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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Catheter-Associated Urinary Tract Infection Prevention
Basics of Infection PreventionHealthcare-Associated Infections Program
Center for Health Care QualityCalifornia Department of Public Health
Last updated 2017
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Objectives Define the scope of healthcare-associated urinary tract
infections (UTI) Review evidence-based clinical practices shown to prevent
catheter-associated urinary tract infections (CAUTI) Discuss strategies to reduce CAUTI within healthcare settings Discuss adherence monitoring and feedback
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
UTI Epidemiology
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80% UTI are catheter-associated (CAUTI)
Leading cause of secondary bloodstream infection (BSI)
10% mortality rate (13,000 attributable deaths annually)
Increases length of stay by 2-4 days Results in antimicrobial overuse and antimicrobial resistance
IHI Catheter-Associated Urinary Tract Infectionhttp://www.ihi.org/topics/CAUTI/Pages/default.aspx
Catheter-Associated Urinary Tract Infection (CAUTI) Toolkit, CDC, 2009https://www.cdc.gov/infectioncontrol/tools/index.html#Infection
APIC Guide to the Elimination of CAUTI, 2008https://www.apic.org/Resource_/EliminationGuideForm/c0790db8-2aca-4179-a7ae-
676c27592de2/File/APIC-CAUTI-Guide.pdf
http://www.ihi.org/topics/CAUTI/Pages/default.aspxhttps://www.cdc.gov/infectioncontrol/tools/index.html#Infectionhttps://www.apic.org/Resource_/EliminationGuideForm/c0790db8-2aca-4179-a7ae-676c27592de2/File/APIC-CAUTI-Guide.pdfhttp://www.ihi.org/topics/CAUTI/Pages/default.aspxhttps://www.cdc.gov/infectioncontrol/tools/index.html#Infectionhttps://www.apic.org/Resource_/EliminationGuideForm/c0790db8-2aca-4179-a7ae-676c27592de2/File/APIC-CAUTI-Guide.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Urinary Catheter Use Use of indwelling urinary catheters high
Medical surgical unit: 10-30% patients ICU: 60-90% patients Nursing home: 7-10% residents
40-50% patients with a urinary catheter in hospital (non-ICU ward) do not have a valid indication for placement
Physicians frequently unaware of use Risk of CAUTI increases each day the urinary catheter remains
NHSN Patient Safety Manual, Chapter 7, UTICDC: Catheter Associated UTI, https://www.cdc.gov/hai/ca_uti/uti.html
APIC Infection Preventionists Guide to Long Term Care, 2013)https://apic.org/APICStore/Products/Product?id=SLS6008
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https://www.cdc.gov/hai/ca_uti/uti.htmlhttps://apic.org/APICStore/Products/Product?id=SLS6008https://www.cdc.gov/hai/ca_uti/uti.htmlhttps://apic.org/APICStore/Products/Product?id=SLS6008
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
UTI in Long Term Care (LTC)
The most common infection in LTC is UTI Bacteriuria also very common
By itself, not associated with adverse outcomes and does not affect survival
Prevalence of indwelling urethral catheters is 7% to 10% Catheterization predisposes to clinical UTI Catheterized urinary tract is the most common source of
bacteremia
SHEA/APIC Guideline: Infection Prevention and Control in Long-Term Care, 2012: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375028/#
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375028/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375028/
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMCAUTI Etiology
Source: Patients colonic or perineal flora Bacteria on hands of personnel
Microbes enter bladder via one of two routes: Extraluminal: the external surface Intraluminal: inside the catheter
Risk of bacteriuria with catheterization Daily: 3% - 10% By day 30: 100%
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Maki D & Tambyah P. Engineering out risk of Infection with urinary catheters. Emerg Infect Dis, 2001
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Pathogens Associated with CAUTI
Escherichia coli 24% Candida albicans 12% Pseudomonas aeruginosa 10% Klebsiella pneumoniae/oxytoca 10% Enterococcus faecalis 7%
NHSN Antimicrobial Resistance Report: Distribution of all Pathogens Reported by HAI Type, Appendix to Table 4, 2011-2014
https://www.cdc.gov/nhsn/xls/reportdatatables/2014-appendix-pathogens.xlsx
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https://www.cdc.gov/nhsn/xls/reportdatatables/2014-appendix-pathogens.xlsxhttps://www.cdc.gov/nhsn/xls/reportdatatables/2014-appendix-pathogens.xlsx
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
CAUTI Prevention 69% CAUTI can be prevented with currently recommended
infection prevention practices 380,000 infections prevented annually 9,000 lives saved
National 2020 CAUTI 5-year prevention goal: 25% decrease from 2015 baseline CDPH HAI Advisory Committee recommended adoption
of national goal for California hospitals
CDC CAUTI Prevention guidelines, 2009: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
HHS National Action Plan, 2013: https://health.gov/hcq/prevent-hai-action-plan.asp
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http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttps://health.gov/hcq/prevent-hai-action-plan.asphttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttps://health.gov/hcq/prevent-hai-action-plan.asp
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
CDC Prevention Recommendations
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Core CAUTI Prevention Strategies Insert catheters only for appropriate indications Leave in place only as long as needed Ensure only properly trained persons insert and maintain Perform hand hygiene Use aseptic technique and sterile equipment for insertion Maintain closed drainage system and unobstructed urine
flow Implement improvement program to achieve appropriate
use of catheters
