Diagnosis, Prevention and Treatment of
CA-UTI in Adults
Review of 2009 IDSA Clinical Practice Guidelines
CID 2010;50: 625-663.
Nov 09 2011
Savitri Aguiar, MD
MOTIVATION
 UTI AS AN EXPLANATION FOR A.M.S IN OLDER
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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 ASB
U.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
INTRODUCTION
 CA-UTI in adults ≥ 18 yo
 Short-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.
INTRODUCTION
 CA-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 cath
 15-25% of patients in a general hosp will have some cath days
 Incidence of CA-B: 3%-8% per day; BY ONE MONTH: 100%
bacteriuric
 < 25% of CA-B develop UTI symptoms.
Catheter literature nomenclature
1)CA-ASB
2)CA-B (asymp or non): predominantly CA-ASB
 Very few are reports on CA-UTI
 Therefore, 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 IMPORTANT
 Pyuria (≥ 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 UTI
 pyuria plus CA-ASB: NOT and indication for ATBC's
 absence 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 PROBLEM
 SIGNS / 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 PROBLEM
 SIGNS / 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. CATHETERIZATION
 using 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 CATH
 Remove 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 CATHS
1)Condom / 2)intermittent / 3)suprapubic cath: insufficient definitive data
to support one over another
 INSERTION TECHNIQUES:
 INTERMITTENT: clean is enough; multiple use caths are ok
 INDWELLING: aseptic technique is required
PREVENTION:TECHNIQUES AFTER
INSERTION
 CLOSED CATHETER SYSTEM: keep it closed and low
 ANTIMICROBIAL COATED CATHS (silver alloy or ATBC): may be
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considered: insufficient data to support recommendation
PROPH 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: NO
ENHANCED 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!
TREATMENT
 SCREENING 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.
TREATMENT
 U/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 response
 Five days levofloxacin may be considered for not severely ill
 Three days ATBC regimen may be considered for women ≤ 65 yo (CA-
UTI without upper U.T. symptoms) after the cath has been removed.
Possible improvements
 Diagnosis
 Study our prevalence / incidence
 F/U on mortality
 Match with bacteremia
 Prevention
 What are our indications? Do we have them clearly written / available?
 Powerchart urinary catheter insertion orders/ automatic removal or
reminder of removal
 Give feedback rates to providers / nurses
 Treatment
 RX duration / ATBC of choice
Quality improvement project
 5-W
 Infection control (use their data collection tool)
 Implement intervention (Published indications? Powerplan?
Auto-D/C Cath?)
 Analyze data
 Publish paper and try to disseminate to the medical wards
REFERENCES
1)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.