Cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis for the management of recurrent urinary tract infections in secondary care: a multicentre, open-label, randomised, non-inferiority trial.

OBJECTIVES: To estimate the cost-effectiveness of methenamine hippurate compared with antibiotic prophylaxis in the management of recurrent urinary tract infections. DESIGN: Multicentre, open-label, randomised, non-inferiority trial. SETTING: Eight centres in the UK, recruiting from June 2016 to June 2018. PARTICIPANTS: Women aged ≥18 years with recurrent urinary tract infections, requiring prophylactic treatment. INTERVENTIONS: Women were randomised to receive once-daily antibiotic prophylaxis or twice-daily methenamine hippurate for 12 months. Treatment allocation was not masked and crossover between arms was allowed. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary economic outcome was the incremental cost per quality-adjusted life year (QALY) gained at 18 months. All costs were collected from a UK National Health Service perspective. QALYs were estimated based on responses to the EQ-5D-5L administered at baseline, 3, 6, 9, 12 and 18 months. Incremental costs and QALYs were estimated using an adjusted analysis which controlled for observed and unobserved characteristics. Stochastic sensitivity analysis was used to illustrate uncertainty on a cost-effectiveness plane and a cost-effectiveness acceptability curve. A sensitivity analysis, not specified in the protocol, considered the costs associated with antibiotic resistance. RESULTS: Data on 205 participants were included in the economic analysis. On average, methenamine hippurate was less costly (-£40; 95% CI: -684 to 603) and more effective (0.014 QALYs; 95% CI: -0.05 to 0.07) than antibiotic prophylaxis. Over the range of values considered for an additional QALY, the probability of methenamine hippurate being considered cost-effective ranged from 51% to 67%. CONCLUSIONS: On average, methenamine hippurate was less costly and more effective than antibiotic prophylaxis but these results are subject to uncertainty. Methenamine hippurate is more likely to be considered cost-effective when the benefits of reduced antibiotic use were included in the analysis. TRIAL REGISTRATION NUMBER: ISRCTN70219762.

Health Care Workers Online YouTube Content Compared to AUA Prevention of Recurrent Urinary Tract Infections in Women Guidelines: An Integrative Review of Quality and Comprehensiveness Analysis.

INTRODUCTION: We document the quality, veracity, and comprehensiveness of recurrent UTI information on YouTube to increase health care workers' (HCWs') awareness of UTI-related content online, and to identify deficits in understanding, clarify misconceptions, and reduce stigmatization risk. METHODS: High-traffic topic search terms were curated by Google Trends to extract 200 videos, of which 45 met inclusion criteria. Five independent reviewers used a standardized questionnaire based on the AUA recurrent UTI guidelines to assess the definition of UTI, marketing content, prophylaxis/prevention strategies, and antibiotic use/stewardship. RESULTS: Incongruent or incomplete guideline UTI definitions were found in 78% (35/45) of videos (K = 0.40), despite 80% (36/45) being authored by HCWs. Forty-two percent (19/45) promoted nonguideline-based hygiene practices; 25% (11/45) advocated front-to-back wiping (K = 0.71). Descriptors identified within the videos included the mention of women with UTI as unclean. Only 55% (25/45) discussed increasing fluid intake (K = 0.59), while 33% (15/45) discussed the use of cranberry supplementation (K = 0.81). CONCLUSIONS: Discussion of hygiene practices which lack a specific guideline statement is particularly evident. Descriptors that characterize women with UTI as "unclean" may create a health equity concern for women experiencing UTIs. These findings should alert HCWs to the scope and emphasis in online education that patients may view to self-educate; both the errors and the issues of equity are problematic. Educational materials on UTI should be based on evidence-based guidelines, such as those by the AUA.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM: To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS: A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS: The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION: Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Leaving no culture undrawn: Time to revisit the CLABSI and CAUTI metrics.

Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are quality metrics for many ICUs, and financial ramifications can be applied to hospitals and providers who perform poorly on these measures. Despite some perceived benefits to tracking these metrics, there are a range of issues associated with this practice: lack of a solid evidence base that documenting them has led to decreased infection rates, moral distress associated with identifying these infections, problems with their definitions, and others. We discuss each of these concerns while also including international perspectives then recommend practical steps to attempt to remediate use of the CLABSI and CAUTI metrics. Specifically, we suggest forming a task force consisting of key stakeholders (e.g., providers, Centers for Medicare & Medicaid Services (CMS), patients/families) to review CLABSI and CAUTI-related issues and then to create a summary statement containing recommendations to improve the use of these metrics.

Single-use digital flexible cystoscope for double J removal versus reusable instruments: a prospective, comparative study of functionality, risk of infection, and costs.

BACKGROUND: The removal of ureteral stent can be performed with disposable or reusable flexible cystoscopes, but limited comparative data are available on functionality, risk of infections, and costs. METHODS: We performed a multicentric, prospective, observational study on patients undergoing in-office ureteral stent removal with Isiris-α® or a reusable Storz™ flexible cystoscope. Study endpoints were the functionality and effectiveness of the devices, the rate of postoperative bacteriuria and UTIs, and the costs of the procedure. RESULTS: A total of 135 patients were included, 80 (59.2%) treated with reusable cystoscopes and 55 (40.8%) with Isiris-α®. No significant baseline differences between groups were detected. Isiris-α® outperformed the reusable device in terms of quality of vision (p 0.001), manoeuvrability (p 0.001), grasper functionality (p < 0.001), and quality of the procedure (p 0.01). Mean procedure time was shorter with Isiris-α® (p < 0.001) due to a shorter instrument preparation time (p < 0.001). No differences were found in terms of perceived patient pain (p 0.34), nor postoperative bacteriuria or symptomatic UTIs. According to our cost analysis, the in-office procedure performed with Isiris-α® was more expensive (+ 137.8€) but was independent from instrument turnover or disinfection. Among limitations of study we acknowledge the lack of randomization, the use of antibiotic prophylaxis in several patients, and the high rate of missing preoperative urine cultures. CONCLUSIONS: Isiris-α® outperforms reusable cystoscopes for in-office ureteral stent removal in terms of total operative time and quality of the procedure, at the cost of being more expensive. No significant differences in postoperative bacteriuria or symptomatic UTIs were found.

Cost-effectiveness analysis of hydrophilic-coated catheters in long-term intermittent catheter users in the UK.

OBJECTIVE: To estimate the cost-effectiveness of single-use hydrophilic-coated intermittent catheters (HCICs) versus single-use uncoated intermittent catheters (UICs) for urinary catheterization. METHODS: The evaluation took a UK national health service (NHS) perspective. The population of interest were people using intermittent catheters, with either a spinal cord injury or multiple sclerosis. A Markov model was developed that estimated costs and clinical evidence over the lifetime of a hypothetical cohort and applied health-related quality-of-life estimates. Model inputs were sourced from published evidence, including a network meta-analysis to inform the treatment effect (reduction in catheter-associated urinary tract infections [CAUTIs]), and were supported by expert opinion. The model outputs included per-patient lifetime costs, quality-adjusted life years (QALYs), and the incremental cost effectiveness ratio (ICER). Event counts were also produced. RESULTS: Using HCICs instead of UICs could prevent seven CAUTI events per patient over a lifetime horizon (1.8 requiring secondary care). Overall, lifetime use of HCICs is £3,183 more expensive than use of UICs per patient. However, for these additional costs, 0.55 QALYs are gained. The ICER is £5,755 per additional QALY gained. Key drivers of the model results were identified and subject to sensitivity analyses. The results were found to be robust to parameter uncertainty. CONCLUSION: HCICs are likely to be a cost-effective alternative to UICs, a result driven by substantial reductions in the number of CAUTIs. Their adoption across clinical practice could avoid a substantial number of infections, freeing up resources in the NHS and reducing antibiotic use in urinary catheter users.

