The federal government’s National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination, launched in 2009, is a multidisciplinary campaign aimed at achieving dramatic reductions in HAIs across the country.1 The four-phase plan focus includes:
- Phase 1: Acute Care Hospitals
- Phase 2: Ambulatory Surgical Centers, End-Stage Renal Disease Facilities, and increasing Influenza Vaccination among Health Care Personnel
- Phase 3: Long-Term Care Facilities
- Phase 4: Antibiotic Stewardship
Catheter-associated urinary tract infections (CAUTIs) are among the seven key targets of this pioneering endeavor.1 A glance at some CAUTI statistics explains why:
- CAUTI is the most common type of HAI reported to the National Healthcare Safety Network (NHSN).2
- 15%-25% of hospitalized patients receive a urinary catheter—the most important risk factor for developing a CAUTI—during their hospitalization.2
- The daily risk of acquiring a CAUTI for a patient with an indwelling urinary catheter is 3%-7%.3
- CAUTIs are estimated to cause 12.9% of hospital-associated bacteremias and is the leading cause of secondary hospital-associated bloodstream infections.3
- The average additional cost associated with an inpatient CAUTI is $13,793 (range $4,694-$29,743).4
- According to the Agency for Healthcare Research and Quality, as many as 50%-70% of CAUTIs are preventable.5
Furthermore, two of the multidrug-resistant organisms identified as “Urgent Threats” on the Centers for Disease Control and Prevention’s (CDC) Antibiotic Resistance Threats in the United States, 2019 report, published in November 2019—Carbapenem-resistant Acinetobacter and Carbapenem-resistant Enterobacteriaceae—can be virulent causes of CAUTI.6 In fact, the CDC states that “patients whose care requires devices like…urinary (bladder) catheters” are among those “most likely to get a CRE infection.” 7
Snapshot on Progress
The campaign against CAUTIs has been a slower success story than some of the other HAIs.8 The initial goal was a 25% reduction in CAUTI rates by 2013 compared to baseline rates in 2008. The process was complicated by a change in CAUTI surveillance protocols, but the 25% reduction was finally achieved in 2016. Another ambitious 25% reduction compared to a baseline of 2015 rates was subsequently set for 2020.8
According to the CDC, the most dramatic reductions in CAUTI rates have been achieved in non-intensive care unit (ICU) patient settings, though progress in ICUs appears to be on the rise as well. The CDC attributes much of the CAUTI success to a reduction in unnecessary urinary catheter use—a widely recognized prevention strategy.8
Getting to the Finish Line
While data shows facilities are adopting more judicious catheter utilization protocols, in their Data Summary of HAIs in the US: Assessing Progress 2006-2016 report, the CDC advises that “good urinary catheter care and careful CAUTI diagnosis” will be imperative in achieving further CAUTI rate reductions.8
Key components of urinary catheter care include: 9-11
- Maintenance of a continuously closed drainage system
- Proper securement and placement of the catheter and collection bag
- Aseptic technique for both collecting urine specimens and replacement when breaks in the system occur
- Maintenance of unobstructed urine flow
- Regular periurethral/meatal cleaning
The “Peri-Care” Debate
As the World Health Organization states, “urinary tract infection is usually caused by endogenous microorganisms from the patient’s own bowel.”11 Bacteria that colonize the perineum can ascend into the urinary tract either during the insertion process or by capillary action after insertion.3 They can also be introduced through improper handling of the collection system.3 As a result, regular cleaning of the perineal area—often called “peri-care”—is a core component of CAUTI prevention guidelines.9-11
The goal is obvious: to reduce the bioburden in the area surrounding the catheter entry point in an effort to reduce the risk that bacteria residing there will contaminate the catheter system and ultimately lead to CAUTI. Studies have found that suboptimal peri-care can be a contributing factor to CAUTI rates, while enhanced peri-care protocols can be associated with CAUTI reductions.13-14
Although there is growing concern over the rise in chlorhexidine gluconate (CHG) resistance among clinical isolates, including warnings from professional organizations such as The Joint Commission, patient bathing—including peri-care with CHG—is a common practice in the United States.14-21 This is despite the fact that CHG is contraindicated for the perineum,22 and its use is not recommended in any CAUTI prevention guidelines: 9-11
- CDC Guideline for Prevention of Catheter-Associated Urinary Tract Infections: “Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.”10
- Society for Healthcare Epidemiology of America, Infectious Diseases Society of America: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update: “Employ routine hygiene; cleaning the meatal area with antiseptic solutions is unnecessary.” 9
- World Health Organization: “Meatal cleansing should be performed regularly to ensure that the meatus is free from encrustations. Cleansing with soap and water is sufficient; application of antimicrobial ointment or disinfectant to the urethral meatus is harmful and should be avoided.”11
Looking to Alternatives: A Novel Topical Hygiene Solution
Theraworx Protect is a multi-ingredient skin formulation designed to reduce macro and micro debris from the skin while simultaneously supporting the skin’s acid mantle and the natural antimicrobial functions of the skin’s outermost layer, the stratum corneum.18-19 As a non-antiseptic, non-drug product, Theraworx Protect can help you achieve your patient bathing and peri-care goals without the risk of antiseptic resistance. Contact us for more information.
