Catheter-associated Urinary Tract Infection Rates Research Articles

Impact of modified CDC/NHSN surveillance definition on the incidence of CAUTI: a study from an Indian tertiary care hospital.

Catheter-associated urinary tract infections (CAUTIs) are one of the most common infections encountered in healthcare settings. Candida spp. were excluded as the causative agents of CAUTIs as per Centres for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) definitions in 2015. To determine the impact of the 2015 definition change on the CAUTI rate of patients admitted to medical and surgical intensive care units (ICUs) of a tertiary care and teaching hospital in India. CAUTI rates were compared in both the ICUs over a period of two years with inclusion and exclusion of Candida spp. Out of the total 116 CAUTI episodes during the study period, a mean of 9.08 CAUTIs per 1000 catheter days were observed in both the ICUs when Candida spp. were included, but the mean CAUTI rate was reduced to 4.78/1000 catheter days when Candida spp. were excluded. The mean CAUTI rate decreased by 46.03% solely by excluding Candida spp. This significant reduction in CAUTI rates may be applicable to institutions having high rates of candiduria in catheterised patients, but may not be applicable in centres where the incidence of candiduria is already low. Disregarding Candida as a causative agent of CAUTI did not impact rates of central line-associated bloodstream infections during the study period.

Microbiological profile, comorbidity, incidence and rate analysis of catheter associated urinary tract infections in adult intensive care

Introduction: Catheter-associated urinary tract infections (CAUTI) being the commonest hospital-acquired infection (HAI) [40%], its burden, aetiology along with antibiotic susceptibility is essential to implement and monitor an effective infection control program. Aims: To assess the incidence and rate of CAUTI in a tertiary care hospital and to identify the common organisms and their antibiotic sensitivity pattern. Settings and Design: Prospective hospital based observational study was carried out in a tertiary care hospital in South Tamilnadu for a period of 2 months (June 2016 to July 2016) after obtaining the Institutional Ethics committee approval. Materials and Methods: Total of 100 catheterized adult ICU patients were observed for signs of UTI on a daily basis. On clinical suspicion of UTI, urine sample was analysed microbiologically. CAUTI among various gender and age groups; pathogenic isolates, antibiotic sensitivity pattern and associated co-morbid conditions were expressed as percentages Results: Incidence of CAUTI was 16/100 catheterization. Device utilization ratio was 0.72. CAUTI rate was 36.2/1000 catheter days. CAUTI was commonly seen among patients with >80 years, females with altered sensorium. Diabetes mellitus (35.7%) was the most common comorbid condition followed by TB (25%). Risk of CAUTI after 3-5 days of catheterization was 11.7% and proportionately increased with prolonged catheterization (100% if >20 days). Escherichia coli (37.5%) followed by Candida Spp. (25%) were common pathogens among 3-5days of catheterization. Pseudomonas Spp. was the commonest isolate after one week of catheterization. Imipenem, colistin resistance was highest among pseudomonas. Conclusions: CAUTI rate was higher than the benchmark set by NHSN (0-4). Appropriate health education, strict infection control practices, appropriate antibiotic policy, proper guided bundle care of catheter are need of the hour to prevent the CAUTI. Keywords: Adult ICU, CAUTI, Comorbid

Implementation of evidence-based strategies to reduce catheter-associated urinary tract infections among hospitalized, post-surgical adults

Several catheter-associated urinary tract infection (CAUTI) prevention interventions were successfully implemented and evaluated on a surgical unit in a community-based hospital. Sustainability of CAUTI prevention efforts requires daily communication between multidisciplinary staff. In our hospital, daily report on CAUTI events and indwelling catheters at a hospital-wide, multidisciplinary safety huddle contributed to an enhanced focus on CAUTI-prevention strategies and unit-level reduction in device use days and CAUTI rates.

Implementation of an external female urinary catheter as an alternative to an indwelling urinary catheter

Until recently, there has been a lack of viable alternative to an indwelling urinary catheter for female patients that require precise urine output measurements. With the introduction of external female urinary catheters, we can now substitute this type of device for an indwelling urinary catheter in many patients, decreasing their risk of catheter-associated urinary tract infections. In this retrospective study, we analyzed the impact of a hospital-wide implementation of an external female urinary catheter at a large academic medical center. The study included female patients, greater than 18 years of age. We compared a 12-month period before and after device implementation to assess the impact on indwelling urinary catheter utilization and catheter-associated urinary tract infections rate. Data included over 220,000 patient days, over 10,000 external urinary catheter days and 33,000 indwelling urinary catheter days. We found a statistically significant decrease in indwelling urinary catheter utilization following the implementation of the external female urinary catheter, but only in intensive care units. It is our recommendation that facilities first implement the device in ICUs as this level of care was where we observed the most significant impact.