A new economic model was developed from a United Kingdom National Health Service perspective, to explore whether hydrophilic-coated intermittent catheters would be "worth" introducing for intermittent catheter users with either a spinal cord injury or multiple sclerosis. More specifically, costs were analyzed alongside clinical evidence and health-related quality-of-life data to investigate whether hydrophilic-coated intermittent catheters would offer a notable health benefit when compared with uncoated intermittent catheters for the assessed population, whilst keeping costs to the National Health Service sufficiently low. Model inputs were sourced from published evidence where possible, and experts were consulted otherwise. The results showed that, whilst lifetime use of hydrophilic-coated intermittent catheters is £3,183 more expensive than use of uncoated intermittent catheters per patient, the health benefit with hydrophilic-coated intermittent catheters offsets these costs, by definition a cost-effective result. This means that hydrophilic-coated intermittent catheters are likely to be a cost-effective alternative to uncoated intermittent catheters. Their adoption across clinical practice could avoid a substantial number of infections, thereby freeing up healthcare resources in the National Health Service and reducing antibiotic use in urinary catheter users.

Effectiveness and health cost analysis between immunoprophylaxis with MV140 autovaccine, MV140 vaccine and continuous treatment with antibiotics to prevent recurrent urinary tract infections.

INTRODUCTION: The objective of this study was to compare the results on prevention of uncomplicated recurrent UTI between continuous use of antibiotics, MV140 autovaccine and MV140 polybacterial vaccine from collection strain. METHODS: 377 patients were prospectively analyzed from January 2017 to August 2019 and divided into 3 groups according to the prophylaxis. Group A (126): antibiotics, Group B (126): MV140 autovaccine, Group C (125): MV140 polybacterial vaccine from the collection strain. Variables analyzed were: gender, age, menopause, number of UTI at baseline and 3 and 6 months after the end of prophylaxis, health cost along follow-up at 3 and 6 months. RESULTS: At 3 months, group A had 0-1 UTI in 65%, group B had 0-1 UTI in 80.8% and group C in 81.7%. At 6 months, group A had 0-1 UTI in 44.4%, group B had 0-1 UTI in 61.6% and group C in 74.6%. Regarding health cost along follow-up, at 3 months group A had euro21,171.87, group B had euro20,763.73 and group C euro18,866.14. At 6 months, health cost was euro32,980.35 in group A, euro28,133.42 in group B, and euro23,629.19 in group C. CONCLUSIONS: MV140 autovaccine and MV140 polybacterial vaccine were more efficient with lower number of UTI at 3 and 6 months and lower health cost along follow-up compared to continued prophylaxis with antibiotics (p < 0.05). Polybacterial MV140 vaccine from collection strain had higher effect to reduce the number of UTI and less health cost than autovaccine.

Randomised controlled trial comparing the clinical and cost-effectiveness of various washout policies versus no washout policy in preventing catheter associated complications in adults living with long-term catheters: study protocol for the CATHETER II study.

BACKGROUND: Various washout policies are widely used in adults living with long-term catheters (LTC). There is currently insufficient evidence on the benefits and potential harms of prophylactic LTC washout policies in the prevention of blockages and other LTC-related adverse events, such as urinary tract infections. CATHETER II tests the hypothesis that weekly prophylactic LTC washouts (normal saline or citric acid) in addition to standard LTC care reduce the incidence of catheter blockage requiring intervention compared to standard LTC care only in adults living with LTC. METHODS: CATHETER II is a pragmatic three-arm open multi-centre superiority randomised controlled trial with an internal pilot, economic analysis, and embedded qualitative study. Eligible participants are adults aged ≥ 18 years, who have had a LTC in use for ≥ 28 days, have no plans to discontinue the use of the catheter, are able to undertake the catheter washouts, and complete trial documentation or have a carer able to help them. Participants are identified from general practitioner practices, secondary/tertiary care, community healthcare, care homes, and via public advertising strategies. Participants are randomised 1:1:1 to receive a weekly saline (0.9%) washout in addition to standard LTC care, a weekly citric acid (3.23%) washout in addition to standard LTC care or standard LTC care only. Participants and/or carers will receive training to administer the washouts. Patient-reported outcomes are collected at baseline and for 24 months post-randomisation. The primary clinical outcome is catheter blockage requiring intervention up to 24 months post-randomisation expressed per 1000 catheter days. Secondary outcomes include symptomatic catheter-associated urinary tract infection requiring antibiotics, catheter change, adverse events, NHS/ healthcare use, and impact on quality of life. DISCUSSION: This study will guide treatment decision-making and clinical practice guidelines regarding the effectiveness of various prophylactic catheter washout policies in men and women living with LTC. This research has received ethical approval from Wales Research Ethics Committee 6 (19/WA/0015). TRIAL REGISTRATION: ISRCTN ISRCTN17116445 . Registered prospectively on 06 November 2019.

