ISK & CA-UTI

Kuntaman
Department of Clinical Microbiology,
Faculty of Medicine Airlangga University
Dr. Soetomo Hospital Surabaya
kuntaman@fk.unair.ac.id 08113410352

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 ISK = UTI = Urinary Tract Infection
defined using
1)  Symptomatic Urinary Tract Infection
(SUTI) criteria,
2)  Asymptomatic Bacteremic UTI
(ABUTI), or
3)  Urinary System Infection (USI)
criteria
4)  CAUTI (Cath Associated UTI)
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 SUTI:  Pa)ent  must  meet  1,  2,  and  3  below:    
1)  One  of  the  following  is  true:    
–  •    Pa)ent  has/had  an  indwelling  urinary  catheter  but  it  has/had  not  
been  in  place  >2  calendar  days  on  the  date  of  event†    
–  OR    
–  •    Pa)ent  did  not  have  a  urinary  catheter  in  place  on  the  date  of  event  
nor  the  day  before  the  date  of  event‡    
2)  Pa)ent  has  at  least  one  of  the  following  signs  or  symptoms:    
–  fever  (>38°C)  in  a  pa)ent  that  is  ≤  65  years  of  age    
–  suprapubic  tenderness*    
–  costovertebral  angle  pain  or  tenderness*    
–  urinary  frequency*    
–  urinary  urgency*    
–  dysuria*    
3)  Pa)ent  has  a  urine  culture  with  no  more  than  two  species  of  
organisms,  at  least  one  of  which  is  a  bacteria  of  ≥105  CFU/ml.    
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 CAUTI:  Pa)ent  must  meet  1,  2,  and  3  below:    
•  Pa)ent  had  an  indwelling  urinary  catheter  that  had  been  in  place  for  
>  2  days  on  the  date  of  event  (day  of  device  placement  =  Day  1)  
AND  was  either:    
–  •    S)ll  present  on  the  date  of  event†,  OR    
–  •    Removed  the  day  before  the  date  of  event‡  (Engat,  Jam  Kerja  jam  07.00)  
•  Pa)ent  has  at  least  one  of  the  following  signs  or  symptoms:  (makna,  
Isnania)  
–  fever  (>38.0°C)    
–  suprapubic  tenderness*    
–  costovertebral  angle  pain  or  tenderness*    
–  urinary  urgency*    
–  urinary  frequency*    
–  dysuria*    
•  Pa)ent  has  a  urine  culture  with  no  more  than  two  species  of  
organisms,  at  least  one  of  which  is  a  bacteria  of  ≥105  CFU/ml.  (Cara  
hitung:  Muzib)  
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 Notes  
•    An  indwelling  urinary  catheter  in  place  would  
cons)tute  “other  recognized  cause”  for  pa)ent  
complaints  of  “frequency”  “urgency”  or  
“dysuria”  and  therefore  these  cannot  be  used  
as  symptoms  when  catheter  is  in  place.    
•    Age  of  >  65  yo:  Fever  and  hypothermia  are  
non-­‐specific  symptoms  of  infec)on  and  cannot  
be  excluded  from  UTI  determina)on  because  
they  are  clinically  deemed  due  to  another  
recognized  cause.    
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 USI  (  Urinary  System  Infec8on)  
1.Pts  has  microb  isolated  from  culture  of  fluid  (excluding  urine)  
or  )ssue  from  affected  site  
2.Pts  has  an  abscess  or  other  evidence  of  infec)on  on  gross-­‐
anatomical  exam,  during  invasive  procedure,  or  on  
histopathologic  exam  
3.Pa)ent  has  at  least  one  of  the  following  signs  or  symptoms:  
•  •Fever  >38°C?  
•  •Localized  pain  or  tenderness  
And  at  least  one  of  the  following:    
•  purulent  drainage  from  affected  site  
•    organisms  cultured  from  blood  and  X-­‐ray  test  evidence  
ofinfec)on  
•  ,  or  radiolabel  scan  [gallium,  techne)um])  
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 USI  (  Urinary  System  Infec8on)  

4.Pa)ent  <1  year  of  age  has  at  least  one  of  the  
following  signs  orsymptoms:  
•  •fever  (>38.0°C);  •hypothermia  (<36.0°C;  •apnea;  
•bradycardia*;  •lethargy*;  •vomi)ng*  

And  at  least  one  of  the  following:    

•  purulent  drainage  from  affected  site  
•  •organisms  cultured  from  blood  and  X-­‐ray  test  
evidence  ofinfec)on,      
 
