We have blogged before how CAUTI is rather ‘unloved’ as an HCAI prevention target. CLABSI reduction, on the other hand, is all the rage. Now, there is a key reason why this makes sense: outcome! A CLABSI is much worse news for a patient than a CAUTI. However, this doesn’t mean we should turn a blind eye to CAUTI, especially since CAUTI is a common root cause for CLABSI! In the US there is an addiional driver for preventing CAUTI: the costs associated with CAUTI are no longer reimbursed by insurers (since 2008). With this in mind, it was great to see a CAUTI reduction study published in NEJM recently (and see some interesting analysis on the Controversies blog).
A few papers on the use of urinary catheters have caught my eye recently. It’s a subject close to my heart and was the subject of my eponymous lecture at the Infection Prevention 2013 meeting in London, available online for insomniacs via the excellent Webber Training Teleclass recording The slides are here. Despite these devices being second to peripheral cannulation in the ‘most’ used devices’ awards annually (and a clear winner in the ‘most overused’ section), the evidence base is somewhat thin. Are they inserted well? Possibly (and indeed probably) not. Do they only get inserted appropriately and are they speedily removed? Um… maybe not. Continue reading
Bells have a certain resonance for me. When they toll, people listen as they are normally of significance. I have just heard one. I have been waiting from this paper to come out since I heard the authors speak about progress at last year’s Infection Prevention Society meeting in Glasgow. Decision-making prior to passing a urinary catheter is something close to my heart, since we need to know why people do things if we are to modify practice. For me, telling people that a list of specific indications for an intervention exists merely makes the decision-maker pick which one on the list fits their desire or perceived need to catheterise most.
According to Dicks et al. (ICHE 2015;36:467-9) the presence of fungi in urine rarely represents true infection. The authors state, that excluding yeast from catheter-associated UTI surveillance definition reduced CAUTI-rates by 25% in community hospitals and at tertiary-care medical center.
While I agree, that in many instances candiduria represents colonization or contamination of the specimen and not invasive candidiasis, and that not all cases of candiduria need treatment, they all warrant a clinical evaluation. In my Iowa years (1992/93) Dick Wenzel, Mike Pfaller and other established the importance of yeast in HAI’s, Pittet and others developed indices to better detect patients with candidemia, and my own research showed that candida in urine was one of the most important warning signs in patients suspected for candidemia. Once excluded from surveillance definitions, will our colleagues still see the importance of this occurrence? True, fungi in urine not always represents true infection, but frequently are a warning sign. I am not sure about the need to change CAUTI definitions, or why one would stop at fungi for exclusion, but in general believe that we should leave our definitions as stable as possible.
Anything that assists clinical staff in making the decision as to which device to use when considering an indwelling urinary catheter is to be welcomed and the latest guidance comes from the prolific group at Ann Arbor. Using the RAND/UCLA Appropriateness Method, a system of identifying the most fitting option in the absence of ‘gold standard’ RCTs, the authors have produced a practical and helpful guide that fills a gap, since existing guidance does take into account commonly-encountered patient characteristics, such as the bariatric or oedematous patient, that make lists of ‘appropriate indications’ in current guidelines challenging to implement.