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

Urgent call for attention to diabetes-associated hospital infections

In this editorial, we discuss the recent article by Zhao et al published in the World Journal of Diabetes, which highlights the importance of recognizing the risk indicators associated with diabetes mellitus (DM). Given the severe implications of healthcare-associated infections (HAIs) in hospitalized individuals- such as heightened mortality rates, prolonged hospitalizations, and increased costs- we focus on elucidating the connection between DM and nosocomial infections. Diabetic patients are susceptible to pathogenic bacterial invasion and subsequent infection, with some already harboring co-infections upon admission. Notably, DM is an important risk factor for nosocomial urinary tract infections and surgical site infections, which may indirectly affect the occurrence of nosocomial bloodstream infections, especially in patients with DM with poor glycemic control. Although evidence regarding the impact of DM on healthcare-associated pneumonias remains inconclusive, attention to this potential association is warranted. Hospitalized patients with DM should prioritize meticulous blood glucose management, adherence to standard operating procedures, hand hygiene pra-ctices, environmental disinfection, and rational use of drugs during hospitalization. Further studies are imperative to explore the main risk factors of HAIs in patients with DM, enabling the development of preventative measures and mitigating the occurrence of HAIs in these patients.

Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis

BACKGROUND

Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use.

METHODS

The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates.

RESULTS

Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003).

CONCLUSION

A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.

A nurse-led multifaceted intervention for the optimal use of indwelling urinary catheters at a tertiary care center: A before-after trial

BACKGROUND

Few interventional studies of catheter-associated urinary tract infection (CAUTI) have been conducted to optimize indwelling urinary catheter (IUC) use in Japan.

METHODS

The nurse-led, before-after study was conducted at a tertiary care center from June 2018 through May 2022. The intervention included 1) the provision of appropriate indications for IUC use, 2) prospective feedback to the primary care providers by ward nurses on unnecessary/inappropriate IUC use with two, separate interventional phases, the first involving intensive care units (ICU) only, the second involving ICU and general wards, and 3) proactive feedback by Infectious diseases physicians in the Infection Control department to the primary care providers regarding IUC discontinuation upon discharge from the ICU.

RESULTS

During the first phase involving the implementation of the intervention only in the ICU, the indwelling urinary catheter-device utilization ratio (IUC-DUR) trend in the general wards decreased by 1.5 % (P = 0.01). However, the addition of the intervention to the general wards in the second phase led to a 2 % increase in the trend (P = 0.010). The CAUTI incidence in neither the ICU nor the general wards changed significantly.

CONCLUSIONS

Although providing feedback on IUC removal at discharge from the ICU and appropriate indications for urinary catheter insertion can reduce inappropriate urinary catheter use, the nurse-led intervention alone was inadequate for reducing the CAUTI incidence.

Urinary catheter alleviation navigator protocol (UCANP): Update to the hospital-wide implementation at a single tertiary health care center

BACKGROUND

Catheter-associated urinary tract infections are commonly reported health care-associated infections. It was demonstrated that the urinary catheter alleviation navigator protocol (UCANP) pilot resulted in a reduction of catheter utilization and catheter days.

METHODS

Quality improvement initiative that was implemented at a single urban, tertiary health care center, focusing on early discontinuation of indwelling urinary catheters (IUCs) and avoidance of reinsertion. The protocol was expanded hospital-wide from September 2020 to April 2022. We compared IUC utilization, IUC standardized utilization ratio (SUR), and catheter-associated urinary tract infection standardized infection ratio in the preintervention period (March 2020 to August 2020) to the postintervention period (May 2022 to October 2022).

RESULTS

Preimplementation, 2 patients with IUC removal were placed on UCANP. Postimplementation, 835 (45%) patients with IUC removal participated in the protocol. The number of patients requiring IUC reinsertion did not differ among the 2 groups. IUC utilization was significantly decreased from 0.28 to 0.24 with a 14% reduction (P = .025). SUR decreased by 11% from 0.778 to 0.693 (P = .007) and standardized infection ratio by 84% from 0.311 to 0.049 (P = .009).

CONCLUSIONS

Our protocol significantly reduced IUC utilization and SUR after hospital-wide implementation. UCANP is a safe and effective strategy that can potentially decrease unnecessary IUCs in patients with transient urinary retention.

The next frontier of healthcare-associated infection (HAI) surveillance metrics: Beyond device-associated infections

In recent years, it has become increasingly evident that surveillance metrics for invasive device-associated infections (ie, central-line-associated bloodstream infections, ventilator-associated pneumonias, and catheter-associated urinary tract infections) do not capture all harms; they capture only a subset of healthcare-associated infections (HAIs). Although prevention of device-associated infections remains critical, we need to address the full spectrum of potential harms from device use and non-device-associated infections. These include complications associated with additional devices, such as peripheral venous and arterial catheters, non-device-associated infections such as nonventilator hospital-acquired pneumonia, and noninfectious device complications such as trauma, thrombosis, and acute lung injury. As authors of the device-associated infection sections in the SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals, we highlight catheter-associated urinary tract infection as an example of the strengths and limitations of the current emphasis on device-associated infection surveillance, suggest performance metrics that present a more comprehensive picture of patient harm, and provide a high-level overview of similar issues with other infection surveillance measures.

Impact of Infection Prevention Programs on Catheter-Associated Urinary Tract Infections Analyzed in Multicenter Study

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) account for a large proportion of healthcare-associated infections and have a significant impact on morbidity, length of hospital stay, and mortality. Adherence to the recommended infection prevention practices can effectively reduce the incidence of CAUTIs. This study aimed to assess the characteristics of CAUTIs and the efficacy of prevention programs across hospitals of various sizes.

METHODS

Intervention programs, including training, surveillance, and monitoring, were implemented. Data on the microorganisms responsible for CAUTIs, urinary catheter utilization ratio, rate of CAUTIs per 1,000 device days, and factors associated with the use of indwelling catheters were collected from 2017 to 2019. The incidence of CAUTIs and associated data were compared between university hospitals and small- and medium-sized hospitals.

RESULTS

Thirty-two hospitals participated in the study, including 21 university hospitals and 11 small- and medium-sized hospitals. The microorganisms responsible for CAUTIs and their resistance rates did not differ between the two groups. In the first quarter of 2018, the incidence rate was 2.05 infections/1,000 device-days in university hospitals and 1.44 infections/1,000 device-days in small- and medium-sized hospitals. After implementing interventions, the rate gradually decreased in the first quarter of 2019, with 1.18 infections/1,000 device-days in university hospitals and 0.79 infections/1,000 device-days in small- and medium-sized hospitals. However, by the end of the study, the infection rate increased to 1.74 infections/1,000 device-days in university hospitals and 1.80 infections/1,000 device-days in small- and medium-sized hospitals.