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 Asymptoma)c  Bacteremic  UTI  
Pa)ent  must  meet  1,  2,  and  3  below:    
1)  Pa)ent  with*  or  without  an  indwelling  urinary  catheter  has  
no  signs  or  symptoms  of  SUTI  1  or  2  according  to  age  (Note:  
Pa)ents  >  65  years  of    age  with  a  non-­‐catheter-­‐associated  
ABUTI  may  have  a  fever  and  s)ll  meet  the  ABUTI  criterion)  
2)  Pa)ent  has  a  urine  culture  with  no  more  than  two  species  of  
organisms,  at  least  one  of  which  is  a  bacteria  of  ≥105  CFU/ml  
(see  Comment  sec)on  below)    
3)  Pa)ent  has  a  posi)ve  blood  culture  with  at  least  one  
matching  bacteria  to  the  urine  culture,  or  meets  LCBI  criterion  
2  (without  fever)  and  matching  common  commensal(s)  in  the  
urine.  All  elements  of  the  ABUTI  criterion  must  occur  during  
the  Infec)on  Window  Period  
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CAUTI= CATHETER ASSOCIATED UTI
Importance of CAUTI:
•  40% HAI
•  8% in Home Care Setting
•  Catheter is RISK factor

Operatinal Deffinition:
•  UTI: ?
•  Post Catheter insertion (Jenis catheter)
•  on Hospitalised Pts

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 Diagnosis CAUTI

Clinical sign/symptom/Lab:
•  Pain/burning in region bladder/urethra
•  Fever/Chill
•  Offensive urine odor
•  Change urine character: cloudy/
sediment
•  Hematuria
•  Asymptomatic with Bact count >
10.000/ml
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 Risk Factors of CAUTI
a)  Cath more than 6 days
b)  Inserted cath in no hygienic place
c)  Not closed system of Cath
d)  Sex, Older age
e)  Pregnant
f)  Malnourished, Impaired immunity
g)  DM
h)  Renal disfunction/Azotemia (S Creat: > 2 mg/dl)
i)  Lower proffesional of insertion
j)  (Engat, 3-4 Risk Factor dgn hasil Risk/Odd Ratio)

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Surveillance:

1) Patient (Symptom) Based

2) Laborataory based

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 Surveillance:

1)  Numerator: The number of Event

2)  Denominator: The number of Event-related days
Ex: Catheter days; Do not use: Patients-days
1)  Incidence: The No of New Cases in a given time
Muzib)
2)  Prevalence: No of Cases, at point time, DIVIDED
byTotal population studies (Isnaniyanti)

Ex: 10 Pts, Cath each 5 days, total 50 days; UTI 3 Pts:

CAUTI: (3/50) x 1000 = 60 promil
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 CAUTI:
1)  During admission
2)  During hospitalization
3)  Presence Catheter: in situ or Intermittent
4)  Location: in-dwelling; supra-pubic, other?
5)  Catheter type: Sylver alloy; Silicon; Foley; Latex;
Others
6)  Catheter Size: (French Grade): 6 10 12 16 18, 20, 24
7)  cont’t

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CAUTI:
7)  Inserted by: Nurse; Doctor; Student; ?
8)  Cleaning solution: Chlorhexidine; Chlorex
9)  On-going days: 1,2,3,4,5,6,7,8,9,10, >10

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 Ex: Monthly rate of CAUTI in ICU
1)  Criteria CAUTI: National Guideline?
2)  Data Collection: Actve Surveillance of ICU Patients
3)  Numerator: New CAUTI per month
4)  Denominator: No of Urine Catheter Days in ICU
5)  Calculation of Incidence Rate:
CAUTI rate =
(No New Cases X 1000) / (No of Catheter days)
(bedakan Prevalence dan Incidence, Engat)

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 INCLUSIONS & EXCLUSION
1)  Admit at 08.00 am: Excluded
2)  Pts transfer to ward after 08.00 am: excluded
3)  Pts left ward, BEFORE Surveyeor team
arrive: excluded (Isnaniyanti)
4)  DATA:
①  Lab Record (Muzib)
②  Temperature chart
③  Medical chart
④  Surgical/Medical/Nurse NOTES
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 Assignments  
•  The  prevalence  of  microorganisms  as  
causa)ve  agents  of  UTI  (Engat)  
•  What  about  the  ESBL  producing  bacteria  as  
causa)ve  agents  in  UTI  (Isnan))  
•  What  is  the  CRE  (Carbapenem  resistant  
Enterobacteriaceae  as  a  causa)ve  agents  of  
UTI  (Muzib)  

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