The validity of using Catheter-associated urinary tract infections (CAUTIs) as an indicator of healthcare quality is currently under debate. Notable professor of medicine and infectious diseases consultant at the Mayo Clinic, Priya Sampathkumar, has argued that using CAUTI as a metric for quality of patient care may sometimes lead to misidentification of infections, and an alternative indicator, catheter-associated bacteria, may provide more accuracy.
For nearly two decades, organizations like the CDC have employed CAUTI as a gauge to assess infection prevention and overall healthcare quality at hospitals. However, Sampathkumar posits that a patient having an infection unveiled during CAUTI screening doesn’t necessarily imply a urinary tract infection (UTI), leading her to suggest the retirement of CAUTI as a metric. In fact, Sampathkumar expresses concern over the term UTI itself, suggesting that what is truly being measured is catheter-associated bacteria.
Despite this, reducing these bacteria remains an important goal, even if their categorization might be flawed. Healthcare-associated infection (HAI) incidents mostly fall under CAUTIs, as they represent close to one-third of HAI cases reported to the National Healthcare Safety Network (NHSN). Nevertheless, in 2009 a significant shift occurred when NHSN altered the definition of CAUTI to exclude asymptomatic bacteriuria, calling for mandatory reporting only of symptomatic and bacteremic cases. This change stirred worries that it would make oversight of hospital-associated infections more complex and have implications for the overall quality of patient care.
Conversely, experts noted that part of the battle against antibiotic resistance involves a reduction in antibiotic treatment for patients with this asymptomatic bacteriuria. Various experts have put forward alternative metrics, such as the NHSN Standardized Infection Ratio or the Standardized Device Utilization Ratio, indicating that these might serve as better measures by differentiating between UTIs and other health events related to catheter use.
Furthermore, Sampathkumar refers to guidelines from the Agency for Healthcare Research and Quality, which are in line with those from the Infectious Diseases Society of America and the U.S. Protective Services Task Force. These caution against treating asymptomatic bacteriuria, a condition where a patient tests positive for a urine culture but displays no symptoms of a UTI, with antibiotics in most cases. Sampathkumar pointed to studies suggesting UTIs are linked to over 13,000 deaths annually.
Despite their significant tie to increased mortality risk, on adjusting for other factors affecting outcomes, CAUTIs do not seem to increase the risk of death. She also brought up a potential loophole in the current system, namely if hospitals abstain from testing for asymptomatic infections which they would not treat anyway, which could be used to manipulate reported UTI rates. With over half of 105 CAUTIs reported in a certain hospital ICU over two years tied to alternative infections and various other causes for fevers, it’s clear that the presence of CAUTI isn’t always indicative of a UTI.
Since CAUTI’s connection to patient harm remains ambiguous and its definition seems to counteract attempts to decrease catheter use, Sampathkumar believes it’s time to stop using it as a quality metric.