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UTI.pdf

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R E S E A R C H

INTRODUCTION Geriatric hip fracture patients are susceptible to a high- er rate of complications, with rates ranging from 7% to 40% (Bliemel et al., 2017; Różańska, Wałaszek, Wolak, & Bulanda, 2016; Thakker et al., 2018). One such complica- tion is catheter-associated urinary tract infection (CAUTI). Risk factors inherent to this population include surgical procedures, immobility, age, and the routine utilization of indwelling urinary catheters in the perioperative period (Detweiler, Mayers, & Fletcher, 2015; Hälleberg Nyman et al., 2013; Zielinski et al., 2015). This complication

negatively impacts both the patient and the institution providing care.

It is reported that 15.5% of hospitalized patients older than 65 years have urinary tract infections (UTIs) (Centers for Disease Control and Prevention [CDC], 2019; Foxman, 2010). Moreover, 6.2% of infectious disease-related deaths are due to UTIs (Alpay, Aykin, Korkmaz, Gulduren, & Caglan, 2018). Implementation of various measures has led to a reduction in the incidence of UTIs; however, UTIs are still prevalent, placing an enormous financial burden on institutions (Polites et al., 2014; Rebmann & Greene, 2010). The Centers for Medicare & Medicaid has deemed that CAUTI is a “reasonably preventable” inhospital com- plication and has terminated reimbursements for these events since 2008 (CDC, 2019). The mean cost of UTI is $862 to $1007 per UTI (Bail et al., 2015; CDC, 2019; Scott, 2010), whereas a systematic review found that the mean cost of CAUTI can exceed $10,000 per CAUTI based on the clinical status of the patient (Hollenbeak & Schilling, 2018).

A vast majority of patients who suffer hip fractures undergo a surgical repair after admission (Bliemel et al., 2017; Johnstone, Morgan, Wilkinson, & Chissell, 1995; Wallace et al., 2019). These repairs have an elevated risk of causing postoperative urinary retention due to the

ABSTRACT Background: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. Objective: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. Methods: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis.

Results: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. Conclusions: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.

Key Words Catheter-associated urinary tract infections, CAUTI, Complications, Elderly, Geriatric, Hip fracture, Hospital costs, Trauma, Urinary tract infections

Author Affiliation: Department of Surgery, Nassau University Medical Center, East Meadow, New York.

The content of this article does not substantially overlap with previously published or submitted work, to the best of the authors’ knowledge.

Authors Shridevi Singh, MD, and Swapna Munnangi, PhD, had full access to all the data in this study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available from the corresponding author L.D. George Angus, MD, upon reasonable request.

The authors declare no conflicts of interest.

Correspondence: L. D. George Angus, MD, Department of Surgery, Nassau University Medical Center, East Meadow, NY 11554 ([email protected]).

Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population

Shridevi Singh, MD ■ L. D. George Angus, MD ■ Swapna Munnangi, PhD ■ Dooniya Shaikh, MD ■ Jody C. Digiacomo, MD ■ Vivek C. Angara, DO ■ Aaron Brown, MD ■ Tayo Akadiri, MD

DOI: 10.1097/JTN.0000000000000603

mailto:[email protected]

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use of anesthesia, patient immobility, and long duration of surgery (Johnstone et al., 1995; Polites et al., 2014; Rowe & Juthani-Mehta, 2013). It is also common prac- tice at some institutions, including our own, to routinely place an indwelling urinary catheter for bladder drain- age during the perioperative period (Bliemel et al., 2017; Hälleberg Nyman et al., 2013). Geriatric trauma patients are a unique patient population with numerous intrinsic risk factors for UTI (Bohl et al., 2017; Magill et al., 2014; Monaghan et al., 2011). Some of these risk factors include female sex, falls, head injury, and altered mental status (Aubron et al., 2012; Bliemel et al., 2017; Zielinski et al., 2015). Elderly patients tend to be institutionalized with lower mobility or have medical comorbidities such as hy- pertension, diabetes, stroke, or dementia that predispose these patients to bladder or bowel incontinence and UTI (Foxman, 2014; Mody & Juthani-Mehta, 2014; Woodford & George, 2009). In addition, less attention to sanitary precautions further predisposes this specific patient pop- ulation to high rates of UTIs (Alpay et al., 2018).

