Cleveland Clinic Foundation researchers have found that a protocol to improve procedures around catheter use and curb testing for urinary tract infections (UTIs) reduced the rate of catheter-associated UTIs (CAUTIs). The results of their investigation—part of a quality improvement initiative—were published in the journal Infection Control and Hospital Epidemiology. 

CAUTIs are among the most common hospital-acquired conditions (HACs). Hospitals have been making greater efforts to reduce their incidence in light of Medicare policies that require institutions to report CAUTIs, that consider the rate of CAUTIs in an institution’s overall value-based reimbursements core, and that penalize hospitals for excessive HACs. At Cleveland Clinic Foundation, clinicians formed a team representing all ICU disciplines as well as infection disease specialists and developed a protocol to reduce CAUTI rates. 

After assessing current practices, the team established a multifaceted intervention with a focus on best practices for the insertion, maintenance, and removal of Foley catheters. It also implemented a “stewardship of testing” protocol based on the American College of Critical Care Medicine and Infectious Disease Society of America guidelines for evaluation of a fever in the critically ill. 

These guidelines acknowledge that most positive urine cultures in patients with bladder catheters are rarely symptomatic and that testing should be reserved for patients meeting key criteria, including kidney transplantation recipients, and those who have recently undergone genitourinary surgery, demonstrate evidence of obstruction, or have an extremely low white blood cell count.  

The hospital implemented the protocol in 2013. Within a year, the number of urine specimens cultured dropped 47% from 4,749 in 2013 to 2,479 in 2014. The CAUTI rate also declined by a third, from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. Given the drop in the rate per 1,000 patient days of HACs from 2.8 in 2013 to 2.4 in 2014, it did not appear that reduced testing resulted in any unrecognized infections. 

“Most efforts to reduce infections, such as CAUTIs, take an approach solely from an infection prevention standpoint, as opposed to evaluating and individualizing appropriate testing in the clinical care setting,” said lead author Katherine Mullin, MD, an infectious disease physician at the Cleveland Clinic. “Our research suggests that combining both approaches is the most effective way to reduce these infections.” 

The researchers recommend additional studies assessing the impact of testing stewardship on antibiotic use and resistance, as well as costs.