CONCLUSION

We implemented interventions to prevent CAUTIs and evaluated their outcomes. The incidence of these infections decreased in the initial phases of the intervention when adequate support and personnel were present. The rate of these infections may be reduced by implementing active interventions such as consistent monitoring and adherence to guidelines for preventing infections.

Patient engagement to counter catheter-associated urinary tract infections with an app (PECCA): a multicentre, prospective, interrupted time-series and before-and-after study

BACKGROUND

The risk of urinary tract infections (UTIs) is increased by unnecessary placement and prolonged use of urinary catheters.

AIM

To assess whether inappropriate use of catheters and catheter-associated UTI were reduced through patient participation.

METHODS

In this multicentre, interrupted time-series and before-and-after study, we implemented a patient-centred app which provides catheter advice for patients, together with clinical lessons, feedback via e-mails and support rounds for staff members. Data on catheter use and infections were collected during a six-month baseline and a six-month intervention period on 13 wards in four hospitals in the Netherlands. Dutch Trial Register: NL7178.

FINDINGS

Between June 25th, 2018 and August 1st, 2019, 6556 patients were included in 24 point-prevalence surveys, 3285 (50%) at baseline and 3271 (50%) during the intervention. During the intervention 249 app users and a median of seven new app users per week were registered (interquartile range: 5.5-13.0). At baseline, inappropriate catheter use was registered for 175 (21.9%) out of 798 catheters, compared to 55 (7.0%) out of 786 during the intervention. Time-series analysis showed a non-significant decrease of inappropriate use of 5.8% (95% confidence interval: -3.76 to 15.45; P = 0.219), with an odds ratio of 0.27 (0.19-0.37; P < 0.001). Catheter-associated UTI decreased by 3.0% (1.3-4.6; P = 0.001), with odds ratio 0.541 (0.408-0.716; P < 0.001).

CONCLUSION

Although UTI significantly decreased after the implementation, patient participation did not significantly reduce the prevalence of inappropriate urinary catheter use. However, the inappropriate catheter reduction of 5.8% and an odds ratio of 0.27 suggest a positive trend. Patient participation appears to reduce CAUTI and could reduce other healthcare-associated infections.

Quality Indicators in Adult Critical Care Medicine

Quality indicators are increasingly used in the intensive care unit (ICU) to compare and improve the quality of delivered healthcare. Numerous indicators have been developed and are related to multiple domains, most importantly patient safety, care timeliness and effectiveness, staff well-being, and patient/family-centered outcomes and satisfaction. In this review, we describe pertinent ICU quality indicators that are related to organizational structure (such as the availability of an intensivist 24/7 and the nurse-to-patient ratio), processes of care (such as ventilator care bundle), and outcomes (such as ICU-acquired infections and standardized mortality rate). We also present an example of a quality improvement project in an ICU indicating the steps taken to attain the desired changes in quality measures.

Catheter-associated urinary tract infection (CAUTI) reduction in a neuroscience intensive care unit: A multidisciplinary approach

Utilizing a multidisciplinary approach to identify catheter-associated urinary tract infection (CAUTI) risks in Neuroscience intensive care patients admitted for aneurysmal subarachnoid hemorrhage, our CAUTI rate decreased from 5.903 per 1,000 catheter days (June 2020-June 2021) to 0.371 per 1,000 catheter days in our postintervention time period (July 2021-March 2023). A review of our clinical treatment guideline to optimize the timing of indwelling urinary catheters and medication management related to bowel regimens has resulted in a sustained CAUTI reduction, particularly in postaneurysmal subarachnoid hemorrhage patients in the Neuroscience intensive care unit.

Perfluoropolyether-incorporated polyurethane with enhanced antibacterial and anti-adhesive activities for combating catheter-induced infection

To avoid the undesired bacterial attachment on polyurethane-based biomedical devices, we designed a class of novel perfluoropolyether-incorporated polyurethanes (PFPU) containing different contents of perfluoropolyether (PFPE) segments. After blending with Ag nanoparticles (AgNPs), a series of bifunctional PFPU/AgNPs composites with bactericidal and anti-adhesion abilities were obtained and correspondingly made into PFPU/AgNPs films (PFPU/Ag-F) using a simple solvent-casting method. Due to its highest hydrophobicity and suitable mechanical properties, PFPU8/Ag-F containing 8 mol% of PFPE content was chosen as the optimized one for the next antibacterial assessment. The PFPU8/Ag-F can effectively deactivate over 99.9% of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) cells at 106 CFU mL-1 within 30 min. Furthermore, the PFPU8/AgNPs composite was used as painting material to form a protective coating for the commercial polyurethane (PU) catheter. The as-prepared PFPU8/Ag coating exhibits high resistance to bacterial adhesion in a continuous-flow artificial urine model in an 8 day exposure. Therefore, it can be expected that the proposed PFPE-containing films and coatings can effectively prevent bacterial colonization and biofilm formation on catheters or other implants, thereby reducing the risk of postoperative catheter-induced infection.

Anti-infective Efficacy of Duloxetine against Catheter-Associated Urinary Tract Infections Caused by Gram-Positive Bacteria

Catheter-associated urinary tract infections (CAUTIs) frequently occur following the insertion of catheters in hospitalized patients, often leading to severe clinical complications. These complications are exacerbated by biofilm-forming organisms such as Staphylococcus aureus, contributing to the emergence of multidrug-resistant (MDR) strains, which complicates treatment strategies. This study aims to investigate the antibacterial, antibiofilm, and antiadhesive properties of duloxetine against S. aureus in the context of CAUTI. Our findings demonstrate that duloxetine exhibits significant antibacterial activity, as evidenced by the agar diffusion method. A minimal inhibitory concentration (MIC) of 37.5 μg/mL was established using the microdilution method. Notably, duloxetine displayed inhibitory effects against biofilm formation on polystyrene surfaces up to its MIC level, as demonstrated by the crystal violet method. Intriguingly, the study also revealed that duloxetine could prevent biofilm formation at lower concentrations and reduce mature biofilms, as confirmed by scanning electron microscopy (SEM) and quantitative biofilm assays. Furthermore, duloxetine-coated silicone catheter tubes exhibited antibacterial properties against S. aureus in a bladder model, visualized by confocal laser scanning microscopy (CLSM) and corroborated through FDA and PI staining, highlighting noticeable morphological changes in S. aureus post-treatment. In conclusion, this study presents duloxetine as a promising alternative agent with antibacterial and antiadhesive properties against S. aureus in the prevention and management of CAUTI, warranting further exploration in the clinical setting.

