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INTRODUCTION
Catheter-associated urinary tract infections (CAUTIs) are among the most common causes of healthcare-associated infections (HAIs), with a high incidence in tertiary general hospitals and small- and medium-sized hospitals.12345
A high incidence of CAUTI can have a significant effect on morbidity, length of hospital stay, burden of antibiotic use, healthcare expenditure, and mortality.6789 An observational study of sixty-one hospitals in Canada reported that 21% of nosocomial bloodstream infections were caused by urinary tract infections (UTIs). Of these, 71% were associated with the use of indwelling catheters. The 30-day mortality rate was 15%.10 Tambyah et al.8 investigated the additional costs associated with CAUTI, which accounted for $20,662 for diagnostic tests and $35,872 for medication, with an average cost of $589 per case.
Sixty-nine percent of CAUTIs can be reduced by following the recommended infection prevention practices.11 Guidelines for the prevention of CAUTI include the proper use of urinary catheters, aseptic insertion, assessment of maintenance and removal, and hand hygiene practices.121314 The Agency for Healthcare Research and Quality, along with the Health Research and Educational Trust, launched a nationwide effort to implement the Comprehensive Unit-based Safety Program (CUSP) to reduce CAUTI in U.S. hospitals. The implementation of CUSP, which includes training, surveillance, and feedback, has decreased the rate of CAUTI in general wards.15
In Korea, the Korean National Healthcare-associated Infections Surveillance System (KONIS) includes CAUTI as a survey target. However, it has only been assessed in tertiary general hospitals and intensive care units (ICUs). Therefore, it is necessary to study the status of CAUTI in hospitals, especially in small- and medium-sized hospitals where surveillance is not performed, except in tertiary hospitals and ICUs, and to develop a program to reduce its incidence.
This study was conducted to assess the characteristics of CAUTI, the interventions implemented to reduce its incidence, and the effectiveness of prevention programs in hospitals of different sizes.
METHODS
Timeline
In April 2017, the researchers formed the CAUTI Prevention Guidelines Intervention Committee. The committee comprises individual teams for training and materials development, infection prevention program development, effectiveness evaluation criteria development, and network operations. Through this committee, we developed intervention programs to prevent CAUTI. Data were collected from 30 participating hospitals with dedicated infection prevention control (IPC) staff. Three months later, we initiated training and monitoring.
In 2018, three hospitals dropped out, but another three hospitals joined the study. We conducted intervention programs and CAUTI surveillance and monitored adherence to the guidelines (Table 1). In April 2018, we produced and distributed promotional materials to prevent CAUTI including posters for hospitals, stickers to be placed on urine bags, and memo boards to attach on monitors for greater exposure to healthcare workers.
Table 1
Program details for catheter-associated UTIs
Ten in-person training sessions were held over a three-year period, and video training materials on CAUTI prevention were produced and shared. A question-and-answer board was set up for participating hospitals to answer the questions.
From May to July 2018 and June to August 2019, the investigators visited all participating hospitals to perform on-site investigations. We collected the medical data of hospitalized patients for three years, from 2017 to 2019 (Fig. 1).
Fig. 1
Timeline for programs to prevent catheter-associated urinary tract infections from 2017 to 2019.
aHand washing, use sterile globe, use sterile drapes, disinfect skin, use disposable lubricant, monitoring for urinary catheter kinking, maintaining a closed system, fixation, use separate collection containers for each patient, regular assessment of urethral catheterization.
bAssessment of the appropriateness of producing the checklist, evaluate the adequacy of monitoring methods, whether intervention activities had been carried out.
Intervention
The indwelling catheterization process was monitored to determine the reason for insertion and adherence to standard urinary catheter insertion guidelines. Patients with indwelling catheters were checked for compliance with the maintenance instructions. The removal of unnecessarily inserted catheters was advised. The CAUTI rate was investigated by completing a UTI registry containing clinical information of the patients. The effectiveness of the training and intervention was shared with the participating hospitals, and feedback was provided.
