Att G.11 LTCF UTI

Urinary Tract Infection (UTI) Event for LTCF
Introduction: The urinary tract is one of the most common sites of healthcare-associated infections,
accounting for 20-30% of infections reported by long-term care facilities (LTCFs). In the LTC resident,
risk factors for developing bacteriuria and UTI include age-related physiologic changes to the
genitourinary tract, comorbid conditions resulting in neurogenic bladder, and instrumentation required to
manage bladder voiding. The point prevalence of asymptomatic bacteriuria in LTC residents can range
from 25-50%. Although the incidence of symptomatic UTI is lower, it still comprises a significant
proportion of infections manifesting in LTCFs and results in a large amount of antibiotic use.

Though prevalence of indwelling urinary catheter use in LTCFs is lower than in the acute care
setting, catheter-associated UTI (CAUTI) can lead to such complications as cystitis, pyelonephritis,
bacteremia, and septic shock. These complications associated with CAUTI can result in decline in
resident function and mobility, acute care hospitalizations, and increased mortality. Prevention of
CA-UTIs is discussed in the CDC/HICPAC document, Guideline for Prevention of Catheterassociated Urinary Tract Infections.
Settings: UTI event reporting is currently available for certified skilled nursing facilities/nursing
homes (LTC:SNF) and intermediate/chronic care facilities for the developmentally disabled
(LTC:DevDis). Infection surveillance should be performed facility-wide.
NOTE: If a resident is transferred to an acute care facility for suspected UTI, it is important to report
this transfer into NHSN. No additional indwelling catheter days are reported after the day of transfer.
NOTE: If a resident is transferred from an acute care facility and develops signs/symptoms of a UTI
within the first 3 calendar days of admission to the LTCF, it would be considered present at the time
of transfer to the LTCF and not attributed to the LTCF. It should be reported back to the transferring
facility.
Requirements: Surveillance for UTI is performed facility-wide for at least six consecutive calendar
months as indicated in the Monthly Reporting Plan for LTCF (CDC 57.141).
Definitions:
Urinary tract infections (UTI) are defined using Symptomatic UTI (SUTI) criteria or Asymptomatic
Bacteremic UTI (ABUTI) criteria (Figures and Table 1). All UTI (SUTI or ABUTI) are reported,
regardless of whether a catheter is in place or not. Catheter-associated SUTIs (CA-SUTI) are
captured if the resident had an indwelling urinary catheter at the time of or within 48 hours before
onset of a SUTI event. NOTE: There is no minimum period of time that the catheter must be in place
in order for the UTI to be considered catheter-associated.
Indwelling catheter: a drainage tube that is inserted into the urinary bladder through the urethra, is
left in place, and is connected to a closed collection system; also called a Foley catheter. Indwelling
catheters do not include straight in-and-out catheters or suprapubic catheters. Only catheter days
among residents with indwelling catheters will be captured as a separate denominator. UTIs in
residents with suprapubic catheters will be captured as SUTI, not CA-SUTI.

Numerator Data: The Urinary Tract Infection (UTI) for LTCF Form (CDC 57.140) is used to
collect and report each SUTI, ABUTI or CA-SUTI that is identified during the month selected for
surveillance. The Instructions for Completion of Urinary Tract Infection for LTCF Form (Tables of
Instructions, Tables XX) includes brief instructions for collection and entry of each data element on
the form. The UTI form includes resident demographic information and information on whether or
not a catheter was present. Additional data include the specific criteria met for identifying the UTI,
whether the resident developed a secondary bloodstream infection, whether the resident was
transferred to an acute care facility for any reason or died from any cause within 30 days of the UTI
event, and the organisms isolated from cultures and their antimicrobial susceptibilities.
Denominator data: Device days and resident days are used for denominators (See Chapter 16 Key
Terms). Urinary catheter days, the monthly sum of the number of residents with an indwelling
catheter each day, are collected daily, at the same time each day, for all residents in the facility using
the Denominators for LTCF Locations form (CDC 57.142). These daily counts are summed and only
the total for the month is entered into NHSN. Indwelling catheter days and resident days are collected
every month for the entire facility. None of the following, suprapubic catheters, in/out straight
catheters or condom catheters should be included when counting indwelling catheter days.
Data Analyses:
The SUTI incidence rate per 1000 resident days is calculated by dividing the number of SUTIs by
the number of resident days and multiplying by 1000. Only SUTIs which are NOT catheter
associated will be included in the SUTI incidence rate.
CA-SUTI incidence rate per 1000 urinary catheter days is calculated by dividing the number of CASUTIs by the number of urinary catheter days and multiplying the result by 1000. Only SUTIs which
develop at the time an indwelling catheter is in place or <48 hours from catheter removal will
contribute to the CA-UTI rate.
The Urinary Catheter Utilization Ratio is calculated by dividing the number of urinary catheter days
by the number of resident days.

Table 1
Criterion
1a

Symptomatic Urinary Tract Infection (SUTI)
For residents without an indwelling catheter:
Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis,
or prostate

AND
A positive urine culture with  105 cfu/ml of no more than 2 species of
microorganisms, or a specimen collected by in and out catheterization with 
102 cfu/ml of any number of organisms.
2a

Fever [Single temperature  37.8C (>100F), or >37.2C (> 99F) on
repeated occasions, or an increase of >1.1oC (>2oF) over baseline] OR
Leukocytosis (>14,000 cells/mm3) or Left shift (>6% or 1,500 bands/mm3)
AND
At least one of the following: Acute costovertebral angle pain or tenderness,
suprapubic pain, or gross hematuria, new or marked increase in incontinence,
urgency, or frequency
AND
A positive urine culture with  105 cfu/ml of no more than 2 species of
microorganisms, or a specimen collected by in and out catheter specimen with
 102 cfu/ml of any number of organisms.

3a

Two or more of the following:
Costovertebral angle pain or tenderness, new or marked increase in
incontinence, urgency, frequency, suprapubic pain, or new gross hematuria
AND
A positive urine culture with  105 cfu/ml of no more than 2 species of
microorganisms, or a specimen collected by in and out catheter specimen with
 102 cfu/ml of any number of organisms.

Criterion

Symptomatic Urinary Tract Infection (SUTI) – CA-SUTI
For residents with an indwelling catheter (or removed within 48 hrs):

1b.

Any one of the following:
a. Fever, rigors OR new onset hypotension, with no alternate site of
infection.
b. Either acute change in mental status or acute functional decline with
no alternate diagnosis and leukocytosis
c. New onset suprapubic pain or costovertebral angle pain or tenderness
d. Purulent discharge from around the catheter or acute pain, swelling, or
tenderness of the testes, epididymis, or prostate.
AND
Urine specimen  105 cfu/ml of any organism(s) collected following placement
of a new catheter (if current catheter has been in place >14 days)

Criterion

Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)

1

Resident with or without an indwelling urinary catheter has no signs or
symptoms (i.e., no urgency, frequency, acute dysuria, suprapubic tenderness,
or costovertebral angle pain or tenderness). If no catheter is in place, fever
alone would not exclude ABUTI if other criteria are met.
AND
A positive urine culture with  105 cfu/ml of no more than 2 species of
microorganisms, or a specimen collected by in and out catheter specimen with
 102 cfu/ml of any number of organisms
AND
A positive blood culture with at least 1 matching uropathogen microorganism
to the urine culture.
**Uropathogen microorganisms are: Gram-negative bacilli, Staphylococcus
spp., yeasts, beta-hemolytic Streptococcus spp., Enterococcus spp., G.
vaginalis, Aerococcus urinae, and Corynebacterium (urease positive).