Healthcare workers' compliance with the catheter associated urinary tract infection prevention guidelines: an observational study in Yemen

BACKGROUND

Catheter-associated urinary tract infection is a global problem but it can be prevented with the appropriate implementation of evidence-based guidelines. This study was conducted to assess the level of compliance of healthcare workers with the catheter-associated urinary tract infection prevention guidelines during the insertion of a urinary catheter.

METHODS

An observational study using a descriptive cross-sectional design was conducted at Sana'a City hospitals, Yemen. All the nurses and physicians from the governmental, teaching, and private hospitals were eligible to participate in the study. The data collection was performed through convenience sampling from March 2020 to December 2020, using a structured observational checklist prepared specifically for this study.

RESULTS

The majority of the urinary catheter insertions were performed by nurses. There were no written policy or procedures for an urinary catheter insertion and no in-service education or training departments in the majority of the hospitals. The overall mean score of compliance was 7.31 of 10. About 71% of the healthcare workers had a high or acceptable level of compliance and 29% had an unsafe level of compliance. Compliance was low for maintaining aseptic technique throughout the insertion procedure, using a single use packet of lubricant jelly, performing hand hygiene immediately before insertion, and securing the urinary catheter once inserted. Factors affecting the healthcare workers compliance were gender, the working ward/unit of the healthcare workers, the availability of a written policy/procedure and a department or unit for in-service education.

CONCLUSION

Yemeni healthcare workers' overall compliance was acceptable but it was unsafe in several critical measures. There is an urgent need for developing, implementing, and monitoring national guidelines and institutional policy and procedures for catheter-associated urinary tract infection prevention. Periodical in-service education and training programs and adequate access to the necessary materials and supplies are paramount.

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: Results from a national survey in the United States

OBJECTIVE

The ways that device-associated infection prevention practices changed during the coronavirus disease 2019 (COVID-19) pandemic remain unknown. We collected data mid-pandemic to assess the use of several infection prevention practices and for comparison with historical data.

DESIGN

Repeated cross-sectional survey.

SETTING

US acute-care hospitals.

PARTICIPANTS

Infection preventionists.

METHODS

We surveyed infection preventionists from a national random sample of 881 US acute-care hospitals in 2021 to estimate the current use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated events (VAE). We compared the 2021 results with those from surveys occurring every 4 years since 2005.

RESULTS

The 2021 survey response rate was 47%; previous survey response rates ranged from 59% to 72%. Regular use of most practices to prevent CLABSI (chlorhexidine gluconate for site antisepsis, 99.0%, and maximum sterile barrier precautions, 98.7%) and VAE (semirecumbent positioning, 93.4%, and sedation vacation, 85.8%) continued to increase or plateaued in 2021. Conversely, use of several CAUTI prevention practices (portable bladder ultrasound scanner, 65.6%; catheter reminders or nurse-initiated discontinuation, 66.3%; and intermittent catheterization, 37.3%) was lower in 2021, with a significant decrease for some practices compared to 2017 (P ≤ .02 for all comparisons). In 2021, 42.1% of hospitals reported regular use of the newer external urinary collection devices for women.

CONCLUSIONS

Although regular use of CLABSI and VAE preventive practices continued to increase (or plateaued), use of several CAUTI preventive practices decreased during the COVID-19 pandemic. Structural issues relating to care during the pandemic may have contributed to a decrease in device-associated infection prevention practices.

Controlled swelling of biomaterial devices for improved antifouling polymer coatings

Nonspecific interactions between cells and implantable elastomers often leads to failure modes for devices such as catheters, cosmetic and reconstructive implants, and sensors. To reduce these interactions, device surfaces can be coated with hydrophilic polymers, where greater polymer density enhances antifouling properties. Although graft-from coating techniques result in higher density polymer films and lower fouling in controlled settings, simpler graft-to methods show similar results on complex implanted devices, despite limited density. To address the need for improved graft-to methods, we developed Graft then shrink (GtS) where elastomeric materials are temporarily swollen during polymer grafting. Herein, we demonstrate a graft-to based method for poly(oligo(ethylene glycol) methyl ether methacrylate) (pOEGMA) on swollen silicone, GtS, that enhances grafted polymer content and fouling resistance. Total grafted polymer content of pOEGMA on toluene swollen silicone increased over ~ 13 × compared to non-swollen controls, dependent on the degree of silicone swelling. Increases in total grafted polymer within the top 200 µm of the material led to bacterial and mammalian cell adhesion reductions of 75% and 91% respectively, compared to Shrink then Graft (StG) antifouling polymer coated controls. GtS allows for the simple 3D coating of swellable elastomers (e.g., silicone medical devices) with improved antifouling pOEGMA coatings.

Bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings: A scoping review

AIM

To identify and map bedside nurses' practice scope and competencies regarding antimicrobial stewardship in acute hospital settings, and develop a competency framework for them.

BACKGROUND

Antimicrobial stewardship requires multidisciplinary engagement including nursing. However, bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings remain unclear.

DESIGN

Scoping review.

METHODS

Using a five-stage framework proposed by Arksey and O'Malley and following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 1422 records were retrieved, and 41 studies were included. In addition to the six practices recommended, this review summarized bedside nurses' contributions to five additional fields as well. Correspondingly, the competencies required by bedside nurses were summarized into eight domains: specialized knowledge, safety medication administration, leadership, education, diagnostic stewardship, infection prevention and control, professional development and professional quality.

CONCLUSION

Nurses' practice scope overlaps greatly with routine nursing practice in antimicrobial stewardship, confirming the evidence that nurses are ideal partners in antimicrobial stewardship. This review developed a competency framework at both basic and advanced levels. Among them, professional knowledge is the foundation, while professional quality motivates nurses to participate. In addition to competency assessment, it can also be used for training and human resource deployment based on seniority or professional level. This could bridge the knowledge gap and improve the engagement of nurses in heavy workload situations.

RELEVANCE TO CLINICAL PRACTICE

This practice scope will provide opportunities for nurses to engage in antimicrobial stewardship. Moreover, nursing competencies identified in this field could facilitate the development of competency-based education interventions, talent assessments, training and recruitment programs.

DATA RESOURCES

PubMed, EMBASE, Web of Science, CINHAL, PsycINFO, Cochrane Library, ProQuest and Scopus were searched from inception to November 2022, with an updated search in March 2023.