The prevention intervention indicator was based on the Centers for Disease Control and Prevention (CDC) UTI guidelines, the 2017 KONIS, and Korean Society for Healthcare-associated Infection Control (KOSHIC) guideline: Healthcare associated Infection Control and Prevention. CAUTI was defined in accordance with the KONIS manual. When the KONIS manual was changed during the study period, the standard of this study was also changed.1416
Data collection and analysis
The following data were collected: age, sex, day of admission, day of infection, ICU or general ward admission, date of urinary catheter insertion, date of urinary catheter removal, clinical symptoms, reason for insertion of the urinary catheter, and compliance with the guidelines for insertion and maintenance of urinary catheters.
The researchers created a checklist to verify compliance with the guidelines. We selected the wards to be monitored in each hospital. Wards were selected in where 15% of the patients had a urinary catheter as a percentage of the total number of inpatients. The responsible staff had made regular observations, 1–2 times a week, to complete the checklist.
The urinary catheter utilization ratio (UCR) was calculated as the number of catheter days divided by the number of patient days multiplied by 100. The rate of CAUTI per 1000 device-days was calculated by dividing the number of CAUTI by the number of catheter days and multiplying the result by 1,000 according to the CDC’s National Healthcare Safety Network.17
We evaluated the microorganisms involved in CAUTI, UCR, CAUTI incidence, and factors affecting the insertion, maintenance, and infection of indwelling catheters. We also compared the incidence of CAUTI and related data between university hospitals and small- and medium-sized hospitals.
The microorganisms were identified using urine cultures. Chromogenic media were provided to those who wished to perform their own cultures when cultures were not available in the hospital.
Statistical analysis
We compared data from university hospitals with those from small- and medium-sized hospitals. Student’s t-test or Mann-Whitney U test was used to compare quantitative data, and Pearson’s χ2 was used to compare qualitative data. Statistical significance was set at P values < 0.05. R (version 3.6.0) was used for the statistical analyses.
RESULTS
Characteristics of participating hospitals
Thirty-two hospitals participated in this study, including twenty-one university hospitals and eleven small- and medium-sized hospitals. Three hospitals had > 900 beds, 13 hospitals had 700–900 beds, 8 hospitals had 400–700 beds, and 8 hospitals had < 400 beds. In the next two years, three small- and medium-sized hospitals were excluded from the study, but three other small- and medium-sized hospitals were included. One hospital each decreased from hospitals with 700–900 beds and hospitals with < 400 beds, whereas the number of hospitals with 400–700 beds increased by two. In 2017, there were 11 hospitals in Seoul, 8 hospitals in Gyeonggi, 5 hospitals in Chungcheong, 3 hospitals in Jeolla, 2 hospitals in Jeju, and 1 hospital each in Incheon, Gyeongsang and Gangwon. In 2018 and 2019, 10 hospitals in Seoul, 7 hospitals in Gyeonggi, 6 hospitals in Chungcheong, 4 hospitals in Jeolla, 2 hospitals in Jeju, and 1 hospital each in Incheon, Gyeongsang and Gangwon participated.
Incidence of CAUTI and UCR
During the study period, the UCR was 0.89, which it remained constant before and after the interventions in the ICUs of university hospitals. The proportion in small- and medium-sized hospitals was 0.79, which was lower than that in university hospitals. After the intervention, the UCR gradually decreased to 0.84. However, in the last quarter of the study, it was 0.91, similar to that in university hospitals. Throughout the study period, the UCR in the general wards of university hospitals remained 0.23. Small- and medium-sized hospitals initially had a lower UCR than university hospitals. However, it gradually increased, and by the end of the study, it was 0.2, which was approximately the same as that in university hospitals.
