ORIGINAL ARTICLE

Rates of urinary catheter-associated urinary tract infection in Saudi MOH hospitals: a 2-year multi-centre study

Yvonne S. Aldecoa¹, Adel Alanazi¹, Ghada Bin Saleh¹, Nasser Alshanbari¹, Tabish Humayun^1*, Faisal Alsheddi¹, Aiman El-Saed², Mohammed Alqahtani¹ and Khalid H. Alanazi¹

¹Surveillance Department, General Directorate of Infection Prevention and Control (GDIPC), Ministry of Health (MOH), Riyadh, Kingdom of Saudi Arabia; ²Infection Prevention and Control Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia

Abstract

Background: The published rates of catheter-associated urinary tract infection (CAUTI) in Saudi Arabia were derived from single-centre studies or nationally non-representative studies.

Objectives: The aim of this study was to estimate CAUTI rates and urinary catheter utilisation (UCU) ratios in 99 Saudi Ministry of Health (MOH) hospitals from all regions.

Methods: A prospective surveillance study was conducted in 15 different types of intensive care units (ICUs) between January 2018 and December 2019. The data were entered into the Health Electronic Surveillance Network (HESN) programme. The methods of the US National Healthcare Safety Network (NHSN) and the Gulf Cooperation Council (GCC) centre for infection control were used.

Results: During 2 years of surveillance covering 919,615 patient-days and 573,720 urinary catheter days, a total of 965 CAUTI events were identified. The overall MOH CAUTI rate was 1.68 (95%confidence interval (CI) 1.58–1.79) per 1,000 urinary catheter days, and the overall UCU was 0.624 (95%CI 0.623–0.625). CAUTI rates were highest in paediatric medical (5.73) and adult medical (2.02) ICUs. UCU were highest in neurosurgical (0.795) and medical surgical (0.743) ICUs. CAUTI standardised infection ratios across different ICUs in Saudi MOH hospitals were 16% lower than NHSN hospitals, 47% lower than GCC hospitals and 69% lower than International Nosocomial Infection Control Consortium (INICC) hospitals. Urinary catheter standardised utilisation ratios across different ICUs in Saudi MOH hospitals were 15% higher than NHSN hospitals, 9% higher than INICC hospitals and 13% lower than GCC hospitals.

Conclusions: The current study is a unique national CAUTI benchmark that can potentially help in the fight against healthcare-associated infection.

Keywords: urinary catheters; catheter-associated infections; urinary tract infections; intensive care units; infection control; benchmarking; surveillance; Saudi Arabia

 

 

The use of Foley’s catheter is an inevitable part of modern healthcare services, especially among intensive care patients, post-operative patients and neurological patients (1). Catheter-associated urinary tract infection (CAUTI) is one of the most frequent healthcare-associated infections (HAIs), representing up to one-third of all HAIs (2–4). CAUTI events cause approximately 10% excess mortality and approximately 10 days of additional stay among patients admitted to intensive care units (ICUs) (5, 6). In addition, they are the leading cause of secondary bloodstream infections (7, 8). Furthermore, CAUTI events are associated with disability, accounting for 16% of the total HAI-related years lived with disability (9). Moreover, they cause a significant increase in healthcare costs due to prolonged hospitalisation and associated morbidity (10).

Approximately 65–70% of the CAUTI events can be potentially prevented with appropriate infection prevention measures and control practices (11). The rate of CAUTI can be significantly reduced through implementation of preventive bundles in hospitalised patients (12). The results of HAI surveillance shared with healthcare providers is a key element of quality improvement and patient safety (13). In addition, CAUTI surveillance with or without other preventive measures has been shown to reduce the utilisation of urinary catheters and the rate of CAUTI (14–16). The rates of CAUTI in Saudi Arabia have been estimated from several reports (17–20). However, some of these reports were derived from single-centre studies (19, 20), and none of them were nationally representative (17–20). Therefore, a national benchmark for CAUTI rates is still lacking. To overcome this, the Saudi Ministry of Health (MOH) started to collect standardised CAUTI data from its hospitals using the new system of health electronic surveillance network (HESN) programme. The objective of the current study was to estimate unit-specific CAUTI rates along with urinary catheter utilisation (UCU) ratios in MOH hospitals and, additionally, to benchmark such rates and ratios with recognised regional and international benchmarks.

Methods

Setting

The total number of hospitals in Saudi Arabia is 484, with a total bed capacity of approximately 75,000 beds. Of these, the MOH is administering 284 hospitals with a total bed capacity of around 43,000 beds (21). The current study was conducted in 99 Saudi MOH hospitals distributed in 20 different geographical regions across Saudi Arabia. Out of 99 hospitals, 86% were general or central hospitals, 9% were maternal and children’s hospitals, and 5% were cardiac hospitals (Table 1). The hospitals included in the CAUTI surveillance had a total bed capacity of 26,399 beds, including 3,560 ICU beds (Table 1).

