Preventing catheter-associated urinary tract infection in the zero-tolerance era

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1 Preventing catheter-associated urinary tract infection in the zero-tolerance era Alexandre R. Marra, MD, a Thiago Zinsly Sampaio Camargo, MD, a Priscila Gonçalves, RN, b Ana Maria Cristina B. Sogayar, MD, a Denis Faria Moura Jr, RN, a Luciana Reis Guastelli, RN, a Carla Andrea C. Alves Rosa, RN, a Elivane da Silva Victor, PhD, c Oscar Fernando Pav~ao dos Santos, MD, a and Michael B. Edmond, MD, MPH, MPA d S~ao Paulo, Brazil, and Richmond, Virginia Background: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care associated infections in the critical care setting. Methods: A quasi-experimental study involving multiple interventions to reduce the incidence of CAUTI was conducted in a medical-surgical intensive care unit (ICU) and in 2 step-down units (SDUs). Between June 2005 and December 2007 (phase 1), we implemented some Centers for Disease Control and Prevention recommended evidence-based practices. Between January 2008 and July 2010 (phase 2), we intervened to improve compliance with these practices at the same time that performance monitoring was being done at the bedside, and we implemented the Institute for Healthcare Improvement s bladder bundle for all ICU and SDU patients requiring urinary catheters. Results: There was a statistically significant reduction in the rate of CAUTI in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], ) before the intervention to 5.0 per 1,000 catheter-days (95% CI, ; P,.001) after the intervention. There also was a statistically significant reduction in the rate of CAUTI in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, ) before the intervention to 12.9 per 1,000 catheter-days (95% CI, ) after the intervention (P 5.014). Conclusion: Our findings suggest that reducing CAUTI rates in the ICU setting is a complex process that involves multiple performance measures and interventions that can be applied to SDU settings as well. Key Words: Health care-associated infection prevention; urinary catheter; intensive care; step-down unit. Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect Control 2011;n:1-6.) Urinary tract infections (UTIs) are commonly acquired in hospitals, with an estimated prevalence of 1%-10%, representing 30%-40% of all nosocomial infections. 1 The most important risk factor for the development of nosocomial UTIs, especially in the intensive care setting, is the presence of a urinary catheter (UC). 1,2 Guidelines from the Centers for Disease Control (CDC) and the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America describe various interventions for preventing catheterassociated UTIs (CAUTIs) in intensive care units (ICUs). 3,4 Each of these recommendations is categorized on the From the Intensive Care Unit, a Infection Control Unit, b and Statistics Department, Instituto Israelita de Ensino e Pesquisa, S~ao Paulo, Brazil c ; and Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia. d Address correspondence to Alexandre R. Marra, MD, Av Albert Einstein, 627/701, Intensive Care Unit, 5th Floor, Morumbi, Sao Paulo , Brazil. alexmarra@einstein.br. Conflict of interest: None to report /$36.00 Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi: /j.ajic basis of existing scientific evidence, theoretical rationale, applicability, and potential economic impact. As part of the 5 Million Lives campaign endorsed by leading US agencies and professional societies, The Institute for Healthcare Improvement ( ihi) recommends that all intensive care units (ICUs) implement a bladder bundle aimed at reducing the incidence of CAUTI to zero. 5 However, in ICUs, UCs might be needed for extended periods, and the duration of catheterization is the most important risk factor for the development of a CAUTI. 6 In addition, ICU patients may be colonized with hospital-acquired organisms, and sometimes a UC must be inserted in urgent situations when optimal attention to aseptic technique might not be feasible. Recent data suggest that non- ICU medical wards have considerably lower device utilization rates than medical ICUs. 7 Unfortunately, however, there are little data regarding the prevention of CAUTIs in step-down units (SDUs). 7 The types of organisms that most commonly cause hospital-acquired UTI change over time, but gram-negative organisms principally enteric gram-negative bacilli are responsible for the great majority of CAUTI cases. 6 The purpose of this prospective, quality improvement study was to examine the effect of a series of interventions implemented in an ICU and 2 SDUs to reduce the incidence of CAUTIs and to analyze the 1