The incidence of CAUTI in the ICUs before the intervention in both university hospitals and small- and medium-sized hospitals increased during the third and fourth quarters of 2017. In the first quarter of 2018, the incidence rate was 2.05 infections/1,000 device-days in university hospitals and 1.44 infections/1,000 device-days in small- and medium-sized hospitals. After the intervention, it gradually decreased to the lowest point in the first quarter of 2019, with 1.18 infections/1,000 device-days in university hospitals and 0.79 infections/1,000 device-days in small- and medium-sized hospitals. However, the infection rate increased again to 1.74 infections/1,000 device-days in university hospitals and 1.80 infections/1,000 device-days in small- and medium-sized hospitals by the end of the study.
The incidence of CAUTI in the general wards of university hospitals was similar to that in the ICUs. Before the intervention, the infection rate in small- and medium-sized hospitals began to decrease in the third and fourth quarters of 2017, which subsequently stabilized at approximately 1 infections/1,000 device-days during the intervention period and increased sharply in the third quarter of 2019, reaching a peak of 2.04 infections/1,000 device-days.
Microorganisms causing CAUTIs
In 2017, the causative pathogens of CAUTI were identified in 191 (73.18%) university hospitals and 70 (26.82%) small- and medium-sized hospitals. Escherichia coli (26.05%) was the most common pathogen, followed by Enterococcus faecium (14.56%), Enterococcus faecalis (13.41%), Pseudomonas aeruginosa (11.88%), Klebsiella pneumoniae (9.58%), and Acinetobacter baumannii (5.75%). The microorganisms causing CAUTI did not differ between the two groups.
The following year, causative pathogens were identified in 367 (73.69%) and 131 (26.31%) CAUTI cases in university hospitals and small- and medium-sized hospitals, respectively. Escherichia coli (19.88%) was the most common pathogen, followed by Enterococcus faecium (16.27%), Pseudomonas aeruginosa (12.65%), Klebsiella pneumoniae (12.25%), Enterococcus faecalis (10.04%), and Acinetobacter baumannii (6.83%). No significant differences were observed in the causative microorganisms of CAUTI between the two groups.
In 2019, causative pathogens were identified in 253 (78.08%) and 70 (22.92%) CAUTI cases in university hospitals and small- and medium-sized hospitals, respectively. Escherichia coli (27.38%) was the most common pathogen, followed by Enterococcus faecium (19.08%), Pseudomonas aeruginosa (16.31%), Klebsiella pneumoniae (11.69%), Enterococcus faecalis (10.15%), and Acinetobacter baumannii (3.08%). We did not observe any significant differences between the two groups.
The proportion of quinolone-resistant and third-generation cephalosporin-resistant organisms among the Enterobacteriaceae isolates was 55–65%. The proportion of vancomycin-resistant enterococcus was 30–50%, and the proportion of carbapenem-resistant pseudomonas was 40–50%. There was no difference in the resistance rates among hospitals (Table 2).
Table 2
Resistance rates of causative microorganisms for catheter-associated urinary tract infections
Interventions for urinary catheterization
In university hospitals and small- and medium-sized hospitals, hand washing during the insertion of the indwelling catheter was performed at a rate of > 90%. Before the intervention, 96% university hospitals and 87% small- and medium-sized hospitals did not use sterile drapes. At the end of the study, they were used in almost all the hospitals. Fixation of the urinary catheter was performed in 90% and 70% of the ICUs of university hospitals and small- and medium-sized hospitals, respectively. After the study, the percentage of urinary catheter fixations in small- and medium-sized hospital ICUs increased to 80%. During the study period, several hospitals did not use separate collection containers for each patient. Regular assessment of urethral catheterization was performed in 91.2% of the university hospitals and 77.7% of the small- and medium-sized hospitals. Following the intervention, the performance rate increased to 100% in both hospitals. However, in the third and fourth quarters of 2019, the correction effect decreased in some general wards. Monitoring for urinary catheter kinking and maintaining a closed system remained at 99% from baseline to mid-study but decreased to 80% at the end of the study. Catheter fixation monitoring increased from 90% to 96% during the study but decreased to 79% at study end.
DISCUSSION
This study evaluated the implementation of interventions to prevent CAUTI in hospitals of various sizes and collected data related to these interventions. University hospitals, which have good infection prevention and control systems, were compared with small- and medium-sized hospitals, which are more vulnerable.
