of infection. Day 9, the patient
becomes hypotensive. The CBC shows a WBC of
15,000, a temp of 38.0. The foot ulcer is
draining moderate amount of purulent drainage, and
the patient is pan cultured. The blood culture and the
urine culture both grow strep pyogenes, and the urine
is showing greater than 10 to the 5th colony-forming
units in that result. The foot culture is positive for
pseudomonas aeruginosa [pause]. Is this a UTI? And if so, what type? 1) No because the
blood’s C to the urine and therefore there is no UTI. Yes, it’s an ABUTI. Or yes, it’s SUTI criterion
1a with a secondary BSI. [ Background conversations ]>>Alright I’m going to
give you 10 more seconds. Maybe I should have had
the “unsure” question 4. Yeah [chuckles]. [Background conversations]
10 more seconds. Give it your best guess. [ Background conversations ]>>Alrighty [pause]. Very good. Yes, this is an Asymptomatic
Bacteremic UTI. Alright. And we’ll go over
the rationale for that. There were no signs
and symptoms. Remember that temperature
was not greater than 38. It was 38 on the nose. And the positive blood
culture has to have at least one uropathogen
matching to the urine culture, which the patient had. What if — this is part 2 —
the organism in both cultures — both the blood and urine
— had been micrococcus? Is this a UTI? Yes, this is an ABUTI? Or No, this is not an ABUTI. Go ahead and vote on that one. [ Background conversations ]>>Okay, listen we’re
almost there. I’m going to go ahead, give
you about 10 more seconds. Finish up your poling. [ Background conversations ]>>Very good. No, this is not an ABUTI. And your rationale here, micrococcus is not
a uropathogen, and therefore this
is not an ABUTI. Remember you need to have — the organisms have to be
on that uropathogen list, and here it is again. And remember, that list is
going to be able to be found in the NHSN manual in your
ABUTI criterion section. It will be right there listed. So that’s helpful for
you to remember, okay? Let’s go on to Case 5. On 8/5 we have a 76-year-old
woman’s admitted from the LTAC at 8:00 am for surgical
debridement of a sacral decub. The medical history’s notable
for severe rheumatoid arthritis and congestive heart failure. A routine admission
UA is performed. It’s positive for leukocyte
esterase and 3 WBC’s by high-powered field
of spun urine. The patient’s afebrile. Denies urinary urgency,
frequency, or pain. And there’s no suprapubic
or CVA pain. And a Foley and a peripheral
IV are inserted in the OR. The next day, 8/6, the wound
care specialist documents that the wound is clean. Temp of 37.4 and the Foley is
draining some cloudy urine. On 8/7 the temp is 38.2
degrees centigrade. The Foley is removed. Encouraged to push PO fluids
and a urine specimen is sent to the lab for culture
and sensitivity. On 8/8 the temp is still 38.6
and the patient’s complaining of dysuria and pain with
palpation to the suprapubic area and bactrim is started. On 8/9 that urine specimen
that was sent on 8/7, the results are back and
are positive for e coli, 100,000 colony-forming units
and the patient is afebrile and preparing for
discharge back to the LTAC. Does this patient have a UTI? And is a CAUTI? 1) No, the UTI was
present on admission. 2) Yes, the patient has a
SUTI 1a and it is a CAUTI. 3) The patient has a SUTI
1b, but it is not a CAUTI. [ Background conversations ]>>Okay I’m going to give
you about 10 more seconds. We’re looking close here, but about 10 more seconds
finish your voting. [ Background conversations ]>>Alrighty. [ Background conversations ]>>Yes. You guys
are doing great. This patient has a SUTI
1a and it is a CAUTI. And we’ll go over the rationale. This all occurred
on hospital Day 3. So it’s been — so greater
than 2 calendar days. And then she had fever
and suprapubic tenderness and the urine culture was
greater than 10 to the 5th of colony-forming units. Now the trick question
there may have been that positive UA on admission. But remember, UA’s
may be positive for non-infectious
reasons, and since symptoms of UTI were definitely
not present on admission and only developed
following Foley insertion, this would meet our
definition for a CAUTI [pause]. Alright? Let’s go on to Case 6. This is a 48-year-old
male who was involved in a motorcycle accident. Has a closed-head injury;
multiple fractures. Taken to the OR for ORIF’s and
evacuation of subdural hematoma. A Foley catheter and left
subclavian catheter placed in the ED and the patient
remains on the ventilator that was placed in the OR. The lungs are clear bilaterally. Now 6 days post-op — we’ve moved on here —
and the temp is 99.8. You have some rhonchi
in the left lung base. The chest x-ray shows a
possible infiltrate atelectasis in this area. The Foley remains in place
draining clear, yellow urine. The patient remains ventilated and has increased
sputum production. Post-op Day 7, you
have a temp of 100.3. The vent settings are
stable and there’s no change to the sputum production. Post-op Day 8 the temp
