A New Shift in Hospital Infection Surveillance: Beyond Device-Associated Infections
Why does this matter?
Until now, hospital infection surveillance systems have mainly focused on three types of infections associated with invasive devices:
Central line-associated bloodstream infection (CLABSI).
Ventilator-associated pneumonia (VAP).
Catheter-associated urinary tract infection (CAUTI).
However, according to the authors of this article, these measures do not capture all harms; they capture only a subset of healthcare-associated infections (HAIs). In addition, they do not give a complete picture of infection risks in hospitals.
Which harms are commonly overlooked?
First, medical devices can cause noninfectious complications. In addition to infection, they can cause other kinds of harm:
A urinary catheter can reduce patient mobility, raise the risk of falls, injure the genitourinary system, and cause patient discomfort.
Similarly, a central venous catheter can lead to blood clots (thrombosis), blockage (occlusion), and venous scarring.
Likewise, a ventilator can cause lung injury from air pressure and volume, as well as acute respiratory distress syndrome (ARDS).
Second, other devices may also cause infectious harm, but large surveillance programs have not addressed them to date. These devices include:
Peripheral intravenous catheters.
Arterial catheters.
Midline catheters.
Third, non-device-associated infections make up a significant share of all infections. For example:
Hospital-acquired pneumonia in non-ventilated patients accounts for about 65% of all hospital-acquired pneumonia. Moreover, its mortality rate is similar to that of ventilator-associated pneumonia.
Likewise, more than half of healthcare-associated urinary tract infections occur in patients who do not have a catheter.
Finally, bacteremia (bloodstream infection) without a central line also belongs in this group.
Using catheter-associated urinary tract infection (CAUTI) as an example, the authors of this article propose new metrics for hospital infection surveillance that provide a more comprehensive picture of patient harm. Table 1 summarizes four proposed measures and what each one captures.
Proposed measure | Captures catheter use | Captures infectious harm¹ | Captures noncatheterized patients | Captures noninfectious harm² | Captures patients without urinary catheters | Electronically captured | Can be adapted to an outpatient measure |
|---|---|---|---|---|---|---|---|
Catheter utilization (SUR/DUR) | Yes | Possibly | NA | Possibly | No | Yes | Yes |
Urine culture or urinalysis utilization rates | No | Yes | Yes | No | Yes | Yes | Yes |
Urine culture contamination (mixed flora) rates | No | Yes | Yes | No | Yes | Yes | Yes |
Composite catheter harm score | Yes | Yes | NA | Yes | No | Possibly | Possibly |
SUR: standardized utilization ratio. DUR: device utilization ratio. NA: not applicable. ¹True infection, antibiotic use. ²Falls, deep vein thrombosis, insertion trauma. Adapted from Advani et al., 2024, Table 1.
The composite catheter harm score is still a proposal. The authors state that further research is needed to develop and validate it.
Challenges of current hospital infection surveillance
Current hospital infection surveillance faces three main challenges.
First, complex definitions and the need for manual chart review create several problems:
Staff workload increases.
In addition, diagnoses carry a risk of error and bias.
Furthermore, strong supporting infrastructure is necessary.
Second, the standardized infection ratio (SIR) has limits of its own:
The CAUTI definition depends on a positive urine culture and documented fever, so diagnosis is susceptible to how common fever is and to changes in testing practices, not only to real changes in catheter care.
In addition, if a hospital reduces catheter use, the apparent infection rate may rise, because the catheterized patients who remain are at higher risk.
Third, incorrect diagnoses and unnecessary antibiotic use are problems as well:
Infection statistics do not record traumatic injury during catheter insertion.
Moreover, unnecessary urine cultures for asymptomatic patients, and the unnecessary antibiotic use that follows, can lead to antibiotic-related harms, including multidrug-resistant colonization.
Practical recommendations for healthcare facilities
To address these gaps, healthcare facilities can take five practical steps:
First, measure the catheter utilization rate as an indicator of the risk of noninfectious harm.
Second, monitor urine culture utilization (ordering) rates to identify inappropriate diagnostic patterns.
Third, measure urine culture contamination rates to improve specimen collection quality.
In addition, expand prevention programs to non-device-associated infections, such as nonventilator pneumonia.
Finally, use electronic systems to extract data automatically and reduce the need for manual review.
Final word
In short, hospital-acquired infections are only one part of the harm patients experience during hospitalization. Therefore, to truly improve the quality of care, hospital infection surveillance systems must go beyond infections associated with specific devices. They must also cover all aspects of patient harm, including noninfectious device complications and non-device-associated infections. Ultimately, developing new metrics, such as catheter utilization rate, urine culture utilization rate, and urine culture contamination rate, is an important step in this direction.
Reference: Advani SD, Cawcutt K, Klompas M, Marschall J, Meddings J, Patel PK. The next frontier of healthcare-associated infection (HAI) surveillance metrics: beyond device-associated infections. Infection Control & Hospital Epidemiology. 2024 Jun;45(6):693-7. doi:10.1017/ice.2023.283
