A New Approach To Reducing CAUTIs

Can culturing process changes reduce the impact of catheter-associated urinary tract infections (CAUTIs)?

Catheter-associated urinary tract infections (CAUTIs) are always a risk of catheterization during hospitalization. Although hospitals work to reduce the burden of CAUTIs, even regulatory and reimbursement interventions through the Centers for Medicaid and Medicare (CMS) have met challenges. However, the results of a recent study suggest that incorporating culturing practices into prevention methods may aid in their effectiveness.

The Centers for Disease Control and Prevention (CDC) report that of the urinary tract infections (UTIs) acquired during hospitalization, 75% are associated with urinary catheters, and roughly 15% to 25% of hospitalized patients have a catheter during their stay. Estimates put the cost of health care-associated infections (HAIs) at $28.4 to $33.8 billion per year in the United States. Each case of a CAUTI is estimated to cost around $800, and that’s not including the cost of an additional infection that might occur following treatment with antibiotics (such as Clostridium difficile).

CAUTIs continue to pose a problem for infection prevention efforts as patients that require urinary catheterization may only be colonized with an organism or have a fever (1 of the criteria components for meeting CAUTI definition per the CDC guidelines) that is related to other issues. CAUTI prevention isn’t easy and although most efforts focus on insertion and maintenance bundles, a recent study, published in the American Journal of Infection Control (AJIC) has underlined the need to incorporate culturing practices.

Knowing when it is appropriate to culture a patient’s urine can be critical. A positive culture and a fever over 38°C meet CAUTI criteria per CDC National Healthcare Safety Network (NHSN) guidelines. However, patients can have a fever for multiple reasons, especially those in intensive care units (ICUs), and that often triggers a urine culture.

If a patient is colonized or experiencing asymptomatic bacteremia (ASB), this may give a practitioner the impression of a CAUTI; however, the investigators in the AJIC study are stressing that urinalysis also plays a vital point. Because many patients in an ICU are unable to verbally or physically convey other signs and symptoms (urgency in urination, flank pain, etc.) there is significant emphasis on the urine culture and fever; but, the investigators highlight the importance of pyuria as a diagnostic component to identifying a UTI.

In their study, by standardizing a negative urinalysis, the investigators were able to cancel 29 urine cultures that could have met criteria (if there was microbial growth) but may have actually been colonization. These cultures may have resulted in unnecessary antibiotic usage.

The study highlighted the importance of not only improving insertion and maintenance bundles (ie, best practice and daily utilization evaluation), but also improving the practice of ordering urine cultures. Traditional CAUTI reduction bundles focus on insertion and maintenance, but establishing a synergistic approach with culturing practices can not only reduce CAUTI rates but also antibiotic usage. In fact, the investigators found that after implementing such a bundle, the CAUTI rate was reduced by one-third in trauma patients over the course of 2 years.

As increasing attention falls to antimicrobial stewardship and reducing healthcare-associated infections, tactics like this are needed to establish a wholistic approach to identifying and preventing CAUTIs.