2 2 Marra et al. American Journal of Infection Control n 2011 differences in CAUTI rates and causative microorganisms in the 2 study phases. METHODS Setting and study design Thus quasi-experimental interrupted time series study was conducted in a 38-bed medical-surgical ICU and in two 20-bed SDUs with the same physical layout in a private tertiary care hospital in S~ao Paulo, Brazil. The ICU has an open staffing model, and admits approximately 2,200 patients annually. All rooms in the ICU and the SDUs are single-bed rooms. The SDU patients are transferred from the medical-surgical ICU, from various wards, and from the Emergency Department. Because this study was considered a quality improvement project, it was not submitted to our Institutional Review Board. The study was carried out in 2 phases. In phase 1 (June 2005 to December 2007), ICU nurses or and physicians (primarily urologists) inserted UCs using aseptic technique with a 2% chlorhexidine preparation for skin antisepsis. Catheter insertion and maintenance were in accordance with CDC guidelines. 3 UCs were not routinely replaced. The decision to remove a UC was made solely by the patient s physician, with catheters kept in place until it is no longer needed or until an adverse event necessitates its removal. Each year, in a convenience sample of patients, UC insertion was directly observed by assigned nurses, who provided feedback on compliance with appropriate practices to the ICU team via . In phase 2 (January 2008 to July 2010), after the hospital s chief executive officer articulated a policy of zero tolerance for CAUTIs, we continued the processes begun in phase 1, but audited these process measures once monthly at random intervals in a small sample of patients undergoing UC insertion. In January 2008, we implemented the bladder bundle. The bundle components included the creation of a UC insertion cart; hand hygiene; chlorhexidine skin and meatal antisepsis; sterile field and sterile gloves; only one attempt at insertion allowed for each catheter (ie, a new catheter used for each attempt); adequate UC balloon inflation; and daily review of the need for a UC with prompt removal if no longer needed. The bundle was used for all ICU and SDU patients requiring a UC. Nurses intervened in this process at the same time that performance monitoring was occurring at the bedside if noncompliance with an element of the bundle (eg, hand hygiene was not performed) was detected during UC insertion. Before the start of phase 2, we delivered a brief presentation to the ICU staff on CAUTI prevention, reviewed the study protocol, and encouraged participation in our UC Bundle Getting to Zero program. During phase 2, each month we provided feedback on compliance with the bundle components via to the ICU and SDU teams (doctors and nurses). We also placed posters in the ICU and SDUs with bar graphs displaying compliance with process of care measures as well as the CAUTI rate, determined by surveillance conducted by the infection control and hospital epidemiology program. We created an ICU nurses group to remove unnecessary UCs daily. Once a day, an ICU nurse (not on clinical duty) checked all of the ICU patients with UCs and asked the ICU doctor on duty if the UC was necessary. Placement of a UC was considered appropriate when the indication was for close monitoring of urine output in an incontinent patient or in a critically ill patient requiring intensive monitoring during vasopressor infusion. 8 The same strategy was followed in the SDUs, but with each bedside nurse questioning the SDU doctors on duty about the need for a UC in each patient. Unfortunately, these data are available for the SDUs only for May-July We did not use impregnated UCs in the ICU and SDU patients. Compliance with all process measures during UC insertion was evaluated for all UCs placed in the ICU and SDUs. Bladder ultrasonography was used sporadically to aid the decision of whether or not to place a UC, and we plan to train all ICU doctors and nurses in the use of bladder ultrasonography to avoid indwelling catheterization. Since October 2009, all ICU and SDU patients with an indwelling device (eg, central venous catheter, UC) receive a daily chlorhexidine bath. Definitions CAUTI surveillance was performed by trained infection control practitioners using the CDC s definition of laboratory-confirmed UTI for the 2 phases of the study. 9 A CAUTI was attributed to a specific unit if it was detected at least 48 hours after admission to or less than 48 hours after discharge from the unit. 3 The device utilization ratio was defined as the number of UC-days divided by the number of patient-days. Microbiological methods All isolates were identified by manual or automated methods and confirmed using the Vitek 2 system (bio- Merieux Vitek, Hazelwood, MO). Statistical analysis A generalized linear model was used to model Poisson distribution count data using the number of CAUTI cases as the dependent variable and the preintervention and postintervention periods as the independent variable. All tests of statistical significance were 2-sided, with the significance level set at P All

