Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle

Clinical outcomes of female external urine wicking devices as alternatives to indwelling catheters: a systematic review and meta-analysis

BACKGROUND

Female patients using indwelling urinary catheters (IUCs) are disproportionately at risk for developing catheter-associated urinary tract infections (CAUTIs) compared to males. Female external urine wicking devices (FEUWDs) have emerged as potential alternatives to IUCs for incontinence management.

OBJECTIVES

To assess the clinical risks and benefits of FEUWDs as alternatives to IUCs.

METHODS

Ovid MEDLINE, Embase, Scopus, Web of Science Core Collection, CINAHL Complete, and ClinicalTrials.gov were searched from inception to July 10, 2023. Included studies used FEUWDs as an intervention and reported measures of urinary tract infections and secondary outcomes related to incontinence management.

RESULTS

Of 2,580 returned records, 50 were systematically reviewed. Meta-analyses assessed rates of indwelling CAUTIs and IUC utilization. Following FEUWD implementation, IUC utilization rates decreased 14% (RR = 0.86, 95% CI = [0.76, 0.97]) and indwelling CAUTI rates nonsignificantly decreased up to 32% (IRR = 0.68, 95% CI = [0.39, 1.17]). Limited only to studies that described protocols for implementation, the incidence rate of indwelling CAUTIs decreased significantly up to 54% (IRR = 0.46, 95% CI = [0.32, 0.66]). Secondary outcomes were reported less routinely.

CONCLUSIONS

Overall, FEUWDs nonsignificantly reduced indwelling CAUTI rates, though reductions were significant among studies describing FEUWD implementation protocols. We recommend developing standard definitions for consistent reporting of non-indwelling CAUTI complications such as FEUWD-associated UTIs, skin injuries, and mobility-related complications.

Comparison of the Impact of COVID-19 on Veterans Affairs and Non-federal Hospitals: a Survey of Infection Prevention Specialists

BACKGROUND

As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock.

OBJECTIVE

To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic.

DESIGN

Cross-sectional national survey administered April 2021 through May 2022.

PARTICIPANTS

Lead infection preventionists from VA and non-federal hospitals across the US.

MAIN MEASURES

Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital's COVID response.

KEY RESULTS

The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, p<.001) and intensive care unit (24 vs. 16, p<.001) beds. VA hospitals were more likely to report no shortages of personal protective equipment or medical supplies during the pandemic (17% vs. 9%, p=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, p<.001) compared with non-federal hospitals. Non-federal hospitals more frequently experienced increased loss of staff due to resignations (76% vs. 53%, p=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p<0.001).

CONCLUSIONS

In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA's structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks.

Catheter-Associated Urinary Tract Infection (CAUTI)

One of the most prevalent health-related illnesses globally is catheter-associated urinary tract infection (CAUTI). CAUTIs account for almost half of all hospital-acquired diseases. Most of the healthcare-acquired urinary tract infections result from catheter tubes implantation. These tubes connect a collecting system and the urinary bladder via the urethra. These are known as indwelling urinary catheters. The length of catheterization has a key role in starting bacteriuria since biofilm eventually forms on all of these devices. Despite the low percentage of people with bacteriuria who start showing symptoms, there is nevertheless a significant burden associated with these contamination due to the repeated use of indwelling urinary devices. Minimizing indwelling device usage and stopping the catheter as soon as medically possible are the two most crucial preventative measures for bacteriuria and infection when device use is required. Efforts to avoid catheter-acquired urinary infections must be implemented and monitored by infection control guidelines in healthcare institutions. These approaches include monitoring device use, the suitability of device justifications, and problems. Ultimately, technological advancements in device substances that inhibit colony generation will be necessary to avoid these infestations. There is still some way by which we can bring down the increased phenomenon of catheter-associated urinary tract contamination by maintaining hygiene while handling the catheter and patients and keeping the infected patients away or isolated from unaffected patients as a precaution. This article mainly focuses on an overview that helps with discussing prevention, risk factors, diagnosis, control and management of CAUTI.

Budget impact analysis of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in New South Wales Hospitals

BACKGROUND

In hospitals, catheter acquired urinary tract infection causes significant resource waste and discomfort among admitted patients. An intervention for reducing indwelling catheterisations - No-CAUTI - was trialled across four hospitals in New South Wales, Australia. No-CAUTI includes: train-the-trainer workshops, site champions, compliance audits, and point prevalence surveys. The trial showed reductions on usual care catheterisation rates at 4- and 9-month post-intervention. This result was statistically non-significant; and post-intervention catheterisation rates rebounded between 4 and 9 months. However, No-CAUTI showed statistically significant catheterisation decreases for medical wards, female patients and for short-term catheterisations. This study presents a budget impact analysis of a projected five year No-CAUTI roll out across New South Wales public hospitals, from the cost perspective of the New South Wales Ministry of Health.

METHODS

Budget forecasts were made for five year roll outs of: i) No-CAUTI; and ii) usual care, among all public hospitals in New South Wales hosting overnight stays (n=180). The roll out design maintains intervention effectiveness with ongoing workshops, quality audits, and hospital surveys. Forecasts of catheterisations, procedures and treatments were modelled on No-CAUTI trial observations. Costs were sourced from trial records, the Medical Benefits Scheme, the Pharmaceutical Benefits Scheme and public wage awards. Cost and parameter uncertainties were considered with sensitivity scenarios.

