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Importance Indwelling urethral catheters (ie, Foley catheters) are important in caring for certain hospitalized patients but can also cause complications in patients. Objective To determine the incidence of infectious and noninfectious patient-reported complications associated with the indwelling urethral catheter. Design, Setting, and Participants A prospective cohort study of consecutive patients with placement of a new indwelling urethral catheter while hospitalized at 1 of 4 US hospitals in 2 states. The study was conducted from August 26, 2015, to August 18, 2017. Participants were evaluated at baseline and contacted at 14 days and 30 days after insertion of the catheter about complications associated with the indwelling urethral catheter and how catheterization affected their social activities or activities of daily living. Exposures Indwelling urethral catheter placement during hospitalization. Patients were enrolled within 3 days of catheter insertion and followed up for 30 days after catheter placement, whether the catheter remained in or was removed from the patient. Main Outcomes and Measures Infectious and noninfectious complications associated with an indwelling urethral catheter as well as how the catheter affected patient social activities or activities of daily living. Results Of 2967 eligible patients, 2227 (75.1%) agreed to participate at 1 of 4 study sites; 2076 total patients were evaluated. Of these, 71.4% were male; mean (SD) age was 60.8 (13.4) years. Most patients (1653 of 2076 [79.6%]) had short-term catheters placed for surgical procedures. During the 30 days after urethral catheter insertion, 1184 of 2076 patients (57.0%; 95% CI, 54.9%-59.2%) reported at least 1 complication due to the indwelling urethral catheter. Infectious complications were reported by 219 of 2076 patients (10.5%; 95% CI, 9.3%-12.0%), whereas noninfectious complications (eg, pain or discomfort, blood in the urine, or sense of urinary urgency) occurred in 1150 patients (55.4%; 95% CI, 53.2%-57.6%) (P

Importance Indwelling devices (eg, urinary catheters and feeding tubes) are often used in nursing homes (NHs). Inadequate care of residents with these devices contributes to high rates of multidrug-resistant organisms (MDROs) and device-related infections in NHs. Objective To test whether a multimodal targeted infection program (TIP) reduces the prevalence of MDROs and incident device-related infections. Design, setting, and participants Randomized clinical trial at 12 community-based NHs from May 2010 to April 2013. Participants were high-risk NH residents with urinary catheters, feeding tubes, or both. Interventions Multimodal, including preemptive barrier precautions, active surveillance for MDROs and infections, and NH staff education. Main outcomes and measures The primary outcome was the prevalence density rate of MDROs, defined as the total number of MDROs isolated per visit averaged over the duration of a resident's participation. Secondary outcomes included new MDRO acquisitions and new clinically defined device-associated infections. Data were analyzed using a mixed-effects multilevel Poisson regression model (primary outcome) and a Cox proportional hazards model (secondary outcome), adjusting for facility-level clustering and resident-level variables. Results In total, 418 NH residents with indwelling devices were enrolled, with 34,174 device-days and 6557 anatomic sites sampled. Intervention NHs had a decrease in the overall MDRO prevalence density (rate ratio, 0.77; 95% CI, 0.62-0.94). The rate of new methicillin-resistant Staphylococcus aureus acquisitions was lower in the intervention group than in the control group (rate ratio, 0.78; 95% CI, 0.64-0.96). Hazard ratios for the first and all (including recurrent) clinically defined catheter-associated urinary tract infections were 0.54 (95% CI, 0.30-0.97) and 0.69 (95% CI, 0.49-0.99), respectively, in the intervention group and the control group. There were no reductions in new vancomycin-resistant enterococci or resistant gram-negative bacilli acquisitions or in new feeding tube-associated pneumonias or skin and soft-tissue infections. Conclusions and relevance Our multimodal TIP intervention reduced the overall MDRO prevalence density, new methicillin-resistant S aureus acquisitions, and clinically defined catheter-associated urinary tract infection rates in high-risk NH residents with indwelling devices. Further studies are needed to evaluate the cost-effectiveness of this approach as well as its effects on the reduction of MDRO transmission to other residents, on the environment, and on referring hospitals. Trial registration clinicaltrials.gov Identifier: NCT01062841.

