CATHETER-RELATED BACTERIURIA AND UTIs/UROSEPSIS

Most individuals with indwelling catheters for more than 7 days have bacteriuria. Bacteriuria alone in a catheterized individual should not be treated with antibiotics.

A long term indwelling catheter(>2 to 4 weeks) increases the chances of having a symptomatic UTI and urosepsis. The incidence of bacteriuria is 4o times greater in individuals with long term indwelling catheter than in those without one. For suspected UTIs in a catheterized individual, the literature recommends removing the current catheter and inserting a new one obtaining a urine sample via the newly inserted catheter.

CLINICAL EVIDENCE THAT MAY SUGGEST UTI

Clinically, an acute deterioration in stable chronic symptoms may indicate an acute infection. Multiple co-existing finding such as a fever with hematuria are more likely to be from a urinary source.

No one lab test alone proves that a UTI is present. For example, a positive urine sample culture will show bacteriuria but that alone is not enough to diagnose a symptomatic UTI. However, several test results in combination with clinical findings can help to identify UTIs such as the presence of pyuria(more than minimal white cells in the urine) in microscopic urinalysis, or a positive urine dipstick test for leukocyte esterase(indicating significant pyuria) of the nitrites (indicating the presence of Enterobacteriaceae). A negative luekocyte esterase or the basence of pyuria strongly suggests that a UTI is not present. A positive leukocyte esterase test alone does not prove that the individual has a UTI. In someone with non-specific symptoms such as a change in function or mental status, bacteriuria alone does not necessarily warrant antibiotic treatment. Additional evidence that could confirm a UTI may include hematuria, fever(which could include variation from the individual’s normal or usual temperature range). Or evidence of pyuria( either by microscopic examination of by dipstick test). In the absence of fever, hematuria, pyuria, or local urinary tract symptoms, other potential causes of non-specific general symptoms, such as fluid and electrolyte imbalance or adverse drug reactions, should be considered instead of , or in addition to a UTI. Although sepsis, including urosepsis, can cause dizziness or falling, there is no clear evidence linking bacteriuria or a localized UTI to an increased fall risk.

INDICATIONS TO TREAT A UTI

Because many residents have chronic bacteriuria, the research-based literature suggests treating only symptomatic UTIs. Symptomatic UTIs are based on the following criteria.

• Residents without a catheter should have at least three of the following signs and symptoms.
• Fever(increase in temperature of >2 degrees F(1.1 degrees C) or rectal temperature > 99.5 degrees F( 37.5 degrees C) or single measurement of temperature > 100 degrees F(37.8 degrees C)
• New or increased burning pain on urination, frequently or urgency;
• New flank or suprapublic pain or tenderness;
• Change in character of urine(e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory( new pyuria or microscopic hematuria); and/or
• Worsening or mental or functional status(e.g., confusion, decreased appetite, unexplained falls, inconsistence of recent onset, lethargy, decreased activity).
• Residents with a catheter should have at least two of the following signs ans symptoms;
• Fever or chills;
• New flank ain or suprapubic pain or tenderness;
• Change in character of urine( e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory( new pyuria or microscopic hematuria); and/or
• Worsening of mental or functional status. Local findings such as obstruction, leakage, or mucosal trauma( hematuria) also may be present.

FOLLOW-UP OF UTIs

The goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria. Therefore, a post-treatment urine culture is not routinely necessary but may be useful in select situations. Continued bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy. Recurrent UTIs ( 2 or more in 6 months) in a noncatheterized individual may warrant additional evaluation. (Such as determination of an abnormal post void residual(PVP) urine volume or a referral to a urologist) to rule out structural abnormalities such as enlarged prostate, prolapsed bladder, periurethral abscess, strictures, bladder calculi, polyps and tumors.

Recurrent symptomatic UTIs in a catheterized or noncatheterized individual should lead the facility to check whether perineal hygiene is performed consistently to remove fecal soling in accordance with accepted practices. Recurrent UTIs in a catheterized individual should lead the facility to look for possible used perineal hygiene catheter care, and to reconsider the relative risk and benefits of continuing the use of an indwelling catheter. Because the major factors(other than an indwelling catheter) the predispose individuals to bacteriuria, including physiological aging changes and chronic comorbid illnesses, cannot be modified readily, the facility should demonstrate that they:

• Employ standard infection control practices in managing catheters and associated drainage system;
• Strive to keep the resident and catheter clean of feces to minimize bacterial migration into the urethra and bladder( e.g., cleaning fecal material away from, rather than towards, the urinary meatus);
• Take measures to maintain free urine flow through any indwelling catheter.
• Assess for fluid needs and implement a fluid management program( using alternative approaches as needed) based on those assesses needs.