IMPACT

This scoping review provides evidence for best nursing practice scope and competency in antimicrobial stewardship in hospitals. However, it is also in line with the commitment of all nurses in the global community to combat antimicrobial resistance, which has become a global threat. An antimicrobial stewardship competency framework for bedside nurses was developed at both the basic and advanced levels. It would facilitate talent assessment, training, recruitment and human resource management by guiding the development of competency-based education interventions.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Implementing strategies to prevent infections in acute-care settings

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Antibiotic Selection and Duration for Catheter-Associated Urinary Tract Infection in Non-Hospitalized Older Adults: A Population-Based Cohort Study

Background

We sought to evaluate the impact of antibiotic selection and duration of therapy on treatment failure in older adults with catheter-associated urinary tract infection (CA-UTI).

Methods

We conducted a population-based cohort study comparing antibiotic treatment options and duration of therapy for non-hospitalized adults aged 66 and older with presumed CA-UTI (defined as an antibiotic prescription and an organism identified in urine culture in a patient with urinary catheterization documented within the prior 90 d). The primary outcome was treatment failure, a composite of repeat urinary antibiotic prescribing, positive blood culture with the same organism, all-cause hospitalization or mortality, within 60 days. We determined the risk of treatment failure accounting for age, sex, comorbidities, and healthcare exposure using log-binomial regression.

Results

Of 4,436 CA-UTI patients, 2,709 (61.1%) experienced treatment failure. Compared to a reference of TMP-SMX (61.9% failure), of those treated with fluoroquinolones, 56.3% experienced failure (RR 0.91, 95% CI: 0.85-0.98) and 60.9% of patients treated with nitrofurantoin experienced failure (RR 1.02, 95% CI: 0.94-1.10). Compared to 5-7 days of therapy (treatment failure: 59.4%), 1-4 days was associated with 69.5% failure (RR 1.15, 95% CI: 1.05-1.27), and 8-14 days was associated with a 62.0% failure (RR 1.05, 95% CI: 0.99-1.11).

Conclusions

Although most treatment options for CA-UTI have a similar risk of treatment failure, fluoroquinolones, and treatment durations ≥ 5 days in duration appear to be associated with modestly improved clinical outcomes. From a duration of therapy perspective, this study provides reassurance that relatively short courses of 5-7 days may be reasonable for CA-UTI.

APSIC guide for prevention of catheter associated urinary tract infections (CAUTIs)

BACKGROUND

The Asia Pacific Society of Infection Control launched the APSIC guide for prevention of catheter associated urinary tract infections in July 2022. It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities in the Asia Pacific region to achieve high standards in infection prevention and control practices during the management and care of patients with a urinary catheter.

METHODS

The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.

RESULTS

It recommends that healthcare institutions have a catheter associated urinary tract infection prevention program that includes surveillance and the use of the insertion and maintenance bundles. Implementation of the bundles is best done using a quality improvement approach with a multidisciplinary team.

CONCLUSIONS

Healthcare facilities should aim for excellence in care of patients with urinary catheters. It is recommended that healthcare facilities have a catheter associated urinary tract infection prevention program as part of their Infection Prevention and Control program.

Catheter-associated urinary tract infection and urinary catheter utilization ratio over 9 years, and the impact of the COVID-19 pandemic on the incidence of infection in medical and surgical wards in a single facility in Western Qatar

INTRODUCTION

Catheter-associated urinary tract infection (CAUTI) is a frequently reported healthcare-associated infection in critical and non-critical patients. Limited data are available about CAUTI incidence in non-critical patients. We aim to describe the incidence of CAUTI over 9 years and evaluate the impact of the pandemic on the incidence in non-critical acute care patients.

METHODS

A retrospective observational study of CAUTI in medical-surgical and maternity wards was carried out at a public hospital in the west of the State of Qatar. Data collected included the annual CAUTI incidence (per 1,000 device days), urinary catheter utilization ratio (UC-UR), etiology, and antimicrobial resistance.

RESULTS

115,238 patient days and 6,681 urinary catheters (UC) days were recorded over the study period, and 9 and 4 CAUTI were confirmed in medical-surgical and maternity wards, respectively. The infection rate was 1.9 per 1,000 UC days, and the UC-UR was 0.06. The CAUTI rate was higher in medical-surgical wards over the COVID-19 period (2.4 × 1,000 UC days) in comparison with the non-COVID-19 period (1.7 × 1,000 UC days) (RR 1.46; 1.12-1.80). However, in the maternity ward, the result was 0 and 2.5 × 1,000 UC days during these periods, respectively. No differences were observed in the infection rate among periods for all patients (RR 1.06; 0.81-1.31). Multidrug-resistant organisms were identified in 7 patients, and non-multidrug-resistant in 6 cases.

CONCLUSION

The study findings describe a lower CAUTI risk over 9 years in non-critical acute care patients. The impact of COVID-19 on the CAUTI risk is mainly related to medical patients who had previously been admitted to critical care. The infection control program should consider these data as a benchmark for quality improvement.

Urinary catheterization prior to PCI worsens clinical outcomes in patients with acute myocardial infarction

BACKGROUND

Indwelling urethral catheters (IUCs) are used to measure urine volume, keep patients on bed rest, or keep the groin area clean in patients with acute myocardial infarction (AMI). However, the association between IUC use and in-hospital urinary-related complications is unknown.

METHODS

This was a single-center retrospective analysis of 303 patients admitted to our hospital in 2018-2020 who had AMI without cardiogenic shock. An IUC was inserted in the emergency room upon initiation of invasive catheter treatment and removed as soon as possible. The primary outcome was in-hospital adverse urinary event (IHAUE), which consisted of in-hospital urinary tract infection and in-hospital gross hematuria.

RESULTS

Of 303 patients, 243 patients (80.2 %) underwent IUC insertion. A lower proportion of patients with IUCs were male (72 % vs. 85 %, p = 0.044). A higher proportion had Killip classification 2 or 3 (13 % vs. 0 %, p = 0.003) or ST-elevation myocardial infarction (65 % vs. 32 %, p < 0.001). IHAUEs occurred significantly more commonly in patients with IUCs than without IUCs (11 % vs. 2 %, p = 0.023). Kaplan-Meier analysis showed that IHAUEs occurred more frequently in patients with IUCs than patients without IUCs (log-rank test p = 0.033). Furthermore, IUC use longer than the median of 2 days was associated with a higher odds ratio (OR) for IHAUE when compared with those without IUC use (OR, 3.65; 95 % confidence interval, 1.28-10.4; p = 0.015). There were no significant differences in in-hospital mortality by IUC status.

CONCLUSIONS

IUC use is associated with a higher risk of IHAUEs in patients with uncomplicated AMI. Routine IUC use might not be recommended.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Prediction of Catheter-Associated Urinary Tract Infections Among Neurosurgical Intensive Care Patients: A Decision Tree Analysis

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the most common device-associated infections in hospitals and can be prevented. To identify the risk factors and develop a risk prediction model for CAUTIs among neurosurgical intensive care unit (NICU) patients.