RESULTS The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I 2 = 0%; τ 2

Despite the national goal to reduce catheter-associated urinary tract infection (CAUTI) by 25% by 2013, limited data exist describing prevention practices for CAUTI in US hospitals and none associate national practice use to CAUTI-specific standardized infection ratios (SIRs).To identify practices currently used to prevent CAUTI and to compare use and SIRs for a national sample of US hospitals with hospitals in the state of Michigan, which launched a CAUTI prevention initiative in 2007 ("Keystone Bladder Bundle Initiative").In 2009, we surveyed infection preventionists at a sample of US hospitals and all Michigan hospitals. CAUTI rate differences between Michigan and non-Michigan hospitals were assessed using SIRs.A total of 470 infection preventionists.Reported regular use of CAUTI prevention practices and CAUTI-specific SIR data.Michigan hospitals, compared with hospitals in the rest of the United States, more frequently participated in collaboratives to reduce health care-associated infection (94% vs 67%, P.001) and used bladder scanners (53% vs 39%, P = .04), as well as catheter reminders or stop orders and/or nurse-initiated discontinuation (44% vs 23%, P.001). More frequent use of preventive practices coincided with a 25% reduction in CAUTI rates in the state of Michigan, a significantly greater reduction than the 6% overall decrease observed in the rest of the United States.We observed more frequent use of key prevention practices and a lower rate of CAUTI in Michigan hospitals relative to non-Michigan hospitals. This may be related to Michigan's significantly higher use of practices aimed at timely removal of urinary catheters, the key focus area of Michigan's Keystone Bladder Bundle Initiative.

Background Indwelling urinary catheters may lead to both infectious and noninfectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use. Methods Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention promoting adherence to appropriate urinary catheter indications. The data were collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of educating clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence to appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methods to estimate rates over time while accounting for the clustering of patients within hospital units. Results The urinary catheter use rate decreased from 18.1% (95% CI, 16.8%-19.6%) at baseline to 13.8% (95% CI, 12.9%-14.8%) at end of year 2 (P Conclusions A statewide effort to reduce inappropriate urinary catheter use was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years.

Objective To assess the influence of perioperative statin treatment on the risk of death, myocardial infarction, atrial fibrillation, and hospital and intensive care unit length of stay in statin-naive patients undergoing cardiac or noncardiac surgery. Data Sources MEDLINE via PubMed, EMBASE, Biosis, and the Cochrane Central Register of Controlled Trials via Ovid. Additional studies were identified through hand searches of bibliographies, trial Web sites, and clinical experts. Randomized controlled trials reporting the effect of perioperative statins in statin-naive patients undergoing cardiac and noncardiac surgery were included. Study Selection Two investigators independently selected eligible studies from original research published in any language studying the effects of statin use on perioperative outcomes of interest. Data Extraction Two investigators performed independent article abstraction and quality assessment. Data Synthesis Fifteen randomized controlled studies involving 2292 patients met the eligibility criteria. Random-effects meta-analyses of unadjusted and adjusted data were performed according to the method described by DerSimonian and Laird. Perioperative statin treatment decreased the risk of atrial fibrillation in patients undergoing cardiac surgery (relative risk [RR], 0.56; 95% CI, 0.45 to 0.69; number needed to treat [NNT], 6). In cardiac and noncardiac surgery, perioperative statin treatment reduced the risk of myocardial infarction (RR, 0.53; 95% CI, 0.38 to 0.74; NNT, 23) but not the risk of death (RR, 0.62; 95% CI, 0.34 to 1.14). Statin treatment reduced mean length of hospital stay (standardized mean difference, −0.32; 95% CI, −0.53 to −0.11) but had no effect on length of intensive care unit stay (standardized mean difference, −0.08; 95% CI, −0.25 to 0.10). Conclusions Perioperative statin treatment in statin-naive patients reduces atrial fibrillation, myocardial infarction, and duration of hospital stay. Wider use of statins to improve cardiac outcomes in patients undergoing high-risk procedures seems warranted.