- Office of Disease Prevention and Health Promotion. National action plan to prevent health care-associated infections: road map to elimination. Available from: https://health.gov/hcq/prevent-hai-action-plan.asp. Accessed September 26, 2019.
- Centers for Disease Control and Prevention. Healthcare-associated infections: catheter-associated urinary tract infection. Available from: https://www.cdc.gov/HAI/ca_uti/uti.html. Accessed December 19, 2019.
- Association for Professionals in Infection Control and Epidemiology. APIC implementation guide: guide to preventing catheter-associated urinary tract infections. 2014. Available from: https://www.ajicjournal.org/article/S0196-6553(18)30243-8/fulltext. Accessed January 7, 2020.
- Agency for Healthcare Research and Quality. Estimating the additional hospital inpatient cost and mortality associated with selected hospital-acquired conditions. 2017. Available from: https://www.ahrq.gov/hai/pfp/haccost2017-results.html Accessed 19 December 2019. Accessed January 7, 2020.
- Agency for Healthcare Research and Quality. Toolkit for reducing catheter-associated urinary tract infections in hospital units: implementation guide. 2015. Available from: https://www.ahrq.gov/hai/cauti-tools/guides/implguide-pt1.html. Accessed January 9, 2020.
- Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States 2019. Available from: https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. Accessed January 9, 2020.
- Centers for Disease Control and Prevention. Healthcare-associated infections: Carbapenem-resistant Enterobacteriaceae. 2019. Available from: https://www.cdc.gov/hai/organisms/cre/cre-patients.html. Accessed January 9, 2020.
- Centers for Disease Control and Prevention. Healthcare-associated infections: data summary of HAIs in the US: assessing progress 2006-2016. Available from: https://www.cdc.gov/hai/data/archive/data-summary-assessing-progress.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fsurveillance%2Fdata-reports%2Fdata-summary-assessing-progress.html. Accessed January 7, 2020.
- Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35(5): 464-479.
- Centers for Disease Control and Prevention. Summary of recommendations: guideline for prevention of catheter-associated urinary tract infections (2009). Available from: https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html#III. Accessed January 7, 2020.
- World Health Organization. Advanced infection prevention and control training: prevention of catheter-associated urinary tract infection (CAUTI): student handbook. Available from: https://www.who.int/infection-prevention/tools/core-components/CAUTI_student-handbook.pdf. Accessed January 9, 2020.
- Sampathkumar P, Barth J. CAUTI reduction at Mayo Clinic. 2016. Available from: https://www.mnhospitals.org/Portals/0/Documents/patientsafety/CAUTI/MayoClinicCAUTI_2016CHAINConference.pdf. Accessed January 9, 2020.
- Reeths A, Merkatoris R. The implementation of a new perineal care protocol to reduce catheter-associated urinary tract infections in the intensive care unit. Am J Infect Control 2016; 44(6): S99.
- Wang JT, Sheng WH, Wang JL, et al. Longitudinal analysis of chlorhexidine susceptibilities of nosocomial methicillin-resistant Staphylococcus aureus isolates at a teaching hospital in Taiwan, J Antimicrob Chemother 2008; 62(3): 514-17.
- Batra R, Cooper BS, Whitely C, et al. Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis 2010; 50(2): 210-7.
- Zhang M, O’Donoghue MM, Hiramatsu K, et al. Prevalence of antiseptic-resistance genes in Staphylococcus aureus and coagulase-negative staphylococci colonizing nurses and the general population in Hong Kong. J Hosp Infect 2011; 78(2): 113-7.
- Suwantarat N, Carroll KC, Tekle T, et al. High prevalence of reduced chlorhexidine susceptibility in organisms causing central line-associated bloodstream infections. Infect Control Hosp Epidemiol 2014; 35(9): 1183-186.
- Choudhury MA, Sidjabat HE, Rathnayake IU, et al. Culture-independent detection of chlorhexidine resistance genes qacA/B and smr in bacterial DNA recovered from body sites treated with chlorhexidine-containing dressings. J Med Microbiol 2017; 66: 447-453.
- Addetia A, Greninger AL, Adler A, et al. A novel, widespread qacA allele results in reduced chlorhexidine susceptibility in staphylococcus epidermis. Antimicrob Agents Chemother 2019; 63(6): e02607-18.
- Kampf G. Acquired resistance to chlorhexidine—is it time to establish an “antiseptic stewardship” initiative? J Hosp Infect 2016; 94:213-27.
- The Joint Commission. CLABSI Toolkit-Chapter 3. Available from: https://www.jointcommission.org/topics/clabsi_toolkit__chapter_3.aspx. Accessed September 27, 2019.
- Drugs.com. Chlorhexidine topical. 2017. Available from: https://www.drugs.com/mtm/chlorhexidine-topical.html. Accessed June 18, 2019.
- Paulson DS, Topp R, Boykin RE, Schultz G, Yang Q. Efficacy and safety of a novel skin cleansing formulation versus chlorhexidine gluconate. Am J Infect Control 2018; 46(11): 1262-1265
- Wiemken TL, Kelley RR, Carrico RM, Binford LE, Guinn BE, Mattingly WA, et al. Efficacy of a novel skin antiseptic against carbapenem-resistant Enterobacteriaceae. Am J Infect Control 2015; 43(4): 380-382.