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Zou Z, Potter RF, McCoy WH, Wildenthal JA, Katumba GL, Mucha PJ, Dantas G, Henderson JP. E. coli catheter-associated urinary tract infections are associated with distinctive virulence and biofilm gene determinants. JCI Insight 2023; 8:e161461. [PMID: 36512427 PMCID: PMC9977300 DOI: 10.1172/jci.insight.161461] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
Urinary catheterization facilitates urinary tract colonization by E. coli and increases infection risk. Here, we aimed to identify strain-specific characteristics associated with the transition from colonization to infection in catheterized patients. In a single-site study population, we compared E. coli isolates from patients with catheter-associated asymptomatic bacteriuria (CAASB) to those with catheter-associated urinary tract infection (CAUTI). CAUTI isolates were dominated by a phylotype B2 subclade containing the multidrug-resistant ST131 lineage relative to CAASB isolates, which were phylogenetically more diverse. A distinctive combination of virulence-associated genes was present in the CAUTI-associated B2 subclade. Catheter-associated biofilm formation was widespread among isolates and did not distinguish CAUTI from CAASB strains. Preincubation with CAASB strains could inhibit catheter colonization by multiple ST131 CAUTI isolates. Comparative genomic analysis identified a group of variable genes associated with high catheter biofilm formation present in both CAUTI and CAASB strains. Among these, ferric citrate transport (Fec) system genes were experimentally associated with enhanced catheter biofilm formation using reporter and fecA deletion strains. These results are consistent with a variable role for catheter biofilm formation in promoting CAUTI by ST131-like strains or resisting CAUTI by lower-risk strains that engage in niche exclusion.
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Affiliation(s)
- Zongsen Zou
- Center for Women’s Infectious Diseases Research
- Department of Internal Medicine, Division of Infectious Diseases
| | - Robert F. Potter
- The Edison Family Center for Genome Sciences and Systems Biology
- Department of Pathology and Immunology, and
| | - William H. McCoy
- Center for Women’s Infectious Diseases Research
- Department of Internal Medicine, Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John A. Wildenthal
- Center for Women’s Infectious Diseases Research
- Department of Internal Medicine, Division of Infectious Diseases
| | - George L. Katumba
- Center for Women’s Infectious Diseases Research
- Department of Internal Medicine, Division of Infectious Diseases
| | - Peter J. Mucha
- Department of Mathematics, Dartmouth College, Hanover, New Hampshire, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology
- Department of Pathology and Immunology, and
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, Missouri, USA
| | - Jeffrey P. Henderson
- Center for Women’s Infectious Diseases Research
- Department of Internal Medicine, Division of Infectious Diseases
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Chuang L, Tambyah PA. Catheter-associated urinary tract infection. J Infect Chemother 2021; 27:1400-1406. [PMID: 34362659 DOI: 10.1016/j.jiac.2021.07.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
This guideline contains updated recommendations on the management and prevention of CAUTIs by the Urological Association of Asia and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection.
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Affiliation(s)
- Leyland Chuang
- Raffles Internal Medicine Centre, Raffles Hospital, Singapore
| | - Paul Anantharajah Tambyah
- University Medicine Cluster, National University Health System, Singapore; Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Trautner BW, Morgan DJ. Imprecision Medicine: Challenges in Diagnosis, Treatment, and Measuring Quality for Catheter-Associated Urinary Tract Infection. Clin Infect Dis 2021; 71:e520-e522. [PMID: 32324234 DOI: 10.1093/cid/ciaa467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/21/2020] [Indexed: 01/19/2023] Open
Abstract
We question the reliability of the vague symptoms that most commonly define catheter-associated urinary tract infection (CAUTI) and encourage further examination of whether the current CAUTI definition reflects a true infection. While diagnosing CAUTI using the current surveillance definition, physicians may be missing a number of nonurinary etiologies for fever, prematurely diagnosing urinary tract infection, and prescribing unnecessary antibiotics. We believe it is time to reconsider the quality metric of CAUTI. By doing so, we can improve antibiotic use and quality of patient care.
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Affiliation(s)
- Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Departments of Medicine and Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel J Morgan
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Division of Genomic Epidemiology and Clinical Outcomes, Department of Epidemiology and Public Health, University of Maryland, Baltimore, Baltimore, Maryland, USA
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Advani SD, Gao CA, Datta R, Sann L, Smith C, Leapman MS, Hittelman AB, Sabetta J, Dembry LM, Martinello RA, Juthani-Mehta M. Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines. Open Forum Infect Dis 2019; 6:5532507. [PMID: 31375836 PMCID: PMC6677670 DOI: 10.1093/ofid/ofz305] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters. Methods We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines. Results On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures. Conclusions Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.
