A multi-center study on bundles of catheter-associated urinary tract infections in intensive care units

doi:10.21203/rs.3.rs-4620033/v1

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A multi-center study on bundles of catheter-associated urinary tract infections in intensive care units

https://doi.org/10.21203/rs.3.rs-4620033/v1

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Background

Catheter-associated urinary tract infections (CAUTIs) are the most common type of healthcare-associated infections (HAIs). Current studies mainly focused on the risk factors, but the method to control is unresolved. We aimed to give an overview of the epidemiology of CAUTIs and to explore the bundles intervention effect in intensive care unit (ICU) inpatients.

Methods

A multi-center, double blind, prospective study was conducted in eight Xiamen’s medical centers during six months, We recruited ICU inpatients who had indwelling urinary catheters > = 48h. Data were analyzed using Chi-Square and student's t-test.

Results

With bundle interventions, the CAUTIs rate in ICUs was decreased from 3.84 to 1.31 per 1000 urinary catheter days. The urinary catheter utilization was significantly decreased after bundles (71.29–62.70%), the average duration of indwelling urinary catheters was significantly decreased as well (7,035 days vs 6,884 days). CAUTIs in patients over 60 years old were found a significantly reduction after bundles. There were 45 causative organisms detected from 36 cases of CAUTIs, including 12 multidrug-resistant bacteria.

Conclusions

Bundles have been shown to reduce the risk of CAUTIs in patients with indwelling catheters in the ICU, especially in the elderly. It also significantly reduces the use of Carbapenem. Therefore, CAUTI bundles are recommended to clinicians.

Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections acquired while receiving medical care that were not present at the time of admission(1). They are the most common adverse event in healthcare, affecting patient safety and causing significant public health problems(1).For example, they are responsible for a high morbidity, mortality, and result in an increased financial burden, which require public attention(2). Among all contributing factors, Catheter-associated urinary tract infections (CAUTIs) accounts for 40% of nosocomial infections and 80% of urinary tract infections (UTIs)(3). According to statistics, CAUTIs are the most common type of HAIs in the United States and the second most common HAIs in Southeast Asia(4, 5). It is supported by a systematic review regarding nosocomial infections of high-income and low-income countries, the cumulative incidence of CAUTIs was estimated to be 4.1 and 8.8 per 1000 catheter-days, respectively(6). In addition, if CAUTIs occurred in older patients, their hospitalization days could increase by 18 days, total hospitalization costs will increased by ¥18,000, and all-cause mortality at discharge increased 2.314-fold(7). Therefore, the question of what method can be used to control the catheter-related presence of bacteria in urine and CAUTI will only grow in importance. For current and future health professionals, the unresolved issues need further researches(8).Therefore, surveillance of CAUTIs and implementation of combined intervention projects (bundles) are crucial to study the status of CAUTIs, reduce CAUTI, hospitalization days, and medical burden, improve the quality of life, and promote the implementation of bundles by Center for Nosocomial Infection Control in Xiamen.

Setting

Eight medical centers in Xiamen including Center for the Nosocomial Infection Control in Xiamen, the First Affiliated Hospital of Xiamen University, Xiamen Children’s Hospital, Xiamen Traditional Chinese Medicine Hospital, Xiamen Haicang Hospital, Xiamen Chang Gung Hospital, and Fudan University Affiliated Zhongshan Hospital, Xiamen Branch. The study included ICU patients from these eight Xiamen medical centers who had indwelling urinary catheter for at least two days and had the catheter removed within 48 hours during the period of January 1^st to June 30^th, 2017. We excluded patients with urinary tract infection, pregnancy, or AIDS.

Urine samples were collected from ICU patients with an indwelling catheter, the morning midstream urine and urine from the urinary catheters were all tested. The isolation of pathogen was confirmed by Gram staining and the standard biochemical tests(9), and each isolate were be tested antimicrobial susceptibility. The isolates of multidrug resistant (MDR) were be defined if they were non-susceptible to >=1 agent in >=3 different antibiotic groups(10). The multidrug resistant organism (MDRO) analysis was also separated into methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and Gram-negative bacteria.

Study design

A prospective study of 6-months duration was conducted, including baseline survey and intervention period. The baseline period run for 3 months from January through March 2017. Following baseline survey, the intervention period was from April through June 2017.