Although current guidelines do not recommend treat- ing asymptomatic bacteriuria (Zalmanovici Trestioreanu, Lador, Sauerbrun-Cutler, & Leibovici, 2015), this specific population subset may not be able to vocalize or validate symptoms due to altered mental status and communica- tion incapability as a result of dementia, stroke, etc. (Tsu- da et al., 2015). Hence, we presume that in this specific patient population, UTI is a missed diagnosis because of the missed clinical correlation needed as per current UTI diagnostic criteria guidelines (CDC, 2019; Rowe & Juthani-Mehta, 2014). Failure in early diagnosis and treat- ment in this specific elderly patient population results in morbid outcomes for patients and significant financial penalties for institutions (Detweiler et al., 2015; Thakker et al., 2018; Zielinski et al., 2014). However, the question arises whether a CAUTI diagnosis is truly the progres- sion of asymptomatic bacteriuria due to the indwelling catheter or is rather a result of comorbid UTI at admis- sion. Therefore, we propose that by screening geriatric hip fracture patients with a urinalysis (UA) within 24 hr of an indwelling urinary catheter that is placed at admission, we will find there is a significant frequency of patients who present with either UTI on admission or with UA findings that could predispose patients to a UTI with an indwelling urinary catheter.

METHODS A retrospective observational study of patients at an ur- ban Level I trauma center, as verified by the American College of Surgeons, was performed. The trauma center is a 500-bed public safety-net hospital that serves 1.4 million people, with approximately 75,000 emergency depart- ment visits and approximately 1,700 trauma admissions each year.

After obtaining approval from the Institutional Review Board (19-205), the trauma registry was queried by us- ing ICD-10 codes S72.001-S72.26 for hip fracture for all patients 65 years and older from January 1, 2017, through December 31, 2018, which were the first 2 years that routine screening UA was included as a component of the multidisciplinary geriatric hip fracture comanagement protocol at this institution (Wallace et al., 2019). Routine screening UAs were obtained within 24 hr of admission. Demographic information, comorbid conditions, prein- jury medications, mechanism of injury, vital signs, Abbre- viated Injury Score, Injury Severity Score, Revised Trau- ma Score, Glasgow Coma Scale, admission disposition, hospital course, intensive care unit (ICU) length of stay, hospital length of stay, complications, disposition, and outcome were extracted from the trauma registry supple- mented by direct review of the electronic medical record. Initially, 193 patient records were identified. However, 10 of these patient records were deemed incomplete and were excluded, as they either did not have at least one of the above data points available or the screening UA per- formed, leaving 183 patients for the final sample. There was no historical control group, as the frequency of UTI and asymptomatic bacteriuria at the time of admission were the variables of interest. All patients were admitted to the ICU as part of our institution's protocol for geriatric hip fracture patients.

Urinary tract infection is a clinical diagnosis with symp- toms of dysuria, urinary frequency, urinary urgency, or suprapubic pain. Catheter-associated urinary tract infec- tion is defined as a UTI in the setting of an indwelling uri- nary catheter that has been in place for more than 2 con- secutive days in an inpatient location, with the catheter being present either the day of UTI diagnosis or removed the day before (CDC, 2021). Urinalysis can be used as a diagnostic tool to reinforce the clinical diagnosis of a UTI with positive results for leukocyte esterase or nitrites in a midstream-void specimen (Schulz, Hoffman, Pothof, & Fox, 2016; Simati, Kriegsman, & Safranek, 2013; Stovall et al., 2013). Leukocyte esterase is specific (94%–98%) and sensitive (75%–96%) for detecting uropathogens equiv- alent to 100,000 colony-forming units (CFU) per ml of urine (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Negative nitrite tests do not rule out a UTI because the causative organism can also be non-nitrate-reducing (e.g., Enterococci species, Staphylococcus saprophyticus, and Acinetobacter species). Therefore, the sensitivity of nitrite tests ranges from 35% to 85%, but with a specific- ity of 95% (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). Nitrite tests can also be falsely negative if the urine specimen is too diluted (Devillé et al., 2004; Nicolle et al., 2005; Simati et al., 2013). In addition, microscopic hematuria may be present in 40%–60% of patients with UTI (Devillé et al., 2004).

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The diagnosis of UTI in this study was made based on the following UA results regardless of clinical symptoms: white blood cells >10/high-power field (hpf), +nitrites, +bacteria. Comparisons of outcomes were then com- pared to subgroups within the data collected. Patients di- agnosed with UTI were treated with antibiotics.