is now 101.9 Fahrenheit. The lung sounds are
clear; chest x-ray clear. Patient still remains on
the vent, and the Foley and central line
still remain in place. Pan cultures are sent. An empiric antibiotic
treatment was begun. Post-op Day 9, the urine
culture shows 100,000 CFU’s of pseudomonas aeruginosa. The sputum has — shows
pseudomonas aeruginosa. And the blood culture
was no growth. The physical assessment
is normal and the patient has no
response to suprapubic or costovertebral
angle palpation. Does this person have a UTI? And if so — patient rather,
have a UTI and if so, what type? Is there 1) No UTI. Yes, it’s an ABUTI. Yes, it’s a SUTI 2a. Or yes, a SUTI 1a? [ Silence ] [ Background conversations ]>>Okay, I’m going to give
you about 10 more seconds. [ Background conversations ]>>Couple more seconds and [ Background conversations ] . Okay. [ Background conversations ]>>Yes. This patient has
a SUTI 1a, 87% of you. That’s great. [ Background conversations ]>>The Foley was in place for
greater than 2 calendar days. You had that fever. Had a positive urine
culture with greater than 10 to the 5th colony-forming units with just the one,
single pathogen. Now let’s put a little
tweak to this. What if the patient
had been afebrile — you didn’t have that temp —
but you had an elevated WBC and the urine was really cloudy. But the culture results
were the same too. Would the patient have a UTI? No UTI. Yes, still a SUTI 1a. Or yes, an ABUTI. [ Background conversations ]>>Yeah. [Background
conversations] . This one? [Background
conversations]. Yes. [ Background conversations ]>>Someone asked if the elevated
WBC’s and the cloudy urine — the WBC’s were in the urine,
and the answer is yes. That was urine WBC’s
were elevated. [Background conversations] but
the patient doesn’t have a temp. [Background conversations] not that I’m giving you
a hint, but — [ Background conversations ]>>Alright 10 seconds. [ Background conversations ]>>Oh. Very good. No UTI. And the rationale
on that, remember this was a
patient without symptoms. At this point we
took the fever away. Remember they don’t have
a matching blood culture, so it can’t be an ABUTI. And the elevated BC and
cloudy urine are not part of our NHSN UTI surveillance
criteria. But I can tell you, I know —
I can’t tell you how many times when I’m investigating a urinary
tract infection and you try to figure out why they
spent this urine specimen, cloudy urine. Man, lots and lots of
times you see that — seems that that’s why they’re
sending the culture was because they saw cloudy urine. But that is not part of
the definition [pause]. Remember your surveillance
definition tends to work better in some patient populations
than others — which we’ve already talked
about a little bit in terms of how they can respond
to being able to express about different symptoms. And the patient should
be thoroughly assessed for UTI symptoms including that suprapubic tenderness
and the CVA pain. And this is where we can — it
can be really helpful in terms of educating your
nurses in terms of good physical assessments
or any of your clinicians. And again, that that
clinical diagnosis may differ from surveillance determination. You know, and you may
see often these 10 to the 5th being treated
by physicians and called, but it doesn’t meet our
surveillance definition, because that to us is a —
would have been when you take that fever away, that would
have been an asymptomatic UTI, which we don’t document
unless it’s ABUTI. Alright, let’s do Case 7. It’s 8/25 and a 73-year-old
patient in a neurosurgical ICU was
admitted following a cerebral vascular accident. Ventilated. Has a subclavian catheter and
a Foley in place on admit, and the patient reacts
only to painful stimuli. A 9 to the WBC is slightly
elevated at 12,000. Temp of 37.4. The urine is cloudy and the
lungs are clear to auscultation. On 9/3 the WBC’s are at
15,800 per cubic millimeter. Temperature of 37.6. Breath sounds slightly course. Minimal clear sputum. Urine unchanged. The blood and endotracheal and
urine specimens are collected and there’s no suprapubic
or CVA pain noted. On 9/4 blood and endotracheal
cultures are no growth and the urine is 10 to the
5th colony-forming units of enterococcus faecium. Does this patient have a UTI? And if so, what type? Yes they have an ABUTI. They have a SUTI criterion 1a. A SUTI criterion 1b. Or no UTI. [ Background conversations ]>>Okay. We just have 10 minutes
left for our case studies, so I want to give you —
get through all these, so let’s wrap this
voting up in 10 seconds. [ Background conversations ]>>Alright. Here we go. [Inaudible] [pause]. Really good. 88% of you correct answer. There is no UTI. Because there were
no urinary symptoms, and there wasn’t a
fever greater than 38 and no matching cultures, the urine surveillance
for UTI are not met. But let’s give it a
little tweak here. What if the patient’s
temp had been 38.1 and the patient also
met the criteria. You saw that pulmonary
stuff going on. Had met criteria
