April 25, 2016

Article Review

Catheter-associated urinary tract infections (CAUTIs) are among the most frequent health care associated infections (HAI) and have been considered by the Centers for Medicare and Medicaid Services as being reasonably preventable “though the application of evidence-based guidelines”. Consequently, CAUTIs have become the prime target in the hospitals' fight against HAI, promoting various programmes based on recommendations from the Centers for Disease Control.

J. Galiczewski recently published a large, integrative review(1) on 14 research articles to identify the most effective interventions preventing CAUTIs in ICUs. Daily review of catheter necessity proved to be the intervention which had the greatest impact. In this review, as in Tominaga’s study(2), the importance of nursing leadership was highlighted; whether it was a single intervention or a whole CAUTI prevention bundle, all projects utilising strict infection control policies achieved a CAUTI decrease.

With the generalisation of electronic medical records and charts, investigators are developing computer surveillance systems to assist early identification of CAUTIs and/or patients at higher risk of developing them. The Massachusetts General Hospital has just published a large prospective study(3) analysing the efficiency of an electronic surveillance (ES) tool at identifying CAUTIs in ICU settings. The evaluated ES tool was composed of computerised algorithms linking daily chart documentation from nursing care records and electronic data (microbiology, lab results and e-case management records).

The study included 17239 indwelling urinary catheter-days among 1683 ICU patients during a 6-month period, evaluated 4 different methods of CAUTI identification: traditional surveillance through manual chart review (TS), electronic tool (ES) surveillance, augmented electronic tool surveillance (AES), and a reference standard (RS) established by two investigators on a subset of CAUTIs detected by TS or ES and confirmed by review. The highest concordance with RS was obtained by the AES, classifying properly the 32 confirmed CAUTIs and the 143 true negatives. The ES tool alone proved a high sensitivity when compared to RS, but its specificity was low. The study confirmed that, while a fully automated surveillance alone cannot be completely reliable, it is extremely efficient at identifying a list of candidate CAUTIs for targeted chart review, reducing the time-consuming manual chart review and improving early detection of patients at risk.

Nevertheless, the main risk for developing a CAUTI remains the duration of catheter insertion, and in critically ill patients, it is not always easy to act on this factor; therefore it may remain a problem in our ICUs (2). However maintaining the highest nurses’ awareness and implication in prevention bundles, and the help provided by the new electronic tools can improve efficiency in early detection, increase targeted interventions and reduce the impact of CAUTI.

Article review prepared and submitted by Silvia Calvino Gûnther, member of the N&AHP Committee, ESICM.


1.    Galiczewski JM. Interventions for the preventions of catheter associated urinary tract infections in intensive care unit: an integrative review. Intensive and Crit Care Nurs  (2015) 32: 1-11. http://dx/doi.org/10.1016/j.iccn.2015.08.007
2.    Tominaga GT, Dhupa A, McAllister SM, Calara R, Peters SA, Stuck A. Eliminating catheter-associated urinary tract infections in the intensive cre unit: is it an attainable goal? The American Journal of Surgery (2014) 208: 065-1070.
3.    Hsu HE, Shenoy ES, Kelbaugh D, Ware W, Lee H, Zakroysky P, Hooper DC, Walensky RP.  An electronic surveillance tool for catheter-associated urinary tract infection in intensive care units. American Journal of Infection Control (2015) 43: 592-599. http://dx/doi.org/101016/j.jic.201502.019

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