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Affiliation(s)
- Sonali D Advani
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Catherine A Gao
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Rupak Datta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence Sann
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cindy Smith
- Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Adam B Hittelman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Louise-Marie Dembry
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Richard A Martinello
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut.,Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Manisha Juthani-Mehta
- Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
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The evolution of catheter-associated urinary tract infection (CAUTI): Is it time for more inclusive metrics? Infect Control Hosp Epidemiol 2019; 40:681-685. [PMID: 30915925 DOI: 10.1017/ice.2019.43] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Tyson AF, Campbell EF, Spangler LR, Ross SW, Reinke CE, Passaretti CL, Sing RF. Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU. J Intensive Care Med 2018; 35:738-744. [PMID: 29886788 DOI: 10.1177/0885066618781304] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). METHODS We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. RESULTS Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). CONCLUSIONS Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.
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Affiliation(s)
- Anna F Tyson
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Eileen F Campbell
- Department of Infection Prevention, Carolinas Medical Center, Charlotte, NC, USA
| | - Lacey R Spangler
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel W Ross
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Caroline E Reinke
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | - Ronald F Sing
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Garcia R, Spitzer ED. Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017; 45:1143-1153. [PMID: 28476493 DOI: 10.1016/j.ajic.2017.03.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/16/2022]
Abstract
Published literature indicates that the unjustified ordering or improper collection of urine for urinalysis or culture from either catheterized patients or those without indwelling devices, or misinterpretation of positive results, often leads to adverse health care events, including increased financial burdens, overreporting of mandated catheter-associated urinary tract infection events, overtreatment of patients with antimicrobial agents, selection of multidrug-resistant organisms, and Clostridium difficile infection. Moreover, national guidelines that provide evidence-based direction on core processes that form the basis for subsequent clinical therapy decisions or surveillance interpretations; that is, the appropriate ordering and collection of urine for laboratory testing and the treatment of patients with symptomatic urinary tract infection, are not widely known or lack adherence. This article provides published evidence on the influence of inappropriate ordering of urine specimens and subsequent treatment of asymptomatic bacteriuria and associated adverse effects; reviews research on bacterial contamination and preservation; and delineates best practices in the collection, handling, and testing of urine specimens for culture or for biochemical analysis in both catheterized and noncatheterized patients. The goal is to provide infection preventionists (IPs) with a cohesive evidence-based framework that will assist them in facilitating the implementation of a urine culture management program that reduces patient harms, enhances the accuracy of catheter-associated urinary tract infection surveillance, improves antibiotic stewardship, and reduces costs.
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Clifford R, Sparks M, Hosford E, Ong A, Richesson D, Fraser S, Kwak Y, Miller S, Julius M, McGann P, Lesho E. Correlating Cleaning Thoroughness with Effectiveness and Briefly Intervening to Affect Cleaning Outcomes: How Clean Is Cleaned? PLoS One 2016; 11:e0155779. [PMID: 27196635 PMCID: PMC4873012 DOI: 10.1371/journal.pone.0155779] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/04/2016] [Indexed: 02/07/2023] Open
Abstract
Objectives The most efficient approach to monitoring and improving cleaning outcomes remains unresolved. We sought to extend the findings of a previous study by determining whether cleaning thoroughness (dye removal) correlates with cleaning efficacy (absence of molecular or cultivable biomaterial) and whether one brief educational intervention improves cleaning outcomes. Design Before-after trial. Setting Newly built community hospital. Intervention 90 minute training refresher with surface-specific performance results. Methods Dye removal, measured by fluorescence, and biomaterial removal and acquisition, measured with culture and culture-independent PCR-based assays, were clandestinely assessed for eight consecutive months. At this midpoint, results were presented to the cleaning staff (intervention) and assessments continued for another eight consecutive months. Results 1273 surfaces were sampled before and after terminal room cleaning. In the short-term, dye removal increased from 40.3% to 50.0% (not significant). For the entire study period, dye removal also improved but not significantly. After the intervention, the number of rooms testing positive for specific pathogenic species by culturing decreased from 55.6% to 36.6% (not significant), and those testing positive by PCR fell from 80.6% to 53.7% (P = 0.016). For nonspecific biomaterial on surfaces: a) removal of cultivable Gram-negatives (GN) trended toward improvement (P = 0.056); b) removal of any cultivable growth was unchanged but acquisition (detection of biomaterial on post-cleaned surfaces that were contaminant-free before cleaning) worsened (P = 0.017); c) removal of PCR-based detection of bacterial DNA improved (P = 0.046), but acquisition worsened (P = 0.003); d) cleaning thoroughness and efficacy were not correlated. Conclusion At this facility, a minor intervention or minimally more aggressive cleaning may reduce pathogen-specific contamination, but not without unintended consequences.
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Affiliation(s)
- Robert Clifford
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Michael Sparks
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Eve Hosford
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Ana Ong
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Douglas Richesson
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Susan Fraser
- Department of Infectious Diseases and Infection Control, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, United States of America
| | - Yoon Kwak
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Sonia Miller
- Department of Infectious Diseases and Infection Control, Fort Belvoir Community Hospital, Fort Belvoir, Virginia, United States of America
| | - Michael Julius
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Patrick McGann
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
| | - Emil Lesho
- Multidrug-resistant organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- * E-mail:
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