METHODS

All patients admitted to the NICU of a tertiary hospital between January 2019 and January 2020 were enrolled. Two decision tree models were applied to analyze the risk factors associated with CAUTIs in NICU patients. The performance of the decision tree model was evaluated.

RESULTS

A total of 537 patients admitted to the NICU with indwelling catheters were recruited for this study. The rate of CAUTIs was 4.44 per 1000 catheter days, and Escherichia coli was the predominant pathogen causing CAUTIs among indwelling catheter patients. The classification and regression tree model displayed good power of prediction (area under the curve : 0.920). Nine CAUTI risk factors (age ≥60 years (P = 0.004), Glasgow Coma Scale score ≤8 (P = 0.009), epilepsy at admission (P = 0.007), admission to the hospital during the summer (P < 0.001), ventilators use (P = 0.007), receiving less than 2 types of antibiotics (P < 0.001), albumin level <35 g/L (P = 0.002), female gender (P = 0.002), and having an indwelling catheter for 7-14 days (P = 0.001) were also identified.

CONCLUSION

We developed a novel scoring model for predicting the risk of CAUTIs in patients with neuro-critical illness in daily clinical practice. This model identified several risk factors for CAUTI among NICU patients, novel factors including epilepsy and admission during the summer, can be used to help providers prevent and reduce the risk of CAUTI among vulnerable groups.

Catheter-associated urinary tract infection: an overview

CAUTIs (catheter-associated urinary tract infections) continue to be one of the most common health-care-related illnesses in the entire globe. CAUTIs are the cause of 40% of all hospital-acquired infections and 80% of all nosocomial urinary tract infections (UTIs). A urine catheter is implanted into a high percentage of inpatients at some point during their hospitalization, and indwelling urinary catheter adoption likely to be on the rise. Urinary catheters, made of plastic materials, inhibit the urinary tract's natural defence mechanisms and enhance the bacterial colonization or biofilm formation on the catheter surface, which may cause CAUTIs. It is associated with increased burden of disease, mortality, hospital bills and length of hospital stay. Therefore, to prevent these infections, technological innovations in catheter materials that limit biofilm formation will be required. Unfortunately, many health-care practitioners are unclear of the precise indications for bladder catheterization and accurate CAUTI criteria, which can lead to unnecessary catheterization, antibiotic overuse for asymptomatic bacteriuria and the spread of resistant organisms. As a result, we discuss CAUTIs in general, including definitions, pathophysiology, causation, indications for catheterization and a variety of effective CAUTI-fighting strategies.

Knowledge, attitudes and practices concerning catheter-associated urinary tract infection amongst healthcare workers: a mixed methods systematic review

AIM

To evaluate healthcare workers' knowledge, attitudes and practices level of prevention and management of catheter-associated urinary tract infection.

DESIGN

A mixed-methods systematic review.

METHODS

Searches were conducted in CINAHL, Cochrane Library, EMBASE, Medline, PubMed and Web of Science databases. Limited literatures published in English before 20 June 2021. Data were analysed and synthesized using thematic analysis by two authors.

RESULTS

Thirty-four articles were included. Healthcare workers' unbalanced varied knowledge level, positive attitudes, undesirable practices of catheter-associated urinary tract infection's prevention and control were identified. Barriers of healthcare workers' knowledge, attitudes and practices level of infection prevention included heavy workload, understaffing, physician variability in indwelling urinary catheter (IUC) practice by diagnosis, nursing variability in IUC placement technique, poor relationship and nurse's poor documentation. Leadership, better education, teamwork, technique training and information technology support, advocacy for nurse-driven protocol and IUC removal reminder were considered as facilitators.

Effectiveness and safety of a program for appropriate urinary catheter use in stroke care: A multicenter prospective study

OBJECTIVES

Since patients with stroke frequently develop bladder dysfunction, a careful approach is required to reduce unnecessary indwelling urinary catheter (IUC) for preventing catheter-associated urinary tract infection (CAUTI). This study aimed to assess the effectiveness and safety of a program to promote appropriate IUC use in stroke care.

METHODS

We conducted a prospective interrupted time series study in three tertiary care hospitals in Japan. Adult patients with acute stroke were eligible. The study consisted of three phases: baseline, education and implementation. Our program included an assessment of IUC indications, educational meetings among healthcare professionals, reminders for removal of inappropriate IUC and a urinary retention protocol. The primary outcome was the proportion of inappropriate IUC use to assess effectiveness. The device utilization ratio and incidence of CAUTI were examined to assess effectiveness, and incidences of urinary retention and all symptomatic urinary tract infection (UTI) were examined to assess safety.

RESULTS

Among 976 patients who met the inclusion criteria, 738 were analysed. Inappropriate IUC use decreased from 50.1% in the baseline phase to 22.5% in the implementation phase (absolute risk reduction in interrupted time series analysis 42.4% [95% confidence interval, 19.2%-65.6%]). The device utilization ratio decreased from 0.302 to 0.194 (p < 0.001), whereas CAUTI did not change significantly (from 8.81 to 8.28 per 1000 catheter-days; incidence rate ratio 0.95 [0.44-1.94]). All symptomatic UTI decreased from 9.5% to 4.9% (p = 0.015), with no increase in urinary retention.

CONCLUSIONS

Our program improved the appropriateness of IUC use in stroke care while ensuring safety.

A novel intervention to reduce noninfectious and infectious complications associated with indwelling urethral catheters in hospitalized older patients: a quasi-experimental study

BACKGROUND

Indwelling urethral catheters are widely used in clinical settings. Catheter-associated urinary tract infection has been recognized as a common adverse event in older patients. However, noninfectious complications are almost 5 times as common as infectious complications, and insufficient attention has been given to noninfectious complications. Given this importance, a novel intervention related to removing unnecessary catheters in a timely manner to promote, after removal, the recovery of self-voiding function is herein developed to reduce infectious and noninfectious complications associated with indwelling urethral catheters in hospitalized older patients.

METHODS

A quasi-experimental study design was adopted. Patients aged 65 and older who had a urinary catheter placed within 24 h of hospital admission were included. All patients were allocated into either an intervention group, in which the novel intervention developed in the study was implemented, or a control group, who received care as usual. The outcomes of this study were to evaluate whether the novel intervention reduced the incidence of the following: catheter-associated urinary tract infections, catheter-associated noninfectious complications, decline in activities of daily living, and new nursing home admissions.

