Targeting Catheter-Associated Urinary Tract Infections in a Trauma Population: A 5-S Bundle Preventive Approach

How COVID-19 impacted CAUTI and CLABSI rates in Alabama

BACKGROUND

The study objective was to quantify infection rate trends for central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 89 Alabama hospitals from 2015 to 2021 to analyze how the COVID-19 pandemic impacted health care delivery.

METHODS

Retrospective analysis of CLABSI and CAUTI rates, from 89 Alabama hospitals via data from the Alabama Department of Public Health from 2015 to 2021.

RESULTS

Based on our modeling strategies, there was a statistically significant decrease in rates of CAUTIs from 2015 to 2019 at an estimated rate of 7% per year (P = 0.0167) and CLABSIs from 2015 to 2018 at an estimated rate of 13% per year (P < .001) in these hospitals. In 2020, the CAUTI and CLABSI rates began increasing at a modeled rate of 29% per year (P = .001) and 35% per year (P < .001) respectively.

DISCUSSION

A review of potential causes for the elevated rate of health care-associated infections illustrated that certain practices may have contributed to increased CAUTI and CLABSI rates. Utilizing staff from noncritical care areas with less experience in health care-associated infection prevention, batching of tasks to conserve personal protective equipment, and a nationwide mental health crisis could have affected infection prevention bundle compliance.

CONCLUSIONS

An increase in CAUTIs and CLABSIs was observed during the pandemic, likely due to the large volume of patients requiring advanced medical care and subsequent depleted resources.

Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US

BACKGROUND

Catheter associated urinary tract infections (CAUTIs) have become a focus for reducing healthcare costs. Reimbursement may be reduced to hospitals with higher rates. The implementation of bundles or other efforts to reduce infection numbers may not be as robust at hospitals caring for more diverse patient populations. This may lead to a disparity in hospital-associated infections rates that may lead to lower reimbursement and a downward spiral of quality of care and racial disparities.

METHODS

We analyzed patients in the National Trauma Data Bank from 2016 to 2017. The final analysis included patients 65 years or older with one or more day of mechanical ventilation. This was the population had the highest rate of CAUTI. We compared white patients to non-whites using students t test, Mann Whitney U test, or chi-square as appropriate. Logistic regression with odds ratios (ORs) and 95% confidence intervals (CI) was computed to identify risk factors for of CAUTI.

RESULTS

Risk factors for developing a CAUTI were race (OR 1.44, 95% confidence interval (95%CI) 1.23-1.71), injury severity score (OR 1.10 per increase of one, 95% CI 1.01-1.02), care at a teaching hospital (OR 1.17, 95%CI 1.02-1.35), private insurance (OR 1.28, 95%CI 1.09-1.51), hypertension (OR 1.18, 95%CI 1.02-1.37), female gender (OR 1.54, 95%CI 1.33-1.77). Non-white patients received care at teaching hospitals more often and had a higher rate of government insurance or no insurance.

DISCUSSION

The Center for Medicare and Medicaid Services (CMS) has put in place a reimbursement modification 87 plan based on the rates of hospital-associated infections including CAUTIs. We have demonstrated non-white 88 patients have higher odds for developing a CAUTI.

CONCLUSION

CMS may potentially worsen the racial disparity by further cutting reimbursement to hospitals who care for higher proportions of non-whites.

Journal club: "Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US"

In this article for Journal Club commentary entitled "Racial Disparities in Catheter Related Urinary Tract Infections Among Elderly Trauma Patients in the US", Keneally et al, conducted a study with the goal of assessing the role of social disparities in catheter associated urinary tract infections (CAUTIs). This cross-sectional study utilized secondary data to determine the possible CAUTI risk in ventilated, older (≥ 65 years of age) trauma patients exploring possible racial structural bias in healthcare. The analysis addressed the following questions in this specific population:While this study does consider race and discusses structural biases, which are important and sparsely researched in healthcare-associated infection (HAI) outcomes, the practice implementations are somewhat limited due to study design and analysis. Therefore, the focus of this Journal Club commentary will be reviewing basic steps Infection Preventionists (IPs) can take to critically appraise the literature for application in their facility's patient population.

