Low- and middle-income countries (LMICs) are known to have higher rates of catheter-associated urinary tract infections (CAUTIs) than high-income nations.1,2 The International Nosocomial Infection Control Consortium (INICC) estimated 3.16 CAUTIs for every 1000 urinary catheter (UC)-days in LMICs.2 In the USA, the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) reported 1.3 CAUTIs per 1000 urinary catheter (UC)-days.3

CAUTI is an independent, significant risk factor (RF) for mortality in the intensive care unit (ICU).3–5 According to an investigation, mortality rates for ICU patients without any healthcare-associated infections (HAIs) are 17.1%, CAUTI mortality rates are 30.15%, and CAUTI combined with central line-associated bloodstream infections and ventilator-associated pneumonia results in a mortality rate of 63.4%.2 Twenty-eight community hospitals in the Southeast of the USA were found to have a median yearly cost of HAIs per facility of USD 594 683, with CAUTIs accounting for a mean of USD 758 per infection.6

Other studies identified the following variables as CAUTI RFs: female sex,7 age > 60,8 length of catheterization,9,10 and poor hygiene.11 A recent Tanzanian study found outpatient settings to carry higher risk for CAUTI than inpatient settings. Individual RFs for those outpatients included older age, level of education, and duration of the catheter.12 A Saudi Arabian study with 81 CAUTI patients found type-O blood type to be a protective factor for CAUTI.13

Nevertheless, no study has simultaneously looked at many Middle Eastern nations to estimate the prevalence of CAUTI RFs in ICUs. In addition, no prospective study has been conducted over eight years. Additionally, no study has examined simultaneously the relationships between the 10 variables listed below and their association with CAUTI: (1) age, (2) sex, (3) length of stay (LOS) before CAUTI acquisition, (4) UC-days before CAUTI acquisition, (5) UC-device utilization (DU) ratio as a marker of patient illness severity, (6) hospitalization type, (7) ICU type, (8) facility ownership, (9) income level of the country according to world bank, and (10) time period. The objectives of this study were to provide CAUTI rates stratified by various variables and determine whether the aforementioned 10 variables are CAUTI RFs.

Methods

Between 1 January 2014 and 12 February 2022, patients admitted to 212 ICUs at 67 hospitals spread across 38 cities in nine Middle Eastern nations (Bahrain, Egypt, Jordan, Kuwait, Lebanon, Morocco, Saudi Arabia, Turkey, and the UAE) participated in this multinational, multi-center, cohort prospective study.

We used the INICC Surveillance Online System (ISOS), an online platform that incorporates CDC/NHSN standards and procedures.14 ISOS gathers patient-specific data on all patients, with and without CAUTI.15 Data from all patients admitted to the ICU allow matching by multiple variables to determine CAUTI RFs.

Data for each patient were gathered at the time of ICU admission. From the moment of admission till discharge, infection prevention professionals (IPPs) visited each ICU patient every day and uploaded the patient data to ISOS.15

In addition to patient information, such as sex, age, hospitalization type, and the use of invasive devices, the information provided at the time of patient admission included location-specific information including the setting, country, city, admission date, and ICU type. IPPs uploaded data about the patient’s invasive devices and positive cultures up until the patient was discharged. A specialist in infectious diseases investigated the patients for HAI. The ISOS instantly shows an alert and refers the IPP to an online module where they may check all the CDC NHSN criteria to validate the existence and type of HAI when IPPs upload the results of the culture to the system.15 The Institutional Review Board of the participating hospitals approved this study. The patients’ and hospital’s names were kept anonymous.

We adopted the CDC’s definitions of HAI (1991) with all their subsequent updates through 2022.14 The updated CDC definitions of HAIs were used by all IPPs of all participant hospitals over the eight years of this study.14 The key definitions are listed below.

CUTI: a UTI where an indwelling UC was in place for more than two consecutive days in an inpatient location on the date of the event, with the day of device placement being day 1, and an indwelling UC was in place on the date of the event or the day before. If an indwelling UC was in place for more than two consecutive days in an inpatient location and then removed, the date of event for the UTI must be the day of device discontinuation or the next day for the UTI to be catheter-associated.14

Indwelling UC: a drainage tube that is inserted into the urinary bladder through the urethra is left in place and connected to a drainage bag (including leg bags). Indwelling UCs used for intermittent or continuous irrigation are also included in CAUTI surveillance.14