RESULTS

Of 106 hospitalized older patients who consented to participate, 92 completed follow-up until discharge, including 49 in the control group and 43 in the intervention group. The patients in the intervention group were significantly older than those in the control group [83.72 ± 9.18 vs. 80.26 ± 7.66, p = 0.038], and no differences were found between the groups in other demographics or present health conditions. Multivariable logistic regression analysis showed that the control group was more likely to develop noninfectious complications [adjusted odds ratio: 3.01, 95% confidence interval: 1.32-6.81] and a decline in ADLs [adjusted odds ratio: 11.20, 95% confidence interval: 3.68-34.00].

CONCLUSIONS

A novel intervention can be effective as a means of reducing noninfectious complications associated with indwelling urethral catheters in hospitalized older patients. This approach will help to standardize urethral catheter care, and it highlights the fact that health care professionals can play a crucial role in preventing harm from urethral catheters.

Reducing Inappropriate Urinary Catheter Use by Involving Patients Through the Participatient App: Before-and-After Study

Background

The risk of urinary tract infections is increased by the inappropriate placement and unnecessary prolongation of the use of indwelling urinary catheters. Sustained behavior change in infection prevention could be promoted by empowering patients through a smartphone app.

Objective

The aim of this study is to assess the feasibility and efficacy of implementation actions on patients’ use of the Participatient app on a clinical ward and to compare 3 survey methods for urinary catheter use.

Methods

Participatient was introduced for all admitted patients at the surgical nursing ward in a university hospital in the Netherlands. Over a period of 3 months, the number of new app users, days of use, and sessions were recorded. In a comparison of urinary catheter use before and after the implementation of the app, 3 methods for point prevalence surveys of catheter use were tested. Surveys were conducted through manual parsing of the text in patients’ electronic medical records, parsing a survey of checkbox items, and parsing nursing notes.

Results

In all, 475 patients were admitted to the ward, 42 (8.8%) installed the app, with 1 to 5 new users per week. The actions with the most ensuing app use were the kick-off with the clinical lesson and recruiting of the intake nurse. Between the survey methods, there was considerable variation in catheter use prevalence. Therefore, we used the standard method of manual parsing in further analyses. Catheter use prevalence decreased from 38% (36/96) to 27% (23/86) after app introduction (OR 0.61, 95% CI 0.32-1.14).

Conclusions

The clinical application of Participatient, the infection prevention app for patients, could be feasible when implementation actions are also used. For surveying indwelling urinary catheter use prevalence, manual parsing is the best approach.

Catheter-Associated Urinary Tract Infections: Current Challenges and Future Prospects

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and cause of secondary bloodstream infections. Despite many advances in diagnosis, prevention and treatment, CAUTI remains a severe healthcare burden, and antibiotic resistance rates are alarmingly high. In this review, current CAUTI management paradigms and challenges are discussed, followed by future prospects as they relate to the diagnosis, prevention, and treatment. Clinical and translational evidence will be evaluated, as will key basic science studies that underlie preventive and therapeutic approaches. Novel diagnostic strategies and treatment decision aids under development will decrease the time to diagnosis and improve antibiotic accuracy and stewardship. These include several classes of biomarkers often coupled with artificial intelligence algorithms, cell-free DNA, and others. New preventive strategies including catheter coatings and materials, vaccination, and bacterial interference are being developed and investigated. The antibiotic pipeline remains insufficient, and new strategies for the identification of new classes of antibiotics, and rational design of small molecule inhibitor alternatives, are under development for CAUTI treatment.

Real world utilization of nurse-driven urinary catheter removal protocol in patients with epidural pain catheters

BACKGROUND

Surgeons use indwelling bladder catheters (IBCs) to avoid urinary retention in patients with epidural analgesic catheters. Reduction of IBC-days is associated with improved catheter-associated urinary tract infection rates (CAUTI). This study investigates real world application of a Nurse-Driven Catheter Removal Protocol (NDCRP) to reduce IBC-days in this patient population.

METHODS

Patients with epidural catheters and IBC were targeted for IBC removal on post-operative day 1 (POD1). Patients were followed for application of the NDCRP, catheterization need, IBC re-anchoring, and complications.

RESULTS

One hundred and thirty-three patients had IBCs removed on POD1 (Protocol Group) and 50 patients did not (Non-Protocol Group). There was a reduction in IBC-days in the Protocol Group despite incomplete adherence to the NDCRP (1.55 days vs 4.64 days; P < .001). Ninety-three patients (70%) were able to spontaneously void after early IBC removal. Fourteen patients (11%) were able to spontaneously void after serial in-and-out catheterization (I/O). No significant difference in re-anchoring was found between the protocol and non-protocol groups (26 vs 4 patients; P = .09).

CONCLUSIONS

Early removal of IBCs (POD1) in patients with epidural catheters with the assistance of an NDCRP is a safe and successful strategy to reduce IBC-days in the hospital.

Antibiofilm activity of green synthesized silver nanoparticles against biofilm associated enterococcal urinary pathogens

Biofilm-formed enterococcal urinary tract clinical isolates (n = 92) were used for studying the antibiofilm activity of cinnamon, ginger, and chemical AgNPs. The average particle sizes of cinnamon, ginger, and chemical AgNPs were 8.7, 41.98, and 55.7 nm, respectively. The results of Fourier transform infrared analysis revealed that phytocompounds, such as cinnamaldehyde and gingerol, were the main compounds incorporated in the synthesis of cinnamon and ginger AgNPs, respectively. The purity and crystalline nature of the AgNPs have been confirmed by energy dispersive X-ray and X-ray Diffraction analysis. The results of antimicrobial activity showed that MIC of ginger, cinnamon, and chemical AgNPs were 37.64, 725.7, and 61.08 μg/ml, respectively. On studying the antibiofilm activity of AgNPs at sub-MIC values (1/2, 1/4, and 1/8 MIC), the results revealed that it was concentration dependent. Therefore, further studies were carried out to evaluate the antibiofilm activity of AgNPs at a concentration of 18 μg/ml. The results showed that ginger and chemical AgNPs reduced the formed biofilm to 39.14% and 65.32% and the number of adherent cells on the urinary catheter surface to 42.73% and 69.84%, respectively, as compared to that of the control, while cinnamon AgNPs showed no significant activity. Accordingly, ginger AgNPs had the most potent antibacterial and antiadherent activity against biofilm-associated enterococcal isolates.

Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study

BACKGROUND

Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals.

METHODS

This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review.

RESULTS

We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients.