Effect of a Female External Urinary Catheter on Incidence of Catheter-Associated Urinary Tract Infection.

BackgroundCatheter-associated urinary tract infections (CAUTIs) can be fatal, and are a source of avoidable expense for patients and hospitals. Prolonged catheterization increases infection risk, and avoiding catheters is crucial for infection prevention. Male external urinary catheters are recommended as a tool to prevent the need for indwelling catheterization. Female external urinary catheters (FEUCs) have intermittently been marketed without wide adoption; one has recently become available but published data is limited.ObjectiveThis retrospective observational study was conducted to investigate the effect of FEUCs on indwelling catheter use and female CAUTIs.MethodsFEUCs were introduced to intensive care units. CAUTI rates and indwelling catheter days were obtained before and after the introduction of the devices.Results CAUTI rates decreased from 3.14 per 1000 catheter days to 1.42 per 1000 catheter days (p=0.013). Female indwelling catheter days decreased, while overall intensive care patient days increased.ConclusionsIntroduction of a FEUC was associated with a statistically significant decrease in CAUTI rate among female intensive care patients. The FEUC may prevent the need for indwelling catheters in some situations.

Changing the culture of urine culturing: Utilizing Agile Implementation to improve diagnostic stewardship in the ICU

Over diagnosis of catheter-associated urinary tract infection (CAUTI) contributes to unnecessary and excessive antibiotic use, selection for resistant organisms, increased risk for Clostridiodes difficile infections, as well as a false elevation in CAUTI rates. Utilizing agile implementation to implement a urine culture algorithm achieved statistically significant reduction in CAUTI rates in a critical care unit resulting in sustainment and spread throughout the system.

Health Care–Associated Infections Among Critically Ill Children in the US, 2013-2018

Central catheter-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) increase morbidity, mortality, and health care costs in pediatric patients. To examine changes over time in CLABSI and CAUTI rates between 2013 and 2018 in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) using prospective surveillance data from community hospitals, children's hospitals, and pediatric units within general hospitals. This time series study included 176 US hospitals reporting pediatric health care-associated infection surveillance data to the National Healthcare Safety Network from January 1, 2013, to June 30, 2018. Patients aged 18 years or younger admitted to PICUs or level III NICUs were included in the analysis. The primary outcomes were device-associated rates of CLABSI in NICUs and PICUs and CAUTI in PICUs (infections per 1000 device-days). Secondary outcomes included population-based rates (infections per 10 000 patient-days) and device utilization (device-days per patient-days). Regression models were fit using generalized estimating equations to assess yearly changes in CLABSI and CAUTI rates, adjusted for birth weight (≤1500 vs >1500 g) in neonatal models. Of the 176 hospitals, 132 hospitals with NICUs and 114 hospitals with PICUs contributed data. Of these, NICUs reported 6 064 172 patient-days and 1 363 700 central line-days and PICUs reported 1 999 979 patient-days, 925 956 central catheter-days, and 327 599 indwelling urinary catheter-days. In NICUs, there were no significant changes in yearly trends in device-associated (incidence rate ratio [IRR] per year, 0.99; 95% CI, 0.95-1.03) and population-based (IRR, 0.96; 95% CI, 0.92-1.00) CLABSI rates or central catheter utilization (odds ratio [OR], 0.97; 95% CI, 0.95-1.00). Results were similar in PICUs, with device-associated (IRR, 1.03; 95% CI, 0.99-1.07) and population-based (IRR, 1.03; 95% CI, 0.99-1.07) CLABSI rates and central catheter utilization (OR, 0.99; 95% CI, 0.97-1.01) remaining stable. While device-associated CAUTI rates in PICUs also remained unchanged over time (IRR, 0.97; 95% CI, 0.91-1.03), population-based CAUTI rates significantly decreased by 8% per year (IRR, 0.92; 95% CI, 0.86-0.98) and indwelling urinary catheter utilization significantly decreased by 6% per year (OR, 0.94; 95% CI, 0.91-0.96). Recent trends in CLABSI rates noted in this study among critically ill neonates and children in a large cohort of US hospitals indicate that past gains have held, without evidence of further improvements, suggesting novel approaches for CLABSI prevention are needed. Modest improvements in population-based CAUTI rates likely reflect more judicious use of urinary catheters.