for probable VAP. Including a bronchioalveolar
lavage with — oop — I’ll have to change
the organism here. With our VAE criteria, we
wouldn’t have enterococcus — I just noticed that —
but we’ll just say we did. Enterococcus faecium. So you have the same
organism now from the BAL as you do in the urine. So here’s the new question. Does this patient have a UTI? No. The patient’s fever
is due to pneumonia. Therefore the patient
is symptomless. Yes, it’s a SUTI 1a. Fever is nonspecific
and may be due to more than one infection at a time. [ Background conversations ]>>What? I know. [ Background conversations ]>>Alright. 10 seconds because we’re getting
close to the end of the day. [ Background conversations ]>>Alright. Here we go. [ Background conversations ]>>Yes. Because fever’s
nonspecific and definitely may
be due to more than one infection at a time. They had — the patient
had a SUTI 1a. The indwelling catheter
was present. The fever and the urine culture,
and greater than 10 to the 5th of a colony-forming units. Alright. We have 4-year-old
admitted following an MVA. Taken to the OR for ORIF
and internal fixation of a left upper and right
lower extremity fractures. Admitted to the Pediatric
Surgical Care Unit with a Foley catheter
draining yellow urine and a right femur attraction. IV in the right antecubital
vein. 8/18 afebrile, taking
clear, liquid diet and beginning oral pain med
using incentive spirometer. The Foley’s draining
yellow urine. 8/19 next day tolerating
a solid diet. The IV is converted
to a saline lock. Foley draining yellow urine. 8/20 the Foley is
removed at 0800 and the patient is
voiding without problems. And the patient has a slight
cough of clear phlegm. 8:21 in the morning, the
patient is requesting a bedpan frequently. Crying with urination. Temp of 37.9. The cough is unchanged and a straight cath urine
specimen’s collected. The urine’s cloudy and the UA is
positive for leukocyte esterase. Nitrite’s negative. A WBC of 10 for high-powered
field. Later that evening
the gram stain of the urine shows
many gram negative rods and empiric Bactrim is started. On 8/23 that culture comes back and it’s 50,000 colony-forming
units of e coli. Does this patient have a UTI? No. Or yes, a SUTI 1b. Yes a SUTI 2a. Or yes, a SUTI 2b. [ Background conversations ]>>Alright. Place your votes. 10 more seconds. [ Background conversations ]>>Alright. [ Background conversations ]>>Yes, this is a SUTI 2a. If you look at that lower
part of the definition, the patient had an indwelling
catheter in place for two days. It had just been removed. And we had frequency and dysuria
that she was complaining of. Leukocyte esterase positive. You had that 10 WBC’s
for high-powered field, and they saw microorganisms. And the organism result was
between that greater than 10 to the 3rd but less than
10 to the 5th [pause]. Well, we only have — we — [ Background conversations ]>>Okay. We’re going to
go to the last couple that lets you practice counting
those denominators we were talking about. So let me get to those. [ Background conversations ]>>All these cases
are in your packet, and you’ll have the
answer sheets as well. Alright. Let’s talk
about counting Foley days for your denominators
we were discussing. So I want you to look
at this, alright? And tell me how many indwelling
catheter days you think you have. Look at the status. This — everything was
counted at 12 noon, okay? In this unit. And do you have 6, 5, 4,
3, 2 or 1 catheter days for that day on the unit? [ Silence ]>>And this one is not a —
this is not one you can vote on, so I’m just going to show you. But just, you know, make
your decision in your head, what you think your
answer is, okay? I’m going to give you
a couple more minutes, but count was done at noon. [ Background conversations ]>>Alright? [ Background conversations ]>>I see most people look
like they — there’s two. And I’m going to show
you where they are here. You have this one,
patient 101, Mr. Black. Had an indwelling
catheter that whole day. And at that — at noon, and 106
had an indwelling Foley at noon. Now you might have
thought there were three, but look at the patient
[inaudible]. They weren’t admitted until
2:00 in the afternoon. So at noon that — they
would not have been there with a Foley. So those are the
only two patients that at noon would
have had a Foley. Okay, let’s try one
more [pause]. Okay. Let’s — same thing. Now this is again, another unit. How many indwelling catheter
days do you see here? And this is a unit where they’re
doing their catheter counting at 11:00 pm. [ Silence ]>>Think you got it? Okay, here we go [pause]. See if you guessed
right on this one. One. [Background conversations]. It looks like people are happy. It’s this patient — Miss
Dallas — is the only one. We don’t count condom caths
and suprapubics don’t count. And that other indwelling,
they’d already been discharged. So we have one Foley
catheter day that day. Great. Well thank
you very much —

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