1238 infection control & hospital epidemiology october 2015, vol. 36, no. 10 NHSN criteria state that signs and symptoms should be
was low in our study, consistent with previous findings.6,7 Although the 2 definitions2,4 have different purposes, this disparity could lead to questioning of the validity of CAUTI data used to drive and evaluate prevention initiatives. How- ever, clinical definitions for CAUTI are also imperfect, and overtreatment of catheter-associated bacteriuria is well described.8 In the present study, alternate sources of fever were found in a third of clinical CAUTI cases, suggesting they were also not true infections. Other limitations are that this study was conducted at a
attributed to CAUTI if there is no other cause for those symptoms.2 However, this “attribution” does not apply to fever. Bacteriuria develops at an average rate of 5% per day of indwelling catheter,5 such that urine cultures performed for fever from any cause have a high pretest probability of being positive and counted as CAUTI. Similar to our study, Al-Qas Hanna et al6 found a strong association of systemic inflam- matory response syndrome and NHSN-defined CAUTI. They also showed that increase in fever prevalence from other causes would increase the number of NHSN-defined CAUTIs. The agreement between NHSN-defined and clinical CAUTI
Affiliations: 1. Department of Epidemiology and Public Health, University
of Maryland School of Medicine, Baltimore, Maryland; 2. University of Maryland Medical Center, Baltimore, Maryland; 3. Wolters Kluwer Health, Madison, Wisconsin. Address correspondence to Surbhi Leekha, MBBS, MPH, 110 S. Paca St,
6th Fl, Baltimore, MD 21201 (
sleekha@epi.umaryland.edu). Received February 11, 2015; accepted May 17, 2015; electronically published
June 22, 2015 © 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3610-0016. DOI: 10.1017/ice.2015.149
references
1. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Centers for Disease Control and Prevention website.
http://www.cdc.gov/nhsn/pdfs/archive/17pscNosInfDef_ NOTcurrent.pdf. Published 2010. Accessed May 7, 2015.
2. National Healthcare Safety Network surveillance for urinary tract infections. Centers for Disease Control and Prevention website.
http://www.cdc.gov/nhsn/acute-care-hospital/CAUTI/index.html. Published 2015. Accessed May 7, 2015.
single center and was based on the 2009 CAUTI definition even though changes were made to the definition in 2015.2 However, there was no change between 2009 and 2015 in how symptoms are assessed.1,2 The following are additional considerations for CAUTI
surveillance. First, emphasize urinary catheter utilization because duration of catheterization is the strongest risk factor for CAUTI and is associated with other adverse outcomes.9,10 Second, include all catheter-associated bacteriuria—experts have argued that this measure represents a justifiable bench- mark for prevention efforts because it predisposes to CAUTI, is associated with antibiotic-resistant bacteria, and leads to unnecessary antimicrobial use.4 This could also allow electronic data capture and save time spent in manual surveillance. Lastly, if symptoms are to be included, consider attributing fever to CAUTI only if no other source is found. Future studies should focus on automated and objective ways of accounting for these concurrent sources of fever to allow further refinement of CAUTI surveillance.
acknowledgments
Financial support. None reported. Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
3. Tambyah PA,MakiDG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch InternMed 2000;160:678–682.
4. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guide- lines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625–663.
5. Garibaldi RA, Burke JP, Dickman ML, CB Smith. Factors predis- posing to bacteriuria during indwelling urethral catheterization. N Engl J Med 1974;291:215–219.
6. Al-Qas Hanna F, Sambirska O, Iyer S, Szpunar S, Fakih MG. Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection. Am J Infect Control 2013;41:1173–1177.
7. Meddings J, Reichert H, McMahon LF Jr. Challenges and proposed improvements for reviewing symptoms and catheter use to identify National Healthcare Safety Network catheter- associated urinary tract infections. Am J Infect Control 2014;42: S236–S241.
8. Trautner BW, Cope M, Cevallos ME, Cadle RM, Darouiche RO, Musher DM. Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis 2009;48:1182–1188.
9. Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K. Urinary catheters: what type do men and their nurses prefer? J Am Geriatr Soc 1999;47:1453–1457.
10. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med 2002;137:125–127.
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