The burden of CAUTIs in critically ill patients has been widely
addressed in the scientific literature worldwide. CAUTIs have been
related to prolonged hospital LOS, bacterial resistance, morbidity,
and increased healthcare costs.2
The incidence of CAUTI is frequently underestimated in
hospitals from resource-limited countries, as in many cases basic
infection control programs cannot be systematically implemented.
If compared with rates in developed countries, the baseline rate of
CAUTI found in this study (13.07 per 1000 urinary catheter-days)
was 10-fold higher than that in the USA (1.5 CAUTI per 1000
urinary catheter-days determined by the CDC/NSHN18) and higher
than that found in the KISS study (2.5 CAUTI per 1000 urinary
catheter-days).19
In comparison with pooled CAUTI rates from developing
countries, our CAUTI baseline rate was higher than the rates
measured in the Fourth International INICC Report published in
2012 (6.3 CAUTIs per 1000 urinary catheter-days).6
As far as we know,there has been no single study addressing the
effectiveness of CAUTI prevention programs in Lebanon, and the
literature on this issue is extremely scant from developing
countries.1 In a previous study conducted in Lebanon in 1997,
CAUTI was the third most common nosocomial infection (18%).20
In a study in Saudi Arabia, the CAUTI rate was 11.4, which is similar
to our baseline rate of 13.07.21
In our study, patient characteristics, such as age, gender, device
use ratio, surgical stay, cancer, endocrine diseases, and abdominal
surgery conditions, as well as urinary catheter mean duration,
were similar and showed similar patientintrinsic risk in both study
phases.
During the implementation of the INICC multidimensional
approach, hand hygiene compliance remained high and was
similar in both phases. Similarly, compliance rates with the correct
position of the urinary catheter (over thigh) and ill patients; management of acute urinary retention and urinary
obstruction; assistance in pressure ulcer healing for incontinent
residents; to consider other methods for management, including
condom catheters or in-and-out catheterization, when appropriate;
to use as small a catheter as possible; use of gloves, a
drape, and sponges; a sterile or antiseptic solution for cleaning
the urethral meatus; a single-use packet of sterile lubricant jelly
for insertion; to insert catheters by use of aseptic technique and
sterile equipment; to empty the collecting bag regularly; to
avoid allowing the draining spigot to touch the collecting
container; and on the cleaning of the meatal area as part of
routine hygiene. These data would greatly contribute to advance
our knowledge with regard to quality improvement in this
setting of a hospital in Lebanon and would provide an accurate
description of the successful results of our approach. Nevertheless,
our main goal was to reduce the high baseline CAUTI rates
found in our ICUs, and although our interventions were
inexpensive, the individual evaluations would have required
more allocation of time, contributing to unnecessary harm for
ICU patients. Finally, we could not quantify in detail some of
the non-quantifiable interventions included in our approach,
such as education and training. Fortunately, as from January
2012, we have been able to collect all these process surveillance
data.
In conclusion, this study is the first multicenter study to
report a substantial reduction in CAUTI rates in the ICU setting
of Lebanon, showing this kind of infection control approach to
be successful. Although the intrinsic risk in some patients was
higher during the intervention period, a multidimensional
approach including improved compliance with CAUTI prevention
measures resulted in significant reductions in the CAUTI
incidence rate. Good as it is, it is worth highlighting that the
reduction in CAUTI rates does not derive from surveillance itself.
This systematically collected data should serve to guide
healthcare professionals in their strategies for improving patient
care practices, such as performance feedback, as demonstrated
in several previous studies conducted in resource-limited
countries.14
These preventive strategies found to be effective in the INICC
ICUs of Lebanon could promote a wider acceptance of infection
control programs in hospitals, leading to significant CAUTI
reductions worldwide. Within the INICC network, investigators
are provided with training and methodological tools to perform
outcome and process surveillance, and to implement effective
infection prevention programs. Furthermore, the publication of
these findings contributes to the fostering of relevant scientific
evidence-based literature from developing countries. For this
reason, every hospital is invited to participate in the INICC project,
which was set up to respond to the compelling need in the
developing world to significantly prevent, control, and reduce
CAUTIs and their adverse effects.