3 Vol. n No. n Marra et al. 3 Table 1. Characteristics of both phases in the ICU and in the SDUs during the 2 study phases ICU SDUs P1 P2 P1 P2 Patient days 24,820 27,584 36,454 34,661 UC days 15,500 14,577 6,633 4,041 UC utilization ratio* Number of CAUTIs Monomicrobial infection, n (%) 102 (93.6) 68 (89.5) 91 (91.9) 46 (87.0) Polymicrobial infection, n (%) 7 (6.4) 8 (10.5) 8 (8.1) 7 (13.2) Age of CAUTI patients, years, mean 6 standard deviation Female sex of CAUTI patients, n (%) 54 (49.5) 43 (56.6) 58 (58.6) 18 (34) UC checklist, n (%) NA 2,105/2,327 (90.5) NA 1,744/1,959 (89.0) Compliance with all process measures for UC insertion, n (%) y 1,174/2,105 (84.3) 1,533/1,744 (87.9) Hand hygiene 1,981/2,105 (94.1) 1,722/1,744 (98.7) Chlorhexidine preparation 1,996/2,105 (94.8) 1,726/1,744 (99.0) Sterile field 1,992/2,105 (94.6) 1,729/1,744 (99.1) Sterile gloves 1,982/2,105 (94.2) 1,720/1,744 (98.6) Surgical mask 1,994/2,105 (94.7) 1,737/1,744 (99.6) Appropriate UC indication, n (%) NA 3,140/3,571 (87.9) NA 301/341 (88.3) z Removal of the inappropriate UC, n (%) NA 372/431 (86) NA 17/40 (42.5) z UTI rate per 1,000 catheter days NA, not available. *Defined as the number of UC-days divided by the number of patient-days. y Defined as the percentage of time the required component was performed without intervention by the bedside nurse. z Data from only May and July data analyses were performed using SPSS for Windows 17.0 (SPSS Inc, Chicago, IL). RESULTS Study sample, compliance, and incidence density of CAUTI in each study phase In ICU phase 1, there were 24,820 patient-days and 15,500 UC-days, for a UC utilization ratio of 0.62 (Table 1). In ICU phase 2, there were 27,584 patient-days and 14,577 UC-days, for a UC utilization ratio of In SDU phase 1, there were 36,454 patient-days and 6,633 UC-days, for a UC utilization ratio of 0.18, and in SDU phase 2, there were 34,661 patient-days and 4,041 UCdays, for a CVC utilization ratio of The majority of CAUTIs were monomicrobial infections in both phases in the ICU and SDUs (Table 1). In phase 2, we assessed compliance with the UC checklist in 90.5% (2,105/2,327) of catheter insertions in the ICU and in 89.0% (1,744/1,959) of those in the SDUs. Compliance with the process measures for catheter insertion is summarized in Table 1. Using Poisson regression, we found a statistically significant reduction in the CAUTI rate in the ICU, from 7.6 per 1,000 catheter-days (95% confidence interval [CI], ) before the intervention to 5.0 per 1,000 catheter-days (95% CI, ) after the intervention (P,.001). We also found a statistically significant reduced CAUTI rate in the SDUs, from 15.3 per 1,000 catheter-days (95% CI, ) before the intervention to 12.9 per 1,000 catheter-days (95% CI, ) after the intervention (P 5.014). Microbiological features As shown in Table 2, 67.0% (81/121) of all microorganisms identified in ICU phase 1 were gram-negative. Other microorganisms included fungi (22.3%; 27/121) and gram-positive organisms (10.7%; 13/121). In ICU phase 2, the distribution of microorganisms was 72.1% (57/79) gram-negative, (15.2%; 12/79) fungi, and (12.7%; 10/79) gram-positive. In SDU phase 1, the majority (71.4%; 90/126) of microorganisms were gram-negative, with smaller proportions of grampositive organisms (15.1%; 19/126) and fungi (13.5%; 17/126). In SDU phase 2, these proportions were 83.0% (49/59) gram-negative, 10.2% (6/59) grampositive, and 6.8% (4/59) fungi. Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli accounted for.70% of the gramnegative pathogens detected in both phases in the ICU and SDUs. Non-albicans Candida was more prevalent than C albicans in both care settings. The most prevalent gram-positive pathogen was Enterococcus faecalis. DISCUSSION Our hospital is engaged in a patient safety program that is a resource from the Institute for Healthcare Improvement. We previously demonstrated that it is