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CDC CAUTI Prevention guidelines, 2009: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Appropriate Indications for Urinary Catheters Acute urinary retention or obstruction Peri-operative use in select (not all) surgeries Assist healing of perineal and sacral wounds in incontinent
patients Hospice, comfort care, palliative care Required immobilization for trauma or surgery Chronic indwelling urinary catheter on admission
Necessity must still be evaluated on admission Accurate measurement of urinary output in critically ill
patients (intensive care, those monitored hourly)CDC CAUTI Prevention guidelines, 2009:
www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
CAUTI Prevention Supplemental Care Practices
Consider alternatives to indwelling urinary catheters Use portable ultrasound devices to assess urinary retention,
reduce unnecessary catheterizations Consider antimicrobial/antiseptic impregnated catheters
Supplemental care practices will not be effective unless primary care practices are used routinely
CDC CAUTI Prevention guidelines, 2009: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Preventing CAUTI in LTC LTC recommendations are the same as hospital
recommendations (3 previous slides) Facility-wide commitment to
Limit catheter use Ensure aseptic catheter insertion by trained personnel Use smallest diameter catheter as possible Avoid irrigation unless the catheter is obstructed Keep collecting bag below the bladder Ensure adequate nutrition and hydration
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
CAUTI Prevention Bundle Examples
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Not RecommendedNo evidence to support UTI prevention:X Complex urinary drainage systemsX Routinely changing of catheters or drainage bagsX Routine antimicrobial prophylaxisX Cleaning the periurethral area with antisepticsX Antimicrobial irrigation of the bladderX Antiseptic / antimicrobial solution instillation into drainage
bagsX Routine screening for asymptomatic bacteriuria
CDC CAUTI Prevention guidelines, 2009: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
UTI Prevention Process Measures Measure catheter use:
Days with Foley catheter Patient days (x 100) = __%
Measure health care provider adherence: Hand hygiene Documentation of catheter insertion and removal Daily assessment of Foley catheter Documentation of indications for use
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CDC CAUTI Prevention guidelines, 2009: www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Adherence Monitoring Tool - UTI Prevention 17
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
UTI Prevention Outcome Measure
Measure infections: Perform UTI surveillance using standardized definitions and
protocols Bacteria in urine alone is not an infection
Must evaluate for other UTI symptoms or have supporting laboratory data
NHSN Patient Safety Module: Chapter 7 Device-Associated Module, CAUTI
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
IP Role in CAUTI Prevention Ensure policies and practice reflect current evidence based
recommendations CDC guidelines
Ensure staff competency upon hire and at least annually New hire orientation Annual skills fair Return demonstration to ensure competency
Establish an adherence monitoring program for core care practices Use tools to measure adherence
Perform UTI surveillance Provide feedback to frontline staff and leaders
Present adherence results with CAUTI incidence to each unit
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM 20
CDPH CAUTI Observations, 131 Facilities, 2016
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Are CAUTI Prevention Core Care Practices Used Routinely in YOUR facility?
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Additional CAUTI Prevention References and Resources Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and HICPAC. Guideline
for Prevention of Catheter-associated Urinary Tract Infections, 2009http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
IHI Program to Prevent CAUTI http://www.ihi.org/topics/CAUTI/Pages/default.aspx
APIC Preventing CAUTI: A patient-centered approach ,2012, http://apic.org/Resource_/TinyMceFileManager/epublications/CAUTI_feature_PS_fall_12.pdf
IDSA Guidelines , Clin Infect Dis 50:625-63, 2010
SHEA/IDSA Compendium, ICHE, 35:464-479, 2014
National Quality Forum (NQF) Safe Practices for Better Healthcare,2010
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http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.ihi.org/topics/CAUTI/Pages/default.aspxhttp://apic.org/Resource_/TinyMceFileManager/epublications/CAUTI_feature_PS_fall_12.pdfhttp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdfhttp://www.ihi.org/topics/CAUTI/Pages/default.aspxhttp://apic.org/Resource_/TinyMceFileManager/epublications/CAUTI_feature_PS_fall_12.pdf
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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM
Questions?
For more information, please contact any
HAI Liaison IP Team member
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mailto:[email protected]
Catheter-Associated Urinary Tract Infection PreventionObjectivesUTI Epidemiology Urinary Catheter UseUTI in Long Term Care (LTC)CAUTI EtiologyPathogens Associated with CAUTICAUTI PreventionCDC Prevention RecommendationsCore CAUTI Prevention StrategiesAppropriate Indications for Urinary CathetersCAUTI Prevention Supplemental Care PracticesPreventing CAUTI in LTCCAUTI Prevention Bundle ExamplesNot RecommendedUTI Prevention Process Measures Adherence Monitoring Tool - UTI Prevention UTI Prevention Outcome MeasureIP Role in CAUTI PreventionSlide Number 20Are CAUTI Prevention Core Care Practices Used Routinely in YOUR facility?Additional CAUTI Prevention References and ResourcesQuestions?