RESULTS

The estimated five-year No-CAUTI roll-out cost was $1.5 million. It had an overall budget saving of $640,000 due to reductions of 100,100 catheterisations, 33,300 urine tests and 6,700 antibiotics administrations. Non-Metropolitan hospitals had a net saving of $1.2 million, while Metropolitan hospitals had a net cost of $0.54 million.

CONCLUSIONS

Compared to usual care, NO-CAUTI is expected to realise overall budget savings and decreases in catheterisations over five years. These findings allow a consideration of the affordability of a wide implementation.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12617000090314 ). First registered 17 January 2017, retrospectively. First enrolment, 15/11/2016.

Administration of indwelling urinary catheters in four Australian Hospitals: cost-effectiveness analysis of a multifaceted nurse-led intervention

BACKGROUND

Urinary catheters are useful among hospital patients for allowing urinary flows and preparing patients for surgery. However, urinary infections associated with catheters cause significant patient discomfort and burden hospital resources. A nurse led intervention aiming to reduce inpatient catheterisation rates was recently trialled among adult overnight patients in four New South Wales hospitals. It included: 'train-the trainer' workshops, site champions, compliance audits and promotional materials. This study is the 'in-trial' cost-effectiveness analysis, conducted from the perspective of the New South Wales Ministry of Health.

METHODS

The primary outcome variable was catheterisation rates. Catheterisation and procedure/treatment data were collected in three point prevalence patient surveys: pre-intervention (n = 1630), 4-months (n = 1677), and 9-months post-intervention (n = 1551). Intervention costs were based on trial records while labour costs were gathered from wage awards. Incremental cost effectiveness ratios were calculated for 4- and 9-months post-intervention and tested with non-parametric bootstrapping. Sensitivity scenarios recalculated results after adjusting costs and parameters.

RESULTS

The trial found reductions in catheterisations across the four hospitals between preintervention (12.0 % (10.4 - 13.5 %), n = 195) and the 4- (9.9 % (8.5 - 11.3 %), n = 166 ) and 9- months (10.2 % (8.7 - 11.7 %) n = 158) post-intervention points. The trend was statistically non-significant (p = 0.1). Only one diagnosed CAUTI case was observed across the surveys. However, statistically and clinically significant decreases in catheterisation rates occurred for medical and critical care wards, and among female patients and short-term catheterisations. Incremental cost effectiveness ratios at 4-months and 9-months post-intervention were $188 and $264. Bootstrapping found reductions in catheterisations at positive costs over at least 72 % of iterations. Sensitivity scenarios showed that cost effectiveness was most responsive to changes in catheterisation rates.

CONCLUSIONS

Analysis showed that the association between the intervention and changes in catheterisation rates was not statistically significant. However, the intervention resulted in statistically significant reductions for subgroups including among short-term catheterisations and female patients. Cost-effectiveness analysis showed that reductions in catheterisations were most likely achieved at positive cost.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000090314). First hospital enrolment, 15/11/2016; last hospital enrolment, 8/12/2016.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Strategies to reduce Gram-negative infections: a community perspective

Infections caused by Gram-negative bacteria continue to be on the rise, despite efforts by the Government and health service to curb their numbers. Most of these infections arise in the community. The case for targeting community-onset healthcare-associated infections is stark and requires a shift in focus from traditionally providing increased efforts in the hospital setting to a diversion of attention to the community. This article describes the challenges faced with increasing Gram-negative bloodstream infections and explores measures being taken to reduce transmission. As recent guidance has highlighted a proliferation within the community setting this article particularly focuses on a three-point plan for primary care. The strategies laid out are to reduce urinary tract infections, improve hydration and control antibiotic usage. Adopting these strategies will assist in reducing infection and targeting efforts where they are needed most.

Outcomes Associated With Insertion of Indwelling Urinary Catheters by Medical Students in the Operating Room Following Implementation of a Simulation-Based Curriculum

PURPOSE

Catheter-associated urinary tract infection (CAUTI) is a priority quality metric for hospitals. The impact of placement of indwelling urinary catheter (IUC) by medical students on CAUTI rates is not well known. This study examined the impact of a simulation-based medical student education curriculum on CAUTI rates at an academic medical center.

METHOD

Patient characteristics, procedural data, and outcome data from all operating room IUC insertions from June 2011 through December 2016 at the Northwestern University Feinberg School of Medicine were analyzed using a multivariable model to evaluate associations between CAUTI and inserting provider. Infection data before and after implementation of a simulation-based IUC competency course for medical students were compared.

RESULTS

A total of 57,328 IUC insertions were recorded during the study period. Medical students inserted 12.6% (7,239) of IUCs. Medical students had the lowest overall rate of CAUTI among all providers during the study period (medical students: 0.05%, resident/fellows: 0.2%, attending physicians: 0.3%, advanced practice clinicians: 0.1%, nurses: 0.2%; P = .003). Further, medical student IUC placement was not associated with increased odds of CAUTI in multivariable analysis (odds ratio, 0.411; 95% confidence interval: 0.122, 1.382; P = .15). Implementation of a simulation-based curriculum for IUC insertion resulted in complete elimination of CAUTI in patients catheterized by medical students (0 in 3,471).

CONCLUSIONS

IUC insertion can be safely performed by medical students in the operating room. Simulation-based skills curricula for medical students can be effectively implemented and achieve clinically relevant improvements in patient outcomes.

Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates

Background

Preventing central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) remains challenging in intensive care units (ICUs).