4 4 Marra et al. American Journal of Infection Control n 2011 Table 2. Characteristics of pathogens causing CAUTIs in the ICU and SDUs during the 2 study phases ICU SDUs P1 P2 P1 P2 Pathogen n % n % n % n % Gram-positive Enterococcus faecalis * * E faecium * Streptococcus spp Staphylococcus aureus S aureus coagulase negative Gram-negative Pseudomonas aeruginosa Klebsiella pneumoniae Escherichia coli Acinetobacter baumannii Proteus mirabilis Enterobacter spp Burkholderia cepacia Serratia marcescens Morganella morganii K ozonae Citrobacter spp Stenotrophomonas maltophilia Fungi Candida albicans C glabrata C tropicalis C parapsilosis C krusei C guilliermondii Trichosporon beigelli Total identified agents *Including 1 case of VRE. possible to reduce the incidence of ventilator-associated pneumonia and central line associated bloodstream infections to zero for certain periods. 10,11 This was one of the reasons for adopting the getting to zero goal as a quality indicator for patient safety in our ICU and SDUs. However, eliminating health care associated infections (HAIs) includes difficulties with the case definition (CDC definition) and risk adjustment (severity ill patients, urinary catheters and so on). The surveillance National Healthcare Safety Network definition of CAUTI includes all UTIs occurring in symptomatic patients with an indwelling UC 9 ; however, this definition lacks specificity, given the difficulty of localizing urinary signs and symptoms with a catheter in situ. 12 That is, the surveillance definition overestimates the true incidence of CAUTI because of the high prevalence of bacteriuria in patients with an indwelling catheter. 13 Moreover, Edmond 14 has pointed out that a getting to zero approach might be associated with adverse unintended consequences. Eliminating HAIs has been identified as an important priority in many hospitals, 5,15 especially since Medicare no longer provides increased payments for treatment of CAUTIs. This is not the situation in Brazilian hospitals, although our hospital s chief executive officer and senior management are responsible for ensuring that the health care system supports an infection prevention and control program to effectively prevent CAUTIs. 4 In our hospital, the prevention of CAUTIs in the ICU and SDUs is a quality indicator that affects employees annual bonuses. Many hospitals have increased the size and the numbers of their ICUs 15 and have added SDUs to provide appropriate care for patients whose illness acuity falls between that of ICU patients and that of ward patients. Weber et al 7 demonstrated that infection rates in SDUs are more similar to those in the ward setting than those in ICUs. We decided to apply the bladder bundle in our SDUs even though there is good evidence supporting this infection control practice only in ICU patients. 5,6 It is important to note that our CAUTI surveillance was performed by trained infection control practitioners using the CDC s definition for the 2 phases of the study in the ICU and in the SDUs. 9 Our

5 Vol. n No. n Marra et al. 5 A 20,0 Incidence density of CAUTI in ICU (per 1,000 catheter-days) 15,0 10,0 5,0 0,0 j 2005 a o d f a j a o d f a j a o d f a j a o d f a j a o d f a j Phase 1 Rate 6-month rolling average Phase 2 B 50,0 40,0 30,0 20,0 10,0 0,0 j 2005 Incidence density of CAUTI in SDUs (per 1,000 catheter-days) a o d f a j a o d f a j a o d f a j a o d f a j a o d f a j Phase 1 Phase 2 Rate 6-month rolling average Fig 1. Incidence density of CAUTIs per 1,000 catheter-days in the ICU (A) and in the SDUs (B). CAUTI, catheterassociated urinary tract infection. CAUTI rate was higher in the SDUs than in the ICU, in disagreement with the findings of Weber et al, 7 who reported a higher rate of all device-associated HAIs in ICUs than in SDUs. We also found a statistically significant difference in CAUTI rates after applying the bladder bundle in our SDUs. Of note, we achieved monthly zero infection rates by applying all of the CAUTI prevention measures recommended in the literature 3,4 in 9 of 31 months in phase 2 of this study. Early studies of impregnated silver-coated UCs found a lower CAUTI rate compared with standard catheters. 16,17 Although silver-coated UCs are more expensive than standard catheters, a cost-effectiveness analysis found that their use actually reduced costs, given the lower costs associated with treatment. 17 Other recent studies have shown no change in CAUTI rates with the use of impregnated catheters. 