infection control & hospital epidemiology october 2015, vol. 36, no. 10 concise communication
Association of National Healthcare Safety Network–Defined Catheter-Associated Urinary Tract Infections With Alternate Sources of Fever
Surbhi Leekha, MBBS, MPH;1 Michael Anne Preas, RN, BSN, CIC;2 Joan Hebden, RN, MS, CIC3
Presented in part: 20th Annual Meeting of the Society for Healthcare Epidemiology of America; Dallas, Texas; April 1–4, 2011.
Infect. Control Hosp. Epidemiol. 2015;36(10):1236–1238
We evaluated the agreement of the 2009 National Healthcare Safety Network definition of catheter-associated urinary tract infections with concurrent alternate sources of fever, finding it
the 2009NHSNsurveillance definition in detecting CAUTI.We suspected poor definition specificity—that is, a large proportion of false-positive cases. In the absence of a gold standard for CAUTI, we evaluated this by measuring the agreement of NHSN-defined CAUTI with (1) clinical diagnosis of CAUTI and (2) alternate sources of fever. We hypothesized that the agreement between NHSN-defined CAUTI and alternate sources of fever would be higher than the agreement between NHSN-defined CAUTI and clinical CAUTI.
methods
We conducted a cross-sectional study at University of Maryland Medical Center, a 757-bed urban tertiary care academic
high, and clinical catheter-associated urinary tract infections, finding it low. This suggests poor definition specificity and lack of utility of including fever in the definition. Surveillance for catheter-associated urinary tract infection (CAUTI) is performed using standard criteria from the Centers for Disease Control and Prevention’sNationalHealthcareSafety Network (NHSN). Criteria were refined in 2009 to discontinue asymptomatic bacteriuria as an infection type and consider only symptomatic and bacteremic cases, and to include lower colony counts in the presence of a positive urinalysis (Table 1).1 Although laboratory criteria were further revised in 2015, there was no change in symptom assessment.2 Notably, if laboratory and catheter criteria are met, fever can define CAUTI, and fever may not be attributed to another condition even if another source of fever is found. Although the emphasis on symptomatic cases is well intended, it is unclear whether it improved the performance of the definition because CAUTI in hospitalized patients is rarely symptomatic and is challenging to diagnose.3,4 The objective of this study was to assess the performance of
of NHSN-defined CAUTI, (2) clinical CAUTI—that is, patient given a diagnosis of and treated forUTI, and (3) alternate sources of fever—that is, infection at a site other than the urinary tract or a noninfectious cause of fever, all within 72 h (before or after) of the index urine culture. Determination of an alternate source of fever was made on the basis of provider-documented diagnoses, including infectious diseases consultations. Noninfectious conditions—for example, central fever, were included if docu- mented as suspected causes of fever. Multiple conditions in the same patient were counted separately. We measured the agreement of NHSN-defined CAUTI with
hospital, using data collected during development and valida- tion of an automated algorithmfor routineCAUTI surveillance. The study was determined not human subjects research by the University of Maryland institutional review board. We queried the hospital’s relational database containing administrative, clinical, and laboratory data for inpatients with positive urine cultures (obtained ≥48 h after admission) and indwelling urinary catheter, from August 1 through September 30, 2010. Patients meeting NHSN urinary catheter and laboratory criteria for CAUTI (Table 1)—that is, those with catheter-associated asymptomatic bacteriuria, constituted the study sample. Medical chartswere then reviewed for (1) signs and symptoms
clinical CAUTI, and with alternate sources of fever, using Cohen’s κ statistic. We also evaluated the association of both NHSN-defined CAUTI and clinical CAUTI with alternate sources of fever usingmultivariable logistic
regression.Organism (bacteria or yeast), pyuria (≤10, 11–25, or >25 white blood cells per high-power field), and colony count (<or≥100,000 colony- forming units per mL) were included as covariates.
results
From August 1 through September 30, 2010, we identified 642 patients with positive urine cultures more than 48 h after admission, of whom 130 (20%) had catheter-associated bacteriuria meeting NHSN urinary catheter and laboratory criteria. Of these, 85 (65%) fulfilled the NHSN CAUTI surveillance definition. All 85 case patients had fever; other signs or symptoms were noted in only 2 cases. Clinical diagnosis of CAUTI occurred in 69 (53%) of the 130 cases. Of 85 NHSN-defined CAUTI, 43 (51%) did not receive
clinical CAUTI diagnoses, whereas of the 69 clinical CAUTI cases, 27 (39%) were not captured by NHSN criteria. Alternate sources of fever were found in 59 (45%) of 130 cases of catheter- associated bacteriuria, in 46 (54%) of 85 NHSN-defined CAUTI, and in 21 (30%) of 69 clinical CAUTI cases. These alternate sources of fever (in decreasing order of number of cases) were respiratory tract infection (22), soft-tissue infection (11), bloodstream infection (with organismother than in urine culture) (6), Clostridium difficile infection (5), central fever (4),
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