Healthcare Associated Urinary Tract Infections: A Protocol for a National Point Prevalence Study

Background: Urinary tract infections account for ~30% of healthcare-associated infections reported by hospitals. Virtually all healthcare-associated urinary tract infections (HAUTIs) are caused by instrumentation of the urinary tract, creating an opportunity to prevent a large proportion of HAUTIs, including catheter-associated urinary tract infections (CAUTIs). In Australia, there is no specific national strategy and surveillance system in place to address HAUTIs or CAUTIs. To determine the need for prospective surveillance of HAUTIs, we propose undertaking a national point prevalence study. This paper describes the methods that could be used to undertake such a study. Methods: A cross-sectional point prevalence design is proposed. The population is all patients hospitalised overnight in Australian hospitals, with the sample to exclude outpatients and those in emergency departments. The proposed operational definition is that used by the Health Protection Agency. A standardised training package for data collectors is recommended with standardised data collection and analysis processes described. Individual patient consent should be waived. Discussion: Explanation of aspects of the proposed methods are provided, primarily based on findings from a pilot study that informed the development of the proposed protocol. This included development and delivery of training for data collectors and use of the Health Protection Agency HAUTI surveillance definition, rather than the Centers for Disease Control definition. Conclusion: Conducting a national point prevalence study on HAUTIs including CAUTIs will provide evidence that can be subsequently used to debate the cost effectiveness and value of prospective surveillance. By conducting a pilot study and critically evaluating that process, we have been able to propose a method that could be used for a single hospital or national study

Ciprofloxacin resistance in community- and hospital-acquired Escherichia coli urinary tract infections: a systematic review and meta-analysis of observational studies

Background During the last decade the resistance rate of urinary Escherichia coli (E. coli) to fluoroquinolones such as ciprofloxacin has increased. Systematic reviews of studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli urinary tract infections (UTI) are absent. This study systematically reviewed the literature and where appropriate, meta-analysed studies investigating ciprofloxacin resistance in community- and hospital-acquired E. coli UTIs. Methods Observational studies published between 2004 and 2014 were identified through Medline, PubMed, Embase, Cochrane, Scopus and Cinahl searches. Overall and sub-group pooled estimates of ciprofloxacin resistance were evaluated using DerSimonian-Laird random-effects models. The I2 statistic was calculated to demonstrate the degree of heterogeneity. Risk of bias among included studies was also investigated. Results Of the identified 1134 papers, 53 were eligible for inclusion, providing 54 studies for analysis with one paper presenting both community and hospital studies. Compared to the community setting, resistance to ciprofloxacin was significantly higher in the hospital setting (pooled resistance 0.38, 95 % CI 0.36-0.41 versus 0.27, 95 % CI 0.24-0.31 in community-acquired UTIs, P \u3c 0.001). Resistance significantly varied by region and country with the highest resistance observed in developing countries. Similarly, a significant rise in resistance over time was seen in studies reporting on community-acquired E. coli UTI. Conclusions Ciprofloxacin resistance in E. coli UTI is increasing and the use of this antimicrobial agent as empirical therapy for UTI should be reconsidered. Policy restrictions on ciprofloxacin use should be enhanced especially in developing countries without current regulations

Point Prevalence Surveys of Healthcare-Associated Urinary Tract Infections: Development, Pilot Testing and Evaluation of Face-to-Face and Online Educational Packages

