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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 3
| Issue : 2 | Page : 44-49 |
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A study of clinical and economical burden imposed by catheter associated urinary tract infection in a tertiary care teaching hospital
Badal Suthar, Prashant C Shah, Niyati Trivedi
Department of Pharmacology, Medical College Baroda, Vadodara, Gujarat, India
| Date of Submission | 23-Nov-2022 |
| Date of Decision | 21-Dec-2022 |
| Date of Acceptance | 03-Jan-2023 |
| Date of Web Publication | 13-Feb-2023 |
Correspondence Address:
Dr. Niyati Trivedi
Department of Pharmacology, Medical College Baroda, Vadodara - 390 001, Gujarat
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/QAIJ.QAIJ_20_22
Background and Objectives: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care-associated infections worldwide. Determination of the clinical and financial burden of CAUTI is of critical importance for all stakeholders for rational and fair allocation of resources. Materials and Methods: This study was a prospective observational study. The microbiological profile, antimicrobial usage, length of hospitalization (LOH), and cost of antimicrobial therapy of the patients diagnosed to have CAUTI were assessed. Data were expressed as mean ± standard deviation and range. Simple regression was used to find an association between the duration of catheterization and the development of CAUTI, one-way ANOVA was used to analyze the organism-specific differences in the above parameters. Results and Interpretation: One hundred and seventy-two patients with CAUTI were identified during the study period. The mean number of days from the insertion of the catheter to the development of the first symptom of CAUTI was 5.19 ± 2.08 days with a range of 2–14 days. Escherichia coli spp. was the most common isolate in 62% of patients. 81.39% of isolates were multidrug resistant. There was no significant difference observed in the days of therapy or length of therapy or LOH in different patients of CAUTI based on the causative organism; however, the cost of acquisition of antimicrobial therapy was found to be significantly different among the different microorganisms. Conclusion: Increasing prevalence of multidrug-resistant organisms has made the management of CAUTIs considerably more challenging. Implementation of optimum preventive measures and antimicrobial stewardship practices is essential. Keywords: Antimicrobial usage matrix, catheter-associated urinary tract infection, cost of therapy, multidrug-resistant organisms
How to cite this article:
Suthar B, Shah PC, Trivedi N. A study of clinical and economical burden imposed by catheter associated urinary tract infection in a tertiary care teaching hospital. QAI J Healthc Qual Patient Saf 2022;3:44-9 |
How to cite this URL:
Suthar B, Shah PC, Trivedi N. A study of clinical and economical burden imposed by catheter associated urinary tract infection in a tertiary care teaching hospital. QAI J Healthc Qual Patient Saf [serial online] 2022 [cited 2023 Mar 27];3:44-9. Available from: https://www.QAIJ.org/text.asp?2022/3/2/44/369615 |
| Introduction | |  |
Urinary tract infections (UTIs) are the fifth most common type of health care-associated infection (HCAI), with an estimated 62,700 UTIs in acute care hospitals in 2015. UTIs additionally account for more than 9.5% of infections reported by acute care hospitals.[1] Virtually all health care-associated UTIs are caused by instrumentation of the urinary tract.
Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay (LOS).[2],[3] In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients[4],[5]
Approximately, 12%–16% of adult hospital inpatients will have an indwelling urinary catheter (IUC) at some time during their hospitalization, and each day, the IUC remains, a patient has a 3%–7% increased risk of acquiring a CAUTI.[6],[7]
In many cases, catheters are placed for inappropriate indications and often left in for longer than clinically necessary, putting the patient needlessly at risk of infection, and contributing to the burden imposed by HCAI.
Although morbidity and mortality from CAUTI are considered to be relatively low compared to other HCAIs, the high prevalence of urinary catheter use leads to a large cumulative burden of infections with resulting infectious complications and deaths.
And while fewer than 5% of bacteriuric cases develop bacteremia,[2] CAUTI is the leading cause of secondary nosocomial bloodstream infections. About 17% of hospital-acquired bacteremias are from a urinary source with an associated mortality of approximately 10%.[8]
An estimated 17%–69% of CAUTI may be preventable with recommended infection control measures.[9] This highlights the potential of catheter prevention interventions to reduce the burden of CAUTI.
Given the high incidence of catheter-related infection and the enhanced emphasis on the quality and costs of health care, it is appropriate to assess the clinical and economic consequences of CAUTI. In doing, infection control professionals and decision makers will gain an improved understanding of the importance of preventing catheter-related infection as well as will help clinicians to optimize the antimicrobial therapy in such cases.
| Materials and Methods | | |
Study setting
This prospective observational study was performed at a 1500-bedded tertiary care teaching hospital in Gujarat state, India.