Successfully Sustaining Infection Reductions: A Catheter–Associated Urinary Tract Infection (CAUTI) Prevention Initiative Five Years In

Background: Infection prevention efforts are complex, and sustaining reductions is even more challenging. At the UNC Medical Center, multidisciplinary hospital-wide work groups implement quality improvement initiatives to prevent healthcare-associated infections. The first and most successful initiative has been our catheter-associated urinary tract infection (CAUTI) prevention effort, which started in 2014. The program led to initial dramatic reductions, with continued reductions in CAUTI rates each year since then. Methods: A multidisciplinary workgroup formed in 2014 developed an evidence-based CAUTI prevention bundle and partnered with the nursing staff in 2015–2016 to implement practice changes as part of our hospital’s quality improvement “Spread of Innovations” model. These changes included (1) creation of a 2-person catheter-insertion checklist; (2) insertion skills validation for all nursing staff and nursing assistants; (3) standardization of a maintenance protocol and subsequent education and skills validation with nurses and nurse assistants; and (4) peer audits of urinary catheter maintenance. Additional initiatives implemented over the past 5 years include (1) routine resident education on CAUTI prevention; (2) annual nurse competencies to reinforce skills around CAUTI prevention; (3) introduction of products (eg, PureWick) as alternatives to indwelling catheters; (4) diagnostic stewardship efforts; (5) revisions to the electronic medical record; and (6) efforts to encourage removal of unnecessary catheters such as the “nurse-driven conversation” and Trial of Void. Results: Our CAUTI rates decreased 65% from 2.94 per 1,000 catheter days in the baseline period of 2014 to 1.02 in 2018. In our ICUs (excluding the neonatal ICU), the rate dropped 75% from 4.30 in 2014 to 1.08 per 1,000 catheter days in 2018. Conclusions: We attribute our continued reductions and successful sustainment of low CAUTI rates to several factors. First, the use of a multidisciplinary team was critical to obtaining buy-in from key stakeholders including nursing, nurse assistants, physicians, pharmacists, performance improvement specialists, and administration. Second, continuation of the maintenance peer audits outside the initial project year has provided an important framework for this project, giving regular opportunities for frontline staff to evaluate patients’ catheter condition and to give feedback to colleagues or “just in time education.” These activities potentially prevent infections in real time. Third, with the many competing priorities demanding clinicians’ attention, it has been important for the CAUTI workgroup to continue to evaluate the problem, to determine where opportunities for improvement remain, and to tailor initiatives to meet those needs. In this way, new work can focus on priorities identified by staff, and CAUTI prevention initiatives remain relevant.Funding: NoneDisclosures: None

Effect of an External Urinary Collection Device on Catheter Associated Urinary Tract Infections in Hospitalized Women

Background: Catheter-associated urinary tract infections (CAUTIs) are a common hospital-acquired infection (HAI) resulting in excess morbidity, mortality, and cost. Urine management can be a challenging issue, particularly in women, due to limited options for control of urinary incontinence. Issues with urinary leakage and worry for subsequent skin break down often leads to indwelling catheter insertion. In the spring of 2018, our facility implemented a female external urine collection device (EUCD) in efforts to decrease catheter days and to limit CAUTIs. Methods: Retrospective, 32-month (January 2017–August 2019), quasi-experimental, before-and-after study. Catheter use and CAUTI were defined according to CDC NHSN criteria. Poisson regression was used to model the rate of CAUTI (per 1,000 patient days [PD] and per 1,000 catheter days [CD]) comparing the 14 months prior to EUCD introduction with the 14 months after introduction and allowing a 3-month introduction period. Results: The CAUTI rate did not change significantly. The overall CAUTI rate per 1,000 PD decreased slightly from 0.24 to 0.20 (P = 0.44; model risk, 0.86; 95% CI, 0.58–1.26) whereas the rate per 1,000 CD increased slightly 1.5 to 1.6 (P = 0.76; model risk, 1.06; 95% CI, 0.73-–1.56). The CAUTI rate for men increased from 0.09 to 0.11 per 1,000 PD (P = 0.42; model risk, 1.29) and from 0.99 to 1.55 per 1,000 CD (P = 0.17; model risk, 1.56). For women, the rate of CAUTI decreased from 0.15 to 0.09 per 1,000 PD (P = 0.10; model risk, 0.61) and from 2.12 to 1.65 per 1,000 CD (P = 0.38; model risk, 0.38). A significant decrease in catheter days (CD per 1,000 PD; P < .0001) was observed for all hospitalized patients (from 158.56 to 128.3; model risk, 0.81), for men (from 87.06 to 72.15; model risk, 0.83), and for women (from 71.49 to 56.15; model risk, 0.79). Of 2,347 adverse events, 5 (0.2%) involved perineal skin breakdown and redness. Three events were related to malposition of the ECUD or inappropriate level of suction and 1 event was related to latex allergy and EUCD use. Conclusions: The introduction of a EUCD for women was associated with a significant decrease in indwelling catheter usage. A trend toward a decrease in CAUTI per 1,000 PD for women was observed (P = .10). Additional studies on whether the EUCD is associated with changes in UTI rates (both CAUTIs and noncatheter UTIs) as well as cost implications of EUCD are warranted.Funding: NoneDisclosures: None

Implementation of a Female External Urinary Catheter Reduces Indwelling Urinary Catheter Use and Catheter-Associated Urinary Tract Infections