Objective: To describe the development, pilot testing and evaluation of face-to-face and online educational training packages for healthcare staff undertaking point prevalence surveys (PPS) of healthcare-associated urinary tract infections (HAUTIs) in Australian hospitals and aged care facilities. Methods: The study involved two phases. A face-to-face educational training package was developed and used in Phase I of the HAUTI PPS data collection conducted in six hospitals. In Phase II, the training package was expanded and modified for online use by healthcare staff in 82 hospitals and 17 aged care facilities. Ten staff evaluated the face-to-face training package in Phase I. For Phase II, 38 staff evaluated the online training package. After each phase, staff completed an online evaluation survey about the usefulness of the training package and ease of data collection. Results: For Phase I, usefulness of the training package was rated highly (100%, n=10) with all respondents rating the training useful in preparing for data collection. Staff in Phase II also reported the online training useful in preparing for data collection and was rated very useful by 21% (n=8) of respondents and useful by 66% (n=25). Some respondents (Phase I, n=4 and Phase II, n=25) provided small amount of text data that was triangulated with quantitative data. Qualitative feedback reinforced quantitative ranking of usefulness of the training package. Conclusion: The training packages were sufficient to train healthcare staff with varying levels of knowledge and skills in undertaking HAUTI PPS in hospitals and/or aged care facilities

Five-year antimicrobial resistance patterns of urinary escherichia coli at an Australian tertiary hospital: Time series analyses of prevalence data

This study describes the antimicrobial resistance temporal trends and seasonal variation of Escherichia coli (E. coli) urinary tract infections (UTIs) over five years, from 2009 to 2013, and compares prevalence of resistance in hospital- and community-acquired E. coli UTI. A cross sectional study of E. coli UTIs from patients attending a tertiary referral hospital in Canberra, Australia was undertaken. Time series analysis was performed to illustrate resistance trends. Only the first positive E. coli UTI per patient per year was included in the analysis. A total of 15,022 positive cultures from 8724 patients were identified. Results are based on 5333 first E. coli UTIs, from 4732 patients, of which 84.2% were community-acquired. Five-year hospital and community resistance rates were highest for ampicillin (41.9%) and trimethoprim (20.7%). Resistance was lowest for meropenem (0.0%), nitrofurantoin (2.7%), piperacillin-tazobactam (2.9%) and ciprofloxacin (6.5%). Resistance to amoxycillin-clavulanate, cefazolin, gentamicin and piperacillin-tazobactam were significantly higher in hospital- compared to community-acquired UTIs (9.3% versus 6.2%; 15.4% versus 9.7%; 5.2% versus 3.7% and 5.2% versus 2.5%, respectively). Trend analysis showed significant increases in resistance over five years for amoxycillin-clavulanate, trimethoprim, ciprofloxacin, nitrofurantoin, trimethoprim-sulphamethoxazole, cefazolin, ceftriaxone and gentamicin (P < 0.05, for all) with seasonal pattern observed for trimethoprim resistance (augmented Dickey-Fuller statistic = 4.136; P = 0.006). An association between ciprofloxacin resistance, cefazolin resistance and ceftriaxone resistance with older age was noted. Given the relatively high resistance rates for ampicillin and trimethoprim, these antimicrobials should be reconsidered for empirical treatment of UTIs in this patient population. Our findings have important implications for UTI treatment based on setting of acquisition

Reducing Catheter-Associated Urinary Tract Infections in Hospitals: Study Protocol for a Multi-Site Randomised Controlled Study

Introduction Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. A number of measures can be taken to reduce the risk of CAUTI in hospitals. Appropriate urinary catheter insertion procedures are one such method. Reducing bacterial colonisation around the meatal or urethral area has the potential to reduce CAUTI risk. However, evidence about the best antiseptic solutions for meatal cleaning is mixed, resulting in conflicting recommendations in guidelines internationally. This paper presents the protocol for a study to evaluate the effectiveness (objective 1) and cost-effectiveness (objective 2) of using chlorhexidine in meatal cleaning prior to catheter insertion, in reducing catheter-associated asymptomatic bacteriuria and CAUTI. Methods and analysis A stepped wedge randomised controlled trial will be undertaken in three large Australian hospitals over a 32-week period. The intervention in this study is the use of chlorhexidine (0.1%) solution for meatal cleaning prior to catheter insertion. During the first 8 weeks of the study, no hospital will receive the intervention. After 8 weeks, one hospital will cross over to the intervention with the other two participating hospitals crossing over to the intervention at 8-week intervals respectively based on randomisation. All sites complete the trial at the same time in 2018. The primary outcomes for objective 1 (effectiveness) are the number of cases of CAUTI and catheter-associated asymptomatic bacteriuria per 100 catheter days will be analysed separately using Poisson regression. The primary outcome for objective 2 (cost-effectiveness) is the changes in costs relative to health benefits (incremental cost-effectiveness ratio) from adoption of the intervention. Dissemination Results will be disseminated via peer-reviewed journals and presentations at relevant conferences.A dissemination plan it being developed. Results will be published in the peer review literature, presented at relevant conferences and communicated via professional networks

