Catheter-associated urinary tract infections (CAUTIs) constitute one of three measures used by the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition (HAC) Reduction Program for scoring a hospital’s quality performance − which, if found to be in the highest quartile of HAC scores, results in a 1% penalty applied to total payments to the hospital.
The use of CAUTI as a quality metric with financial and reputational consequences for hospitals resulted in a significant amount of feedback to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) about the validity of the UTI surveillance definition. This feedback prompted a review process led by a working group consisting of internal CDC members and external subject matter experts who reviewed a number of controversial topics regarding the UTI surveillance definitions. One of the major topics was how to improve the specificity of the UTI criteria, particularly where fever was the only symptom.1
The issue cited by many critics is that the definition requires reporting of CAUTI with fever as the sole symptom even if another possible source of fever is identified. The working group acknowledged that during the 4 year period of January 1, 2009 to January 31, 2013, 80% of the CAUTIs reported to NHSN used fever as the sole clinical criterion to meet the definition. However, it was felt that allowing exclusion of CAUTI reporting if another NHSN-defined source of fever was identified would introduce subjectivity and additional workload for infection preventionists performing surveillance.
A recent paper by Tedja and colleagues2 highlights how the non-specificity of the NHSN criteria for CAUTI can potentially influence the publicly reported data in intensive care unit (ICU) patients. The authors evaluated 105 CAUTIs identified using the NHSN definition in ICU patients; 97% of the urine cultures were obtained for evaluation of fever. Additional chart review found that 68% of the patients had an alternative explanation for the fever. The researchers conclude that the “practice of obtaining cultures in response to fever results in CAUTIs” that are not clinically relevant and do not represent a good measure of hospital quality.
A commentary by Livorsi and Perencevich regarding this paper3 questions the use of the CAUTI surveillance definition as a hospital quality metric and offers a few alternate metrics for consideration. They are: 1) urinary catheter utilization 2) the incidence of bacteremia secondary to CAUTI and 3) the incidence of NHSN-defined CAUTIs in which the patient received antibiotics targeting the urine culture results. Two of these metrics are already monitored by infection preventionists (IPs) and I would propose that a metric focused on directed antibiotic therapy for CAUTI might be a good first step for IPs into the realm of antimicrobial stewardship. I would welcome the thoughts of other infection prevention professionals.
1 Allen-Bridson K, Pollock D, Gould CV. Promoting prevention through meaningful measures: Improving the Centers for Disease Control and Prevention’s National Healthcare Safety Network urinary tract infection surveillance definitions. Am J Infect Control 2015;43:1096-8.
2 Tedja R, Wentink J, O’Horo JC, Thompson R, Sampathkumar P. Catheter-Associated Urinary Tract Infections in Intensive Care Unit Patients. Infect Control Hosp Epidemiol 2015;36(11):1330-1334.
3 Livorsi DJ, Perencevich EN. CAUTI Surveillance: Opportunity or Opportunity Cost? Infect Control Hosp Epidemiol 2015;36(11): 1335-1336.