We’d like to extend our sincerest gratitude to Katherine from Lifepoint Health for catching an error with this CDI scenario. The error has been corrected.
H&P: 85 yo F presents to the ED from home with abdominal pain and fatigue. UA was positive for UTI. Will obtain Urine Culture, replace foley, and start Levaquin while awaiting culture results.
PMH: Urinary retention w/chronic foley, PAF, HTN, CVA-no residual, rheumatoid arthritis
Home medications: metoprolol, methotrexate, leflunomide, coumadin
Vitals: 98.0, 78, 20, 136/82, RA 98%
PE: Elderly female, A&Ox3, Respiratory: Clear; Cardio: regular heart beat; GU: foley in place, cloudy urine; Musculoskeletal: slight deformity of hands, able to ambulate with walker.
Labs: Admission: WBC 14.3, Hgb 11.4
Day 2: Labs stable except: Urine Culture: e-coli, Sensitivity: resistance to ciprofloxacin. Will start Vancomycin
Discharge Summary: Patient admitted with UTI related to chronic foley. Was treated with IV Vancomycin and will continue at skilled nursing facility for total of 14 days. Patient to follow up with GU outpatient. Avoid large crowds, utilize a mask when out and about in the community, and practice good hand washing to decrease chance of infection.
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient is immunocompromised which puts her at a risk for antimicrobial resistance. She has a UTI related to chronic indwelling foley which is a high-risk circumstance for antimicrobial infections. The culture sensitivity states resistance to ciprofloxacin. The provider did not document the resistance to ciprofloxacin. The provider must document an infection has become drug resistant e.g. “resistant to ciprofloxacin” or “multi-drug resistant” per Pinson & Tang.
Diagnostic criteria for Antimicrobial Resistance:
- Urine culture sensitivity stating resistance to ciprofloxacin
Treatment for Antimicrobial Resistance:
- Vancomycin IV x14 days
UASI Recommends:
Query for antimicrobial resistance for a CC on this case
Also recommend query for immunodeficiency due to medications since the patient is on immunosuppressants (Methotrexate) for rheumatoid arthritis. This would provide an additional CC and HCC
Documentation without clarification:
Principal Diagnosis: T83.511A-Infection and inflammatory reaction d/t indwelling urethral catheter
Secondary Diagnosis: HTN, PAF, Rheumatoid arthritis, UTI
Working DRG: 700 Other kidney and urinary tract diagnoses w/CC
RW: 0.7408 GLMOS: 3.2 SOI/ROM: 2/1
Documentation with clarification:
Principal Diagnosis: T83.511A-Infection and inflammatory reaction d/t indwelling urethral catheter
Secondary Diagnosis: Z16.23-Resistance to quinolones and fluoroquinolones, D84.821-Immunodeficiency due to drugs, HTN, PAF, Rheumatoid arthritis, T45.1x5A-adverse effect of antineoplastic and immunosuppressive drugs, initial encounter
Working DRG: 699 Other kidney and urinary tract diagnoses w/CC
RW: 1.0121 GLMOS: 3.2 SOI/ROM: 2/1
CDI Educational Tips:
- Antimicrobial resistance (AMR) definition: When microbes including bacteria, fungi, parasites, and viruses no longer respond to a drug that previously treated them effectively. AMR can lead to the following issues:
- Infections that last longer, lengthen hospital stays, and are costlier to treat
- A higher risk of disease spreading
- A greater chance of fatality due to infection
- Most common drug-resistant organisms encountered among inpatients are: Staphylococcus aureus (MRSA), Enterococcus faecium (potential resistance to all currently used antibiotics), streptococcus pneumoniae (Pneumococcus), gram-negative coliforms (primarily Klebsiella pneumoniae and E. coli), Pseudomonas, Acinetobacter, Clostridium difficile (C. diff), Candida
- High-risk MDR circumstances may include:
- Immunosuppression of any cause
- Indwelling catheters
- Ventilator status / recently ventilated
- Recently hospitalized (especially ICU)
- Recent antibiotic therapy (especially broad-spectrum)
- Structural lung disease like bronchiectasis and cystic fibrosis (Pseudomonas)
- Personal history of an MDR infection or known MDR colonization
- Direct exposure to another person’s MDR infection in any setting but especially in home
- Most common situations associated with MDR infections are ventilator associated pneumonia (VAP), catheter-related bloodstream infection (CRBSI), and catheter-associated urinary tract infections (CAUTI)
- AMR is definitively diagnosed using culture and sensitivity/susceptibility testing
- “Antimicrobial resistance is a global health and development threat…Misuse and overuse of antimicrobials are the main drivers in the development of drug-resistant pathogens.” Antimicrobial resistance (who.int)
- “Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16 resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance” icd-10-cm Official Guidelines for Coding and Reporting FY 2023
- Resistance to antimicrobial drugs is classified under the Z16 category. The codes within this category provide a CC as a secondary diagnosis
- Instructional note: “code first the infections” An Excludes1 note identifies that codes from this group should not be assigned with combination codes that identify both the infection and the drug resistance:
- Methicillin-resistant staphylococcus aureus infection (A49.02)
- Methicillin -resistant staphylococcus aureus pneumonia (J15.212) Methicillin
- Sepsis due to Methicillin-resistant staphylococcus aureus (A41.02)
- A large percentage of those who contract antimicrobial-resistant infections are immunocompromised. Record review should seek to capture this if applicable
- Treatment of MDR infections typically requires one or more potent, broad-spectrum antibiotic like vancomycin, gentamicin, piperacillin, cefepime, imipenem/tazobactam often for 14 days or more
Resources:
2023 ACDIS pocket guide
Pinson & Tang pocket guide
Antimicrobial Resistance (who.int)
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.