Welcome to the 2021 National Heath Safety Network or NHSN Quick Learn series.
These are brief and informative presentations from the Centers for Disease Control and Prevention.
They serve as an educational resource for healthcare facilities working to prevent Healthcare
Associated Infection or HAI’s.
This Quick Learn focuses on the 2021 changes to the NHSN Urinary Tract Infection, or UTI,
Protocol found in the NHSN Patient Safety Manual Chapter seven.
Please visit the NHSN website to view the full chapter.
By the end of this lesson, you will be able to accurately identify Symptomatic Urinary
Tract Infection or SUTI and Asymptomatic Bacteremic Urinary Tract Infections or ABUTI events as
well as discuss the removal of the Urinary System Infection USI event from the major
infection type UTI.
First, we will review the change to the SUTI criterion.
Fever documented within the Infection Window Period, or IWP, is eligible for use to meet
SUTI for all patient ages with or without an Indwelling Urinary Catheter or IUC.
This includes SUTI 1-a, SUTI 1-b and SUTI 2.
As a result of this change in use of fever in SUTI, a patient greater than 65 years of
age with fever within the IWP and with or without an IUC in place for greater than 2
days on the date of event will no longer meet ABUTI but will meet SUTI 1-b.
NHSN provides the following guidance to establish a beginning point for applying the new criteria
for non-associated device UTI.
If the urine culture collection date occurs on or after January 1, 2021 and can be used
such that an NHSN urinary tract infection criterion can be met, the infection will be
assigned as a 2021 infection (that is the date of event will be in 2021) regardless
of the actual date of event determination or DOE.
This method of assignment for date of event only applies to the 2020 to 2021 transition period.
Another change is the removal of USI as a UTI specific type event.
The Urinary System Infection or USI is no longer a specific type event within the major event UTI.
USI is a major type event whose criterion can be seen in the Patient Safety Component Manual Chapter 17.
USI is available for secondary blood stream infection or BSI, assignment and as a specific
surgical site infection or SSI, organ/space infection site.
UTI and USI can occur simultaneously and each creates its own repeat infection timeframe,
or RIT, and secondary blood attribution period or SBAP.
NHSN provides the following guidance to establish a beginning point for applying the new criteria
for USI event type transition.
In general, if the diagnostic test date, or first sign or symptom in the absence of a
diagnostic test, occurs on or after January 1, 2021 and can be used such that an NHSN
USI site-specific infection criteria can be met, the infection will be assigned as a 2021
infection (that is the date of event will be in 2021) regardless of the actual date of event determination.
This method of assignment for date of event only applies to the 2020 to 2021 transition period.
Why the Changes to Urinary Tract Infection Protocol?
The Healthcare Infection Control Practices Advisory Committee or HICPAC recommended allowing
the use of fever for patients great than 65 years of age without an eligible IUC in place
to simplify the application of the UTI definitions.
The USI change provides clinical relevance.
Having USI as a specific event under UTI major event had the potential to preclude the ability
to have both an USI and a SUTI or ABUTI identified during the same RIT.
The change in 2021 allows both USI and UTI to be identified and both events reported.
This allows for more accurate event reporting.
Let's look at the 1st change, as it applies to SUTI where fever may be used as the only
sign or symptom within the IWP to meet UTI for all patient ages, there is no longer an
age restriction, with or without an IUC.
Next, let’s review a scenario that applies this change.
SUTI 1-b Scenario 1.
On March 25th a male patient, 67 years of age was admitted to an acute care hospital
for trauma; an IUC was inserted.
On March 26th the IUC was still in place; and the patient had a fever of 39.0 degrees Celsius.
On March 28th, the IUC was discontinued early in the morning then at noon the patient complained of urinary frequency.
On March 29th, a urine culture was collected and grew greater than 100,000 colony forming
units or CFUs per milliliter of E. coli The Determination.
We determine the event by setting the IPW using the date of the urine collection.
The IWP is defined as the 7-days during which all site-specific infection criteria must be met.
It includes the collection date of the urine, the 3 calendar days before and the 3 calendar days after.
In this case the IWP is March 26th through April 1st.
The first eligible element within the IWP is the fever which occurs on March 26th.
March 26th is the date of event or DOE.
The DOE occurred on the second day of admission.
The IUC was not in place greater than 2 consecutive days on the date of event.
The event is present on admission or POA and is determined to be a SUTI 1b.
For the next example a female, 79 years of age was admitted to an acute care hospital
for altered mental status on June 16th.
An IUC was present.
No fever was documented on admission nor were any other UTI symptoms or signs.
No UTI signs or symptoms were documented on June 17th or 18th.
On June 19th the patient became unresponsive and was transferred to the Intensive Care Unit
with a fever of 39.5 degrees Celsius.
An IUC was inserted.
On June 20th, a urine culture was collected that grew greater than 100,000 CFUs per milliliter of Klebsiella pneumoniae.
The Determination.
We determine the event by setting the IWP using the date of the urine collection.
In this case the IWP is June 17th through June 22nd using the urine collection date of June 20th.
The first eligible element within the IWP is the fever on June 19th.
The DOE is June 19th.
The DOE occurred on the 4th day of admission.
The IUC was not in place greater than 2 consecutive days.
The event is healthcare associated or HAI SUTI 1b.
When the HAI SUTI 1-b event is entered into the NHSN application, Urinary Catheter is
set to Neither-not catheter associated-Neither in place nor removed.
Fever is available for this patient who is greater than 65 years of age.
The application of change to ABUTI.
In 2020 Patients with or without an indwelling urinary catheter has no signs or symptoms
or SUTI 1 or 2 according to age.
Patients greater than 65 years of age with a non-catheter associated ABUTI may have a
fever and still meet the ABUTI criterion.
In 2021 patients with or without an indwelling urinary catheter must have no signs or symptoms
of SUTI 1 or 2 according to age for the ABUTI criterion to be met.
For an event to be considered an IUC associated the patient must have had an IUC in place
for more than 2 consecutive days in an inpatient location on the date of event, and the IUC
was in place on the date of event or the day before.
Catheter - associated ABUTI is reportable if Catheter – associated urinary tract infection
is in the facility’s reporting plan for the location.
When the Healthcare Acquired Infection ABUTI event is entered into NHSN, Urinary Catheter
is set to Neither-not catheter associated; Neither in place nor removed.
No signs or symptoms are available for this patient who is greater than 65 years of age.
The 3rd change to the UTI protocol is the removal of the Urinary System Infection or USI event.
USI events with a date of event January 1, 2021 or later will no longer be a site-specific
infection under the major infection UTI.
A UTI (symptomatic and asymptomatic urinary tract infection) and an USI event can be identified
during the same repeat infection timeframe.
Meeting UTI does not exclude the ability to identify an USI.
USI site-specific infection criteria can still be found in NHSN Patient Safety Component
Surveillance Definitions for Specific Types of Infections Chapter 17 and can be used for
secondary BSI assignment and as a specific SSI organ/space infection site.
In 2020 USI was a Specific Event under the UTI Event Type.
The image on the right shows how the change appears within the NHSN application in 2021
USI is an Event Type, on its own and is included in the dropdown listing.
In summary the changes reviewed apply to events with date of event January 1, 2021 or later.
Fever is an element that can be used to meet UTI in all ages of patients as well as catheter
or non-catheter associated events.
Urinary System Infection is removed from the NHSN UTI Protocol and remains in CDC/NHSN
Surveillance Definitions for Specific Types of Infections Chapter 17.
This concludes the NHSN Urinary Tract Infection Protocol Change.
If you have any questions regarding the content of this presentation, please contact nhsn@cdc.gov.