18,19 Interestingly, in a systematic review and meta-analysis, Meddings et al 20 found that a dramatically reduced CAUTI rate in ICU patients without the use of coated catheters could be achieved simply by evaluating the need for a UC each day. We do not use impregnated, silver-coated UCs in our ICU and SDUs. To the best our knowledge, the present study is the first to evaluate CAUTI preventive measures for SDU patients that also have been applied to ICU patients. This study has several limitations. First, this was not a randomized trial, but rather a quasi-experimental, interrupted time series study. Quasi-experimental study designs are frequently used when conducting a controlled trial is not logistically feasible. Thus, other unmeasured factors might have occurred coincident with the interventions that were implemented in January 2008 (ie, the bladder bundle), resulting in a decreased CAUTI rate in our ICU. This seems unlikely, however, given the fact that no decrease in CAUTI rate had been seen over the previous several years (Fig 1). Second, we collected data only in small audits (ie, no continuous data collection) on preintervention process measure compliance, and the resulting lack of data hindered our ability to evaluate the full impact of bundle implementation. However, a significant difference in CAUTI rates was demonstrated between the ICU and the SDUs, and we achieved a zero infection rate by applying the CAUTI prevention measures recommended in the literature. 4 Finally, this study was performed at a single medical center, and our results might not be generalizable to other hospitals, given differences in staffing, patient populations, and resources. In conclusion, the process measures for CAUTI presented here are derived from published guidelines and other relevant literature. Interventions to reduce CAUTI should be a priority not only for all inpatient settings including ICUs, but also for SDUs. Further research into CAUTI prevention is still needed.

6 6 Marra et al. American Journal of Infection Control n 2011 References 1. Richard MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21: Garrouste Orgeas M, Timsit JF, Soufir L, Tafflet M, Adrie C, Philippart F, et al. Impact of adverse events on outcomes in intensive care unit patients. Crit Care Med 2008;36: Gould CV, Umscheid CA, Rajender K, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, Available from: cauti/001_cauti.html. Accessed September 28, Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care 2006;15: Shuman EK, Chenoweth CE. Recognition and prevention of healthcareassociated urinary tract infections in the intensive care unit. Crit Care Med 2010;38(8 Suppl):S Weber DJ, Sickbert-Bennett EE, Brown V, Rutala WA. Comparison of hospital-wide surveillance and targeted intensive care unit surveillance of healthcare-associated infections. Infect Control Hosp Epidemiol 2007;28: Apisarnthanarak A, Rutjanawech S, Wichansawakun S, Ratanabunjerdkul H, Patthranitima P, Thongphubeth K, et al. Initial inappropriate urinary catheter use in a tertiary-care center: Incidence, risk factors, and outcomes. Am J Infect Control 2007;35: Horan TC, Andrus M, Dudeck MA. Centers for Disease Control and Prevention/National Healthcare Safety Network surveillance definition of health care associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36: Marra AR, Cal RG, Silva CV, Caserta RA, Paes AT, Moura DF Jr, et al. Successful prevention of ventilator-associated pneumonia in an intensive care setting. Am J Infect Control 2009;37: Marra AR, Cal RG, Dur~ao MS, Correa L, Guastelli LR, Moura DF Jr, et al. Impact of a program to prevent central line associated bloodstream infection in the zero-tolerance era. Am J Infect Control 2010;38: Tambyah PA, Knasinski V, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic. Arch Intern Med 2000;160: Stark RP, Maki DG. Bacteriuria in the catheterized patient: What quantitative level of bacteriuria is relevant? N Engl J Med 1984;311: Edmond MB. Getting to zero: Is it safe? Infect Control Hosp Epidemiol 2009;30: Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32: Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. A randomized crossover study of silver-coated urinary catheters in hospitalized patients. Arch Intern Med 2000;160: Rupp ME, Fitzgerald T, Marion N, Helget V, Puumala S, Anderson JR, et al. Effect of silver-coated urinary catheters: Efficacy, costeffectiveness, and antimicrobial resistance. Am J Infect Control 2004;32: Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: Antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med 2006;144: Srinivasan A, Karchmer T, Richards A, Song X, Perl TM. A prospective trial of a novel, silicone-based, silver-coated Foley catheter for the prevention of nosocomial urinary tract infections. Infect Control Hosp Epidemiol 2006;27: Meddings J, Rogers MA, Macy M, Saint S. Systematic review and metaanalysis: Reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 2010;51:

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