January, 15, 2013 Presented by: Carolyn Gould, MD, MSCR Division of Healthcare Quality Promotion

1. Improving Appropriateness of Diagnosis and Treatment of Catheter-Associated Urinary Tract Infection National Content Call January, 15, 2013 Presented by: Carolyn Gould, MD, MSCR Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

2. Disclosures Nothing to Disclose

3. Outline • Discuss incidence and prevalence of asymptomatic bacteriuria (ASB) in different patient populations • Discuss symptomatic UTI criteria in patients with an indwelling urinary catheter • Define indications for screening and treatment of ASB • Discuss impact of inappropriate antimicrobial treatment

4. Case Study • 85 year old man with prostate cancer and chronic urinary catheter is transferred to hospital from nursing home after change in mental status and fall • Patient is afebrile with normal WBC count and no localizing symptoms • Urinalysis showed 15-20 WBC/hpf • Urine culture drawn from catheter grew multiple bacterial species • Patient treated with piperacillin-tazobactam for “urosepsis”

5. Case Study (continued) • On day #3, patient developed fever and elevated WBC count • Repeat urine culture sent from a new catheter grew MDR P. aeruginosa, resistant to pip-tazo • Antibiotics switched to imipenem • Patient developed acute abdominal pain and profuse, watery diarrhea • C. difficile toxin test was positive • Patient developed toxic megacolon and sepsis, was transferred to ICU, and subsequently died

6. Impact of CAUTI • Most common type of HAI > 30% of infections reported to NHSN • Up to 139,000 hospital-onset, symptomatic CAUTIs occur annually • Leading cause of secondary BSI with ~10% mortality • $131 million in excess direct medical costs Hidron AI et al. ICHE 2008;29:996-1011 Richards M, et al. Crit Care Med 1999;27:887-92 Wise M, et al. SHEA Abstract, Dallas, TX 2011 Scott R, et al. SHEA Abstract, Dallas, TX 2011

7. Source of microorganisms Pathogenesis of CAUTI Endogenous (meatal, rectal, or vaginal colonization) Exogenous (contaminated hands of healthcare personnel during catheter insertion or manipulation of collecting system) Figure from: Maki DG, Tambyah PA. Emerg Infect Dis 2001;7:1-6

8. Asymptomatic Bacteriuria (ASB)

9. Asymptomatic bacteriuria • Definition • Quantitative culture with ≥105 colony forming units/ml in an appropriately collected urine specimen without clinical signs/symptoms localizing to the urinary tract • Incidence of bacteriuria with indwelling urinary catheters • 3-10% per catheter-day • 26% of people with a catheter between 2-10 days • 100% of people with long-term (>30 d) catheters • Bacteriuria is rarely symptomatic

10. IDSA Guidelines: Signs and symptoms compatible with CAUTI • new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; • flank pain; • costovertebral angle tenderness; • acute hematuria; • pelvic discomfort; • In those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness • In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, or sense of unease are also compatible with CAUTI Hooton TM. Clin Infect Dis 2010;50

11. National Healthcare Safety Network Surveillance Definitions for SUTI http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

12. Prevalence of ASB Nicolle LE et al. Clin Infect Dis 2005; 40:643–54

13. Management of ASB: DON’T screen/ treat Nicolle, LE. Int J Antimicrob Agents. 2006; 28S:S42-S48

14. Risks of antimicrobial use for ASB • Selection for antimicrobial resistant pathogens • Adverse reactions to antimicrobial • C. difficile infection

15. When is it recommended to screen for and treat ASB? • In pregnant women • Before transurethral resection of the prostate and other urologic procedures where mucosal bleeding is anticipated • “No recommendation can be made for screening for or treatment of asymptomatic bacteriuria in renal transplant or other solid organ transplant recipients.” Nicolle LE et al. Clin Infect Dis 2005; 40:643–54

16. No benefit of treating ASB in long-term catheterized patients • Randomized, controlled trial of cephalexin use in asymptomatic long-term catheterized patients for susceptible organisms over 12-44 weeks • No differences in: • Weekly prevalence of bacteriuria (>98% in both groups) • Incidence or duration of bacteriuric episodes • Number of bacterial strains present • Febrile days • Catheter obstruction • 75% of bacteria in control group remained susceptible to cephalexin, compared to 36% in treatment group Warren JW. JAMA 1982;248:454-8

