The ways that device-associated infection prevention practices changed during the coronavirus disease 2019 (COVID-19) pandemic remain unknown. We collected data mid-pandemic to assess the use of several infection prevention practices and for comparison with historical data.

Repeated cross-sectional survey.

US acute-care hospitals.

Infection preventionists.

We surveyed infection preventionists from a national random sample of 881 US acute-care hospitals in 2021 to estimate the current use of practices to prevent catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated events (VAE). We compared the 2021 results with those from surveys occurring every 4 years since 2005.

The 2021 survey response rate was 47%; previous survey response rates ranged from 59% to 72%. Regular use of most practices to prevent CLABSI (chlorhexidine gluconate for site antisepsis, 99.0%, and maximum sterile barrier precautions, 98.7%) and VAE (semirecumbent positioning, 93.4%, and sedation vacation, 85.8%) continued to increase or plateaued in 2021. Conversely, use of several CAUTI prevention practices (portable bladder ultrasound scanner, 65.6%; catheter reminders or nurse-initiated discontinuation, 66.3%; and intermittent catheterization, 37.3%) was lower in 2021, with a significant decrease for some practices compared to 2017 (P ≤ .02 for all comparisons). In 2021, 42.1% of hospitals reported regular use of the newer external urinary collection devices for women.

Although regular use of CLABSI and VAE preventive practices continued to increase (or plateaued), use of several CAUTI preventive practices decreased during the COVID-19 pandemic. Structural issues relating to care during the pandemic may have contributed to a decrease in device-associated infection prevention practices.

To assess the extent to which evidence-based practices are regularly used in acute care hospitals in different countries.

Cross-sectional survey study. Participants and setting: Infection preventionists in acute care hospitals in the United States (US), the Netherlands, Switzerland, and Japan.

Data collected from hospital surveys distributed between 2015 and 2017 were evaluated to determine the use of practices to prevent catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and Clostridioides difficile infection (CDI). Descriptive statistics were used to examine hospital characteristics and the percentage of hospitals reporting regular use of each infection prevention practice.

Survey response rates were 59% in the United States, 65% in the Netherlands, 77% in Switzerland, and 65% in Japan. Several recommended practices were used in the majority of hospitals: aseptic catheter insertion and maintenance (CAUTI), maximum sterile barrier precautions (CLABSI), semirecumbent patient positioning (VAP), and contact precautions and routine daily cleaning (CDI). Other prevention practices for CAUTI and VAP were used less frequently, particularly in Swiss and Japanese hospitals. Established surveillance systems were also lacking in Dutch, Swiss and Japanese hospitals.

Most hospitals in the United States, the Netherlands, Switzerland, and Japan have adopted certain infection prevention practices. Clear opportunities for reducing HAI risk in hospitals exist across all 4 countries surveyed.

Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship.

Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression.

Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies.

Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.

Collaborative programs have helped reduce catheter-associated urinary tract infection (CAUTI) rates in community-based nursing homes. We assessed whether collaborative participation produced similar benefits among Veterans Health Administration (VHA) nursing homes, which are part of an integrated system.

This study included 63 VHA nursing homes enrolled in the “AHRQ Safety Program for Long-Term Care,” which focused on practices to reduce CAUTI.

Changes in CAUTI rates, catheter utilization, and urine culture orders were assessed from June 2015 through May 2016. Multilevel mixed-effects negative binomial regression was used to derive incidence rate ratios (IRRs) representing changes over the 12-month program period.

There was no significant change in CAUTI among VHA sites, with a CAUTI rate of 2.26 per 1,000 catheter days at month 1 and a rate of 3.19 at month 12 (incidence rate ratio [IRR], 0.99; 95% confidence interval [CI], 0.67–1.44). Results were similar for catheter utilization rates, which were 11.02% at month 1 and 11.30% at month 12 (IRR, 1.02; 95% CI, 0.95–1.09). The numbers of urine cultures per 1,000 residents were 5.27 in month 1 and 5.31 in month 12 (IRR, 0.93; 95% CI, 0.82–1.05).

No changes in CAUTI rates, catheter use, or urine culture orders were found during the program period. One potential reason was the relatively low baseline CAUTI rate, as compared with a cohort of community-based nursing homes. This low baseline rate is likely related to the VHA’s prior CAUTI prevention efforts. While broad-scale collaborative approaches may be effective in some settings, targeting higher-prevalence safety issues may be warranted at sites already engaged in extensive infection prevention efforts.

Infect Control Hosp Epidemiol 2018;820–825

Urinary catheters, many of which are placed in the emergency department (ED) setting, are often inappropriate, and they are associated with infectious and noninfectious complications. Although several studies evaluating the effect of interventions have focused on reducing catheter use in the ED setting, the organizational contexts within which these interventions were implemented have not been compared.

A total of 18 hospitals in the Ascension health system (ie, system-based hospitals) and 16 hospitals in the state of Michigan (ie, state-based hospitals led by the Michigan Health and Hospital Association) implemented ED interventions focused on reducing urinary catheter use. Data on urinary catheter placement in the ED, indications for catheter use, and presence of physician order for catheter placement were collected for interventions in both hospital types. Multilevel negative binomial regression was used to compare the system-based versus state-based interventions.

A total of 13,215 patients (889 with catheters) from the system-based intervention were compared to 12,104 patients (718 with catheters) from the state-based intervention. Statistically significant and sustainable reductions in urinary catheter placement (incidence rate ratio, 0.79; P=.02) and improvements in appropriate use of urinary catheters (odds ratio [OR], 1.86; P=.004) in the ED were observed in the system-based intervention, compared to the state-based intervention. Differences by collaborative structure in changes in presence of physician order for urinary catheter placement (OR, 1.14; P=.60) were not observed.