Table 1. Ministry of Health (MOH) hospitals enrolled in the Health Electronic Surveillance Network (HESN) which contributed the current CAUTI surveillance data, 2018–2019

Enrolled Hospitals data	<200 beds	200–300 beds	>300 beds	Total
Type of hospital
General/central	33 (80.5%)	35 (89.7%)	17 (89.5%)	85 (85.9%)
Maternal and children	3 (7.3%)	4 (10.3%)	2 (10.5%)	9 (9.1%)
Cardiac	5 (12.2%)	0 (0.0%)	0 (0.0%)	5 (5.1%)
Total	41 (100.0%)	39 (100.0%)	19 (100.0%)	99 (100.0%)
Surveillance numbers
Patient days	138,010	441,152	340,453	919,615
Urinary catheter days	98,772	260,595	214,354	573,720
CAUTI events	201	511	253	965
Bed capacity
Total beds	4,723	11,385	10,291	26,399
ICU beds	645	1,382	1,533	3,560
CAUTI, catheter-associated urinary tract infection; ICU, intensive care unit.

Design

A prospective surveillance study was conducted between 1 January 2018 and 31 December 2019 using the HESN programme.

Population

All included hospitals had at least 100-bed capacity, one ICU, a microbiology laboratory and a full-time microbiologist. The data were obtained from 15 different types of ICUs. The data were included in the analysis if at least 50 urinary catheter days of surveillance were reported per the reporting year, 2018 or 2019 (Table 2).

Table 2. Rates of catheter-associated urinary tract infections (CAUTIs) by type of intensive care unit (ICU) enrolled in the Health Electronic Surveillance Network (HESN), 2018–2019

Type of ICU	Number of ICUs*	Urinary catheter days	CAUTI events	Mean CAUTI rate	95% Confidence interval	Percentile**
						10%	25%	50% (median)	75%	90%
Burn	8	3,253	5	1.54	0.19–2.88
Medical	47	73,600	149	2.02	1.70–2.35	0.00	0.00	1.06	3.45	5.41
Medical cardiac	29	20,344	20	0.98	0.55–1.41	0.00	0.00	0.00	1.51	2.19
Medical surgical	161	420,588	724	1.72	1.60–1.85	0.00	0.00	0.94	2.49	4.28
Neurological	2	289	0	0.00	0.00–0.00
Neurosurgical	3	6,156	11	1.79	0.73–2.84
Paediatric cardiothoracic	2	428	0	0.00	0.00–0.00
Paediatric medical	10	4,883	28	5.73	3.61–7.86
Paediatric medical surgical	38	22,312	16	0.72	0.37–1.07	0.00	0.00	0.00	0.89	5.67
Paediatric surgical	2	505	0	0.00	0.00–0.00
Prenatal	1	54	0	0.00	0.00–0.00
Respiratory	3	2,300	0	0.00	0.00–0.00
Surgical	9	10,679	5	0.47	0.06–0.88
Surgical cardiothoracic	5	3,915	3	0.77	0.00–1.63
Trauma	4	4,414	4	0.91	0.02–1.79
Total	324	573,720	965	1.68	1.58–1.79	0.00	0.00	0.46	2.18	4.23
*ICUs contributing less than 50 urinary catheter days per year were excluded from the analysis. **Standard percentiles were calculated only when at least 20 hospitals were contributing data for a specific type of ICU.

Methods

The surveillance methodology was similar to the methods recommended by the US National Healthcare Safety Network (NHSN) (22) and the Gulf Cooperation Council (GCC) Centre for Infection Control (23). It was an active, patient-based, prospective targeted surveillance that was carried out in specific ICUs for specific durations after a local infection risk assessment.

Definitions

CAUTI was defined as a symptomatic urinary tract infection (SUTI) or an asymptomatic bacteremic urinary tract infection UTI (ABUTI) in a patient who had an indwelling urinary catheter. The catheter had to be in place for more than 2 days and in place at the date of CAUTI or the day prior. The symptoms included fever, suprapubic pain or tenderness, or costovertebral angle pain or tenderness, and additionally, urinary urgency, frequency or dysuria only if the catheter was not in place (22, 23). A physician’s diagnosis of UTI that did not match the surveillance criteria was not an acceptable diagnosis for CAUTI. The UCU, intended to provide a standardized indication of the extent of catheter use, was calculated by dividing the number of catheter-days by the number of patient-days in each participating ICU.