Background: Using alternatives to indwelling urinary catheters plays a vital role in reducing catheter-associated urinary tract infections (CAUTIs). We assessed the impact of introducing female external catheters on urinary catheter utilization and CAUTIs. Methods: In a 500-bed academic medical center, female external catheters were implemented on October 1, 2017, with use encouraged for eligible females with urinary incontinence but not meeting other standard indications for urinary catheters. Nurses were educated and trained on female external catheter application and maintenance, and infection prevention staff performed surveillance case reviews with nursing and medical staff. We determined the number of catheter days for both devices based on nursing documentation of device insertion or application, maintenance, and removal. We used the CAUTI and DUR (device utilization ratio) definitions from the CDC NHSN. Our primary outcomes were changes in DUR for both devices 21 months before and 24 months after the intervention in both intensive care units (ICUs) and non-ICU wards. We used a generalized least-squares model to account for temporal autocorrelation and compare the trends before and after the intervention. Our secondary outcome was a reduction in CAUTIs, comparing females to males. Results: In total, there were 346,213 patient days in 35 months. The mean rate of patient days per month increased from 7,436.4 to 7,601.9 after the implementation of female external catheters, with higher catheter days for both urinary catheters (18,040 vs 19,625) and female external catheters (22 vs 12,675). After the intervention, the DUR for female external catheters increased (0 vs 0.07; P < .001) and for urinary catheters the DUR decreased (0.12 vs 0.10; P < .001) (Fig. 1). A reduction in urinary catheter DUR was observed in ICUs (0.29 vs 0.27; P < .001) but not wards (0.08 vs 0.08; P = NS) (Fig. 2). Of the 39 CAUTIs, there was no significant overall change in the rate per 1,000 catheter days (1.22 vs 0.87; P = .27). In females (n = 20 CAUTI), there was a 61% reduction in the CAUTI rate per 1,000 catheter days (0.78 vs 0.31; P = .02), but no significant change in the rate in males (0.44 vs 0.56; P = .64). The CAUTI rate per 1,000 catheter days among females decreased in the ICUs (1.14 vs 0.31; P = .04) but not in wards (0.6 vs 0.33; P = .96). Conclusions: In a setting with a baseline low UC DUR, successful implementation of female external catheters further modestly reduced UC DUR and was associated with a 61% decrease in CAUTI among females in the ICU but not in wards. Further interventions to better identify appropriate patients for female external catheters may improve patient safety and prevent patient harm.Funding: NoneDisclosures: None

Amidst the CAUTI Metrics Hurley Burly, a Sustained SURly Success Adaptable for Reducing Other Nosocomial Infections

Background: Surveillance metrics for catheter-associated urinary tract infections (CAUTIs) are subject to ongoing debate and refinement to best capture infectious catheter-related harm (ICRH) and noninfectious catheter-related harm (NCRH). Indwelling urinary catheters cause 5 times more NCRH than ICRH. The commonly used standardized infection ratio (SIR) does not fully capture NCRH nor the impact of prevention efforts in all settings. Alternatively, device utilization rates and ratios (DUR) do not reflect differences in other factors that may describe levels of device use. DUR lose comparability over time and across settings and can mask truly effective interventions by selecting for a higher risk group of catheterized patients. Experts now advocate use of the standardized utilization ratio (SUR). We sought to implement a multidimensional intervention to reduce exposure risk, CAUTI, and NCRH across a 5-hospital healthcare system, totaling 1,692 acute-care beds. Methods: The intervention comprised the following elements: (1) an interactive educational campaign comprising one-on-one engagements between infection preventionists and frontline providers, encouraging the use of female external urinary collection devices and male custom-fitted condom catheters, rewarding overall participation, device utilization, hand hygiene, and CAUTI rates; (2) educational emails to all staff from top executives; (3) increasing the urinalysis reflex to culture threshold from >5 to ≥10 WBCs; and (4) clinical decision support (CDS) for ordering urine cultures for patients with indwelling catheters and for encouraging Foley catheter alternatives and catheter removal. Monthly, quality department representatives discuss unit level DURs with managers, who then discuss patient-level device use at daily huddles with physicians and advanced practice providers. Significance was determined using the 2-tailed t test. The results are listed in Table 1. Discussion: One year after the intervention, use of device alternatives increased 5-fold, CDS-driven ordering predominated, and the SIR and SUR remained significantly decreased. These successes are especially notable because , a ventricular-assist device program was launched in the postintervention period. By the end of the study, the program became the second-busiest of its type in the United States, resulting in a group of patients at high risk of device use and infection in the postintervention period, but absent in the preintervention period. numerous reports of effective interventions for reducing CAUTI have been published, we found no large studies using the SUR as the main metric. The limitations of this study include the lack of a population SIR and data pertaining to catheter-related bacteriuria and antibiotic usage. However, this approach is easily customizable to any infection, device, and diagnostic test.Disclosures: NoneFunding: None