Statistical Analysis Descriptive statistics were used to summarize the demo- graphic and clinical variables in the study sample. Con- tinuous variables were summarized by presenting mean and standard deviation. Categorical variables were sum- marized using frequency and percentages. The study sample was stratified into two groups based on whether

or not the patient had a UTI upon admission. Continu- ous variables were compared using unpaired Student's t-test. The Fisher exact test or Pearson χ2 test was used to examine the association of categorical variables with UTI on admission. A p value < .05 was considered sta- tistically significant. Statistical analysis was performed using SAS version 9.4 (SAS Institute, Cary, NC).

RESULTS The study sample consisted of 183 hip fracture patients who met the inclusion criteria. Of these 183 patients, 36.07% had a UTI on admission, and 63.93% did not. Table 1 depicts the baseline clinical and demographic characteristics of the study sample stratified by the UTI

TABLE 1 Demographic and Clinical Characteristics

Variable

Total Sample (n = 183)

n (%)

UTI on Admission (n = 66; 36.07%)

n (%)

No UTI on Admission (n = 117; 63.93%)

n (%) p Value Age, M (SD), year 84.9 (8.0) 86.2 (7.5) 84.2 (8.3) .108

Sex

Female 140 (76.5) 53 (80.3) 87 (74.4) .363

Male 43 (23.5) 13 (19.7) 30 (25.6)

Mechanism of injury .715

Fall from bed 5 (2.7) 1 (1.5) 4 (3.4)

Fall from chair 10 (5.5) 3 (4.5) 7 (6.0)

Fall from stairs 19 (10.4) 7 (10.6) 12 (10.3)

Fall from toilet 2 (1.1) 2 (1.1) 1 (0.8)

Fall same level 141 (77.0) 50 (75.8) 91 (77.8)

Fall unspecified 2 (1.0) 1 (1.5) 1 (0.8)

Other 4 (2.2) 3 (4.5) 1 (0.8)

Mortality 8 (4.4) 4 (6.1) 4 (3.4) .401

ICU length of Stay, Mdn (IQR), day 3 (1.0) 3 (3.0) 2 (1.0) .004

Hospital length of stay, Mdn (IQR), day 4 (4.0) 5 (5.0) 4 (3.0) .118

CAUTI 8 (4.4) 0 (0.0) 8 (6.8)

Foley days, Mdn (IQR), day 2 (1.0) 2 (1.0) 2 (1.0) .593

Injury Severity Score, M (SD) 9.9 (2.9) 10.2 (3.1) 9.7 (2.8) .307

Glasgow Coma Scale, M (SD) 14.7 (1.2) 14.5 (1.6) 14.8 (.88) .219

Hospital disposition .806

Acute rehabilitation 91 (49.7) 29 (43.9) 62 (53.0)

Died full code/withdrawal of care 8 (4.4) 4 (6.1) 4 (3.4)

Home 4 (2.2) 2 (3.0) 2 (1.7)

Skilled nursing facility 15 (8.2) 6 (9.1) 9 (7.7)

Subacute rehabilitation 61 (33.3) 24 (36.4) 37 (31.6)

Other nursing facility 4 (2.2) 1 (1.5) 3 (2.6)

Note. CAUTI = catheter-associated urinary tract infection; ICU = intensive care unit; IQR = interquartile range; UTI = urinary tract infection.

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status upon admission. The average age of the patients was 84.9 years (M = 84.9, SD = 8). The majority (76.5%) were female. Fall from the same level was the most com- mon mechanism of injury (77%). The mortality rate was 4.4%. Advance directives were in place for 8.2% of the patients. The median ICU length of stay was 3 days (in- terquartile range [IQR] = 1), and median hospital length of stay was 4 days (IQR = 4). Overall, eight patients, or 4.4% of the study sample, had CAUTI, six of whom were female. A Foley catheter was in place for a me- dian of 2 days (IQR = 1). Acute rehabilitation was the most common discharge disposition (49.7%). There was a statistically significant increase in median ICU length of stay in those with UTI on admission compared with those without. All other demographic and clinical characteristics did not demonstrate any statistically significant difference between the two groups.

Comorbidities in the study sample were summarized in Table 2. Hypertension was the most common comor- bid condition in the overall study sample and the groups stratified by UTI status on admission. There were no sig- nificant differences in the comorbid conditions between those who had a UTI on admission and those who did not. The inhospital complications in the study sample were summarized in Table 3. Unplanned returns to the operating room (2.2%) and ICU (2.3%) were the most common inhospital complications observed in the study sample. The inhospital complications were not signifi- cantly different between those who had a UTI on admis- sion and those who did not.