CONCLUSION

This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Potent, Broad-Spectrum Antimicrobial Effects of S-Nitroso-N-acetylpenicillamine-Impregnated Nitric Oxide-Releasing Latex Urinary Catheters

Although numerous prevention and intervention techniques have been developed to counteract catheter-associated urinary tract infections (CAUTIs), urinary catheters remain one of the most common sources of hospital-acquired infections. Nitric oxide (NO), a gaseous free radical responsible for regulating many physiological functions in the body, has gained immense popularity due to its potent, broad-spectrum antimicrobial activity, which is capable of combating medical device-associated infections. In this work, a straightforward solvent-swelling method was used to load the NO donor S-nitroso-N-acetyl-penicillamine (SNAP) into commercial latex catheters (SNAP-UCs) for the first time. The effects of swelling catheters with different concentrations of SNAP solutions (25-125 mg/mL SNAP in tetrahydrofuran (THF)) were studied by measuring the NO release kinetics, SNAP loading, and SNAP leaching. SNAP-UCs impregnated with a 50 mg/mL SNAP-THF solution were found to maximize the amount of SNAP loaded into the latex (0.115 ± 0.009 mg SNAP/mg catheter) and showed physiological levels of NO release (>2 × 10^-10 mol min^-1 cm^-2) over 7 days and minimal SNAP leaching (<2%). SNAP-UCs showed impressive in vitro contact-based and diffusible antimicrobial efficacy against three CAUTI-associated pathogens, reducing the viability of adhered and planktonic Escherichia coli, Proteus mirabilis, and Staphylococcus aureus by ∼98.0 to 99.1% (adhered) and 86.3-96.3% (planktonic) compared to control latex catheters. In vitro cytotoxicity against 3T3 mouse fibroblasts using a CCK-8 assay showed that SNAP-UCs were noncytotoxic (>90% viability). In summary, SNAP-UCs show stable, noncytotoxic NO release characteristics capable of potent, broad-spectrum antimicrobial activity, demonstrating great potential for reducing the devastating effects associated with CAUTIs.

Effectiveness of implementing a preventive urinary catheter care bundle in hip fracture patients

Background

Urinary catheter (UC)–associated infections are one of the most common preventable healthcare-associated infections (HAIs) and they frequently occur in older, frail populations.

Aim

The study aim was to describe the incidence of UC-associated infection in elderly patients undergoing hip fracture surgery after implementing a preventive care bundle.

Methods

A longitudinal prospective study using a before-and-after design. The bundle was theory driven and involved the co-creation of a standard operational procedure, education and practical training sessions. Prospectively collected registry data were analysed. Univariable statistics and multivariable logistic regressions were used for analyses.

Results

2,408 patients with an acute hip fracture were included into the study. There was an overall reduction in UC catheter associated-associated urinary tract infections, from 18.5% (n = 75/406) over time to 4.2% (n = 27/647). When adjusting for all identified confounders, patients in phase 4 were 74% less likely to contract an UC-associated infection (OR, 0.26; 95% CI, 0.15–0.45, p < 0.0001).

Discussion

Bundled interventions can reduce UC-associated infections substantially, even in elderly frail patients. Partnership and co-creation as implementation strategies appear to be promising in the fight against HAI.

Urinary catheter alleviation navigator protocol (UCANP): Overview of protocol and review of initial experience

BACKGROUND

Given the associated morbidity, mortality, and financial consequences of catheter associated urinary tract infections (CAUTIs), efforts should be made to mitigate the risk. We sought to describe, and report results for a post-catheter removal bladder management protocol focused on decreasing catheter reinsertion, catheter days, and overall CAUTI risk.

METHODS

This was a quality improvement initiative implemented over a 3-month period at a single urban, tertiary health care center. Patients with an indwelling urinary catheter deemed eligible for removal were followed and cared for according to the study protocol. Rates of catheter reinsertion, catheter days, and assessment of CAUTI risk were compared between cohorts.

RESULTS

A total of 173 patients were eligible for protocol enrollment. Catheter reinsertion rate was 16% during the pilot, compared to 21% and 27% for the historical cohorts, (P = .02). The mean number of catheter day's during the study was 1.4 days, compared to 9.5 and 5.6 days in the historical cohorts (P = .004). Catheter hours (OR 1.010 95% CI 1.005 - 1.015 P < .0001.) was a predictor of catheter reinsertion during the pilot.

CONCLUSIONS

Our protocol resulted in a reduction of catheter reinsertion rates and number of catheter days. Expansion of this protocol to a larger patient cohort is required.

Catheter-associated urinary tract infection reduction in critical care units: a bundled care model

Catheter-associated urinary tract infections (CAUTIs) represent approximately 9% of all hospital acquired infections, and approximately 65%–70% of CAUTIs are believed to be preventable. In the spring of 2013, Boston Medical Center (BMC) began an initiative to decrease CAUTI rates within its intensive care units (ICUs). A CAUTI taskforce convened and reviewed process maps and gap analyses. Based on Centers for Disease Control and Prevention (CDC) and Institute for Healthcare Improvement (IHI) guidelines, and delineated by the Healthcare Infection Control Practices Advisory Committee 2009 guidelines, all BMC ICUs sequentially implemented plan–do–study–act cycles based on which measures were most easily adaptable and believed to have the highest impact on CAUTI rates. Implementation of five care bundles spanned 5 years and included (1) processes for insertion and maintenance of foley catheters; (2) indications for indwelling foley catheters; (3) appropriate testing for CAUTIs; (4) alternatives to indwelling devices; and (5) sterilisation techniques. Daily rounds by unit nursing supervisors and inclusion of foley catheter necessity on daily ICU checklists held staff accountable on a daily basis. With these interventions, the total number of CAUTIs at BMC decreased from 53 in 2013 to 9 in 2017 (83% reduction) with a 33.8% reduction in indwelling foley catheter utilisation during the same time period. Adapted protocols showed success in decreasing the CAUTI rate and indwelling foley catheter usage in all of the BMC ICU’s. While all interventions had favourable and additive trends towards decreasing the CAUTI rate, the CAUTI awareness education, insertion and removal protocols and implementation of PureWick female incontinence devices had clear and significant effects on decreasing CAUTI rates. Our project provides a framework for improving HAIs using rapid cycle testing and U-chart data monitoring. Targeted education efforts and standardised checklists and protocols adapted sequentially are low-cost and high yield efforts that may decrease CAUTIs in ICU settings.

Prevention of Healthcare-associated Infections in Intensive Care Unit Patients

Healthcare-associated infections contribute to morbidity, mortality, and increased cost in intensive care unit patients. Understanding evidence-based prevention strategies can help to optimize patient outcomes.

A Statewide Collaborative Quality Initiative To Improve Antibiotic Duration And Outcomes Of Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia

Background

Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS).