Women have higher mortality rates after coronary artery bypass graft (CABG) surgery compared with men. Explanations for this sex difference are controversial. The objective of this study was to assess whether infection contributes to the increased risk of mortality in women.We conducted a cohort study of 9218 Michigan Medicare beneficiaries hospitalized for CABG surgery. The prevalence of infection at any site during hospitalization was determined. Patients were followed up for 100 days after surgery to assess vital status. Analyses were conducted using proportional hazards regression and population attributable risk.Women hospitalized for CABG surgery were more likely to have an infection than men (16.1% vs 9.8%, P.001), regardless of age, race, type of admission, hospital volume, or presence of comorbidities. Infections of the respiratory tract, urinary tract, digestive tract, and skin and subcutaneous tissue were more common in women than in men. The risk of death in men increased 3-fold with infection, whereas the risk in women increased 1.8-fold. The interaction between infection and sex on mortality was significant after adjusting for age, type of admission, and presence of comorbidities (P = .008). The unadjusted percentage of deaths attributable to female sex was 13.9%, which decreased to 0.3% when adjusted for infection. Of the excess deaths in women, 96% could be accounted for by the differential distribution of infection between the sexes.The increased risk of mortality after CABG surgery in women may be explained by underlying differences in the prevalence of infection among men and women.

ContextThe Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents’ well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents.ObjectiveTo summarize the literature regarding the effect of interventions to reduce resident work hours on residents’ education and quality of life.Data SourcesWe searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings.Study SelectionStudies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States.Data ExtractionFor each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form.Data SynthesisFifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents’ lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents’ quality of life. Many studies had major limitations in their design or conduct.ConclusionsPast interventions suggest that residents’ quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents’ quality of life and quality of patient care.

Symptoms suggestive of acute urinary tract infection (UTI) constitute one of the most common reasons for women to visit clinicians. Although the clinical encounter typically involves taking a history and performing a physical examination, the diagnostic accuracy of the clinical assessment for UTI remains uncertain.To review the accuracy and precision of history taking and physical examination for the diagnosis of UTI in women.We conducted a MEDLINE search for articles published from 1966 through September 2001 and manually reviewed bibliographies, 3 commonly used clinical skills textbooks, and contacted experts in the field.Studies were included if they contained original data on the accuracy or precision of history or physical examination for diagnosing acute uncomplicated UTI in women. One author initially screened titles and abstracts found by our search. Nine of 464 identified studies met inclusion criteria.Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion and consensus with a third author.Four symptoms and 1 sign significantly increased the probability of UTI: dysuria (summary positive likelihood ratio [LR], 1.5; 95% confidence interval [CI], 1.2-2.0), frequency (LR, 1.8; 95% CI, 1.1-3.0), hematuria (LR, 2.0; 95% CI, 1.3-2.9), back pain (LR, 1.6; 95% CI, 1.2-2.1), and costovertebral angle tenderness (LR, 1.7; 95% CI, 1.1-2.5). Four symptoms and 1 sign significantly decreased the probability of UTI: absence of dysuria (summary negative LR, 0.5; 95% CI, 0.3-0.7), absence of back pain (LR, 0.8; 95% CI, 0.7-0.9), history of vaginal discharge (LR, 0.3; 95% CI, 0.1-0.9), history of vaginal irritation (LR, 0.2; 95% CI, 0.1-0.9), and vaginal discharge on examination (LR, 0.7; 95% CI, 0.5-0.9). Of all individual diagnostic signs and symptoms, the 2 most powerful were history of vaginal discharge and history of vaginal irritation, which significantly decreased the likelihood of UTI when present (LRs, 0.3 and 0.2, respectively). One study examined combinations of symptoms, and the resulting LRs were more powerful (24.6 for the combination of dysuria and frequency but no vaginal discharge or irritation). One study of patients with recurrent UTI found that self-diagnosis significantly increased the probability of UTI (LR, 4.0).In women who present with 1 or more symptoms of UTI, the probability of infection is approximately 50%. Specific combinations of symptoms (eg, dysuria and frequency without vaginal discharge or irritation) raise the probability of UTI to more than 90%, effectively ruling in the diagnosis based on history alone. In contrast, history taking, physical examination, and dipstick urinalysis are not able to reliably lower the posttest probability of disease to a level where a UTI can be ruled out when a patient presents with 1 or more symptoms.