After obtaining the consent of hospitals’ leadership and their head of ICUs, specialists elected from each hospitals receiving standardized training by Center for the Nosocomial Infection Control. The training was about the definition of CAUTI, urine specimen collection, contents of Bundle and data collection. After the training, these investigators explained the project to the head nurse and the head of ICUs, and trained ICU healthcare professionals in the unified way.

Following the requirement of the study, eight participating hospitals conducted unified protocol and bundles. The investigators checked patients with CAUTI every day and monitored the adherence rate of Bundle. The investigators were required to make at least 90 observations and complete the "CAUTI Monitoring Registration Form" for patients with an indwelling catheter for more than 48 hours. Whether assessing catheterization indications, hand hygiene, aseptic operation, normative catheter placement, medical records, nursing records and isolation of multidrug-resistant organism (MRDO) patients were all included in this form. All data extracted from the form were reported to Center for the Nosocomial Infection Control on the 10th of each month. Staff of Center for the Nosocomial Infection Control responsible for collecting and summarizing every quarter. Before sending data to data analyst, the data collectors anonymizes the data, which eliminated information bias. The data analyst analyzed data and discovered high-risk factors of CAUTI, and feedback to participating hospitals.

Bundles

Bundles consisted of following measures:1) assessing catheterization indications. 2) aseptic operation. 3) hand hygiene. 4) alcohol-based hand rub for each bed. 5) separation from patients with multidrug-resistant bacterial infections. 6) daily assessment of readiness for extubation by physicians. 7) daily recorded the presence of indwelling urinary catheters by nurses. 8) health education for patients and their families, and provide instructions of catheter fixation and bladder function training.

Definitions and Indicators of CAUTI

1.5.1 CAUTI was diagnosed according to the CAUTI’s diagnostic criteria issued by the CDC National Health Care Safety Network (CDC-NHSN) in 2015 (11).

1.5.2 Catheter-associated urinary tract infection rate was calculated by dividing the number of CAUTI by urinary catheter (UC)-days and multiplied by 1000.

1.5.3 Urinary catheter utilization rate was calculated by dividing the number of days of patients with urinary catheterization by the total number of their hospital days.

1.5.4 Compliance rate of bundles was calculated by dividing the number of patients with CAUTI implemented bundle measures by the number of patients with CAUTI supposed to be implemented bundle measures and multiplied by 100.

1.5.5 All the participating hospitals are categorized as 'tertiary hospitals' which means that they are comprehensive hospital at the national, provincial, or city level, with more than 500 beds.

Statistical analysis

All statistical analyses were performed using SPSS 21.0 (SPSS Inc., Chicago, IL, USA). Chi-Square was used to analyze categorical variables, and Student's t-test was used to analyze continuous variables. The mean value was presented along with a standard deviation (SD). A P -value < 0.05 was considered statistically significant.

Demographic characteristics of study patients

Between 1 January 2017 and 30 June 2017, 1,118 patients were included for this survey, including 673 males and 445 females. The mean age was 58.53±20.13 years, hospitalized at ICUs ranged from 1 to 444 days with the mean of 9.93±23.49 days. There were 588 (52.6%) in the baseline period and 530 (47.4%) in the intervention period. There were no differences between the patient characteristics in the baseline period and the intervention period (Table 1). The age of CAUTI patients during baseline was from 1 to 94 years old, with an average age of 59.03±20.02 years old, APACHII score in the average was 17.3±20.34, and patients with high-risk factors comprising 48.1%. Patients in bundles group was from 3 to 95 years old with the mean of 57.98±20.26 years old, APACHII score in the average was 15.8±21.06, and patients with high-risk factors comprising 49.2%. There existed no significant differences in acute physiology score of these two groups as well (P > 0.05), APACHII score was 17.3±20.34 and 15.8±21.06, separately.

Table 1. Characteristics of study participants

Characteristics		Total	Baseline	Bundles
Overall total, n (%)		1118(100)	588(52.6)	530(47.4)
Age group (years) , n (%)	<60	540(48.3)	282(48.0)	258(48.7)
	>=60	578(51.7)	306(52.0)	272(51.3)
Gender, n(%)	Male	673(60.2)	353(60.0)	320(60.4)
	Female	445(39.8)	235(40.0)	210(39.7)
High-risk factors, n (%)	With	544(48.7)	283(48.1)	261(49.2)
	Without	574(51.3)	305(51.9)	269(50.8)
Operation, n (%)	Yes	574(51.3)	287(48.8)	287(54.2)
	No	544(48.6)	301(51.2)	243(45.8)
APACHII score	0～	965(86.3)	518(88.1)	447(84.3)
	20～	544(48.7)	70(11.9)	83(15.7)

