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The Centers for Medicare and Medicaid (CMS) Hospital-Acquired Condition (HAC) Reduction Program now scores hospitals on quality metrics and imposes stiff financial penalties for poor performance. A major HAC-score component is incidence of catheter-associated urinary tract infections (CAUTIs) based on the National Healthcare Safety Network (NHSN) definition, which involves three criteria: (1) presence of a urinary tract catheter, (2) a urine culture growing >105 colony-forming units/mL of bacteria, and (3) signs or symptoms of a urinary tract infection. In a 2-year retrospective cohort analysis, researchers at the Mayo Clinic examined the clinical characteristics of NHSN-defined CAUTIs occurring in their institution's adult intensive care units.
During 2012 and 2013, 105 CAUTIs were identified (overall incidence, 2.5/1000 catheter days). The pathogens most commonly identified were yeasts (50%), Escherichia coli (18%), Enterococcus species (12%), and Pseudomonas species (6%). The predominant indication for urine culture was fever, but 68% of patients had possible alternative explanations for fever. None of the patients with no other explanation for fever received antimicrobial therapy specifically targeted at treating the NHSN-defined CAUTI. In only six of CAUTIs was there a blood culture positive for the same organism within 2 days, and for these cases, it was difficult to determine whether the urinary tract was the source of the bacteremia, or the positive urine culture was due to filtration of bacteria from the bloodstream into the urine.
Tedja R et al. Catheter-associated urinary tract infections in intensive care unit patients. Infect Control Hosp Epidemiol 2015 Nov; 36:1330. (http://dx.doi.org/10.1017/ice.2015.172)
Livorsi DJ and Perencevich EN.CAUTI surveillance: Opportunity or opportunity cost? Infect Control Hosp Epidemiol 2015 Nov; 36:1335. (http://dx.doi.org/10.1017/ice.2015.174)
Comment
This study shows that NHSN-defined CAUTIs in the intensive care unit have limited clinical significance and a low complication rate. Still, the hefty penalties imposed by the CMS HAC reduction program are leading hospitals nationwide to devote major efforts to lowering their rates of reported CAUTIs. Editorialists suggest several alternative metrics that might be more meaningful, including urinary-catheter utilization rates, incidence of CAUTI-associated bacteremias, or incidence of CAUTIs that are treated with appropriate antibiotic therapy.