Catheter-Associated Urinary Tract Infection Reduction in the Solutions for Patient Safety Pediatric Safety Engagement Network

Background: Catheter-associated urinary tract infections (CAUTIs) are a leading cause of healthcare-associated infection. Catheter insertion and maintenance bundles have been developed to prevent CAUTIs, but they have not been extensively validated for use in pediatric populations. We report the CAUTI prevention efforts of a large network of children’s hospitals. Methods: Children’s hospitals joined the Solution for Patient Safety (SPS) safety engagement network from 2011 through 2017 and elected to participate in CAUTI prevention efforts, with 26 hospitals submitting data initially and 128 participating by the end. CAUTI prevention recommendations were first released in May 2012, and insertion and maintenance bundles were released in May 2014 (Table 1). Hospitals reported on CAUTIs, patient days, urinary catheter line days (CLD), and they tracked reliability to each bundle. For the network, control charts were used to plot CAUTI rates, urinary catheter utilization, and reliability to each bundle component. Results: Following the introduction of the pediatric CAUTI insertion and maintenance bundles, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1,000 CLD (Fig. 1). Centerline shifts occurred both before and after the 2015 CDC CAUTI definition change, which may also have contributed to a centerline shift. Urinary catheter utilization rates did not decline during the intervention period. Network reliability to the insertion and maintenance bundles increased to 95.4% and 86.9%, respectively. Conclusions: Insertion and maintenance bundles aimed at preventing CAUTIs were introduced across a large network of children’s hospitals. Across the network, the rate of urinary tract infections among hospitalized children with indwelling urinary catheters decreased 61.6%.Funding: NoneDisclosures: None

Catheter-Associated Urinary Tract Infections (CAUTIs) Reduction: A Multidisciplinary Approach

Background: CAUTIs remain one of the most common hospital-acquired infections (HAIs) accounting for prolonged hospital stay and increased healthcare costs. According to the NHSN, the standardized infection ratio (SIR) at our institution was 1.6 compared to national average of 0.84 in 2018. We highlight the interventions implemented in our institution to prevent CAUTIs. These interventions have shown a reduction in the rate of CAUTIs, the SIR, Foley catheter days, and institutional cost. Methods: In addition to standard CAUTI prevention practices, we hypothesized that we could decrease CAUTIs through the daily implementation of specific practices. We developed a comprehensive interdisciplinary team which included the staff or charge registered nurse (RN), the unit manager, an infection preventionist, an advanced practice registered nurse (APRN), a pharmacist with an antimicrobial focus, and a physician from the infectious disease department who would conduct daily rounds on different units in the institution for education and assessment of catheter indications. A detailed review and analysis of the urine culture orders for patients with a Foley catheter was performed. A nurse-driven Foley catheter removal protocol before urine culture collection was initiated. We implemented a Foley catheter bundle that has guidelines for Foley insertion, best practice competency, and urinary catheter best practice algorithm and advocated alternative use of male or female external catheter. We educated physicians about ordering a reflexive urine analysis test followed by urine culture instead of testing either individually after removal of a Foley catheter. Lastly, we performed a root-cause analysis on all reported CAUTIs. These policies were implemented in a 435-bed tertiary-care center in November 2018, and we present data from 1-year before and after the interventions. Results: At our institution, we had 71 CAUTIs, with an SIR of 1.6, a standardized utilization ratio (SUR) of 0.92, 27,621 Foley days, and institutional cost of $979,303 compared to 40 CAUTIs with an SIR of 1, an SUR of 0.88, 24,193 Foley days, and institutional cost $537,927 after implementing our interventions. Conclusions: CAUTIs can be reduced by implementing specific measures that include infection control team rounds, nurse-driven protocol, and the use of Foley catheter bundles. Measures should be undertaken to prioritize these practices as part of a protocol. We advocate further studies to evaluate these measures. Education programs for healthcare professionals concerning CAUTIs and its complications can be implemented to carry out the prevention methods efficiently.Funding: NoneDisclosures: None

