Adherence to CDC guidelines for the placement, maintenance and removal of catheters and American College of Critical Care Medicine and Infectious Disease Society of America guidelines for evaluating fever in a critically ill patient reduced catheter-associated urinary tract infections in the ICU, according to recent findings.
“Reduction in UTIs has become a major focus of hospitals throughout the country because they result in prolonged hospital stays and increase health care costs,” Katherine Mullin, MD, of the Cleveland Clinic, said in a press release. “In our prevention model of catheter-associated UTIs, we included guidance for which patients should be tested, excluding those without symptoms or high-risk of invasive infection.”
Mullin and colleagues established a network of all ICU and infection prevention disciplines with the institution-wide goal of decreasing catheter-associated UTIs. Interventions included assessment of competency with catheter insertion and maintenance; maintaining a closed system; initiation of a nurse-driven protocol for catheter removal; improved fidelity of electronic documentation of catheters; implementation of preservative tubes for specimen collection; and periodic maintenance audits of catheters.
Monthly meetings were also held to consider guidelines from the American College of Critical Care Medicine and Infectious Disease Society of America for assessment of fever in critically ill patients, which were implemented by all ICU disciplines in the network. The joint guidance from these organizations suggest that, when assessing fever in the critically ill, urine cultures should only be evaluated in patient populations at high risk for invasive infection. Such patients include kidney transplant recipients; individuals who are neutropenic or have recently undergone genitourinary surgery; and those with signs of obstruction.
Screening for catheter-associated UTIs and hospital-acquired bloodstream infections (BSIs), as defined by the National Healthcare Safety Network (NHSN), was performed on a regular basis and documented in an infection prevention database. Patient days were acquired through an administrative source and device days were calculated manually per NHSN guidelines. Data on catheter-associated UTIs, hospital-acquired BSIs and hospital-acquired BSIs resulting from Enterobacteriaceae were collected and compared. Orders for urine cultures were tracked by service.
The study was conducted from Jan. 1, 2013 to Dec. 31, 2014. Data were obtained from ICUs in the pediatric, medical, surgical, neurological, cardiac, heart failure and cardiothoracic surgery disciplines, comprising 215 adult and 25 pediatric beds in a tertiary care academic medical center with a total of 1,268 beds.
There were 11,117 ICU admissions in 2013, which led to 74,705 patient days, and 11,589 ICU admissions in 2014, resulting in 75,569 patient days. Device use ratios were 0.7 in 2013 and 0.68 in 2014. The number of urine specimens cultured declined from 4,749 in 2013 to 2,479 in 2014, according to the researchers. The catheter-associated UTI rate was reduced from 3 per 1,000 catheter days in 2013 to 1.9 in 2014 (rate ratio, 0.6291; 95% CI, 0.49-0.81). Decreases in the rates of hospital-acquired BSIs and hospital-acquired BSIs secondary to Enterobacteriaceae did not reach statistical significance.
“Our approach began with attention to best practice for insertion, maintenance and removal of Foley catheters,” the researchers wrote. “Subsequently, we emphasized ‘stewardship of testing’ by following published guidance for evaluation of a fever prior to ordering a urine culture in a critically ill patient. The culmination of these efforts was a significant reduction in catheter-associated UTIs.”
Future research should evaluate whether stewardship of testing in the ICU results in “downstream benefits” on the use of antibiotics, the development of resistance and resource use during hospital stays, they added. – by Julia Ernst, MS
Disclosures: The researchers report no relevant financial disclosures.