Patient and Family Engagement in Catheter-Associated Urinary Tract Infection (CAUTI) Prevention: A Systematic Review

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are detrimental to health and are largely preventable with adherence to CAUTI prevention guidelines. Patient and family engagement in CAUTI prevention is often encouraged in these guidelines; however, little is known about how this engagement is operationalized in practice. A systematic review was conducted to synthesize the content, format, and outcomes of interventions that engage patients and/or families in CAUTI prevention.

METHODS

Two reviewers independently screened records from four databases up to March 2021 and searched reference lists of final articles. Included articles were primary research, tested an intervention, involved indwelling urinary catheters, and described at least one patient and/or family engagement method. Articles were appraised for quality using the Downs and Black checklist.

RESULTS

After 720 records were screened, 12 were included. Study quality ranged from good to poor, scoring lowest in internal validity. The most common formats of patient/family engagement were flyers/handouts (83.3%) and verbal education (58.3%). Common content areas were urinary catheter care and maintenance strategies. Most study outcomes (83.3%) measured CAUTI rates, and half measured patient/family-related outcomes. Improvements were seen in at least one outcome across all studies, but less than half (41.7%) showed statistically significant results.

CONCLUSION

The researchers found that most interventions lacked sufficient detail on the content, delivery, and/or outcome measurement of patient/family engagement, which limits transferability. More high-quality, generalizable trials are warranted in this area. Future research should focus on integrating publicly available resources into practice that can be tested for comprehension and revised based on feedback from target audiences.

Foley catheter with noble metal alloy coating for preventing catheter-associated urinary tract infections: a large, multi-center clinical trial

Background

Catheter-associated urinary tract infections (CAUTI) are among the most frequent healthcare-associated infections in the world. They are associated with increased mortality, prolonged hospital stay and increased healthcare costs. The objective of this study was to evaluate the efficacy of the noble metal alloy (NMA) coated BIP Foley Catheter in preventing the incidence of symptomatic CAUTI in a large cohort of patients in India.

Methods

This multi-center, prospective study included 1000 adult patients admitted to six hospitals across India for urology, surgery and ICU requiring urethral catheterization and admission for ≥ 48 h. Patients were allocated to the NMA-coated BIP Foley Catheter group or a non-coated control catheter group, with a randomization ratio of 3:1. CAUTI surveillance was conducted at study entry, upon catheter removal, and 2 days after catheter removal. For statistical analysis, categorical data (e.g. gender) were compared using the chi-square or Fischer test, and numerical data were compared using the two-sample t-test. Associations were evaluated using logistic regression.

Results and conclusions

The incidence of symptomatic CAUTI was reduced by 69% in the BIP Foley Catheter group compared to the control group (6.5 vs 20.8 CAUTI/1000 catheter days), with an incidence rate ratio of 0.31 (95% confidence interval: 0.21–0.46; p < 0.001). A reduction in the cumulative CAUTI incidence was evident in the BIP Foley Catheter group within 3 days after catheterization; this reduction was maintained up to ~ 30 days, and the largest reductions were seen between 3 and 11 days. There were no serious adverse events related to either catheter, and the percentage of patients with ≥ 1 adverse event was significantly lower in the NMA-coated BIP Foley Catheter group than in the control group (21.6% vs. 48.4%; p = 0.001). In conclusion, the NMA-coated BIP Foley Catheter was effective in reducing CAUTI and was well tolerated, with a lower incidence of adverse events compared to the uncoated catheter.

Trial registration This study was registered prospectively (28 September 2015) in the Clinical Trials Registry of India (trial number CTRI/2015/09/006220; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=12631&EncHid=&userName=bactiguard).

The impact of educational interventions for patients living with indwelling urinary catheters: A scoping review