CAUTI: A Journey of Micturition at MICU Since 2014

Background: Catheter-associated urinary tract infections (CAUTIs) have gained popularity in recent years for increasing morbidity and mortality in multiple healthcare settings. In fact, they are the most common type of healthcare-associated infection (HAI) in US hospitals, and they account for ~35% of HAIs. Objectives: At our institution, CAUTI rates were higher than the national average; therefore, various preventative protocols were implemented. Southeast Health’s Medical ICU (MICU) has taken many measures to decrease the CAUTI incidence. Methods: We conducted an observational study with a retrospective analysis of the data beginning in 2014 after a poor performance at prevention of CAUTIs as noted in the Leapfrog Hospital Survey. As part of improving prevention measures in MICU, we started a lean project in 2015 that primarily focused on systems-based practices and improvements in the existing nurse protocols. Results: We were successful in this endeavor and in August 2018 the Alabama Department of Public Health (ADPH) reported that we still lower than the national average in prevention of CAUTIs. This finding led us to tighten the protocols and to appoint 2 infection preventionists in the MICU. With the assistance of the infection preventionists, we were able to actively decrease indwelling catheter and device days with daily multidisciplinary rounds to access the necessity for catheter use. We also set monthly attainable targets and reinforced nurse driven protocols with educational in-service programs. One of the most significant additions was the introduction of female external catheters (Purewick) in December 2019 and male external catheters (Liberty) in May, 2019. Our results showed a significant reduction in the number of CAUTIs divided by number of Foley catheter days in the MICU from 32 of 7,435 in 2014 to 1 of 5,934 in 2019. We are excited to see reduction in the CAUTIs with our above measures. We will continue our measures to reach our target of 0 CAUTIs, and we plan to remain above the national average.Funding: NoneDisclosures: None

Catheter-Associated Urinary Tract Infection Reduction in a Pediatric Safety Engagement Network.

Catheter-associated urinary tract infections (CAUTIs) are a leading cause of health care-associated infection. Catheter insertion bundles (IBs) and maintenance bundles (MBs) have been developed to prevent CAUTIs but have not been extensively validated for use in pediatric populations. We report the CAUTI prevention efforts of a large network of children's hospitals. Children's hospitals joined the Children's Hospitals' Solutions for Patient Safety engagement network from 2011 to 2017, using an open start time engagement approach, and elected to participate in CAUTI prevention efforts, with 26 submitting data initially and 128 at the end. CAUTI prevention recommendations were first released in May 2012, and IBs and MBs were released in May 2014. Hospitals reported on CAUTIs, patient-days, and urinary catheter-line days and tracked reliability to each bundle. For the network, run charts or control charts were used to plot CAUTI rates, urinary catheter use, and reliability to each bundle component. After the introduction of the pediatric CAUTI IBs and MBs, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1000 catheter-line days. Centerline shifts occurred both before and after the 2015 Centers for Disease Control and Prevention CAUTI definition change. Urinary catheter use rates did not decline during the intervention period. Network reliability to the IBs and MBs increased to 95.4% and 86.9%, respectively. IBs and MBs aimed at preventing CAUTIs were introduced across a large network of children's hospitals. Across the network, the rate of urinary tract infections among hospitalized children with indwelling urinary catheters decreased 61.6%.

CAUTIs in Patients With Thoracic Epidurals

Background: The Surgical Care Improvement Project 9 (SCIP 9) mandates the removal of urinary catheters within 48 hours following surgery to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Although patients with thoracic epidurals are not exempt from SCIP 9, these patients may be inherently different from other surgical patients. Early removal of Foley catheters may cause urinary retention and recatheterization, which in turn can lead to CAUTI or urethral trauma. Our hospital’s current policy is to allow Foley catheters to remain in place until the thoracic epidural is removed. The goal of our study was to identify and compare the rate of CAUTI in patients with thoracic epidural catheters to the rate of CAUTI in patients without thoracic epidural catheters Methods: We performed a retrospective cohort study of patients with and without thoracic epidurals who had Foley catheters during hospitalization from July 1, 2017, to May 31, 2019. We used descriptive statistics to compare CAUTI rates based on unit between the 2 groups of patients. Results: We identified 1,834 unique patients with thoracic epidurals and urinary catheters during the study period. We found 4 CAUTIs of 9,896 catheter days (0.4 CAUTIs per 1,000 catheter days) in patients with epidural catheters and 43 CAUTIs of 36,809 catheter days (1.17 CAUTI per 1,000 catheter days) in patients without thoracic epidurals for a rate ratio of 0.346 (95% CI, 0.1242– 0.9639; P < .03). We conducted a sensitivity analysis on a subset of patients admitted under the cardiothoracic service and compared the patients with Foley catheters with and without thoracic epidurals. In this subset, we found 1 CAUTI in 5,890 catheter days (0.17 CAUTI per 1,000 catheter days) in patients with thoracic epidurals and 4 CAUTIs in 9,429 catheter days (0.42 CAUTIs per 1,000 catheter days) in patients without thoracic epidurals), for a rate of 0.4002 (95% CI, 0.0447–3.5808; P < .39). In this subgroup, 7.0% of patients with thoracic epidurals required a second Foley catheter compared to 16.9% of patients without thoracic epidurals who required a second Foley catheter (P < .01). Conclusions: Although patients with thoracic epidurals maintain Foley catheters beyond 48 hours, the CAUTI rate in these patients is lower than in patients without thoracic epidurals. Therefore, removing Foley catheters within 48 hours of surgery in patients with thoracic epidurals may not reduce the risk of CAUTI and, in fact, could be harmful. Further evaluation of confounding variables is warranted.Funding: NoneDisclosures: None