Objective

The Agency for Healthcare Research and Quality Safety Program for ICUs aimed to reduce CLABSI and CAUTI in units with elevated rates.

Methods

Invited hospitals had at least one adult ICU with elevated CLABSI or CAUTI rates, defined by a positive cumulative attributable difference metric (CAD >0) in the Centers for Disease Control and Prevention’s Targeted Assessment for Prevention strategy. This externally facilitated programme implemented by a national project team and state hospital associations included on-demand video modules and live webinars reviewing a two-tiered approach for implementing key technical and socioadaptive factors to prevent catheter infections, using principles and tools based on the Comprehensive Unit-based Safety Program. CLABSI, CAUTI and catheter use data were collected (preintervention 13 months, intervention 12 months). Multilevel negative binomial models assessed changes in catheter-associated infection rates and catheter use.

Results

Of 366 recruited ICUs from 220 hospitals in 16 states and Puerto Rico for two cohorts, 280 ICUs completed the programme including infection outcome reporting; 274 ICUs had complete outcome data for analyses. Statistically significant reductions in adjusted infection rates were not observed (CLABSI incidence rate ratio (IRR)=0.75, 95% CI 0.52 to 1.08, p=0.13; CAUTI IRR=0.79, 95% CI 0.59 to 1.06, p=0.12). Adjusted central line utilisation (IRR=0.97, 95% CI 0.93 to 1.00, p=0.09) and adjusted urinary catheter utilisation were unchanged (IRR=0.98, 95% CI 0.95 to 1.01, p=0.14).

Conclusion

This multistate programme targeted ICUs with elevated catheter infection rates, but yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilisation in the first two of six planned cohorts. Improvements in the interventions based on lessons learnt from these initial cohorts are being applied to subsequent cohorts.

Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre- and postintervention study

AIMS AND OBJECTIVES

This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted "bundled" care intervention.

BACKGROUND

Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate.

DESIGN

A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach.

METHODS

A multifaceted intervention involving a "No CAUTI" catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9 months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1).

RESULTS

A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9 months. Variability in preintervention IDC prevalence existed across hospitals (8%-16%). Variability in reduction was evident across hospitals at 4 months (between -2% and 4%) and 9 months (between 0%-8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided.

CONCLUSIONS

Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9 months postintervention.

RELEVANCE TO CLINICAL PRACTICE

Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based "No CAUTI" bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

Work systems analysis of sterile processing: decontamination

BACKGROUND

Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes.

OBJECTIVE

In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.

METHODS

The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix.

RESULTS

We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries.

CONCLUSIONS

Ensuring patients and technicians' safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.

Change in staff perspectives on indwelling urinary catheter use after implementation of an intervention bundle in seven Swiss acute care hospitals: results of a before/after survey study

OBJECTIVE

To evaluate changes in staff perspectives towards indwelling urinary catheter (IUC) use after implementation of a 1-year quality improvement project.

DESIGN

Repeated cross-sectional survey at baseline (October 2016) and 12-month follow-up (October 2017).

SETTING

Seven acute care hospitals in Switzerland.

PARTICIPANTS

The survey was targeted at all nursing and medical staff members working at the participating hospitals at the time of survey distribution. A total of 1579 staff members participated in the baseline survey (T₀) (49% response rate) and 1527 participated in the follow-up survey (T₁) (47% response rate).

INTERVENTION

A multimodal intervention bundle, consisting of an evidence-based indication list, daily re-evaluation of ongoing catheter need and staff training, was implemented over the course of 9 months.

MAIN OUTCOME MEASURES

Staff knowledge (15 items), perception of current practices and culture (scale 1-7), self-reported responsibilities (multiple-response question) and determinants of behaviour (scale 1-7) before and after implementation of the intervention bundle.

RESULTS

The mean number of correctly answered knowledge questions increased significantly between the two survey periods (T₀: 10.4, T₁: 11.0; p<0.001). Self-reported responsibilities with regard to IUC management by nurses and physicians changed only slightly over time. Perception of current practices and culture in regard to safe urinary catheter use increased significantly (T₀: 5.3, T₁: 5.5; p<0.001). Significant changes were also observed for determinants of behaviour (T₀: 5.3, T₁: 5.6; p<0.001).

CONCLUSION

We found small but significant changes in staff perceptions after implementation of an evidence-based intervention bundle. Efforts now need to be targeted at sustaining and reinforcing these changes, so that restrictive use of IUCs becomes an integral part of the hospital culture.

Quantitative Results of a National Intervention to Prevent Hospital-Acquired Catheter-Associated Urinary Tract Infection: A Pre-Post Observational Study

BACKGROUND

Many hospitals struggle to prevent catheter-associated urinary tract infection (CAUTI).

OBJECTIVE

To evaluate the effect of a multimodal initiative on CAUTI in hospitals with high burden of health care-associated infection (HAI).

DESIGN

Prospective, national, nonrandomized, clustered, externally facilitated, pre-post observational quality improvement initiative, for 3 cohorts active between November 2016 and May 2018.

SETTING

Acute care, long-term acute care, and critical access hospitals, including intensive care and non-intensive care wards.

PARTICIPANTS

Target hospitals had a high burden of Clostridioides difficile infection plus central line-associated bloodstream infection, CAUTI, or hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection, defined as cumulative attributable differences above the first tertile in the Targeted Assessment for Prevention (TAP) strategy. Some additional nonrecruited hospitals also joined.