Background Catheter-associated urinary tract infection (UTI) is associated with increased morbidity, mortality, and costs. A recent meta-analysis concluded that silver alloy catheters reduce the incidence of UTI by 3-fold; however, clinicians must decide whether the efficacy of such catheters is worth the extra per unit cost of $5.30. Objective To assess the clinical and economic impact of using silver alloy urinary catheters in hospitalized patients. Methods The decision model, performed from the health care payer's perspective, evaluated a simulated cohort of 1000 hospitalized patients on general medical, surgical, urologic, and intensive care services requiring short-term urethral catheterization (2-10 days). We compared 2 catheterization strategies: silver alloy catheters and standard (noncoated) urinary catheters. Outcomes included the incidence of symptomatic UTI and bacteremia and direct medical costs. Results In the base-case analysis, use of silver-coated catheters led to a 47% relative decrease in the incidence of symptomatic UTI from 30 to 16 cases per 1000 patients (number needed to treat = 74) and a 44% relative decrease in the incidence of bacteremia from 4.5 to 2.5 cases per 1000 patients (number needed to treat = 500) compared with standard catheters. Use of silver alloy catheters resulted in estimated cost savings of $4.09 per patient compared with standard catheter use ($20.87 vs $16.78). In a multivariate sensitivity analysis using Monte Carlo simulation, silver-coated catheters provided clinical benefits over standard catheters in all cases and cost savings in 84% of cases. Conclusions Using silver alloy catheters in hospitalized patients requiring short-term urinary catheterization reduces the incidence of symptomatic UTI and bacteremia, and is likely to produce cost savings compared with standard catheters.

ContextA recent randomized controlled trial and meta-analysis indicated that central venous catheters impregnated with an antiseptic combination of chlorhexidine and silver sulfadiazine are efficacious in reducing the incidence of catheter-related bloodstream infection (CR-BSI); however, the ultimate clinical and economic consequences of their use have not been formally evaluated.ObjectiveTo estimate the incremental clinical and economic outcomes associated with the use of antiseptic-impregnated vs standard catheters.DesignDecision analytic model using data from randomized controlled trials, meta-analyses, and case-control studies, as well as safety data from the US Food and Drug Administration.Setting and PatientsA hypothetical cohort of hospitalized patients at high risk for catheter-related infections (eg, patients in intensive care units, immunosuppressed patients, and patients receiving total parenteral nutrition) requiring use of a central venous catheter.InterventionShort-term use (2-10 days) of chlorhexidine–silver sulfadiazine–impregnated multilumen central venous catheters and nonimpregnated catheters.Main Outcome MeasuresExpected incidence of CR-BSI and death attributable to antiseptic-impregnated and standard catheter use; direct medical costs for both types of catheters.ResultsIn the base-case analysis, use of antiseptic-impregnated catheters resulted in a decrease in the incidence of CR-BSI of 2.2% (5.2% for standard vs 3.0% for antiseptic-impregnated catheters), a decrease in the incidence of death of 0.33% (0.78% for standard vs 0.45% for antiseptic-impregnated), and a decrease in costs of $196 per catheter used ($532 for standard vs $336 for antiseptic-impregnated). The decrease in CR-BSI ranged from 1.2% to 3.4%, the decrease in death ranged from 0.09% to 0.78%, and the costs saved ranged from $68 to $391 in a multivariate sensitivity analysis.ConclusionOur analyses suggest that use of chlorhexidine–silver sulfadiazine–impregnated central venous catheters in patients at high risk for catheter-related infections reduces the incidence of CR-BSI and death and provides significant saving in costs. Use of these catheters should be considered as part of a comprehensive nosocomial infection control program.

ContextCentral venous catheters impregnated with chlorhexidine and silver sulfadiazine have recently been introduced for the prevention of catheter-related infections. However, there remains some uncertainty regarding the efficacy of these catheters because of conflicting reports in the literature.ObjectiveTo evaluate the efficacy of chlorhexidine–silver sulfadiazine–impregnated central venous catheters in the prevention of catheter-related bloodstream infection.Data SourcesStudies identified from a computerized search of the MEDLINE database from January 1966 to January 1998, reference lists of identified articles, and queries of principal investigators and the catheter manufacturer.Study SelectionRandomized trials comparing chlorhexidine–silver sulfadiazine–impregnated central venous catheters with nonimpregnated catheters were included. The outcomes assessed were catheter colonization and catheter-related bloodstream infection confirmed by catheter culture.Data ExtractionTwelve studies met the inclusion criteria for catheter colonization and included a total of 2611 catheters. Eleven studies with a total of 2603 catheters met the inclusion criteria for catheter-related bloodstream infection. Most patients in these studies were from groups considered to be at high risk for catheter-related infections. Summary statistics were calculated using Mantel-Haenszel methods under a fixed-effects model.Data SynthesisThe summary odds ratio for catheter colonization was 0.44 (95% confidence interval [CI], 0.36-0.54; P