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Shmoury AH, Hanna W, Zakhour J, Zahreddine NK, Kanj SS. Epidemiology and microbiology of catheter-associated urinary tract infections: A 14-year surveillance study at a tertiary care center in Lebanon. J Infect Public Health 2024; 17:825-832. [PMID: 38537577 DOI: 10.1016/j.jiph.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 03/12/2024] [Accepted: 03/19/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are the most common device-associated healthcare-acquired infections and pose a significant burden on patients and healthcare systems worldwide. However, there is a paucity of data on CAUTI epidemiology and microbiology in the Middle East and North Africa (MENA) region, including Lebanon. METHODS This 14-year retrospective cohort study was conducted at a tertiary care center in Lebanon. It analyzed data on all adult patients diagnosed with CAUTI between January 2009 and December 2022 in intensive care units (ICUs) and between June 2011 and December 2022 in regular units. Incidence rates, urinary catheter utilization ratios, and microbiological profiles were collected and analyzed. RESULTS A total of 620 CAUTI cases were identified during the study period. The overall CAUTI rate was 2.4 per 1000 catheter-days, with higher rates in ICUs (3.2 per 1000 catheter-days) compared to regular units (1.4 per 1000 catheter-days). No significant changes in the rates were noted despite implementing many interventions. The most common pathogens were Gram-negative bacteria, with Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae being predominant. Multidrug-resistant organisms represented 48% of all isolates. Enterobacterales were largely extended-spectrum β-lactamase (ESBL) producing, and most Acinetobacter baumannii isolates showed multidrug resistance. CONCLUSIONS This study provides important insights into CAUTI epidemiology and microbiology in a tertiary care center in Lebanon, addressing the knowledge gap in this area in the MENA region. Despite implementing prevention measures, CAUTI rates remained stable over the 14-year period. The findings highlight the need for continuous improvement in infection prevention practices, diagnostic stewardship, and antimicrobial stewardship, especially given the rising threat of antimicrobial resistance. These results can serve as a guide for the development of targeted preventive strategies to reduce the burden of CAUTIs, particularly in low- and middle-income countries where antimicrobial resistance is a major issue.
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Affiliation(s)
- Abdel Hadi Shmoury
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wael Hanna
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johnny Zakhour
- Department of Internal Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nada Kara Zahreddine
- Infection Control and Prevention Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Souha S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon; Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon.
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Using statistical process control charts to measure changes from a nurse-driven protocol to remove urinary catheters. Am J Infect Control 2022; 50:1355-1359. [PMID: 35278490 DOI: 10.1016/j.ajic.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Implementing a nurse-driven protocol (NDP) to remove indwelling urinary catheters is a strategy to reduce catheter-associated urinary tract infections (CAUTI). The purpose of this project was to implement a comprehensive NDP to reduce indwelling urinary catheter utilization and CAUTI rates at a large academic health system. METHODS Statistical process control charts, a quality improvement method, was used to identify special cause variation. A formal protocol was developed to provide guidance for nurses to remove indwelling urinary catheters when no longer indicated. Changes were also made within the electronic health record. RESULTS Signals of improvement were not noted on the Statistical process control charts for urinary catheter utilization or CAUTI rates. The frequency with which the NDP was documented (process measure) was assessed, showing it is used approximately 600 times each month. Of those catheters removed by the NDP, an average of 6% were reinserted within 48 hours (balancing measure). DISCUSSION Our findings differed from other literature as we did not see a reduction in urinary catheter utilization after implementing a NDP. However, our project adds to the literature as we also evaluated process and balancing measures. CONCLUSIONS A NDP for urinary catheter removal provides nurses with the autonomy to remove catheters when no longer indicated; however, other interventions should be added to a comprehensive CAUTI-prevention program.
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Advani SD, Sickbert-Bennett E, Moehring R, Cromer A, Lokhnygina Y, Dodds-Ashley E, Kalu IC, DiBiase L, Weber DJ, Anderson DJ. The Disproportionate Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Healthcare-Associated Infections in Community Hospitals: Need for Expanding the Infectious Disease Workforce. Clin Infect Dis 2022; 76:e34-e41. [PMID: 35997795 PMCID: PMC9452131 DOI: 10.1093/cid/ciac684] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/26/2022] [Accepted: 08/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic had a considerable impact on US healthcare systems, straining hospital resources, staff, and operations. However, a comprehensive assessment of the impact on healthcare-associated infections (HAIs) across different hospitals with varying level of infectious disease (ID) physician expertise, resources, and infrastructure is lacking. METHODS This retrospective longitudinal multicenter cohort study included central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), Clostridioides difficile infections (CDIs), and ventilator-associated events (VAEs) from 53 hospitals (academic and community) in Southeastern United States from 1 January 2018 to 31 March 2021. Segmented negative binomial regression generalized estimating equations models estimated changes in monthly incidence rates in the baseline (01/2018-02/2020) compared to the pandemic period (03/2020-03/2021, further divided into three pandemic phases). RESULTS CLABSIs and VAEs increased by 24% and 34%, respectively, during the pandemic period. VAEs increased in all phases of the pandemic, while CLABSIs increased in later phases of the pandemic. CDI trend increased by 4.2% per month in the pandemic period. On stratifying the analysis by hospital characteristics, the impact of the pandemic on healthcare-associated infections was more significant in smaller sized and community hospitals. CAUTIs did not change significantly during the pandemic across all hospital types. CONCLUSIONS CLABSIs, VAEs, and CDIs increased significantly during the pandemic, especially in smaller community hospitals, most of which lack ID physician expertise. Future efforts should focus on better understanding challenges faced by community hospitals, strengthening the infection prevention infrastructure, and expanding the ID workforce, particularly to community hospitals.
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Affiliation(s)
- Sonali D Advani
- Corresponding Author: Sonali D. Advani MBBS, MPH, Assistant Professor of Medicine, Division of Infectious Diseases, Duke University School of Medicine, 315 Trent Drive, Hanes House, Room 154, Durham, NC, 27710, United States,
| | - Emily Sickbert-Bennett
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - Rebekah Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Andrea Cromer
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, US
| | - Elizabeth Dodds-Ashley
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
| | - Ibukunoluwa C Kalu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, NC, US
| | - Lauren DiBiase
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - David J Weber
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, US
| | - Deverick J Anderson
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, US,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, US
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Advani S, Vaughn VM. Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges. Curr Infect Dis Rep 2021; 23:16. [PMID: 34602864 PMCID: PMC8486281 DOI: 10.1007/s11908-021-00760-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting. RECENT FINDINGS Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood. SUMMARY Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.
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Affiliation(s)
- Sonali Advani
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Infection Control Outreach Network, Durham, NC, USA
| | - Valerie M. Vaughn
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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