Urinary tract infections overlooked by hospitals

Small number of facilities use proven strategies

A relatively small percentage of hospitals in the United States have a strategic approach to preventing urinary tract infections (UTIs), according to a study recently published in the journal Clinical Infectious Diseases.1 In fact, the researchers add, very few facilities are using certain strategies with proven benefits.

The study was based on a survey sent to infection control coordinators at 719 hospitals across the country (72% of the facilities responded). Among the findings:

  • 56% of the respondents did not have a system for monitoring which patients had urinary catheters placed;
  • 74% did not monitor catheter duration;
  • only 30% reported regularly using antimicrobial catheters and portable bladder scanners;
  • 14% used condom catheters;
  • 9% used catheter reminders.

"Despite the strong link between urinary catheters and subsequent urinary tract infections, our study showed there is no strategy that is widely used by U.S. hospitals to prevent hospital-acquired UTI," says senior author Sarah Krein, PhD, RN, a research assistant professor of internal medicine and research investigator at the VA Ann Arbor (Michigan) Healthcare System. "The most commonly used practices — bladder ultrasound and antimicrobial catheters — were each used in less than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in fewer than 10% of U.S. hospitals."

Moreover, notes Krein, nearly half of hospitals lacked a system that tells them which patients currently have a catheter, and three-quarters lacked a system that can tell them how long a patient has had a catheter or whether one has been removed. Nearly one-third of hospitals didn't even track the UTI rates in their patient populations.

Why is performance poor?

As for why hospitals are not performing better in this area, "we are not able to shed much light on this issue based on our quantitative data alone," says Krein. However, she adds, "we have another manuscript that will be published this spring in Infection Control and Hospital Epidemiology in which we provide some insights based on qualitative data that were also collected as part of the study."

In a related editorial in Clinical Infectious Diseases, Lindsay E. Nicolle, MD, of the department of internal medicine and medical microbiology at the University of Manitoba, Health Sciences Centre, offered some thoughts, while at the same time noting, "it is remarkable that so few facilities measure this risk exposure."2 Nicolle posits that:

  • There is limited morbidity that can be attributed to hospital-acquired urinary tract infections;
  • It is uncommon to see death directly attributable to hospital-acquired urinary tract infections;
  • Estimated costs of these infections are significantly lower than those for other health care-related infections.

Best practices available

Nevertheless, says Krein, there is evidence available to demonstrate which practices are and are not effective in preventing these infections. "As part of the study, we asked about the use of several practices that have been evaluated to prevent hospital-acquired UTI, including using indwelling catheters only when necessary, removing catheters when no longer needed via the use of various reminder systems, using antimicrobial catheters in those at highest risk of infection, using external (or condom-style) catheters in appropriate men, using portable ultrasound bladder scans to detect post-void residual urine amounts, and using alternatives to indwelling urethral catheters such as suprapubic or intermittent catheterization," Krein notes. "Practices no longer recommended due to lack of evidence include use of antimicrobial agents in the drainage bag, rigorous frequent meatal cleaning, and use of bladder irrigation were also examined."

There are a number of strategies that hospitals might consider to improve performance, based on their patient population and available resources, notes Krein. "However, one approach that has been shown to reduce UTI rates and decrease the duration of catheterization for many patients is to implement a simple reminder system that asks doctors every day whether a patient's catheter is necessary, or even makes catheter removal the default action unless a physician says otherwise."

References

  1. Saint S, Kowalski CR, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, Forman J, Banaszak-Holl J, Damschroder L and Krein SL. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clin Microbiol Infect 2008; 46:243-250.
  2. Nicolle, LE. The Prevention of Hospital-Acquired Urinary Tract Infection. Clin Microbiol Infect DOI:10.1086/524663.

[For more information, contact:

Sarah Krein, PhD, RN, research assistant professor of internal medicine, VA Ann Arbor (Michigan) Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105. Phone: (800) 361-8387.]