Reducing urinary catheter use: a protocol for a mixed methods evaluation of an electronic reminder system in hospitalised patients in Australia

Introduction Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. Prolonged urinary catheterisation is the main risk factor for development of CAUTIs; hence, interventions that target early catheter removal warrant investigation. The study&rsquo;s objectives are to examine the efficacy of an electronic reminder system, the CATH TAG, in reducing urinary catheter use (device utilisation ratio) and to determine the effect of the CATH TAG on nurses&rsquo; ability to deliver patient care.Methods and analysis This study uses a mixed methods approach in which both quantitative and qualitative data will be collected. A stepped wedge randomised controlled design in which wards provide before and after observations will be undertaken in one large Australian hospital over 24 weeks. The intervention is the use of the CATH TAG. Eligible hospital wards will receive the intervention and act as their own control, with analysis undertaken of the change within each ward using data collected in control and intervention periods. An online survey will be administered to nurses on study completion, and a focus group for nurses will be conducted 2&thinsp;months after study completion. The primary outcomes are the urinary catheter device utilisation ratio and perceptions of nurses about ease of use of the CATH TAG. Secondary outcomes include a reduced number of cases of catheter-associated asymptomatic bacteriuria, a reduced number of urinary catheters inserted per 100 patient admissions, perceptions of nurses regarding effectiveness of the CATH TAG, changes in ownership/interest by patients in catheter management, as well as possible barriers to successful implementation of the CATH TAG.Ethics and dissemination Approval has been obtained from the Human Research Ethics Committees of Avondale College of Higher Education (2017:15) and Queensland Health (HREC17QTHS19). Results will be disseminated via peer-reviewed journals and conference presentations

How registry data are used to inform activities for stroke care quality improvement across 55 countries : A cross-sectional survey of Registry of Stroke Care Quality (RES-Q) hospitals

Background and purpose The Registry of Stroke Care Quality (RES-Q) is a worldwide quality improvement data platform that captures performance and quality measures, enabling standardized comparisons of hospital care. The aim of this study was to determine if, and how, RES-Q data are used to influence stroke quality improvement and identify the support and educational needs of clinicians using RES-Q data to improve stroke care. Methods A cross-sectional self-administered online survey was administered (October 2021–February 2022). Participants were RES-Q hospital local coordinators responsible for stroke data collection. Descriptive statistics are presented. Results Surveys were sent to 1463 hospitals in 74 countries; responses were received from 358 hospitals in 55 countries (response rate 25%). RES-Q data were used “always” or “often” to: develop quality improvement initiatives (n = 213, 60%); track stroke care quality over time (n = 207, 58%); improve local practice (n = 191, 53%); and benchmark against evidence-based policies, procedures and/or guidelines to identify practice gaps (n = 179, 50%). Formal training in the use of RES-Q tools and data were the most frequent support needs identified by respondents (n = 165, 46%). Over half “strongly agreed” or “agreed” that to support clinical practice change, education is needed on: (i) using data to identify evidence–practice gaps (n = 259, 72%) and change clinical practice (n = 263, 74%), and (ii) quality improvement science and methods (n = 255, 71%). Conclusion RES-Q data are used for monitoring stroke care performance. However, to facilitate their optimal use, effective quality improvement methods are needed. Educating staff in quality improvement science may develop competency and improve use of data in practice