ICU: intensive care unit; MV = mechanical ventilator

Comparison of patients in different groups

There were no significant differences in duration of urinary catheters, antibacterial drug combination, and indwelling endotracheal tube or tracheostomy tube between two groups (P > 0.05) as shown in Table 2. However, bundles significantly reduced hospitalization days in ICU (c²=13.665, P=0.008), 11.13±27.28 length of stays in ICU among baseline group, but 7.02±19.07 days in bundles patients, with the approximately 4.11 days reduction in the average.

Table 2. Indicators of patients in baseline and bundles groups

Indicators		Baseline	Bundles
Hospitalization days*, n (%)	0～	519(88.3)	488(92.1)
	20～	69(11.7)	42(7.9)
Urinary catheter days, n (%)	0～	486(82.7)	459(86.6)
	20～	102(17.3)	72(13.6)
Central venous catheterization, n (%)	Yes	408(69.4)	333(62.8)
	No	180(30.6)	197(37.2)
Ventilator, n(%)	With	355(60.4)	303(57.2)
	Without	233(39.6)	227(42.8)
Combination of antibacterials	Yes	220(37.4)	206(38.87)
	No	368(62.6)	324(61.13)
Carbapenems use*, n (%)	Yes	148(25.2)	129(24.3)
	No	440(74.8)	401(75.7)

* means there were statistically difference between two groups.

ICU: intensive care unit; MV = mechanical ventilator

CAUTIs and indwelling urinary catheters

As depicted in Table 3, 36 patients with CAUTI infection were identified. The rate of CAUTI decreased significantly from 3.84‰ (27/7,035) to 1.31‰ (9/6,884) (c²=8.637，P=0.003). The total hospitalization days of study patients was 20,848 in ICUs, the duration of indwelling catheter was 13,919 days, the total indwelling urinary catheter utilization was 66.76%. Urinary catheter utilization rate was significantly decreased after bundles. 71.29% (7,035/9,868) in baseline period, while 62.70% (6,884/10,980) in bundles period, with a great difference (c²=173.034, P < 0.001).

Table 3. Changes of CAUTI in patients with indwelling catheters between baseline group and bundles group

Characteristics		Baseline group（n=588)		Bundles group (n=530)		P -value
Characteristics		CAUTI	without CAUTI	CAUTI	without CAUTI	P -value
Age group（years）	< 60	7	275	8	250	0.662
	>= 60	17	289	4	268	0.009
Gender, n	Male	15	338	8	312	0.212
	Female	9	226	4	206	0.229
Hospitalizaiton, days	0～	13	506	8	480	0.337
	20～	17	52	7	35	0.322
High-risk factors	With	16	267	10	251	0.32
	Without	8	297	2	267	0.086
Operation	Yes	13	274	8	279	0.266
	No	11	290	4	239	0.155
APACHII score	0～	22	496	8	439	0.028
	20～	2	68	3	80	0.793
Urinary catheter days	0～	10	476	4	454	0.132
	20～	14	88	8	64	0.609
Ventilator	With	19	336	10	293	0.201
	Without	5	228	2	225	0.268
Central venous catheterization	Yes	20	388	10	323	0.192
	No	4	176	2	195	0.350
Carbapenems use	Yes	3	145	7	122	0.130
	No	21	419	5	396	0.003

ICU: intensive care unit

Pathogen profile

Among the total of 45 strains of pathogens were detected in urine samples of 36 CAUTI patients, MRDO were 12 strains. Obtained multidrug-resistant bacteria were all gram-negative bacteria, comprising 5 strains of multidrug-resistant Acinetobacter baumannii (41.7%), 4 strains of carbapenem-resistant Escherichia coli (33.3%), and 3 strains of carbapenem-resistant Klebsiella pneumoniae (25%). There were no noticeable differences between MRDO profile among two groups.

Bundles compliance

Investigators from 8 participating medical centers observed 764 times totally. With more than 80 percent of the observations, each of the bundles was executed. Table 4 shows hand hygiene and nursing records were highly compliance, exceeding 94%, while isolation of patients with MDRO only implemented 612 times during 764 observations (80.10%). In addition, compliance rate of medical records was substantially less than nursing records, with a gap of nearly 6%.