HESN programme

HESN is an integrated, semi-automated, national electronic surveillance system that has several domains to uniformly monitor communicable diseases, disease epidemics, immunisation and HAIs across Saudi Arabia (24). It allows users at different hospitals to continually and uniformly report HAIs to the General Directorate of Infection Prevention and Control (GDIPC) at Riyadh, Saudi Arabia. CAUTI and urinary catheter use data were collected by infection control practitioners (ICPs) at respective hospitals. The data were directly entered into the HESN programme at two levels: urinary catheter bundle form and CAUTI event form. The number of urinary catheter days was estimated using daily count at a fixed time (usually around 8.00 AM) for all patients with a urinary catheter or an electronic count that was within ±5% of the manually collected daily count. The surveillance department of GDIPC at MOH provided the included hospitals with the required training in surveillance definitions, surveillance methodology, use of HESN programme and information technology support. Training workshops followed by hands on training were conducted in all regions (during 2017) before the start of the study.

Statistical analysis

The data from all regions were extracted from the HESN programme and analysed using SPSS. Data extraction, management, analysis and interpretation were carried out centrally at the GDIPC. CAUTI rates (expressed per 1,000 urinary catheter days) and UCU ratios were calculated and stratified by type of ICU (18, 25). Confidence intervals (CIs) (18) and standard percentiles (25) were calculated for both CAUTI rates and UCU ratios. Percentiles were not calculated for ICU types with less than 20 data points (during a hospital year of surveillance). To benchmark the current CAUTI rates and UCU ratios with regional and international benchmarks, standardised infection ratios (SIRs) and standardised utilisation ratio (SUR) were calculated (respectively) after adjusting for differences in ICU types. SIR and SUR were calculated by dividing the number of observed CAUTI events and urinary catheter days (respectively) by their expected values (22). The expected values were calculated using the published reports of NHSN (25, 26), GCC (18) and International Nosocomial Infection Control Consortium (INICC) (27). P-values were two-tailed. P-value <0.05 was considered as significant. Statistical analyses were performed using SPSS software (release 25.0, Armonk, NY: IBM Corp.).

Results

During 2 years of surveillance covering 919,615 patient-days and 573,720 urinary catheter days, a total of 965 CAUTI events were identified. As shown in Table 2, the overall CAUTI rate was 1.68 per 1,000 urinary catheter days with 95%CI ranging between 1.58 and 1.79. The 50th, 75th and 90th percentiles were 0.46, 2.18 and 4.23, respectively. Five types of ICUs contributed 95% of the urinary catheter days surveyed in all types of ICUs: adult medical surgical, adult medical, paediatric medical surgical, adult medical cardiac and adult surgical. CAUTI rates per 1,000 urinary catheter days were highest in paediatric medical (5.73), adult medical (2.02), adult neurosurgical (1.79) and adult medical surgical (1.72) ICUs. There were no CAUTI events reported in adult respiratory, paediatric surgical, paediatric cardiothoracic, adult neurological and prenatal ICUs. The 90th percentiles of CAUTI rates per 1,000 urinary catheter days ranged from 2.19 in adult medical cardiac ICUs to 5.67 in paediatric medical surgical ICUs.

As shown in Table 3, the overall UCU ratio was 0.624, with the 95%CI ranging between 0.623 and 0.625. The 50th, 75th and 90th percentiles were 0.59, 0.78 and 0.88, respectively. The UCU ratios were highest in the following adult ICUs: neurosurgical (0.795), medical surgical (0.743), respiratory (0.724), trauma (0.723) and medical (0.715) ICUs. The UCU ratios were lowest in the following ICUs: adult burn (0.204), paediatric medical (0.211) and paediatric medical surgical (0.211) ICUs. The 90th percentiles of UCU ratios ranged between 0.45 in paediatric medical surgical ICUs and 0.91 in adult medical ICUs.

Table 3. Urinary catheter utilisation ratios by type of intensive care unit (ICU) enrolled in the Health Electronic Surveillance Network (HESN), 2018–2019