17. No benefit of treating ASB in diabetic women Harding GKM et al. N Engl J Med 2002;347:1576-83

18. No benefit of treating asymptomatic funguria • Randomized, placebo-controlled trial of treatment of funguria in 316 asymptomatic or minimally symptomatic hospitalized patients • No differences in eradication of funguria 2 weeks after therapy for catheterized and non-catheterized patients • No invasive fungal infections or fungal-related deaths noted in either group Sobel JP. Clin Infect Dis 2000;30:19-24

19. Is pyuria diagnostic? Hooton TM. Clin Infect Dis 2010;50

20. Pyuria and ASB Nicolle LE et al. Clin Infect Dis 2005; 40:643–54

21. Pyuria in the elderly – not useful Over 90% of older adults with positive urine cultures (bacteriuria) have pyuria No evidence of poor clinical outcomes with high levels If LE and Nitrite are both negative, then strongly predictive that a urinary tract infection is not present Bottom line: Don’t get the test unless you know how to interpret AND plan on acting on the results Nicolle LE. Infect Control Hosp Epidemiol 2001;22:167-175 Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed. 2009

22. Inappropriate treatment of catheter-associated ASB • Of 164 episodes of CA-ASB identified at one center over 3 months, 53 (32%) treated inappropriately with antibiotics • Independent risk factors for inappropriate treatment of ASB: • Predominant organism gram-negative • Higher urine WBC • Older age • Three patients developed C. difficile infection shortly after treatment for ASB Cope M. Clin Infect Dis 2009;48:1182-8

23. “When antimicrobial agents are prescribed for the treatment of UTIs, not only the antimicrobial spectrum of the agent but also the potential ecological disturbances, including the risk of emergence of resistant strains, should be considered.”

24. Collateral damage • Rampant use of fluoroquinolones (often used to treat diagnoses of community-associated pneumonia and UTIs) has contributed to the rise of the virulent, FQ-resistant epidemic NAP1/BI strain of C. difficile • Overprescribing for pneumonia driven by CMS process-of-care measure to treat patients within 4 hours of arriving to ED • Evaluation of CMS policy of non-payment for hospital-acquired CAUTI: no evidence of overtesting for UTI on admission or increased FQ use in 16 months after implementation of policy Wachter RM et al. Ann Intern Med 2008;149:29 Morgan DJ et al. Clin Infect Dis 2012;55:923-9

25. Antimicrobial exposure and recurrent CDI • Non-CDI antimicrobial therapy after an episode of CDI is common and is associated with a 3-fold increase in odds of recurrent disease • SHEA-IDSA CDI Guideline: “Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible, as this may influence the risk of CDI recurrence” Drekonja DM et al. Am J Med 2011;124:1081 Cohen SH et al. Infect Control Hosp Epidemiol 2010;31:431-55

26. Electronic memorandum reduces inappropriate treatment of ASB and culture-negative pyuria • 26% of patients with ASB/CNP inappropriately treated with antimicrobials • Educational memorandum placed in EMR reduced mean duration of antimicrobial use (2.2 days vs. 6.3 days, p < .001) • Adverse events from antimicrobials occurred in 3/30 controls (2 cases of CDI, 1 case of QT-interval prolongation) Linares LA et al. Infect Control Hosp Epidemiol 2011;32:644-8

27. Strategies to reduce treatment of ASB • Reduce inappropriate catheter use • Reduce inappropriate orders for urine cultures • Avoid reflex orders for UA/Ucx for “soft” indications (e.g., falls) • Difficult for clinicians to ignore a positive culture, regardless of symptoms • Pressure to treat – from patients, families, even surveyors (anecdotal reports from LTC) Doernberg SB, V Dudas, KK Trivedi, ID Week 2012, Poster presentation

28. Patients with chronic catheters: best practices for diagnosis and management • Indwelling catheter in place for > 2 weeks at onset of CAUTI: • If still indicated, replace catheter and obtain urine culture from new catheter prior to initiation of antimicrobial therapy • If catheter not indicated, discontinue catheter and obtain culture of a voided midstream urine specimen prior to initiation of antimicrobial therapy Hooton TM. Clin Infect Dis 2010;50

29. Summary • Screening for and treatment of ASB not indicated in patients with catheters (with few exceptions) • Presence of pyuria not diagnostic of CAUTI • Absence of pyuria is useful for ruling out CAUTI • Inappropriate treatment of ASB can lead to adverse events (especially CDI) and selection of antimicrobial resistant pathogens

30. Thank you!Questions? For more information, please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/ TTY: 1-888-232-6348 Email: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusion in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and prevention.

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