DISCUSSION The elimination of all CAUTI is not attainable; however, it is necessary to take “reasonable preventive” measures

TABLE 2 Comorbidities

Comorbidity

Total Sample (n = 183)

n (%)

UTI on Admission (n = 66; 36.07%)

n (%)

No UTI on Admission (n = 117; 63.93%)

n (%) p Value Anticoagulation 48 (26.2) 20 (30.3) 28 (23.9) .347

Bleeding disorder 3 (1.6) 1 (1.5) 2 (1.7) .920

CHF 37 (20.2) 14 (21.2) 23 (19.7) .802

Chronic renal failure 15 (8.2) 5 (7.6) 10 (8.5) .217

Cirrhosis 2 (1.1) 0 (0.0) 2 (1.7) .536

Congenital anomaly 1 (0.5) 0 (0.0) 1 (0.8) .639

COPD 12 (6.6) 7 (10.6) 5 (4.3) .064

Dementia 43 (23.5) 18 (27.3) 25 (21.4) .366

DOH status 28 (15.3) 9 (13.6) 19 (16.2) .639

Cancer 10 (5.5) 2 (3.0) 8 (6.8) .277

Hypertension 131 (71.6) 45 (68.1) 86 (73.5) .443

Major psychiatric illness 3 (1.6) 1 (1.5) 2 (1.7) .921

Mental personal disorder 8 (4.4) 2 (3.0) 6 (5.1) .505

Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8) .639

Respiratory disease 6 (3.3) 4 (6.0) 2 (1.7) .113

PAD 9 (4.9) 5 (7.6) 4 (3.4) .128

SP CVA 9 (4.9) 4 (6.0) 5 (4.3) .233

Smoker 13 (7.1) 6 (9.0) 7 (6.0) .168

Steroid use 1 (0.5) 0 (0.0) 1 (0.8) .639

PNA 1 (0.5) 0 (0.0) 1 (0.8) .639

ARDS 1 (0.5) 0 (0.0) 1 (0.8) .639

Note. ARDS = acute respiratory distress syndrome; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection.

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to mitigate this inhospital complication that also has a significant financial burden on institutions. By ceasing re- imbursements for hospital-acquired UTI, there has been a reduction in UTI rates (CDC, 2019). Yet, there is still a significant prevalence of hospital-acquired UTIs that is burdensome to the host institution (Chenoweth, Gould, & Saint, 2014; Gould et al., 2010; Hassan, Tuckman, Pat- rick, Kountz, & Kohn, 2010). This study looked at a spe- cific patient population with two important characteris- tics that deem them at high risk for UTI at admission or postadmission: age and fractured hip. This study aimed to assess the frequency of a positive UA at admission in elderly hip fracture patients, which was found to be 36%. Bliemel et al. (2017) found that 24% of their elder- ly hip fracture patients sustained an inhospital UTI. The patients in Bliemel et al.’s study were assessed with a UA and urine culture after indwelling catheter removal in those who had clinical symptoms specific for UTI or diffuse symptoms of fatigue, fever, or weakness (Bliemel et al., 2017). In our study, we screened and treated pa- tients based on UA results at admission as per our in- hospital protocol for elderly hip fractures. By doing so, rates of CAUTI may have been reduced. In our study period, eight of 183 (4.4%, Table 4) patients developed CAUTI during their hospital course, and 66 of 183 (36%, Table 1) patients had UTI on admission. The increased incidence of CAUTI seen in previous studies compared to our data supports the theory that the colonization of urine with bacteria might have already been present and untreated. It is generally recommended that patients with asymptomatic bacteriuria should not be treated, and for the nonelderly hip fracture patient, we agree. The limita- tion in obtaining symptomatology history in this specific

patient population due to their comorbidities (e.g., de- mentia) and the significant incidence of positive UA at admission in this study supports the theory that the clini- cal diagnosis of UTI should be assessed objectively and thus treated appropriately in elderly hip fracture patients.

Study Limitations The retrospective design of the study is a limitation in itself. Our data were collected by analyzing medical re- cords, which intrinsically lends itself to systematic bias. The validity of data relating to such things as laboratory values and interpretation can therefore not be fully guar- anteed. Our sample size was also small, and we hope to elaborate with future studies. However, as a pilot study, we believe that publishing our findings will engage the academic community and help determine future study parameters. Furthermore, as a descriptive, observational study, there are limitations as there are no control groups, and interpretation of results is therefore theoretical.