Beyond Bundles in Prevention of CAUTI and UTI’s

Background: Urinary tract infections (UTIs) are common healthcare-associated infections. Evidenced-based practice (EBP) successes of catheter associated urinary tract infection (CAUTI) bundles has resulted in rates decreasing >50% in community-based nursing homes. The South Texas Community Living Center (CLC SA), our 42-bed long-term care and rehabilitation center, conducts routine infection prevention surveillance. During routine surveillance, the infection prevention team noticed an increase in UTI percentages and CAUTI rates. Thus, we sought to increase compliance with standard CAUTI bundles, and we implemented an intervention called the “bladder bundle.” Methods: A multidisciplinary team (ie, infection preventionist, clinical nurse leader, simulation director, educator, leadership and frontline staff champions) identified and evaluated practices through documentation of audits and safety rounds during April and May of 2017 (FY19 QTR 3). The comprehensive bladder bundle was initiated in June 2017, based on EBP interventions and included education for staff with audit and feedback. The team reviewed the literature and expanded the bladder bundle to include a comprehensive urinary note and oral hydration program for the veterans in addition to the standard CAUTI bundles (ie, minimize catheter use, use with appropriate indications, consider alternatives to catheters, proper insertion and securement). In May 2018, a facility-wide, hospital-wide initiative focused on a new urinary catheter insertion kit, insertion competencies and perineal care to improve outcomes. This initiative was added to our bladder bundle for CLC SA. Results: Before the intervention (FY16 Q3 to FY17 Q2), percentages of veterans with a UTI had increased to 4.65%, in FY17 Q3, this rate had increased to 11.76%. After the intervention (FY17 Q4 to FY19 Q3) the percentage dropped significantly to 0%, and this rate has now been sustained for 8 quarters. Our CLC SA has remained at zero harm and has no NHSN CAUTI has occurred since October 2017 (FY18Q1). The catheterization in bladder days has decreased from 162 days in FY14 to 49 in FY18, and for the first 2 quarters of FY19, there were only 25 days. For the last 8 quarters, documentation compliance has increased, as has use of BB interventions. Conclusions: The continuous improvement project targeted within the CLC SA, with education to staff, audit and feedback tools, and a comprehensive urinary note with the oral hydration program in combination with the standard CAUTI bundles, have improved veteran health outcomes and have expanded provider and nursing practices. The interprofessional team approach enhanced the success of this project.Funding: NoneDisclosures: None

Surveillance of Healthcare-Associated Bloodstream and Urinary Tract Infections in a National Level Network of Indian Hospitals

Background: Healthcare-associated infections (HAIs) are a major global threat to patient safety. Systematic surveillance is crucial for understanding HAI rates and antimicrobial resistance trends and to guide infection prevention and control (IPC) activities based on local epidemiology. In India, no standardized national HAI surveillance system was in place before 2017. Methods: Public and private hospitals from across 21 states in India were recruited to participate in an HAI surveillance network. Baseline assessments followed by trainings ensured that basic microbiology and IPC implementation capacity existed at all sites. Standardized surveillance protocols for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were modified from the NHSN for the Indian context. IPC nurses were trained to implement surveillance protocols. Data were reported through a locally developed web portal. Standardized external data quality checks were performed to assure data quality. Results: Between May 2017 and April 2019, 109 ICUs from 37 hospitals (29 public and 8 private) enrolled in the network, of which 33 were teaching hospitals with >500 beds. The network recorded 679,109 patient days, 212,081 central-line days, and 387,092 urinary catheter days. Overall, 4,301 bloodstream infection (BSI) events and 1,402 urinary tract infection (UTI) events were reported. The network CLABSI rate was 9.4 per 1,000 central-line days and the CAUTI rate was 3.4 per 1,000 catheter days. The central-line utilization ratio was 0.31 and the urinary catheter utilization ratio was 0.57. Moreover, 3,542 (73%) of 4,742 pathogens reported from BSIs and 868 (53%) of 1,644 pathogens reported from UTIs were gram negative. Also, 1,680 (26.3%) of all 6,386 pathogens reported were Enterobacteriaceae. Of 1,486 Enterobacteriaceae with complete antibiotic susceptibility testing data reported, 832 (57%) were carbapenem resistant. Of 951 Enterobacteriaceae subjected to colistin broth microdilution testing, 62 (7%) were colistin resistant. The surveillance platform identified 2 separate hospital-level HAI outbreaks; one caused by colistin-resistant K. pneumoniae and another due to Burkholderia cepacia. Phased expansion of surveillance to additional hospitals continues. Conclusions: HAI surveillance was successfully implemented across a national network of diverse hospitals using modified NHSN protocols. Surveillance data are being used to understand HAI burden and trends at the facility and national levels, to inform public policy, and to direct efforts to implement effective hospital IPC activities. This network approach to HAI surveillance may provide lessons to other countries or contexts with limited surveillance capacity.Funding: NoneDisclosures: None