UC/DU ratio: UC/DU is the ratio of UC days to patient days for each location type. As such, the UC/DU of a location measures the use of invasive devices and constitutes an extrinsic CAUTI RF. UC/DU ratio also serves as a marker for the severity of illness which is an intrinsic RF for HAI.14

Types of healthcare facilities: (a) publicly owned: owned or controlled by a public corporation or a governmental body, where control is the capacity to decide on the corporate strategy; (b) not-for-profit privately owned: legal or social organizations established for the exclusive goal of creating goods and services, whose legal position prohibits them from serving as a source of revenue, profit, or other financial gains for the unit(s) that established, controlled, or financed them; and (c) for-profit privately owned: healthcare facilities created to produce goods and services with potential to bring in financial gains for owners.16

To estimate rates of CAUTI per 1000 UC days, we divided the number of CAUTIs by the number of UC days and multiplied the result by 1000.

To estimate CAUTI RFs using multiple logistic regression, patients with and without CAUTI were compared. We analyzed the following 10 variables and their association with the outcome (CAUTI): age; sex; LOS before CAUTI acquisition; UC-days before CAUTI acquisition; UC/DU ratio as a marker of severity of illness of patient; hospitalization type (medical and surgical); ICU type (cardio-thoracic, neurologic, neuro-surgical, adult-oncology, medical, medical-surgical, pediatric, respiratory, surgical, trauma, coronary, and pediatric-oncology); facility ownership (publicly owned, not-for-profit privately owned, for-profit privately owned, and teaching hospitals);16 and time period (period 1: 1998–2001, period 2: 2002–2005, period 3: 2006–2009, period 4: 2010–2013, period 5: 2014–2017, and period 6: 2018–2022). We did not analyze the impact of the type of UC used because the use of suprapubic catheters was < 1%, showing a lack of balance with indwelling catheters. The evaluated outcome was the acquisition of CAUTI according to
CDC/NHSN definitions.14

Statistically significant variables were independently associated with an increased risk for CAUTI. The Wald test was employed as the test statistic, and a two-sided 0.05 type I error rate was chosen as the level of statistical significance. The adjusted odds ratios (aORs) and associated 95% CIs for statistically significant factors were calculated from the results of multiple logistic regression. All statistical analyses were performed using R Software version 4.1.3, Tidymodels (https://cran.r-project.org/).

Results

This international, multicenter, cohort, prospective surveillance study of CAUTIs was carried out in 212 ICUs of 67 hospitals in 38 cities, across nine Middle Eastern nations participating in INICC from 1 January 2014 to 12 February 2022.

A total of 580 cases of CAUTI were identified among 50 637 patients across 434 523 patient days. Data on the setting and the patient are presented in Table 1. Table 2 displays the stratified CAUTI rate by ICU type, facility ownership type, country economic level as determined by the World Bank, and UC type.

Using multiple logistic regression, the following variables were identified as significantly associated with CAUTI [Table 3]: age, rising risk 1.0% yearly (aOR = 1.01, 95% CI: 1.01–1.02; p < 0.001); female sex (aOR = 1.31, 95% CI: 1.09–1.56; p < 0.001); LOS before CAUTI acquisition, rising risk 6.0% daily (aOR = 1.06, 95% CI: 1.05–1.06; p < 0.001); and UC/DU ratio (aOR = 1.11, 95% CI: 1.06–1.14; p < 0.001). Lower-middle income countries (aOR = 4.11, 95% CI: 2.49–6.76; p < 0.001) had a similar risk to upper-middle countries (aOR = 3.75, 95% CI: 1.83–7.68; p < 0.001), but both were higher RFs compared to high-income countries. The ICU with the highest risk for CAUTI was neurologic ICU (aOR = 27.35, 95% CI: 23.03–33.12; p < 0.001), followed by medical ICU (aOR = 6.18, 95% CI: 2.07–18.53; p < 0.001) when compared to cardiothoracic ICU. The period 2014–2016 (aOR = 7.36, 95% CI: 5.48–23.96; p < 0.001) and the period 2017–2019 (aOR = 1.15, 95% CI: 3.46–15.61; p < 0.001) had a similar risk to each other, but a higher risk when compared to the time period 2020–2022.

The pooled CAUTI rate per 1000 UC days was 1.84. Age, sex, LOS, UC/DU ratio, lower- and upper-middle income countries, neurologic ICU, and time periods 1 and 2 were associated with the highest risks for CAUTI. After adjusting all confounders in this study, surgical hospitalization and facility ownership were not associated with CAUTI risk.