CONCLUSIONS Based on our findings, we strongly believe that if an ad- mission UA was conducted for elderly hip fracture patients and positive results were treated accordingly, there would be a significant reduction in the diagnosis of CAUTI. An indwelling urinary catheter is commonly placed in elderly hip fracture patients, increasing their inherent risk for a UTI based on catheter placement alone. This study has also demonstrated the increased incidence of positive UA as an additional theoretical risk factor for CAUTI in these patients. Because of potential for serious complica- tions, mortality, and financial burden on institutions, early identification of urinary tract infection or asymptomatic

TABLE 3 Inhospital Complications

Complication

Total Sample (n = 183)

n (%)

UTI on Admission (n = 66; 36.07%)

n (%)

No UTI on Admission (n = 117; 63.93%)

n (%) p Value Cardiac arrest with CPR 2 (1.0) 1 (1.5) 1 (0.8) .464

Myocardial infarction 1 (0.5) 0 (0.0) 1 (0.8) .639

Unplanned intubation 4 (2.2) 2 (3.0) 2 (1.7) .322

Unplanned return to OR 4 (2.2) 0 (0.0) 4 (3.4) .164

Unplanned return to ICU 1 (0.5) 1 (1.5) 0 (0.0) .361

Acute renal failure 3 (1.6) 1 (1.5) 2 (1.7) .446

Severe sepsis 3 (1.6) 0 (0.0) 3 (2.6) .259

Coagulopathy 1 (0.5) 0 (0.0) 1 (0.8) .639

Acute renal injury 1 (0.5) 1 (1.5) 0 (0.0) .361

Other 1 (0.5) 0 (0.0) 1 (0.8) .639

Note. CPR = cardiopulmonary resuscitation; ICU = intensive care unit; OR = operating room; UTI = urinary tract infection.

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bacteriuria should be identified and treated in a protocol- ized manner in elderly hip fracture patients. These pro- tocols can lower the incidence of CAUTI and improve outcomes in this susceptible and high-risk population. Although routine screening for urinary tract infection is a common measure adopted in geriatric wards, it has not been common practice among elderly trauma patients. This article brings forward the need to adopt this common practice to reduce the likelihood of a CAUTI being attrib- uted to institutions, given the high risk of infection/colo- nization in the geriatric population. Therefore, we recom- mend that all elderly hip fracture patients be screened at admission with a UA and be treated appropriately.

Acknowledgments We thank the patients at Nassau University Medical Cent- er for trusting us with their care. We also thank the staff

of the trauma department at Nassau University Medical Center for their continued commitment to patient care.

KEY POINTS • Catheter-associated urinary tract infections (CAUTIs) are a

well-known complication among the geriatric hip fracture population.

• CAUTI has negative consequences for both the patient and the institution and may be due to urinary tract infection (UTI) present on admission.

• This study observed outcomes in geriatric hip fracture patients who underwent routine UTI screening on admission.

• The results of this study suggest reduced rates of CAUTI compared to previously published literature.

• The results suggest there may be a role in routine UTI screening for geriatric hip fracture patients.

TABLE 4 Comorbidities With CAUTI But No UTI on Admission

Comorbidity CAUTI (n =8; 4.4%)

n (%)

No UTI on Admission Excluding CAUTI (n = 109)

n (%) Anticoagulation 4 (50) 24 (22.0)

Bleeding disorder 0 (0.0) 2 (1.83)

CHF 3 (37.5) 20 (18.3)

Chronic renal failure 0 (0.0) 10 (9.2)

Cirrhosis 1 (12.5) 1 (0.9)

Congenital anomaly 0 (0.0) 1 (0.9)

COPD 0 (0.0) 5 (4.6)

Dementia 3 (37.5) 22 (20.2)

DOH status 5 (62.5) 14 (12.8)

Cancer 2 (25.0) 6 (5.5)

Hypertension 6 (75.0) 80 (73.4)

Major psychiatric illness 0 (0.0) 2 (1.8)

Mental personal disorder 0 (0.0) 6 (5.5)

Myocardial infarction 1 (12.5) 0 (0.0)

Respiratory disease 0 (0.0) 2 (1.8)

PAD 0 (0.0) 4 (3.7)

SP CVA 0 (0.0) 5 (4.6)

Smoker 0 (0.0) 7 (6.4)

Steroid use 0 (0.0) 1 (0.9)

PNA 0 (0.0) 1 (0.9)

ARDS 0 (0.0) 1 (0.9)

Note. ARDS = acute respiratory distress syndrome; CAUTI = catheter-associated urinary tract infection; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; DOH = Department of Health; PAD = peripheral arterial disease; PNA = pneumonia; SP CVA = status post cerebrovascular accident; UTI = urinary tract infection.

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