美国CDC尿路感染的指南.docx
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美国CDC尿路感染的指南.docx
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美国CDC尿路感染的指南
UrinaryTractInfection(Catheter-AssociatedUrinaryTractInfection[CAUTI]andNon-Catheter-AssociatedUrinaryTractInfection[UTI])andOtherUrinarySystemInfection[USI])Events
Introduction:
Urinarytractinfections(UTIs)arethefourthmostcommontypeofhealthcare-associatedinfection,withanestimated93,300UTIsinacutecarehospitalsin
2011andaccountformorethan12%ofinfectionsreportedbyacutecarehospitals1.Virtuallyallhealthcare-associatedUTIsarecausedbyinstrumentationoftheurinarytract.
CAUTIcanleadtosuchcomplicationsasprostatitis,epididymitis,andorchitisinmales,andcystitis,pyelonephritis,gram-negativebacteremia,endocarditis,vertebralosteomyelitis,septicarthritis,endophthalmitis,andmeningitisinallpatients.ComplicationsassociatedwithCAUTIcausediscomforttothepatient,prolongedhospitalstay,andincreasedcostandmortality2.Ithasbeenestimatedthateachyear,morethan13,000deathsareassociatedwithUTIs.3
PreventionofCAUTIisdiscussedintheCDC/HICPACdocument,GuidelineforPreventionofCatheter-associatedUrinaryTractInfection4.
Settings:
Surveillancemayoccurinanyinpatientlocation(s)wheredenominatordatacanbecollected,suchascriticalintensivecareunits(ICU),specialtycareareas(SCA),step-downunits,wards,inpatientrehabilitationlocations,andlongtermacutecarelocations.NeonatalICUsmayparticipate,butonlyoffplan(notasapartoftheirmonthlyreportingplan).AcompletelistingofinpatientlocationsandinstructionsformappingcanbefoundintheCDCLocationsandDescriptionschapter.
Note:
SurveillanceforCAUTIsafterthepatientisdischargedfromthefacilityisnotrequired.However,ifdiscovered,anyCAUTIswithadateofeventonthedayofdischargeorthenextdayisattributabletothedischarginglocationandshouldbeincludedinanyCAUTIsreportedtoNHSNforthatlocation(seeTransferRule).Noadditionalindwellingcatheterdaysarereported.
Definitions:
PresentonAdmission(POA):
InfectionsthatarePOA,asdefinedinChapter2,arenotconsideredHAIsandthereforeareneverreportedtoNHSN.
Healthcare-associatedinfections(HAI):
AllNHSNsitespecificinfectionsmustfirstmeettheHAIdefinitionasdefinedinChapter2beforeasitespecificinfection(e.g.,CAUTI)canbereportedtoNHSN.
Urinarytractinfections(UTI)aredefinedusingSymptomaticUrinaryTractInfection(SUTI)criteria,AsymptomaticBacteremicUTI(ABUTI),orUrinarySystemInfection(USI)criteria(SeeTable1andFigure3).
Dateofevent(DOE):
ForaUTI,thedateofeventisthedatewhenthefirstelementusedtomeettheUTIinfectioncriterionoccurredforthefirsttimewithinthe7-dayInfectionWindowPeriod.SeedefinitionofInfectionWindowPeriodinChapter2.
Synonyms:
infectiondate,eventdate.
Indwellingcatheter:
Adrainagetubethatisinsertedintotheurinarybladderthroughtheurethra,isleftinplace,andisconnectedtoadrainagebag(includinglegbags).ThesedevicesarealsocalledFoleycatheters.Condomorstraightin-and-outcathetersarenotincludednorarenephrostomytubes,ileoconduits,orsuprapubiccathetersunlessaFoleycatheterisalsopresent.IndwellingurethralcathetersthatareusedforintermittentorcontinuousirrigationareincludedinCAUTIsurveillance.
Catheter-associatedUTI(CAUTI):
AUTIwhereanindwellingurinarycatheterwasinplacefor>2calendardaysonthedateofevent,withdayofdeviceplacementbeing
Day1,
AND
anindwellingurinarycatheterwasinplaceonthedateofeventorthedaybefore.Ifanindwellingurinarycatheterwasinplacefor>2calendardaysandthenremoved,thedateofeventfortheUTImustbethedayofdiscontinuationorthenextdayfortheUTItobecatheter-associated.
ExampleofAssociatingCatheterUsetoUTI:
ApatientinaninpatientunithasaFoleycatheterinsertedandthefollowingdayisthedateofeventforaUTI.Becausethecatheterhasnotbeeninplace>2calendardaysonthedateofevent,thisisnotaCAUTI.However,dependingonthedateofadmission,thismaybeahealthcare-associatedUTI.
Notes:
∙SUTI1bandUSIcannotbecatheter-associated.
∙Indwellingurinarycathetersthatareremovedandreinserted:
If,afterindwellingurinarycatheterremoval,thepatientiswithoutanindwellingurinarycatheterforatleast1fullcalendarday(NOTtobereadas24hours),thentheurinarycatheterdaycountwillstartanew.Ifinstead,anewindwellingurinarycatheterisinsertedbeforeafullcalendardayhaspassedwithoutanindwellingurinarycatheterbeingpresent,theurinarycatheterdaycountwillcontinue.