INTERVENTION

Multimodal intervention, including Practice Change Assessment tool to identify infection prevention and control (IPC) and HAI prevention gaps; Web-based, on-demand modules involving onboarding, foundational IPC practices, HAI-specific 2-tiered approach to prioritize and implement interventions, and TAP resources; monthly webinars; state partner-led in-person meetings; and feedback. State partners made site visits to at least 50% of their enrolled hospitals, to support self-assessments and coach.

MEASUREMENTS

Rates of CAUTI and urinary catheter device utilization ratio.

RESULTS

Of 387 participating hospitals from 23 states and the District of Columbia, 361 provided CAUTI data. Over the study period, the unadjusted CAUTI rate was low and relatively stable, decreasing slightly from 1.12 to 1.04 CAUTIs per 1000 catheter-days. Catheter utilization decreased from 21.46 to 19.83 catheter-days per 100 patient-days from the pre- to the postintervention period.

LIMITATIONS

The intervention period was brief, with no assessment of fidelity. Baseline CAUTI rates were low. Patient characteristics were not assessed.

CONCLUSION

This multimodal intervention yielded no substantial improvements in CAUTI or urinary catheter utilization.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Supporting patients with long-term catheterisation to reduce risk of catheter-associated urinary tract infection

More than 90 000 of the UK adult population are estimated to have a urinary catheter, with 24% likely to develop symptoms of catheter-associated urinary tract infection (CAUTI). The consequences of having a CAUTI are reduced quality of life, risk of hospitalisation and increased mortality. The authors undertook a literature review of primary research studies to identify how nurses could support patients to maintain effective catheter care to reduce the risk of CAUTI. Four themes emerged: education, knowledge, empowerment and communication. The authors therefore conclude that consistent knowledge, clear communication and treating patients as partners in the decision-making process can help build trust and allow empower patients. This will enable patients to make safe and healthy decisions about their catheter, particularly with regard to personal hygiene and optimal fluid intake, to reducing the risk of CAUTI.

The evolution of catheter-associated urinary tract infection (CAUTI): Is it time for more inclusive metrics?

Catheter-associated urinary tract infection (CAUTI) has long been considered a preventable healthcare-associated infection. Many federal agencies, the Centers for Medicare and Medicaid Services (CMS), and public and private healthcare organizations have implemented strategies aimed at preventing CAUTIs. To monitor progress in CAUTI prevention, the National Healthcare Safety Network (NHSN) CAUTI metric has been adopted nationally as the primary outcome measure and has been refined over the past decades. However, this surveillance metric may underestimate infectious and noninfectious catheter harm. We suggest evolving to more inclusive performance metrics to better reflect quality improvement efforts underway in hospitals. The standardized device utilization ratio (SUR) provides a good surrogate for preventable catheter harm. On the other hand, a population-based metric that combines both standardized infection ratio (SIR) and SUR would address both infectious and noninfectious harm, while adjusting for population risk. Finally, electronically captured catheter-associated bacteriuria may contribute essential information on local testing stewardship.

Achieving balance between implementing effective infection prevention and control practices and maintaining a home-like setting in U.S. Department of Veterans Affairs nursing homes

Nursing homes present a unique challenge for implementing infection prevention and control practices while striving to maintain a home-like environment. Medical devices such as urinary catheters and central venous catheters have become a part of nursing home care but can predispose residents to associated infections. Because evidence-based prevention bundles were implemented, catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) were monitored in all U.S. Department of Veterans Affairs (VA) nursing homes, and outcomes were evaluated. Bundle components for CLABSIs focused on insertion technique, site selection, and routine assessment of central line necessity, while the CAUTI bundle focused on insertion technique, appropriate indication, and routine assessment of urinary catheter necessity. From October 2010 through September 2016, VA nursing homes reported nationwide reductions of CAUTIs (51.2%; P < .0001) and CLABSIs (25.0%; P = .0009).

Urinary Catheter-Associated Infections

Catheter-associated urinary tract infection remains one of the most prevalent, yet preventable, health care-associated infections. General prevention strategies include strict adherence to hand hygiene and antimicrobial stewardship. Duration of urinary catheterization is the most important modifiable risk factor. Targeted prevention strategies include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives should be considered. If catheterization is necessary, proper aseptic practices for insertion and maintenance and closed catheter collection systems are essential for prevention. The use of bladder bundles and collaboratives aids in the effective implementation of prevention measures.

Breaking the Chain of Infection in Older Adults: A Review of Risk Factors and Strategies for Preventing Device-Related Infections

Device-related infections (DRIs) are a significant cause of morbidity and mortality among older adults. Indwelling devices (urinary catheters, percutaneous feeding tubes, and central venous catheters) are frequently used in this vulnerable population. Indwelling devices provide a portal of entry for pathogenic organisms to invade a susceptible host and cause infection and are an important target for infection prevention and antimicrobial stewardship efforts. Within the "Chain of Infection" that leads to DRIs in older adults, multiple opportunities exist to implement interventions that "break the links" and reduce colonization with multidrug-resistant organisms, reduce infections, and improve antimicrobial use.