An ED intervention consisting of establishing institutional guidelines for appropriate catheter placement and identifying clinical champions to promote adherence was associated with reducing unnecessary urinary catheter use under a system-based collaborative structure.

Infect Control Hosp Epidemiol 2018;39:77–84

The impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non–VA nursing homes.

VA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative.

Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire.

A total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; P<.001) and were more likely to have committees that reviewed healthcare-associated infections. Compared with non-VA facilities, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs 66%; P<.001), sharing CAUTI data with leadership (94% vs 70%; P=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004).

Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems.

Infect Control Hosp Epidemiol 2017;38:287–293

To assess knowledge about infection prevention among nursing home personnel and identify gaps potentially addressable through a quality improvement collaborative.

Baseline knowledge assessment of catheter-associated urinary tract infection, asymptomatic bacteriuria, antimicrobial stewardship, and general infection prevention practices for healthcare-associated infections.

Nursing homes across 14 states participating in the national “Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infection.”

Licensed (RNs, LPNs, APRNs, MDs) and unlicensed (clinical nursing assistants) healthcare personnel.

Each facility aimed to obtain responses from at least 10 employees (5 licensed and 5 unlicensed). We assessed the percentage of correct responses.

A total of 184 (78%) of 236 participating facilities provided 1 response or more. Of the 1,626 respondents, 822 (50.6%) were licensed; 117 facilities (63.6%) were for-profit. While 99.1% of licensed personnel recognized the definition of asymptomatic bacteriuria, only 36.1% knew that pyuria could not distinguish a urinary tract infection from asymptomatic bacteriuria. Among unlicensed personnel, 99.6% knew to notify a nurse if a resident developed fever or confusion, but only 27.7% knew that cloudy, smelly urine should not routinely be cultured. Although 100% of respondents reported receiving training in hand hygiene, less than 30% knew how long to rub hands (28.5% licensed, 25.2% unlicensed) or the most effective agent to use (11.7% licensed, 10.6% unlicensed).

This national assessment demonstrates an important need to enhance infection prevention knowledge among healthcare personnel working in nursing homes to improve resident safety and quality of care.

Infect. Control Hosp. Epidemiol. 2016;1–6

To examine regional variation in the use and appropriateness of indwelling urinary catheters and catheter-associated urinary tract infection (CAUTI).

Cross-sectional study.

US acute care hospitals.

Hospitals were divided into 4 regions according to the US Census Bureau. Baseline data on urinary catheter use, catheter appropriateness, and CAUTI were collected from participating units. The catheter utilization ratio was calculated by dividing the number of catheter-days by the number of patient-days. We used the National Healthcare Safety Network (NHSN) definition (number of CAUTIs per 1,000 catheter-days) and a population-based definition (number of CAUTIs per 10,000 patient-days) to calculate CAUTI rates. Logistic and Poisson regression models were used to assess regional differences.

Data on 434,207 catheter-days over 1,400,770 patient-days were collected from 1,101 units within 726 hospitals across 34 states. Overall catheter utilization was 31%. Catheter utilization was significantly higher in non-intensive care units (ICUs) in the West compared with non-ICUs in all other regions. Approximately 30%–40% of catheters in non-ICUs were placed without an appropriate indication. Catheter appropriateness was the lowest in the West. A total of 1,099 CAUTIs were observed (NHSN rate of 2.5 per 1,000 catheter-days and a population-based rate of 7.8 per 10,000 patient-days). The population-based CAUTI rate was highest in the West (8.9 CAUTIs per 10,000 patient-days) and was significantly higher compared with the Midwest, even after adjusting for hospital characteristics (P = .02).

Regional differences in catheter use, appropriateness, and CAUTI rates were detected across US hospitals.

Bloodstream infection (BSI) secondary to nosocomial urinary tract infection is associated with substantial morbidity, mortality, and additional financial costs. Our objective was to identify predictors of nosocomial urinary tract-related BSI.

Matched case-control study.

Midwestern tertiary care hospital.

Cases n = 298) were patients with a positive urine culture obtained more than 48 hours after admission and a blood culture obtained within 14 days of the urine culture that grew the same organism. Controls (n = 667), selected by incidence density sampling, included patients with a positive urine culture who were at risk for BSI but did not develop one.

Conditional logistic regression and classification and regression tree analyses.

The most frequently isolated microorganisms that spread from the urinary tract to the bloodstream were Enterococcus species. Independent risk factors included neutropenia (odds ratio [OR], 10.99; 95% confidence interval [CI], 5.78-20.88), renal disease (OR, 2.96; 95% CI, 1.98-4.41), and male sex (OR, 2.18; 95% CI, 1.52-3.12). The probability of developing a urinary tract-related BSI among neutropenic patients was 70%. Receipt of immunosuppressants (OR, 1.53; 95% CI, 1.04-2.25), insulin (OR, 4.82; 95% CI, 2.52-9.21), and antibacterials (OR, 0.66; 95% CI, 0.44-0.97) also significantly altered risk.

The heightened risk of urinary tract-related BSI associated with several comorbid conditions suggests that the management of nosocomial bacteriuria may benefit from tailoring to certain patient subgroups. Consideration of time-dependent risk factors, such as medications, may also help guide clinical decisions in reducing BSI.

Infect Control Hosp Epidemiol 2012;33(10):1001-1007