Figure1:
AssociatingCatheterUsetoUTI
March31
(Hospitalday3)
April1
April2
April3
April4
April5
April6
PatientA
Foley
Day3
Foley
Day4
Foleyremoved(FoleyDay5)
Foleyreplaced(FoleyDay6)
Foley
Day7
FoleyremovedDay8
NoFoley
PatientB
Foley
Day3
Foley
Day4
Foleyremoved(FoleyDay5)
NoFoley
Foleyreplaced(FoleyDay1)
Foley
Day2
Foley
Day3
Rationale:
NHSNsurveillanceforinfectionisnotaimedataspecificdevice.Insteadsurveillanceisaimedatidentifyingrisktothepatientthatistheresultofdeviceuseingeneral.
∙Intheexamplesabove,PatientAiseligibleforaCAUTIbeginningonMarch31,throughApril6th,sinceaFoleywasinplaceforsomeportionofeachcalendardayuntilApril6th.AUTIwithdateofeventonApril6thwouldbeaCAUTIsincethecatheterhadbeeninplacegreaterthan2daysandwasremovedthedaybeforethedateofevent.
∙PatientBiseligibleforaCAUTIonMarch31(FoleyDay3)throughApril3.Thecatheterhadbeeninplace>2daysandanHAIoccurringonthedayofdevicediscontinuationorthefollowingcalendardayisconsideredadevice-associatedinfection.
∙IFthepatientdidnothaveaCAUTIbyApril3,thepatientisnoteligibleforaCAUTIuntilApril6,whenthesecondindwellingurinarycatheterhadbeeninplaceforgreaterthan2days.(Note:
NHSNwillnotrequiretheUTItobeattributedtoaspecificindwellingurinarycatheterwhenreporting.)
Locationofattribution:
TheinpatientlocationwherethepatientwasassignedonthedateoftheUTIevent.SeeDateofEventdefinition(above).SeeExceptiontoLocationofAttribution(below).
ExceptiontoLocationofAttribution
TransferRule:
IfthedateofeventforaUTIisonthedateoftransferordischarge,orthenextday,theinfectionisattributedtothetransferring/discharginglocation.ThisiscalledtheTransferRuleandexamplesareshownbelow.ReceivingfacilitiesshouldshareinformationaboutsuchHAIswiththetransferringlocationorfacilitytoenableaccuratereporting.
ExamplesoftheTransferRule:
∙PatientistransferredinthemorningtothemedicalwardfromtheMSICUafterhavingtheFoleycatheterremoved,whichhadbeeninplacefor6days.ThedayoftransferisthedateofeventfortheCAUTI.ThisisreportedtoNHSNasaCAUTIfortheMSICUbecausethedateofevent(datewhenthefirstelementofUTIcriteriafirstappearedduringtheinfectionwindow)wasthedayoftransferfromthatlocation.
∙OnMonday,patientwithaFoleycatheterinplaceistransferredfromthemedicalwardtothecoronarycareunit(CCU).WednesdayintheCCU,patienthasafeverandurineculturecollectedthatdayispositivefor100,000CFU/mlofE.coli.ThisisreportedtoNHSNasaCAUTIfortheCCU,becausetheUTIdateofeventisLATERTHANthedayaftertransfer.
∙ApatienthasaFoleycatheterremovedoncatheterday5andisdischargedthesamedayfromhospitalA’surologyward.Thenextday,theIPfromHospitalBcallstoreportthatthispatienthasbeenadmittedtoHospitalBmeetingUTIcriteria.ThisCAUTIshouldbereportedtoNHSNforHospitalAandattributedtotheurologywardbecausethedateofeventisthenextdayaftertransfer.
∙PatientintheMICUwithaFoleycatheter,whichhasbeeninplacefor4days,istransferredtothemedicalward.Thedayaftertransferisdeterminedtobethedateofeventforacatheter-associatedABUTI.ThisisreportedtoNHSNasanABUTIfortheMICUbecausethedateofeventwasthenextdayaftertransfer.
MultipleTransfers
IninstanceswhereapatienthasbeentransferredtomorethanonelocationonthedateofaUTI,orthedaybefore,attributetheUTItothefirstlocationinwhichthepatientwashousedthedaybeforetheUTI’sdateofevent.
Figure2:
MultipleTransferswithintheTransferRuleTimeFrame
3/22
3/23
3/24
Locationsinwhichpatientwashoused
UnitA
UnitAUnitBUnitC
UnitCUnitD
ThisisalsothedateofeventforaCAUTI.CAUTIisattributedtoUnitAsinceUnitAwasthefirstlocationinwhichthepatientwashousedthedaybeforethedateofevent.
Table1.UrinaryTractInfectionCriteria
Criterion
UrinaryTractInfection(UTI)
SymptomaticUTI(SUTI)
Mustmeetatleastoneofthefollowingcriteria:
SUTI1a
Catheter-associatedUrinaryTractInfection(CAUTI)
Patientmustmeet1,2,and3below:
1.Patienthadanindwellingurinarycatheterthathadbeeninplacefor>2daysonthedateofevent(dayofdeviceplacement=Day1)ANDwaseither:
∙Presentforanyportionofthecalendardayonthedateofevent†,OR
∙Removedthedaybeforethedateofevent‡
2.Patienthasatleastoneofthefollowingsignsorsymptoms:
•fever(>38.0°C)
•suprapubictenderness*
•costovertebralanglepainortenderness*
•urinaryurgency^
•urinaryfrequency^
•dysuria^
3.Patienthasaurineculturewithnomorethantwospeciesoforganismsidentified,atleastoneofwhichisabacteriumof≥105CFU/ml(SeeCommentSectiononpage7-8).AllelementsoftheUTIcriterion
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