Type of ICU	Number of ICUs*	Patient days	Urinary catheter days	Utilisation ratio	95% confidence interval	Percentile**
						10%	25%	50% (median)	75%	90%
Burn	8	15,945	3,253	0.204	0.198–0.210
Medical	47	103,007	73,600	0.715	0.712–0.717	0.40	0.54	0.72	0.87	0.91
Medical cardiac	29	61,642	20,344	0.330	0.326–0.334	0.19	0.26	0.36	0.47	0.72
Medical surgical	161	566,259	420,588	0.743	0.742–0.744	0.36	0.58	0.73	0.82	0.89
Neurological	2	562	289	0.514	0.473–0.556
Neurosurgical	3	7,741	6,156	0.795	0.786–0.804
Paediatric cardiothoracic	2	1,552	428	0.276	0.254–0.298
Paediatric medical	10	23,106	4,883	0.211	0.206–0.217
Paediatric medical surgical	38	105,868	22,312	0.211	0.208–0.213	0.06	0.10	0.15	0.30	0.45
Paediatric surgical	2	2,048	505	0.247	0.228–0.265
Prenatal	1	184	54	0.293	0.228–0.359
Respiratory	3	3,176	2,300	0.724	0.709–0.740
Surgical	9	15,618	10,679	0.684	0.676–0.691
Surgical cardiothoracic	5	6,801	3,915	0.576	0.564–0.587
Trauma	4	6,106	4,414	0.723	0.712–0.734
Total	324	919,615	573,720	0.624	0.623–0.625	0.13	0.34	0.59	0.78	0.88
*ICUs contributing less than 50 urinary catheter days per year were excluded from the analysis. **Standard percentiles were calculated only when at least 20 hospitals were contributing data for a specific type of ICU.

Figure 1 compares CAUTI rates and UCU ratios in adult and paediatric ICUs in MOH hospitals with other recognised benchmarking networks. CAUTI rates in adult ICUs in MOH hospitals were exactly the same as NHSN rates (1.7 each), lower than GCC rates (3.3), and much lower than INICC rates (5.3). CAUTI rates in paediatric ICUs in MOH hospitals (0.7) were lower than NHSN rates (2.5) and INICC rates (5.6). UCU ratios in adult ICUs in MOH hospitals (0.74) were slightly higher than NHSN ratios (0.60) and INICC ratios (0.62) but slightly lower than GCC ratios (0.85). UCU ratios in paediatric ICUs in MOH hospitals were exactly the same as NHSN ratios (0.21 each) and lower than INICC rates (0.31).

Fig. 1. Comparisons of CAUTI rates (above) and urinary catheter utilisation ratios (below) between the Saudi health electronic surveillance network (HESN) and other recognised benchmarking networks.
Note: Adult and paediatric ICUs were medical-surgical ICUs. NHSN, US National Healthcare Safety Network; INICC, International Nosocomial Infection Control Consortium of developing countries; GCC, Gulf Cooperation Council countries; CAUTI, catheter-associated urinary tract infection; UC, urinary catheter.

Table 4 compares CAUTI rates and UCU ratios in MOH hospitals with the three benchmarks using SIR and SUR, respectively. CAUTI SIR across all types of ICUs in MOH hospitals were significantly lower than the recognised benchmarks; 16% lower than NHSN hospitals, 47% lower than GCC hospitals and 69% lower than INICC hospitals. Urinary catheter SUR across all types of ICUs in MOH hospitals were 15% higher than NHSN hospitals, 9% higher than INICC hospitals and 13% lower than GCC hospitals.

Table 4. Comparisons of CAUTI rates and urinary catheter utilisation ratio between the Saudi Health Electronic Surveillance Network (HESN) and other recognised benchmarking networks after adjustment for different types of ICUs

	HESN vs. NHSN	HESN vs. INICC	HESN vs. GCC
CAUTI rates
Number of ICU types included	14	10	3
Observed CAUTI events	965	932	740
Expected CAUTI events	1152.1	2970.2	1405.6
Standardised infection ratio (SIR)	0.84	0.31	0.53
95% confidence interval of SIR	0.79–0.89	0.29–0.33	0.49–0.57
P-value	<0.001	<0.001	<0.001
Urinary catheter utilisation ratios
Number of ICU types included	14	10	3
Observed urinary catheter days	573,720	564,597	437,423
Expected urinary catheter days	499,872	519,268	500,438
Standardised utilisation ratio (SUR)	1.148	1.087	0.874
95% confidence interval of SUR	1.145–1.151	1.084–1.090	0.871–0.877
P-value	<0.001	<0.001	<0.001
CAUTI, catheter-associated urinary tract infection; ICU, intensive care unit