Reducing the rate of post-surgical urinary tract infections in orthopedic patients

Urinary tract infection (UTI) is the fourth leading cause of healthcare-associated infections, with approximately 70%-80% being attributed to the inappropriate use of indwelling catheters. In many cases, indwelling catheters are used inappropriately without any valid indication, creating potentially avoidable and significant patient distress, discomfort, pain and activity restrictions, together with substantial care burden, cost and hospitalisation. In the Division of Orthopedic Surgery at Toronto Western Hospital (TWH), we identified UTI rate reduction as a quality improvement priority. Patients who underwent total hip and knee joint replacements and hip fracture repairs at TWH were monitored for the incidence of UTI and the usage of catheters. The data collected as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) revealed UTI rate of 2.1% among 666 patients who were treated between January and June 2016. Data collected through a custom field in the ACS NSQIP workstation further revealed that indwelling catheters were overused, with 55.2% of patients receiving indwelling catheters in the same time period. These data were presented to the orthopaedic leadership group and surgeons at TWH in July 2016 to set the quality improvement target and create the working group. Nursing staff was provided education to strictly follow the institutional catheter-associated UTI prevention guidelines and change ideas based on the guidelines were implemented in July 2016. As a result, the rate of UTI decreased to 1.1% and the use of indwelling catheter decreased to 19.8% among 883 patients who were treated between July 2016 and March 2017. The study indicated that a systematic approach, engaging all front-line staff including nurse educators and nurse practitioners, helps to facilitate implementation of practice changes. We expect that ongoing reminders and education ensure that the changes are sustainable.

Decreasing Catheter-Associated Urinary Tract Infections in the Neurological Intensive Care Unit: One Unit's Success

BACKGROUND

Catheter-associated urinary tract infections are preventable adverse outcomes that increase hospital morbidity, mortality, and costs. These infections are particularly prevalent in intensive care units.

OBJECTIVES

To describe the success of an 18-bed neurological intensive care unit in using several nurse-implemented strategies that reduced the number of catheter-associated urinary tract infections.

METHODS

A prospective, interventional design with application of evidence-based practices to reduce catheter-associated urinary tract infections was used.

RESULTS

Before implementation of the strategies, 40 catheter-associated urinary tract infections were reported for 2012 and 38 for 2013. The standardized infection ratio was 2.04 for 2012 (95% CI, 1.456-2.775) and 2.34 (95% CI, 1.522-3.312) for 2013. After implementation of the strategies, significantly fewer catheter-associated urinary tract infections were reported. In 2014, a total of 15 infections were reported, and the standardized infection ratio was less than 1.0 (95% CI, 0.685-1.900).

CONCLUSIONS

Application of current evidence-based practices resulted in a substantial decrease in the number of catheter-associated urinary tract infections and a lower standardized infection ratio. These findings support current recommendations for "bundling" to maximize outcomes.

A flowchart for building evidence-based care bundles in intensive care: based on a systematic review

Purpose

The Institute for Healthcare Improvement is the founder of the care bundled approach and described the methods used on how to develop care bundles. However, other useful methods are published as well. In this systematic review, we identified what different methods were used to design care bundles in intensive care units. The results were used to build a comprehensive flowchart to guide through the care bundle design process.

Data sources

Electronic databases were searched for eligible studies in PubMed, EMBASE and CINAHL from January 2001 to August 2014.

Study selection

There were no restrictions on the types of study design eligible for inclusion. Methodological quality was assessed by using the Downs & Black-checklist or Appraisal of Guidelines, REsearch and Evaluation II.

Data extraction

Data extraction was independently performed by two reviewers.

Results of data synthesis

A total of 4665 records were screened and 18 studies were finally included. The complete process of designing bundles was reported in 33% (6/18). In 50% (9/18), one of the process steps was described. A narrative report was written about care bundles in general in 17% (3/18). We built a comprehensive flowchart to visualize and structure the process of designing care bundles.

Conclusion

We identified useful methods for designing evidence-based care bundles. We built a comprehensive flowchart to provide an overview of the methods used to design care bundles so that others could choose their own applicable method. It guides through all necessary steps in the process of designing care bundles.

TWOC around the clock: a multimodal approach to improving catheter care

BACKGROUND

Urinary tract infections (UTI) are the second-largest group of healthcare-associated infections (HCAI). The Saving Lives Urinary Catheter Care Bundle was introduced to reduce catheter-associated urinary tract infections (CAUTI). In response, we implemented a catheter care group to examine ways to improve catheter care in an acute hospital NHS Trust.

METHODS

We adopted a multimodal approach, revolving around four components: (1) Catheter Care Pathway; (2) HOUDINI checklist; (3) catheter magnets; and (4) use of bladder ultrasound scanners.

RESULTS

The yearly CAUTI prevalence survey showed an annual reduction in CAUTI from 2012-2013 to 2014-2015 (3.5% to 2.4%). Evaluations of the multimodal approach have highlighted limitations, leading to priorities being established around provision of tools, education, and use of measurement and feedback.

CONCLUSIONS

Our multimodal approach demonstrates CAUTI rate improvements are achievable, directly benefiting patients. However, long-term maintenance of multimodal components is required to ensure sustained benefit. Engagement and accountability have emerged as significant challenges to the effectiveness and longevity of the catheter care group. We suggest greater emphasis on such challenges if long-term national or international improvement is to be achieved.

Urinary Tract Infections

Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, yet preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Targeted strategies for prevention of CAUTI include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and closed catheter collection system is essential for preventing CAUTI. The use of "bladder bundles" and collaboratives aids in the effective implementation of CAUTI prevention measures.