The UCR were similar over the three years. Reportedly, 38% of physicians are unaware that their patients have urinary catheters placed.18 In our study, the proportion of patients who were unaware of the reason for urethral catheterization in the ICUs was 38.9% in university hospitals and 34.5% in small- and medium-sized hospitals, whereas this proportion in the general wards was 33.8% in university hospitals and 47% in small- and medium-sized hospitals. The reason for indwelling catheterization is often not documented in patients’ medical records, and this information is not effectively communicated among healthcare providers. Because the reason is unknown, the decision to retain or remove urethral catheters is often made without considering removal, resulting in no change in the UCR.
The incidence of CAUTI in the ICUs decreased in both university and small- and medium-sized hospitals after the intervention were initiated in the first quarter of 2018 but increased again before the end of the study. As the interventions at the participating hospitals continued, their effectiveness decreased compared to that in the initial period. In 2019, new targets were added to the existing Korean National Healthcare-associated Infections Surveillance System (KONIS), including central line associated bloodstream infection surveillance and neonatal ICU surveillance. In addition, changes in healthcare policy, such as the introduction of infection prevention and control payments, have increased the number of hospitals participating in existing surveillance activities.19 As a result, in some of the hospitals in the study, participation in the new surveillance activities increased the workload of the IPC team, leading to fatigue among the limited IPC staff. This is thought to explain the decline in monitoring activities observed just before the end of the study and is also associated with deterioration.
The causative strains identified were Escherichia coli, Enterococcus faecium, Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. The strains or rates of antibiotic resistance did not differ significantly between the years. Resistance to ciprofloxacin and third-generation cephalosporins in K. pneumoniae and E. coli were 50–80% and > 50%, respectively. The high rate of antibiotic resistance should be considered while selecting antibiotics, especially because most patients with suspected UTI tend to opt for quinolones or third-generation cephalosporins as their primary treatment. Multidrug-resistant bacteria are common, with 30–50% of enterococci being resistant to vancomycin and half of pseudomonas being resistant to carbapenems. There were no differences in microbials or rates of antibiotic resistance between university hospitals and small- and medium-sized hospitals, which is similar to other previous study.20 It can be concluded that there is an exchange of patients between university hospitals and small- and medium-sized hospitals, and that resistant bacteria are shared. Therefore, interventions in small- and medium-sized hospitals are important for managing the resistant bacteria associated with UTI.
This study examined several factors that influence the incidence of CAUTI, including hand hygiene, use of sterile drapes, proper fixation of urethral catheters, use of separate collection containers, use of disposable lubricants, skin disinfection, and assessment of the necessity of indwelling catheters. All hospitals observed hand hygiene practices before the intervention. However, there were increases in the use of sterile drapes, proper immobilization of urethral catheters, and use of separate collection containers after the intervention.
Our study has several limitations. First, the participants expressed difficulty with the number and complexity of items they had to enter during the computerized entry process. This may have resulted in missing data or misidentification during data entry. Second, some patients were transferred from outside departments or hospitals after unmonitored urethral catheterization. In these cases, it is difficult to verify if the guidelines were followed at the time of insertion, which may have affected the CAUTI-related factor analysis. Third, we included hospitals of different sizes and with different roles to ensure the diversity of the study subjects. This study included university, small- and medium-sized, long-term care, and burn hospitals. However, considering the staffing required for intervention activities, the study was conducted in hospitals with more than 300 beds and dedicated IPC staff, and there were limitations in the evaluation of smaller hospitals.
We investigated the factors affecting CAUTI, implemented interventions to prevent CAUTI, and determined their effectiveness. We found a reduction in the incidence of CAUTI in the initial stages of the intervention when active support and staffing were in place. The incidence rate of CAUTI may be reduced through active interventions, including conducting of guidelines for the prevention of CAUTI. To achieve this, it is essential to have an adequate workforce to support the interventions.
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