Table 4. CAUTI bundles compliance

Bundles content	Executions times (n)	Compliance rate (%)
Assessing catheterization indications	715	93.50
Hand hygiene	719	94.11
aseptic operation	717	93.85
Normative catheter placement	717	93.85
Medical records	675	88.35
Nursing records	719	94.11
Isolation of MRDO patients	612	80.10
Health education	710	92.93

Compliance rate (%) = executions times/total observations*100.

Total observation of each content was designated (764 times).

MRDO: multidrug-resistant organism

The CAUTI bundles aimed to prevent patients with indwelling catheters from infection. 8 ICUs of Xiamen medical centers implemented the 7-component bundles, and 1,118 patients in total were participant in the study. Notably, after CAUTI bundles implementation, there was a significant reduction in CAUTI rates, plummeting from 3.84 to 1.31 per 1000 catheter days.

Besides, massive studies have indicated that old age, long hospital days, and long catheterization duration are the high-risk factors of CAUTI(12-16). Our study confirmed that bundles in ICU can significantly reduce CAUTI, especially among patients over 60 years old.

Additionally, bacterial isolates found in urinary catheterized patients mainly are Enterococcus, Klebsiella, Pseudomonas according to other research, which is different from our results(17-19). However, the Acinetobacter baumannii is the most common bacteria detected in ICU(19). Therefore, it is reasonable that Acinetobacter baumannii detected ranks first in our results.

Furthermore, bundles decreased Carbapenems use, which was found in our study. Currently, antibiotic resistance rates in CAUTI are dramatically high worldwide(20). If the bundle measures can reduce the use of Carbapenem, in other words, it can reduce antibiotic resistance rates in CAUTI and reduce the medical burden.

Bundles’ execution was also accordance with the facts. It revealed that isolation of multidrug-resistance patients had the lowest compliance, which may be related to the shortage of medical resources in Xiamen, the increasing number of patients with drug-resistant bacterial infections, and the insufficient single rooms in the ICU. High hand hygiene compliance in post bundles was similar to results from other research(21).

It is important to acknowledge the limitations of this study. The lack of refinement of the cut-off points of some factors, for example, ICU hospitalization, can be divided into smaller ranges to further discuss whether they are statistically significant after bundles in further study.

In summary, our CAUTI bundles led to a significant reduction in the CAUTI rate, decreasing from 3.84 to 1.31 per 1000 catheter days. The widespread of CAUTI bundles effectively reduces HAI led by CAUTI infection, reduces hospitalization days in the ICU and the use of Carbapenem and provides more safer environment for older patients with indwelling catheters.

CAUTIs, HAIs, ICU, UTIs, AIDS, MDR, MDRO, CDC, CDC-NHSN, UC, SPSS, SD, APACHII, MV

Ethics approval and consent to participate

The Ethics Committee of the First Affiliated Hospital of Xiamen University, Children's Hospital of Fudan University (Xiamen Branch), Xiamen Children's Hospital, Xiamen Hospital of Traditional Chinese Medicine, Xiamen Changgeng Hospital, Women and Children’s Affiliated Hospital of Xiamen university, Xiamen Medical College Affiliated Haicang Hospital, Zhongshan Hospital(Xiamen), Fudan University approved this study. The matched clinical information was collected and analyzed with each participant written informed consent. Meanwhile, for participants under the age of 16, the consent was obtained from a parent or guardian on behalf. All participants consented that the matched clinical information would be submitted for publication.

Consent for publication

Not applicable.

Availability of data and material

Restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study is supported by Xiamen Health and Medicine Guidance Project (3502Z20224ZD1010).

Authors' contributions

Huiping Huang recruited the parsticipating hospital and funding, Lei Huang and Chuanpeng Wang collected and analyzed the data, Sihan Yan wrote the main manuscipt text and proof-reading, Tingting Wu, Deqin Chen, Tingting Chen, Hongbing Chen, Weimin Huang, Alin Xue, Jianzhou Yang provided the data from their hospital, Houzhi Chen prepared figures, Guihua Zhuang responsible for submitting manuscript.

Acknowledgements

We would like to thank everyone who helped with this study.

Conflict of interest

None to report.

Funding/support

This study is supported by Xiamen Health and Medicine Guidance Project (3502Z20224ZD1010).

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No competing interests reported.

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You are reading this latest preprint version

A multi-center study on bundles of catheter-associated urinary tract infections in intensive care units

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Results

Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1