The Project Protect Infection Prevention Fellowship: A model for advancing infection prevention competency, quality improvement, and patient safety

BACKGROUND

The Centers for Disease Control and Prevention 2016 Healthcare-Associated Infections (HAI) Progress Report documented no change in catheter-associated urinary tract infections (CAUTIs) between 2009 and 2014. There is a need for investment in additional efforts to reduce HAIs, specifically CAUTI. Quality improvement fellowships are 1 approach to expand the capacity of dedicated leaders and infection prevention champions.

METHODS

The fellowship used a model that expanded collaboration among disciplines and focused on partnership by recruiting a diverse cohort of fellows and by providing 1-on-1 mentoring to enhance leadership development. The curriculum supported the Association for Professionals in Infection Control and Prevention Competency Model in 2 domains: leadership and performance improvement and implementation science.

RESULTS

The fellowship was successful. The fellows and mentors had self-reported high level of satisfaction, fellows' knowledge increased, and they demonstrated leadership, quality improvement, and implementation science competency within the completed capstone projects.

CONCLUSIONS

A model encompassing diverse educational topics, discussions, workshops, and mentorship can serve as a template for developing infection prevention champions. Although this project focused on CAUTI, this template can be used in a variety of settings and applied to a range of other HAIs and performance improvement projects.

Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): a pre-post control intervention study

Background

Urinary tract infection (UTI) as the most common healthcare-associated infection accounts for up to 36% of all healthcare-associated infections. Catheter-associated urinary tract infection (CAUTI) accounts for up to 80% of these. In many instances indwelling urinary catheter (IDC) insertions may be unjustified or inappropriate, creating potentially avoidable and significant patient distress, embarrassment, discomfort, pain and activity restrictions, together with substantial care burden, costs and hospitalisation. Multifaceted interventions combining best practice guidelines with staff engagement, education and monitoring have been shown to be more effective in bringing about practice change than those that focus on a single intervention. This study builds on a nurse-led initiative that identified that significant benefits could be achieved through a systematic approach to implementation of evidence-based practice.

Methods

The primary aim of the study is to reduce IDC usage rates by reducing inappropriate urinary catheterisation and duration of catheterisation. The study will employ a multiple pre-post control intervention design using a phased mixed method approach. A multifaceted intervention will be implemented and evaluated in four acute care hospitals in NSW, Australia. The study design is novel and strengthened by a phased approach across sites which allows for a built-in control mechanism and also reduces secular effects. Feedback of point prevalence data will be utilised to engage staff and improve compliance. Ward-based champions will help to steward the change and maintain focus.

Discussion

This study will improve patient safety through implementation and robust evaluation of clinical practice and practice change. It is anticipated that it will contribute to a significant improvement in patient experiences and health care outcomes. The provision of baseline data will provide a platform from which to ensure ongoing improvement and normalisation of best practice. This study will add to the evidence base through enhancing understanding of interventions to reduce CAUTI and provides a prototype for other studies focussed on reduction of hospital acquired harms. Study findings will inform undergraduate and continuing education for health professionals.

Trial registration

ACTRN12617000090314. Registered 17 January 2017. Retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2268-2) contains supplementary material, which is available to authorized users.

Implementing clinical guidelines to prevent catheter-associated urinary tract infections and improve catheter care in nursing homes: Systematic review

BACKGROUND

Catheter-associated urinary tract infection is the most common health care-associated infection, is considered avoidable, and has cost implications for health services. Prevalence is high in nursing homes, but little research has been undertaken to establish whether implementing clinical guidelines can reduce infection rates in long-term care or improve quality of urinary catheter care.

METHODS

Systematic search and critical appraisal of the literature.

RESULTS

Three studies evaluated the impact of implementing a complete clinical guideline. Five additional studies evaluated the impact of implementing individual elements of a clinical guideline.

CONCLUSIONS

Prevention of catheter-associated urinary tract infection in nursing homes has received little clinical or research attention. Studies concerned with whole guideline implementation emerged as methodologically poor using recognized criteria for critically appraising epidemiologic studies concerned with infection prevention. Research evaluating the impact of single elements of clinical guidelines is more robust, and their findings could be implemented to prevent urinary infections in nursing homes.

Surface modification strategies for combating catheter-related complications: recent advances and challenges

This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.

Urinary Catheter Management for Nonurologists: A Resident Driven Educational Initiative

INTRODUCTION

Prevention of catheter associated urinary tract infection relies on timely catheter removal and care of indwelling catheters. Educational and quality improvement initiatives to prevent catheter associated urinary tract infection should address the basics of urinary catheter placement and management. Internal medicine residents are an appropriate target for these efforts and they may lack formal training in these issues. We developed a resident driven orientation session that covers basic Foley catheter management principles called the TIPS (Troubleshooting, Indications and Practice Sessions) program.

METHODS

Urology residents at our institution were queried on common consultations for urinary catheter related issues. The incoming intern internal medicine class at our institution completed a pre-TIPS survey that evaluated their baseline urological experience and knowledge. A 1-hour didactic session led by urology residents was followed by hands-on directed practice with mannequins. The web based survey was repeated 1 month later.

RESULTS

Of the total of 60 residents 54 (90%) completed the initial survey. In medical school 38 of 54 residents (70%) had never rotated in urology. Upon repeating the survey at 1 month the response rate was 34 of 60 residents (57%). The proportion of residents confident in their ability to troubleshoot catheter problems increased from 50% to 88% (p <0.05). Knowledge of indications, clot retention and proper catheter technique also improved (p <0.05).

