ArticlesEffect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial
Introduction
Urinary tract infections (UTIs) are one of the most common hospital-associated infections with 93 000 annual cases reported in the USA, incurring an excess cost of US$900 per episode.1, 2 38% of these occur in the intensive care unit (ICU) where urinary catheters are commonly used.1
Risk factors for UTIs include female sex, aged 65 years or older, compromised immune system, and urinary catheters. Although prevention is needed for all-cause UTIs, prevention strategies have focused on catheter-associated UTIs that account for 80% of hospital-associated UTIs.3 Guidelines emphasise appropriate catheter indications, aseptic insertion, maintenance of a closed unobstructed drainage system, and timely removal.4 Body decolonisation, which could affect catheter-related and non-catheter related UTIs, has not been explored in large-scale studies.
UTIs in the ICU setting are difficult to diagnose because patients are often sedated and unable to verbalise symptoms such as dysuria, urinary frequency, or urgency. Thus, these symptoms are poor predictors of UTI in the ICU setting.5 Because of this difficulty, many studies have used colony count thresholds in urinary cultures to suggest UTI for known uropathogens.6, 7, 8 Even though this measure probably shows a mixture of UTIs and asymptomatic bacteriuria, this approach allows a pragmatic and objective definition that correlates with antibiotic treatment by clinicians.9
In 2013, a large cluster-randomised trial of hospitals (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) reported that universal decolonisation of adult ICU patients with a chlorhexidine bath every day and a short course of mupirocin nasal ointment resulted in a reduction in both meticillin-resistant Staphylococcus aureus (MRSA) clinical cultures and all pathogen bloodstream infections.10 We aim to assess the effect of the three REDUCE MRSA Trial interventions on bacteriuria and candiduria in patients in hospital ICUs.
Section snippets
Study design and participants
We did a secondary analysis of the REDUCE MRSA trial, a cluster-randomised trial of 43 hospitals (clusters; 74 adult ICUs) in the USA assigned to three MRSA prevention strategies. Patients admitted to participating hospital ICUs during baseline and intervention periods were included in the REDUCE MRSA study; we used these patient data. The trial included a 12-month baseline period from Jan 1, 2009, to Dec 31, 2009, a phase-in period from Jan 1, 2010, to April 7, 2010, and an 18-month
Results
From June 24, 2009, to Dec 10, 2009, 55 hospitals were screened and recruited and from this total, 45 (82%) hospitals were enrolled into the REDUCE MRSA trial (figure 1). 45 hospitals (78 adult ICUs) in 16 states were randomly assigned to one of three different prevention strategies for MRSA (figure 1). 43 hospitals (74 ICUs) initiated the assigned intervention; but two hospitals (four ICUs) randomly assigned were excluded from analyses because they met pre-existing exclusion criteria, which
Discussion
Our findings suggest that universal decolonisation could be a potentially new and effective strategy for the prevention of overall bacteriuria and high-level candiduria in only male ICU patients (panel).
Despite established guidance for UTI prevention,15, 16 data show that UTIs have not abated.24, 25 In fact, the USA reported a slight rise in UTIs between 2009 and 2012.25 Thus, advancements in effective UTI prevention strategies are needed.
Although the decolonisation intervention included both
References (35)
- et al.
Biofilms and catheter-associated urinary tract infections
Infect Dis Clin North Am
(2003) - et al.
Incidence and risk factors for acquiring nosocomial urinary tract infection in the critically ill
J Crit Care
(2002) - et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives
J Clin Epidemiol
(1993) - et al.
Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review
J Hosp Infect
(2012) - et al.
Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial
Lancet Infect Dis
(2014) - et al.
Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial
Lancet
(2013) - et al.
Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection
Am J Infect Control
(2013) - et al.
Trends in catheter-associated urinary tract infections among a national cohort of hospitalized adults, 2001–2010
Am J Infect Control
(2014) - et al.
Multistate point-prevalence survey of health care-associated infections
N Engl J Med
(2014) - et al.
A meta-analysis of cost and financial impact on the US health care system
JAMA Intern Med
(2013)