Methods

This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1–day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering.

Results

A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ± 1–day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%–25.0%]) to 45.9% (predicted probability, 43.9% [36.8%–51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07–1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96–.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87–.95]).

Conclusions

Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

Urinary Tract Infections: 2021 Update

Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.

Liposomal Bupivacaine Injection in Nuss Procedure Allows Narcotic Avoidance and Improved Outcomes

Background: The Nuss procedure has provided a minimally invasive surgical solution for pectus excavatum with excellent long-term outcomes. However, opioid avoidance, cost reduction, and length of stay (LOS) still offer room for improvement. The focus of this study is to identify the impact of Bupivacaine liposome injectable suspension (Exparel) on outcomes. Methods: A retrospective review at a Pediatric specialty hospital from October 1, 2014 to December 31, 2019 was performed. All patients underwent a Nuss procedure (n = 19) for pectus excavatum. The cohort comprised a control group that did not use liposomal Bupivacaine (Standard, n = 9) and an interventional group that received liposomal Bupivacaine (n = 10). Nonparametric Wilcoxon rank-sum tests and chi-squared or Fisher's exact tests were used to assess significance (P < .05). Results: Overall, the entire population was 68.4% male and had an average age of 15 years. There was a significant difference between the Standard and Liposomal Bupivacaine groups for total cost ($60,746 versus $13,289), total Morphine Milligram Equivalents (MME) (282 versus 76.8 MME) and Epidural Catheter usage (100% versus 0%). There was also a significant difference between groups for LOS (5.00 days versus 3.00 days) and Foley catheter usage (100% versus 20%). Conclusions: There is a significant impact of liposomal Bupivacaine usage on epidural catheter avoidance and opioid administration correlating with a significantly decreased total cost and decreased LOS. While more study is necessary, liposomal Bupivacaine for Nuss procedure offers improvement of postoperative patient outcomes and drastic cost savings.

Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges

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.

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections

OBJECTIVE

To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs).

DESIGN

Retrospective before-and-after study that took place between March 2013 and February 2017.

SETTING

An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU.

PATIENTS

Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI.

INTERVENTION

Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods.

RESULTS

There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532).

CONCLUSIONS

Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review

BACKGROUND

This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria.

METHODS

A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes.

RESULTS

Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult.

CONCLUSIONS

A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

Intervention to reduce unnecessary urinary catheter use in a large academic health science centre: A one-group, pretest, posttest study with a theory-based process evaluation

Aim

To evaluate an intervention to reduce unnecessary urinary catheter use and prevent catheter‐associated urinary‐tract infections (CAUTI) in hospitalized patients across an academic health science centre.

Methods

We conducted a one‐group, pretest, posttest study with a theory‐based process evaluation. Phase 1 consisted of a pre/postintervention to test the impact of a CAUTI protocol. Audits on four units were conducted, and data were analysed descriptively. Phase 2 consisted of a theory‐based process evaluation to understand the barriers/enablers to the implementation. Semistructured interviews were conducted and then analysed using a systematic approach.

Results

In Phase 1, all inpatients with urinary catheters admitted to the units (N = 4) during the study period (N = 99, pre) and (N = 99, post) were included. CAUTI prevalence rate was 18.2% pre versus 14.1% post (p = .563). In Phase 2, participants (N = 18) who worked on the units were interviewed, and a total of 13 barriers and 19 enablers were found.

Imprecision Medicine: Challenges in Diagnosis, Treatment, and Measuring Quality for Catheter-Associated Urinary Tract Infection

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.

Preventive Measures and Management of Catheter-Associated Urinary Tract Infection in Adult Intensive Care Units in Saudi Arabia

Catheter-associated Urinary Tract Infection (CAUTI) has been studied worldwide as part of device-related healthcare infection. CAUTI is one of the most commonly reported infections in the literature, which occurs during clinical practice in Intensive Care Units (ICUs) and non-ICU departments. Many studies have covered the CAUTI rate in Saudi Arabia mainly in the ICU covering single or multiple hospitals as surveillance for device-related infections in the ICU. Few studies have conducted an interventional approach that examined the implementation of infection control protocols and then compared them to international practice as a standard. This review aims to explore the literature to provide insight into the infection control practices that have been reported in Saudi Arabia during the last two decades on the preventive measures and clinical consequences of CAUTIs. Very few studies have recorded the pattern of resistant microorganisms that burdens clinical practice in ICUs concerning CAUTIs. Only one study compared the type of catheter materials and discussed the effect of these materials on reducing CAUTIs. It is essential to cover catheter utilization and to understand how a sufficient infection control protocol with educational programs for healthcare personnel can transform practice, for the better, regarding CAUTI rates in Saudi hospitals. There is a demand for more interventional and epidemiological studies on the causes and factors affecting the rate of CAUTI in the area. Studies may help reduce the CAUTI incidence rate, which consequently reduces the costs and morbidity associated with this type of infection and other healthcare-related infections.

Barriers and enablers to implementinghospital-acquired urinary tract infection prevention strategies: a qualitative study using the Theoretical Domains Framework

BACKGROUND

Consistent implementation of evidence-based hospital-acquired urinary tract infection (UTI) prevention strategies remains a challenge in acute and subacute care settings. Addressing the evidence-practice gap requires an understanding of factors affecting implementation of hospital-acquired UTI prevention strategies in this high-risk setting.

AIM

To identify the perceived barriers and enablers of clinicians to implementing hospital-acquired UTI prevention strategies in an Australian subacute hospital.

METHODS

Qualitative semi-structured virtual interviews, underpinned by the Theoretical Domains Framework (TDF), were conducted with purposively selected nurses (N = 8) and doctors (N = 2) at one subacute metropolitan hospital. Interview data were content-analysed using the TDF as the coding framework.

FINDINGS

Eight TDF domains were identified as important in understanding barriers and enablers to implementing hospital-acquired UTI prevention strategies: Knowledge, Skills, Beliefs about capabilities, Emotion, Professional role and identity, Environmental context and resources, Goals, and Behavioural regulation. Barriers were poor awareness of clinical practice guidelines for hospital-acquired UTI prevention; lack of training; staff shortages; competing workloads; lack of procedural equipment for urinary catheterization; difficulty with implementing prevention strategies in cognitively impaired patients; language barriers; and lack of feedback and use of incident reporting data to influence clinical practice. Presence of a proactive staff culture and positive team approach to work emerged as enablers. Audit and feedback, clinical champions, education, and patient information resources in languages other than English were identified as potential enablers.

CONCLUSION

The findings will inform development of theoretically informed behaviour change interventions to promote successful implementation of hospital-acquired UTI prevention strategies in the subacute setting.