Study population
Cases were all patients admitted in the wards of the tertiary care teaching hospital, from July 2019 to March 2020, for noninfectious conditions, inserted with an indwelling catheter, who satisfied the criteria of CAUTI[10] and had given written informed consent were included in the study.
Wherein CAUTI was diagnosed using the following criteria, either singly or in combination according to the Centers for Disease Control and Prevention (CDC) guidelines.[10]
Symptomatic UTI 1a: CAUTI Criteria (any age)
The patient must meet 1, 2, and 3 below:
- Patient had an IUC that had been in place for more than 2 consecutive days in an inpatient location on the date of event and was either:
- Present for any portion of the calendar day on the date of event or
- Removed the day before the date of event.
- Patient has at least one of the following signs or symptoms:
- Fever (>38.0°C)
- Suprapubic tenderness*
- Costovertebral angle pain or tenderness*
- Urinary urgency^
- Urinary frequency^
- Dysuria.^
*No other recognized cause
^These symptoms cannot be used when catheter is in place
- Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of ≥105 CFU/ml.
All elements of the UTI criterion must occur during the infection window period.
Data collection procedure
Urine samples sent from various clinical departments to the microbiology department were screened on a daily basis. Those having positive urine culture, their detailed reports were collected, including the name of the organism involved and its sensitivity pattern. Such cases were followed up in the respective departments. Patients diagnosed to have CAUTI by the treating physician, as per the inclusion criteria, were enrolled. Demographic and clinical details of such patients were obtained from the case records of the patient as well as by consultation with the treating physician. Such patients were followed up on a daily basis till the outcome related to CAUTI was achieved.
The cost of the antimicrobials used for the treatment of CAUTI was obtained from the purchasing department of our hospital setting.
Data analysis
Statistical analysis was performed using the Graph pad Prism software (GraphPad Prism version 9.4.1 for Windows, GraphPad Software, San Diego, California USA, www.graphpad.com). The data are expressed as mean ± standard deviation (SD) or number (%). Days of therapy (DOT), length of therapy (LOT), and cost data were also expressed in range (min–max).
To find an association between the duration of catheterization and onset of CAUTI, simple linear regression analysis was used. For the analysis of the organism-wise mean difference, one-way ANOVA was used. P < 0.05 was considered statistically different.
| Results | | |
One hundred and seventy-two patients with CAUTI were identified during the study period. The mean ± SD age of the patients in our study was found to be 48.4 ± 18.06 years and the median was 50 years. The male-to-female ratio was 1:1.12.
All the patients included in the study were admitted to the hospital with noninfectious etiology. Among them, 81 (47%) patients were admitted for surgical intervention, 43 (24%) patients were admitted due to cardiovascular disease, 18 (10%) patients were admitted due to disease related to the central nervous system, 15 (9%) patients were admitted for the treatment of respiratory disease, 11 (6%) patients were admitted for renal disorders, and 6 (3%) patients were admitted for diseases related to the liver.
All the patients were inserted into the indwelling catheter on the day of admission or the next day with mean number of days from admission to the hospital to insertion of the urinary indwelling catheter was 0.23 ± 0.43 with a range of 0–2 days.
The mean number of days from the insertion of the catheter to the development of the first symptom of CAUTI was 5.19 ± 2.08 days with a range of 2–14 days.
[Table 1] displays the cumulative incidence of CAUTI with the duration of catheterization. Simple linear regression was used to find the association between the same. We observed a significant relationship (P < 0.0001) between the duration of catheterization and the incidence of CAUTI, with R2 0.99. All the patients included in our study developed CAUTI within 18 days of catheterization. | Table 1: Cumulative incidence of catheter-associated urinary tract infection as per the duration of catheterization
Click here to view |
Organisms isolated with their sensitivity pattern
Escherichia coli spp. was the most common isolate in 106 (62%) patients out of a total of 172, followed by Pseudomonas aeruginosa in 28 (16%), Klebsiella spp. in 23 (13%) patients, and Proteus spp. in 15 (9%) patients.
Each isolate was tested against seven different antimicrobial agents (AMAs). Among them, each isolate was resistant to a mean of 4.72 ± 1.91 AMAs tested against it. One hundred and forty isolates out of a total of 172 (81.39%) were multidrug-resistant organisms (MDRO), i.e., resistant to three or more classes of AMAs tested against it.[11] The highest percentage of MDRO was observed for Proteus spp, with all 15 isolates being MDRO and four isolates among them were resistant to all AMAs tested against them. These isolates were later subjected to testing against the 8th AMA, i.e., fosfomycin and found to be sensitive [Table 2].