CONCLUSIONS

A focused educational session about common urological catheter management scenarios resulted in improved internal medicine resident confidence in catheter troubleshooting and knowledge of basic urinary catheter placement indications. These educational sessions may be a method to improve nonurology resident education and awareness of common urological issues.

The effect of a short educational intervention on the use of urinary catheters: a prospective cohort study

Objective

To assess the effectiveness of implementation of evidence-based recommendations to reduce catheter-associated urinary tract infections (CAUTIs).

Design

Prospective cohort study, conducted in 2010-12, with a before and after design.

Setting

A major referral university hospital.

Participants

Data were collected before (n = 244) and 1 year after (n = 255) the intervention for patients who received urinary catheters.

Intervention

The intervention comprised two elements: (i) aligning doctors' and nurses' knowledge of indications for the use of catheters and (ii) an educational effort consisting of three 30- to 45-minute sessions on evidence-based practice regarding catheter usage for nursing personnel on 17 medical and surgical wards.

Main Outcome Measures

The main outcome measures were the proportion of (i) admitted patients receiving urinary catheters during hospitalization, (ii) catheters inserted without indication, (iii) inpatient days with catheter and (iv) the incidence of CAUTIs per 1000 catheter days. Secondary outcome measures were the proportion of (i) catheter days without appropriate indication and (ii) patients discharged with a catheter.

Results

There was a reduction in the proportion of inpatient days with a catheter, from 44% to 41% (P = 0.006). There was also a reduction in the proportion of catheter days without appropriate indication (P < 0.001) and patients discharged with a catheter (P = 0.029). The majority of catheters were inserted outside the study wards.

Conclusions

A short educational intervention was feasible and resulted in significant practice improvements in catheter usage but no reduction of CAUTIs. Other measures than CAUTI may be more sensitive to detecting important practice changes.

Qualitative validation of the CAUTI Guide to Patient Safety assessment tool

BACKGROUND

Hospital-acquired infection, including catheter-associated urinary tract infection (CAUTI), is common. Although CAUTI is usually preventable, hospital units may struggle to reduce CAUTI rates. The CAUTI guide to patient safety (GPS) was developed to assess a unit's CAUTI prevention activities. Our aim was to qualitatively validate the GPS.

METHODS

We interviewed participants from 2 units in each of 4 hospitals. Each unit's nurse manager completed the GPS and then discussed their answers with a trained research assistant. Semistructured interviews were conducted with unit nurses and physicians. We compared the nurse managers' answers to the unit physicians' and nurses' responses and assessed agreement.

RESULTS

A total of 49 participants from 4 medical intensive care units and 4 medical-surgical units were interviewed. Nurse managers found the GPS helpful and complete. There was higher agreement between nurse managers and unit nurses than with physicians. Some questions generated more disagreement than others. Our findings suggest that the GPS is comprehensive and may be best used to stimulate discussions between stakeholders to address key issues.

CONCLUSIONS

Using the GPS to assess several stakeholders' views could allow a given unit to move its CAUTI prevention efforts forward in a more informed manner.

Antimicrobial Resistance in the Intensive Care Unit

Bacterial infections are a frequent cause of hospitalization, and nosocomial infections are an increasingly common condition, particularly within the acute/critical care setting. Infection control practices and new antimicrobial development have primarily focused on gram-positive bacteria; however, in recent years, the incidence of infections caused by gram-negative bacteria has risen considerably in intensive care units. Infections caused by multidrug-resistant (MDR) gram-negative organisms are associated with high morbidity and mortality, with significant direct and indirect costs resulting from prolonged hospitalizations due to antibiotic treatment failures. Of particular concern is the increasing prevalence of antimicrobial resistance to β-lactam antibiotics (including carbapenems) among Pseudomonas aeruginosa and Acinetobacter baumannii and, recently, among pathogens of the Enterobacteriaceae family. Treatment options for infections caused by these pathogens are limited. Antimicrobial stewardship programs focus on optimizing the appropriate use of currently available antimicrobial agents with the goals of improving outcomes for patients with infections caused by MDR gram-negative organisms, slowing the progression of antimicrobial resistance, and reducing hospital costs. Newly approved treatment options are available, such as β-lactam/β-lactamase inhibitor combinations, which significantly extend the armamentarium against MDR gram-negative bacteria.

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care

BACKGROUND

Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI.

METHODS

The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates.

RESULTS

Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001).

CONCLUSIONS

A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).

Maintaining the Momentum of Change: The Role of the 2014 Updates to the Compendium in Preventing Healthcare-Associated Infections

Preventing healthcare-associated infections (HAIs) is a national priority. Although substantial progress has been achieved, considerable deficiencies remain in our ability to efficiently and effectively translate existing knowledge about HAI prevention into reliable, sustainable, widespread practice. “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates” is the product of a highly collaborative endeavor designed to support hospitals' efforts to implement and sustain HAI prevention strategies.