Aim: To explore the impact of educational interventions for patients living with indwelling urinary catheters. Methods: Systematic scoping review in accordance with PRISMA guidelines, guided by Cochrane methodology, quality appraisal using Centre for Evidence-Based Medicine (CEBM) Joanna Briggs Institute (JBI), GRADE criteria and Quality Improvement Minimum Quality Criteria Set Version 1.0 (QI-MQCS V 1.0) tools. Studies (n = 446) were retrieved from CINAHL, Cochrane Library, Scopus and Medline from 2000 to 2020. Results: A total of 15 primary research studies were included in the narrative thematic synthesis, nine were from the USA, two from Australia, two from the UK, one from Italy and one from Turkey. These 15 studies were published between 2003 and 2019 and accounted for 19918 patients with an age range 15-99 years. Study design varied; there were 11 quantitative and 4 qualitative studies. Studies were of low-moderate quality. A total of four themes were identified; (i) information needs of patients living with long-term catheters; (ii) core learning content and educational approaches; (iii) feasibility and effectiveness of educational interventions to reduce complications and improve quality of life; and (iv) common outcome measures. Conclusion: The dissemination of information and the delivery of urinary catheter education to patients is inadequate. Core components of educational interventions should address fluid intake, bowel management, hygiene and self-monitoring/management, including adverse events. There is a need for future robust trials of educational and self-management interventions to improve the quality of life of patients living with indwelling urinary catheters in the community. Impact: This review addressed the educational needs of patients living with indwelling urinary catheters and the impact of educational interventions. Despite the heterogeneity in educational interventions, all studies included in this review reported the specific approach undertaken was effective in minimising catheter-associated complications and improving the quality of life of patients.

Catheter-Associated Urinary Tract Infections among Trauma Patients: Poor Quality of Care or Marker of Effective Rescue?

Background: Catheter-associated urinary tract infection (CAUTI) is associated generally with worse outcomes among hospitalized patients, but the impact of CAUTI on clinical outcomes is poorly described in trauma patients. We hypothesized that trauma patients with CAUTI would have worse outcomes such as longer length of stay (LOS), fewer discharges to home, and higher outcome of death. Methods: Patients with LOS >2 d in the 2016 Trauma Quality Improvement Program (TQIP) database were included. Patients with and without CAUTI were matched 1:1 via a propensity score using patient, injury, and hospital factors as covariates. Matched pair analysis was performed to compare difference in clinical outcomes between patients with and without CAUTI. Results: There were 238,274 patients identified, of whom 0.7% had a diagnosis of CAUTI. Prior to matching, CAUTI patients had a higher mortality rate (6.6% vs. 3.4%, p < 0.01), but groups differed significantly. There were 1,492 matched pairs created, with effective reduction in bias; post-match propensity score covariates all had absolute standardized differences <0.1. In matched pair analysis, CAUTI patients had lower outcome of death compared with patients without CAUTI (6.7% vs. 10.1%, p < 0.01). The CAUTI was associated with longer length of stay, more intensive care unit and ventilator days, more unplanned events, and fewer discharges to home (all p < 0.01). Conclusions: Trauma patients with CAUTI had lower outcome of death compared with patients without CAUTI, despite worse clinical outcomes in all other aspects. This difference may be associated with "rescue" care in the form of unplanned events, and CAUTI may be an unintended consequence of this "rescue" care, rather than a marker of poor quality of care.

Management of blunt intraperitoneal bladder rupture: Case report and literature review

INTRODUCTION

Urinary bladder ruptures are an uncommon injury, occurring in less than 1% of all blunt abdominal trauma. Extraperitoneal bladder ruptures are generally associated with pelvic fractures and usually managed nonoperatively. Conversely, intraperitoneal injuries are often caused by large compressive and shear forces produced during seatbelt injuries and almost invariably require surgical intervention.

PRESENTATION OF CASE

A 29-year-old woman presented as a trauma alert after a motor vehicle collision with abdominal/flank pain and gross hematuria. Free intraperitoneal fluid was found on ultrasound and CT imaging. Exploratory laparotomy located an intraperitoneal rupture across the bladder dome. The patient recovered without complications, was discharged on postoperative day three, and continued bladder catheter care at home for an additional week until outpatient follow up and catheter removal.

DISCUSSION

As evidence for surgical management of bladder trauma continues to grow, clinical practice guidelines have been developed for trauma surgeons. Recent recommendations from the Eastern Association for the Surgery of Trauma appraise the evidence for cystography in the perioperative setting. Postoperative care is focused on preventing catheter-associated urinary tract infections in patients recovering from urotrauma in the critical care setting.

CONCLUSION

We present a case of intraperitoneal bladder rupture in the setting of a blunt traumatic seatbelt injury. Our patient recovered uneventfully after surgical repair, a three-day hospitalization, and ten days with an indwelling bladder catheter.