96.22% (102 out of 106) of E. coli isolates were MDRO, and 14 among them were resistant to all seven AMAs tested. Later, they also exhibited sensitivity to fosfomycin. The resistance rate for Klebsiella spp. was also high with 19 out of 23 isolates being MDRO. Pseudomonas aeruginosa was sensitive to most of the AMAs tested against it, except for levofloxacin, where 25 out of 28 isolates were resistant [Table 2].
Antimicrobial therapy in patients of catheter-associated urinary tract infection
All 172 patients were initially prescribed empirical antimicrobials after the first symptom of CAUTI. The average number of AMAs prescribed as empirical therapy was 2.17 ± 0.97. Amoxycillin + Clavulanate (37.7%) and Piperacillin + Tazobactam (29.06%) were the most commonly prescribed antibacterials as empirical therapy, followed by Cefoperazone + Sulbactam (15%) and Ceftriaxone (15%). Metronidazole was prescribed as empirical therapy to 84 (48.83%) patients.
DOT and LOT are commonly used antimicrobial usage metrics.[12] DOT is defined as the number of days that a patient receives an AMA (regardless of dose). Any dose of an antibiotic that is received during a 24-h period represents 1 DOT. The DOT for a given patient on multiple antibiotics will be the sum of DOT for each antibiotic that the patient is receiving.[12]
LOT is defined as the number of days that a patient receives systemic AMAs, irrespective of the number of different drugs. Therefore, LOT will be lower than or equal to DOT because each antibiotic received is its own DOT.[12]
The ratio of DOT/LOT may be useful as a benchmarking proxy for the frequency of combination antibiotic therapy versus monotherapy. That is, ratio = 1, identifies monotherapy; ratio >1 identifies combination therapy.
In the present study, the mean DOT after the development of the event was 18.07 ± 4.32 days and the mean LOT was 10.41 ± 1.70 days with a ratio of DOT/LOT 1.73.
The mean length of hospitalization (LOH) after the diagnosis of CAUTI in our study was 14.8 ± 2.49 days. However, few patients suffering from neurological disease continued hospitalization even after recovery from CAUTI. Hence, LOH attributable to CAUTI could not be identified.
However, all the patients stayed in the hospital till the completion of their antimicrobial regimen. Hence, the minimum LOH attributable to CAUTI can be considered 10.41 ± 1.70 days.
We analyzed whether there was any difference in the DOT, LOT, or LOH attributable to the causative organism. However, as shown in [Table 2], there was no significant difference in the DOT or LOT, or LOH in different patients of CAUTI based on the causative organism.
The direct cost of antimicrobial treatment
The cost of antimicrobial therapy involved, a sum of the cost of all antimicrobials including those used for empirical as well as targeted therapy after the diagnosis of CAUTI, till the outcome for the same was achieved.
The total direct cost of AMAs per patient was 1322.40 ± 984.24 INR. The difference in the cost of acquisition of antimicrobial therapy was found to be significant among the different microorganisms with P < 0.0001 [Table 2].
| Discussion | | |
CAUTI is one of the most common HCAIs worldwide and is a result of the widespread use of urinary catheterization in hospitals and long-term care facilities much of which is inappropriate.
Although largely preventable, a sizable amount of time, cost, and other resources are expended by health-care institutions, even those with limited resource facilities, for the management of CAUTI, especially in those patients having symptomatic bacteriuria.
In our study, we collected data of 172 patients from various departments, who were diagnosed to have CAUTI during the study period.
The mean age of the patients included in the study was 48 ± 18.06 years with 132 out of 172 (76.74%) patients from the working (15–64 years) age group.[13]
The mean duration of catheterization before the onset of CAUTI was found to be 5.19 ± 2.08 days, which was comparable to that reported by other studies.[14],[15],[16] All patients included in our study developed CAUTI within 18 days of catheterization. We observed a significant relationship (P < 0.0001) between the duration of catheterization and the incidence of CAUTI, with R2 0.99.
Longer the duration of catheterization, the more the chance of the development of CAUTI. Patients continue to acquire new organisms at a rate of about 3%–7% per day. In long-term catheterization, that is by the end of 30 days, CAUTI develops in 100% of patients usually with 2 or more symptoms or clinical signs.[7],[10],[17]
In our study, E. coli spp was the most commonly isolated organism in 62% of patients followed by Pseudomonas aeruginosa, Proteus, and Klebsiella spp. The bacteriological profile isolated at our center was found similar to that reported earlier.[10],[17],[18]
One hundred and forty (81.39%) isolates were MDRO, i.e., resistant to three or more classes of AMAs tested against them. 102/106 (96.22%) of E. coli isolates were MDRO and all Proteus isolates were MDRO. Out of 172 isolates, 106 (i.e. 61.62%) were fluoroquinolone-resistant. Twenty-eight isolates were resistant to all seven AMAs tested. However, they were sensitive to fosfomycin.