22 -Year Results of an Intensive Care Unit Infection Control Program in Ribeirao Preto, Brazil

Background: Healthcare-associated infection (HAI) control programs have improved patient care all over the world. Our program was implemented in 1997 in a general intensive care unit (ICU) based upon surveillance of HAI with regular infection rates feedback to the ICU team and implementation of best practices such as hand hygiene (HH) and oral care for ventilated patients, optimal care, and early removal of invasive devices. Objective: To report our decreasing HAI rates in the past 22 years. Methods: Hospital Sao Francisco 20-bed ICU admits 120–140 surgical and clinical patients monthly, with 90% occupancy. The HAI infection control team implemented HAI surveillance and developed several protocols for HAI prevention. In the past 5 years, ICU personnel initiated the collection of several indicators using random direct observations of HH compliance, central venous catheter correct care, and appropriated oral care, among others. HAI definitions followed Brazilian Health Ministry HAI definitions and were expressed as infections per 1,000 patient days (total HAI rate) and device-related infections per 1,000 device days. Catheter-associated urinary tract infection (CAUTI), central-line–associated blood stream infection (CLABSI) and ventilator-associated pneumonia (VAP) rates are reported here. The study period spanned January 1997 to August 2019. Measurement of antibiotic utilization (ie, meropenem, vancomycin, and piperacillin-tazobactam) was calculated by dividing the of antibiotic consumed vials by the daily defined dose and patient days. Results: The total HAI, CAUTI, CLABSI, and VAP rates dropped 70%, 85%, 84%, and 87%, respectively, from 1997 to 2019 (Table 1). From 2009 to 2019, we detected decreases in hospital use of meropenem from 52 to 38, in vancomycin from 50 to 40, and in piperacillin-tazobactam from 144 to 88. Conclusions: HAI control programs can be effective in ICUs, with impressive results, but it requires time and considerable effort. Data on compliance with basic infection control measures should accompany HAI data and should be shared with the ICU team because ICU team participation is essential to keeping the program alive. Broad-spectrum antibiotics use also decreased, with potential benefits to the hospital flora.Funding: NoneDisclosures: None

Piloting a Quality Improvement Intervention for Urinary Catheter Removal to Reduce Catheter-Associated Urinary Tract Infection in a Medical Intensive Care Unit

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most prevalent healthcare-associated infections (HAIs) globally, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs. Interventions that support prompt removal of the urinary catheter are evidence-based actions to effectively reduce CAUTI rates.1Objective: At the National Hospital of Tropical Disease (NHTD), catheter removal interventions in the intensive care unit (ICU) were implemented using quality improvement (QI) methodology to reduce CAUTI incidence and urinary catheter device utilization. Methods: Training was performed for ICU clinical staff with knowledge checks before and after the program. A bedside visual reminder of CAUTI risk and checklist to assess catheter need were implemented. Weekly compliance of provided visual reminders and checklists were measured using a simple audit tool. Device utilization ratios (DURs, ratios of device days to patient days), and CAUTI incidence rates (per 1,000 device days) were collected at baseline (July–September 2018) and quarterly thereafter until June 2019. Statistical significance was determined by an independent t test. Results: In the first quarter (October–December 2018), the CAUTI incidence rate decreased from 8.9 to 1.3 per 1,000 device days (P = .036). The ICU staff trained in CAUTI prevention, mean knowledge scores before and after training increased from 68% to 87%. The DUR decreased slightly from 0.59 to 0.55 after the first-quarter training then steadily increased in the following quarter (0.60; January–March 2019) and after the intervention (0.54; April–June 2019). CAUTI incidence rates also increased but were still lower than at baseline: 4.8 and 6.3 per 1,000 days of device use. Compliance of reminders was 51% during the first quarter, increased slightly in the second quarter 62%, then decreased to 40% during the last quarter. The nurses’ adherence to the daily checklist remained stable (>75%). Conclusions: This CAUTI prevention project was the first use of quality improvement methodology to implement change at NHTD. A trend decrease in CAUTI was observed, though a greater decrease occurred at the beginning of the intervention. Limited compliance of daily reminders is likely reflected in no statistically significant decrease in DUR. Possibly, this quality improvement project raised awareness among clinicians to improve general CAUTI prevention practices in the ICU without decreasing DUR. Given limited compliance with reminder and checklists, the intervention will be revised during the next PDSA cycle to improve adherence.1Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–289.Funding: NoneDisclosures: None