1496
Table 2. Urinary Catheter Utilization, Urine Cultures and CAUTI Rates in 2014 and 2015 at Both Facilities Hospital A
Ana Cecilia Bardossy et al
Hospital B P Variable Urinary catheter utilization ratio 2014 2015 P Value 0.82 (4,686/5,691) 0.85 (4,855/5,737) .18 2014
0.67 (8,710/ 12,983)
2015
0.64 (9139/ 14,191)
Urine culture rate per 1,000 patient days 30.9 (176/5,691) 13 (75/5,737) <.0001 45.2 (587/12,983) 34.8 (494/ 14,191)
% Positive Urine cultures
Positive urine cultures rate per 1,000 patient days
CAUTI rate per 1,000 device days Note. CAUTI, catheter-associated urinary tract infection.
Our study has some limitations. It includes a quasi- experimental before-and-after design without a control arm, and without baseline data from 2014 to compare process mea- sures. We did not account for fever prevalence, an important factor that may influence the NHSN surveillance definition events. In addition, the possibility of classification bias exists when abstracting information related to appropriateness reasons for using urinary catheter and potential variations when imple- menting intervention activities at each institution. Furthermore, cultural factors could have influenced adoption at both facilities. We conclude that even with structured efforts to reduce NHSN-
defined CAUTI events in intensive care, mixed results occur, and they may be heavily influenced by culturing practices. Therefore, we highlight 2 important issues. First, the device utilization ratio should be considered as an additional performance measure for urinarycatheterharm.7 Second, culturing stewardship may dis- proportionately help reduce NHSN-defined CAUTI events, com- pared to interventions focused on reducing bacteriuria risk of the catheterized.8 Culturing stewardship does not result in less harm related to clinical CAUTI, but it has key implications on curbing unnecessary antimicrobial use for asymptomatic bacteriuria.9 Our findings underscore the importance of both working to reduce catheter use and incorporating “improving the culture of culturing” to the resident physicians training in teaching institutions.10
Acknowledgments. The authors thank resident physicians and nurses from both institutions who participated during the study period.
Financial support. This study was supported by a contract from the Agency for Healthcare Research and Quality (grant nos. HHSA290201000025I and HHSA29032001T) under a subcontract with the Health Research and Educa- tional Trust. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.
Conflicts of interest. Dr Reyes reports grants from Theravance, Cubist, and the Centers for Disease Control and Prevention, outside the submitted work. Dr Zervos reports consultancy for Cempra, grants from National Institute of Health, National Safety Foundation, Paratek, Cempra, Melinta, Merck, Cerexa, Pfizer, Tetraphase, Genentech, Allergan, Michigan Department of Community
Health, and the Centers for Disease Control and Prevention, outside the submitted work. All other authors report no conflict of interest relevant to this article.
References
1. AHRQ Safety Program for Reducing CAUTI in Hospitals. Resident physicians as champions in preventing device-associated infections: focus on reducing catheter-associated urinary tract infections. AHRQ Pub No. 15-0073-6-EF. Agency for Healthcare Research and Quality website.
https://www.ahrq.gov/sites/default/files/publications/files/resphys-cham- pions_2.pdf Published September 2015. Accessed September 13, 2018.
2. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter‐associated urinary tract infections, 2009. Infect Control Hosp Epidemiol 2010; 31:319–326.
3. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:464–479.
4. NHSN Newsletter September 2014. NHSN e-news, 2014;9(3):1–23. Centers for Disease Control and Prevention website.
http://www.cdc. gov/nhsn/newsletters/. Published 2014. Accessed August 11, 2018.
5. Saint S, Greene MT, Krein SL, et al. A program to prevent catheter- associated urinary tract infection in acute care. N Engl J Med 2016;374:2111–2119.
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. Fakih MG, Gould CV, Trautner BW, et al. Beyond infection: device utilization ratio as a performance measure for urinary catheter harm. Infect Control Hosp Epidemiol 2016;37:327–333.
8. Mullin KM, Kovacs CS, Fatica C, et al. A multifaceted approach to reduction of catheter-associated urinary tract infections in the intensive care unit with an emphasis on “stewardship of culturing.” Infect Control Hosp Epidemiol 2017; 38: 186–188.
9. Garcia R, Spitzer ED. Promoting appropriate urine culture management to improve health care outcomes and the accuracy of catheter-associated urinary tract infections. Am J Infect Control 2017; 45: 1143–1153.
10. Fakih MG, Khatib R. Improving the culture of culturing: critical asset to antimicrobial stewardship. Infect Control Hosp Epidemiol 2017; 38:377–379.
6.3% (11/176) 1.9 (11/5,691)
1.7 (8/4,686)
9.3% (7/75) 1.2 (7/5,737)
0.8 (4/4,855)
Value .006
<.0001
.42 10.7% (63/587) 11.5% (57/494) .67 .34
.22 1.2 (10/8,710) 2.2 (20/9,139) .09
P Value Comparing Hospital A and B 2015
<.0001 <.0001 .57 4.9 (63/12,983) 4 (57/14,191) .30 .002 .06
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