Antimicrobial resistance among urinary pathogens is an ever-increasing problem. As reported by CDC national health-care safety network,[10] about a quarter of E. coli isolates and one-third of P. aeruginosa isolates from CAUTI cases were fluoroquinolone-resistant. Resistance of gram-negative pathogens to other agents, including third-generation cephalosporins and carbapenems, was also substantial.
The formation of biofilms by urinary pathogens on the surface of the catheter and drainage system occurs universally with prolonged duration of catheterization.[17],[18] Over time, the urinary catheter becomes colonized with microorganisms living in a sessile state within the biofilm, rendering them resistant to antimicrobials, and host defenses and virtually impossible to eradicate without removing the catheter. The role of bacteria within biofilms in the pathogenesis of CAUTI is unknown and is an area requiring further research.
In our study, it was observed that the most commonly empirical treatment was prescribed from the β-lactam group (51%) including co-amoxiclav, piperacillin/tazobactam, and ceftriaxone. Although the pattern of empirical prescription for CAUTI in our setup was according to the prescribed guidelines;[19],[20] however, 66% of patients needed a change or had to add an AMA in their empirical regimen based on the microbiology report due to the high prevalence of resistance among the prescribed AMAs.
Empiric therapy should be based on some key factors such as the severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use, which may have led to resistant bacteria, and local antimicrobial resistance data. Moreover, once cultures are available, antibiotic selections should be refined to narrow the antimicrobial spectrum. Treatment duration should be limited to 7–14 days, depending on the treatment response.
The length of antimicrobial treatment for CAUTI in our study was found to be 10.41 ± 1.70 days with a median of 10 days and a range of 5–18 days. The mean duration of hospital stay after the diagnosis of CAUTI in our study was 14.8 ± 2.49 days. However, we could not calculate the LOH attributable to CAUTI, due to preexisting chronic disease of the patient, which also required prolonged hospitalization.
In the guidelines of ICMR[19] and NICE[20] for CAUTI, it is recommended to use one antimicrobial per day for the treatment in CAUTI. The ratio of DOT/LOT in our study was found to be 1.73 ± 0.38 which indicates the average number of antimicrobials prescribed per day in the case of CAUTI.
The average cost of antimicrobials used for CAUTI in our study was, 1322 ± 984 INR. The cost of antimicrobial was obtained from the hospital purchase department and our's is a state government-funded hospital, therefore, the cost of antimicrobial treatment calculated from our hospital setup may not be generalized to other health-care settings.
We could not evaluate the total cost of illness attributable to CAUTI, as most of the patients were suffering from chronic conditions, and needed prolonged hospitalization; it was difficult to find out the exact cause attributable to CAUTI in such conditions. However, as most of the patients suffering from CAUTI were from the working age group, and the minimum average duration of hospitalization for the treatment of CAUTI was 10.41 ± 1.70 days, it can be said that CAUTI, resulted in a significant economic impact on the patient, due to loss of wedges for the similar duration.
As most of the financial burden associated with CAUTIs is due to the length of in-patient hospital stay, outpatient parenteral antimicrobial therapy (OPAT) programs, or switching to oral medications should be considered an option to assist in the patient's transition of care outside the hospital. Once clinical improvement has been recognized, most patients with UTIs can be managed in the outpatient setting using either oral antimicrobials or OPAT safely and effectively. Early effective therapy followed by the above-noted transitions of care strategies is good for patients by reducing their exposure to other nosocomial pathogens and limiting the need for IV access as well as for the institution by reducing the LOS and overall cost of care.[10]
Limitations
As all the data were obtained manually, it was practically not possible to identify the actual incidence of CAUTI out of the total number of patients catheterized.
Active surveillance for CAUTI was not carried out, only those patients who were symptomatic for CAUTI were considered, so the actual incidence of asymptomatic cases may be higher.
Many patients included in the study were suffering from chronic neurological conditions that required prolonged hospitalization; it was not possible to identify the additional LOH attributable to CAUTI, so the indirect cost of treatment could not be identified.
| Conclusion | | |
The clinical and economic implications of CAUTI are worrisome from both quality of care perspective as well as the financial liability of the treating institution. With the increasing prevalence of MDRO has made the management of CAUTIs considerably more challenging. Implementation of optimum preventive measures and antimicrobial stewardship practices is essential for the optimum utilization of limited resources.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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