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Prevention of Device-Related Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in hospitalized patients. Up to 15% of patients develop an infection while hospitalized in the United States, which accounts for approximately 1.7 million HAIs, 99,000 deaths annually and over 10 billion dollars in costs per year. A significant percentage of HAIs are preventable using evidenced-based strategies. In terms of device-related HAIs it is estimated that 65-70% of catheter-line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are preventable. To prevent CLABSIs a bundle which includes hand hygiene prior to insertion and catheter manipulation, use of chlorhexidene alcohol for site preparation and maintenance, use of maximum barrier for catheter insertion, site selection, removing nonessential lines, disinfect catheter hubs before assessing line, and dressing changes are essential elements of basic practices. To prevent CAUTIs a bundle that includes hand hygiene for insertion and catheter or bag manipulation, inserting catheters for appropriate indications, insert using aseptic technique, remove catheters when no longer needed, maintain a close system keeping bag and tubing below the bladder are the key components of basic practices.

Emergency Department Catheter-Associated Urinary Tract Infection Prevention: Multisite Qualitative Study of Perceived Risks and Implemented Strategies

BACKGROUND

Existing knowledge of emergency department (ED) catheter-associated urinary tract infection (CAUTI) prevention is limited. We aimed to describe the motivations, perceived risks for CAUTI acquisition, and strategies used to address CAUTI risk among EDs that had existing CAUTI prevention programs.

METHODS

In this qualitative comparative case study, we enrolled early-adopting EDs, that is, those using criteria for urinary catheter placement and tracking the frequency of catheters placed in the ED. At 6 diverse facilities, we conducted 52 semistructured interviews and 9 focus groups with hospital and ED participants.

RESULTS

All ED CAUTI programs originated from a hospitalwide focus on CAUTI prevention. Staff were motivated to address CAUTI because they believed program compliance improved patient care. ED CAUTI prevention was perceived to differ from CAUTI prevention in the inpatient setting. To identify areas of ED CAUTI prevention focus, programs examined ED workflow and identified 4 CAUTI risks: (1) inappropriate reasons for urinary catheter placement; (2) physicians' limited involvement in placement decisions; (3) patterns of urinary catheter overuse; and (4) poor insertion technique. Programs redesigned workflow to address risks by (1) requiring staff to specify the medical reason for catheter at the point of order entry and placement; (2) making physicians responsible for determining catheter use; (3) using catheter alternatives to address patterns of overuse; and (4) modifying urinary catheter insertion practices to ensure proper placement.

CONCLUSIONS

Early-adopting EDs redesigned workflow to minimize catheter use and ensure proper insertion technique. Assessment of ED workflow is necessary to identify and modify local practices that may increase CAUTI risk.

Implementing a National Program to Reduce Catheter-Associated Urinary Tract Infection: A Quality Improvement Collaboration of State Hospital Associations, Academic Medical Centers, Professional Societies, and Governmental Agencies

Catheter-associated urinary tract infection (CAUTI) represents a significant proportion of healthcare-associated infections (HAIs). The US Department of Health and Human Services issued a plan to reduce HAIs with a target 25% reduction of CAUTI by 2013. Michigan's successful collaborative to reduce unnecessary use of urinary catheters and CAUTI was based on a partnership between diverse hospitals, the state hospital association (SHA), and academic medical centers. Taking the lessons learned from Michigan, we are now spreading this work throughout the 50 states. This national spread leverages the expertise of different groups and organizations for the unified goal of reducing catheter-related harm. The key components of the project are (1) centralized coordination of the effort and dissemination of information to SHAs and hospitals, (2) data collection based on established definitions and approaches, (3) focused guidance on the technical practices that will prevent CAUTI, (4) emphasis on understanding the socioadaptive aspects (both the general, unit-wide issues and CAUTI-specific challenges), and (5) partnering with specialty organizations and governmental agencies who have expertise in the relevant subject area. The work may serve in the future as a model for other large improvement efforts to address other hospital-acquired conditions, such as venous thromboembolism and falls.

Diagnosing inflammation and infection in the urinary system via proteomics

Background

Current methodology for the diagnosis of diseases in the urinary system includes patient symptomology, urine analysis and urine culture. Asymptomatic bacteriuria from urethral colonization or indwelling catheters, sample contamination from perineal or vaginal sources, and non-infectious inflammatory conditions can mimic UTIs, leading to uncertainty on medical treatment decisions.

Methods

Innovative shotgun metaproteomic methods were used to analyze urine sediments from 120 patients also subjected to conventional urinalysis for various clinical reasons including suspected UTIs. The proteomic data were simultaneously searched for the presence of microbial agents, inflammation, immune responses against pathogens, and evidence of urothelial tissue injury. Hierarchical clustering analysis was performed to identify host protein patterns discerning UTI from urethral colonization and vaginal contamination of urine samples.

Results

Organisms causing more than 98% of all UTIs and commensal microbes of the urogenital and perineal area were identified from 76 urine sediments with detection sensitivities estimated to be similar to urine culture. Proteomic data permitted a thorough evaluation of inflammatory and antimicrobial immune responses. Hierarchical clustering of the data revealed that high abundances of proteins from activated neutrophils were associated with pathogens in most cases, and correlated well with leukocyte esterase activities and leukocyte counts via microscopy. Proteomic data also allowed assessments of urothelial injury, by quantifying proteins highly expressed in red blood cells and contributing to the acute phase response. Lactobacillus and Gardnerella vaginalis were frequently identified suggesting urethral colonization and/or vaginal contamination of urine.

Conclusions

A metaproteomic approach of interest for routine urine clinical diagnostics is presented. As compared to urinalysis and urine culture methods, the data are derived from a single experiment for a given sample and provide additional insights into presence or absence of inflammatory responses and vaginal contamination of urine specimens.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-015-0475-3) contains supplementary material, which is available to authorized users.