Discussion

Pooled rates of CAUTI in our study conducted in ICUs were lower than the pooled CAUTI rates reported by INICC.2 CAUTI rate in ICUs of LMICs was 3.16 CAUTIs per 1000 UC days per the last INICC report.2 However, pooled rates of CAUTI in our present study were higher than those of ICUs of the CDC/NHSN report, 1.3 CAUTI per 1000 UC days.3 According to our study, the CAUTI rate at ICUs in lower-middle-income countries in the Middle East was 2.75 per 1000 UC days; the CAUTI rate at ICUs in upper-middle-income countries was 2.47 per 1000 UC days; and the CAUTI rate at ICUs in high-income countries was 1.64 per 1000 UC days. The highest CAUTI rate was in the lower-middle-income countries, and the lowest was in the high-income countries. This was consistent with previous studies comparing CAUTI rates in ICUs of LMICs with CAUTI rates in ICUs of high-income countries.17

In the present study, female sex was a significant RF for CAUTI. Similarly, in an urban academic health system of over 2500 beds, encompassing two large academic medical centers, two community hospitals, and a pediatric hospital, Letica-Kriegel et al,18 found that being female statistically increased the chances of acquiring CAUTI.

The LOS before the acquisition of CAUTI was associated with 6.0% daily increase in the risk of CAUTI. A study conducted in cardiac surgical patients by Gillen et al,19 similarly showed the role of LOS before CAUTI acquisition as a significant RF for CAUTI through both univariate and multivariate analyses.

We found that the UC/DU ratio was associated with the risk for CAUTI. Likewise stated by Meddings et al,20 utilization of UCs, such as unnecessary placement and prolonged usage, are large RFs for acquiring a CAUTI. Their results showed that using a reminder or a stop order was able to reduce CAUTI rate by 52%.

We discovered that the risk for CAUTI was decreasing over our eight-year-long period of the study, which is consistent with recent improvements in infection prevention techniques. To avoid this particular bias and also to adjust to changes in infection prevention and control practices, we adjusted our analysis to the time period.

We identified a similar CAUTI rate in those patients using an indwelling catheter compared with those using a suprapubic catheter. This is consistent with the study of Baan et al,21 which found a similar CAUTI rate comparing both catheter types. We identified a higher risk for CAUTI in patients using an indwelling catheter compared with those using a suprapubic catheter. This is inconsistent with the study of Han et al,22 who found that indwelling catheterization was not associated with an increased urinary tract infection risk compared to suprapubic tubes and intermittent catheterization if the catheterization duration was for ≤ 5 days. However, a suprapubic tube or intermittent catheterization was associated with a lower rate of urinary tract infection in the case of longer-term catheterization in the postoperative period.

Some of the CAUTI RFs identified in our study were unlikely to be amenable to change, such as age, sex, ICU type, and country income level. However, some others can be improved; for example, LOS before the acquisition of a CAUTI, UC/DU ratio and neurologic ICUs. Based on our findings, it is suggested that we focus on strategies to reduce the UC/DU ratio, reduce LOS, and implement an evidence-based set of CAUTI prevention recommendations, such as those published by the Healthcare Infection Control Practices Advisory Committee.23 In addition, the high rate of CAUTI prevalent in the Middle East1,2,24,25 can be reduced by utilizing a strategy of monitoring compliance with recommendations and providing performance feedback to healthcare personnel, as demonstrated in several low- and medium-income countries.24–29

Our research has some limitations. Firstly, because this study is a part of a surveillance system in which hospitals voluntarily engage at no cost, it is not representative of all hospitals in the Middle East. Secondly, the CAUTI rates in our research are probably lower than the overall rates in the region because the hospitals that volunteered to participate in our surveillance system are most likely to have higher-quality CAUTI surveillance and prevention programs. Thirdly, the proportion of suprapubic catheters used was significantly lower than that of indwelling catheters and for that reason, we did not analyze the impact of this variable. Lastly, we used the UC/DU ratio as a marker for the severity of patients’ illnesses rather than the severity of illness scores that were gathered by the IPPs of the collaborating hospitals.

Conclusion

Our study identified several independent RFs for CAUTI in ICUs, mainly age, female sex, LOS, UC/DU ratio, neurologic ICU, and the country’s income level. Some of these RFs have been identified in previous studies, further validating our results. Our findings have important implications for CAUTI prevention, including reducing the LOS and UC/DU ratio and implementing evidence-based prevention recommendations.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

references

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