Discussion

Using huge-standardised data, the current study is documenting CAUTI rates and UCU ratios in almost 100 Saudi MOH hospitals. The overall rate was 1.68 per 1,000 urinary catheter days. This rate is considered lower than CAUTI rates previously reported in Saudi Arabia (17–20). For example, CAUTI rates per 1,000 urinary catheter days ranged between 0.0 and 11.8 in ICUs of 12 referral and secondary MOH hospitals (17), between 1.3 and 4.1 in ICUs of four National Guard hospitals (18), and between 6.6 and 10.0 in three ICUs of Saudi Aramco Medical Services Organisation (19). The lower CAUTI rate in the current study can be explained by several factors. Firstly, the majority of previous local CAUTI data were collected based on the older CAUTI definition (18–20), while the current study used the new CAUTI definition. It has been shown that the new NHSN CAUTI definition introduced in 2015 resulted in a large reduction of CAUTI rates (7, 8). Secondly, some of the previous local CAUTI data were collected before widespread implementation of the urinary catheter bundle (18–20), whereas the current data were collected while the urinary catheter bundle was fully implemented. The implementation of the urinary catheter bundle resulted in a significant reduction of CAUTI rates (12). Thirdly, the majority of previous local CAUTI data were collected from one to three types of ICUs (17–20), while the current data were collected from 15 different ICUs, some of them had zero CAUTI rates. Finally, despite the training and auditing done by the GDIPC, under-reporting of CAUTI events to the new HESN system cannot be completely excluded.

The UCU ratio ranged between 0.20 and 0.80 with an average ratio of 0.62. The current UCU ratios are considered similar or slightly lower than those previously reported in Saudi Arabia (17–19). For example, UCU ranged between 0.06 and 0.85 in 12 MOH hospitals (17), between 0.39 and 0.69 in the Saudi Aramco Medical Services Organisation (19), and between 0.85 and 0.96 in four National Guard hospitals (18). The slightly lower UCU ratios in the current study may be related to the inclusion of paediatric ICUs in the current study but their exclusion in previous local reports (17–19). Paediatric ICUs in the current and international studies are known for their lower UCU ratios (25–27).

The current CAUTI rates were generally lower than the recognised international benchmarks, especially after adjusting for the type of ICUs. The difference was minimal with NHSN hospitals (25, 26) and considerable with INICC and GCC hospitals (18, 27). Similar to the local comparisons discussed above, the data used in these reports were mainly based on the older CAUTI definition and were collected before full implementation of the urinary catheter bundle (18, 27). Interestingly, the differences in UCU ratios between this study and recognised international benchmarks were minimal. The slightly lower urinary catheter SUR in MOH hospitals compared with GCC hospitals may be related to the presence of paediatric data in the current report but not the GCC report (18). The generally high UCU ratios in the current report and the recognised international benchmarks may indicate the need for more work to reduce catheter utilisation, including training and education (14, 15).

The current study can serve perfectly as a national benchmark for CAUTI. The benchmarking use of this study is supported by the large, unprecedented number of hospitals included, the coverage of 20 geographical regions, and the use of the same electronic data collection system. Additionally, this has been further facilitated by presenting unit-specific rates and ratios and by calculating CIs and standard percentiles for both rates and ratios. Moreover, the use of the same surveillance methodology and the same electronic platform ensured the homogeneity of the calculated rates and ratios. Yet, several challenges still need to be overcome to further improve CAUTI surveillance in MOH hospitals, including data validation, site audits and rapid turnover of ICPs (29).

Conclusion

The current study estimated CAUTI rates and UCU ratios in 15 different types of ICUs from 99 MOH hospitals distributed in 20 different regions. The overall CAUTI rate was 1.68 per 1,000 urinary catheter days, and the overall UCU ratio was 0.62. MOH CAUTI rates adjusted for the type of ICUs were 16 to 69% lower than recognised benchmarks. Interestingly, the differences in UCU ratios between this study and recognised international benchmarks were minimal. The current study is a unique national CAUTI benchmark that can potentially help in the fight against HAI (28). As HAIs increase morbidity, mortality, length of hospital stay and financial loss, certain initiatives are necessary to prevent and control them (30).

Acknowledgements

The authors thank General Directorate of Infection Prevention and Control (GDIPC), ICPs (Infection Control Practitioners), Regional Coordinators and HESN (Health Electronic Surveillance Network) Team at Ministry of Health (MOH), Riyadh, Kingdom of Saudi Arabia.

Authors’ contributions

Yvonne S. Aldecoa: Data collection and manuscript writing. Adel Alanazi: Drafting the article and data collection. Ghada Bin Saleh: Data Analysis and interpretation. Nasser Alshanbari: Results calculation and compilation. Tabish Humayun: Study design, Manuscript writing and Discussion. Faisal Alsheddi: Data collection and analysis. Aiman El-Saed: Data Analysis, review of final manuscript and final approval of the manuscript to be published. Mohammed Alqahtani: Results and discussion. Khalid H. Alanazi: Final review and critical revision of the article.

Ethical approval

Ethical approval (exempt status) was provided by the Institutional Review Board, King Fahad Medical City, Riyadh.

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