Adoption of Single-Use Clean Intermittent Catheterization Policies Does Not Appear to Affect Genitourinary Outcomes in a Large Spinal Cord Injury Cohort.

PURPOSE: In April 2008, Medicare amended its policy for clean intermittent catheterization, increasing coverage from 4 reused catheters per month to up to 200 single-use catheters. The primary reason for the policy change was an assumed decrease in risk of urinary tract infection with single-use catheters. Given its economic/environmental impact (∼50-fold increase in cost and plastic waste) and a paucity of supporting evidence, we retrospectively evaluate the policy's effect in a prospective spinal cord injury registry. MATERIALS AND METHODS: We accessed data for the years 1995 to 2020 from the National Spinal Cord Injury Database focusing on 1-year follow-up in those unable to volitionally void after injury. We asked 2 questions: (1) Did hospitalizations for genitourinary reasons decrease after the clean intermittent catheterization policy change?; and (2) Did clean intermittent catheterization adoption and adherence increase after the clean intermittent catheterization policy change? RESULTS: During the study period, 2,657 of the 6,843 (38.8%) participants unable to volitionally void after spinal cord injury were hospitalized during their first follow-up year. Of the cohort performing clean intermittent catheterization, fewer individuals were hospitalized for genitourinary reasons prior to the clean intermittent catheterization policy change compared to after (10.6% vs 14.6%, P < .001), a finding that persisted on multivariate logistic regression (odds radio, 0.67, P < .001). In addition, the number of individuals performing clean intermittent catheterization at 1-year follow-up was less after the policy change compared to prior (57.0% vs 59.1%, P = .044). CONCLUSIONS: Our findings suggest the 2008 policy change shifting clean intermittent catheterization coverage from catheter reuse to single-use did not decrease hospitalizations for urinary tract infection or increase clean intermittent catheterization uptake in individuals with spinal cord injury.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

BACKGROUND: Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. METHODS: As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. RESULTS: Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). CONCLUSION: Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT.

BACKGROUND: Daily, low-dose antibiotic prophylaxis is the current standard care for women with recurrent urinary tract infection. Emerging antimicrobial resistance is a global health concern, prompting research interest in non-antibiotic agents such as methenamine hippurate, but comparative data on their efficacy and safety are lacking. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of methenamine hippurate (Hiprex®; Mylan NV, Canonsburg, PA, USA) compared with current standard care (antibiotic prophylaxis) for recurrent urinary tract infection prevention in adult women. DESIGN: Multicentre, pragmatic, open-label, randomised, non-inferiority trial of 12 months' treatment with the allocated intervention, including an early, embedded qualitative study and a 6-month post-treatment observation phase. The predefined non-inferiority margin was one urinary tract infection per person-year. SETTING: Eight UK NHS secondary care sites. PARTICIPANTS: A total of 240 adult women with recurrent urinary tract infection requiring preventative treatment participated in the trial. INTERVENTIONS: A central randomisation system allocated participants 1 : 1 to the experimental (methenamine hippurate: 1 g twice daily) or control (once-daily low-dose antibiotics: 50/100 mg of nitrofurantoin, 100 mg of trimethoprim or 250 mg of cefalexin) arm. Crossover between treatment arms was permitted. MAIN OUTCOME MEASURES: The primary clinical outcome was incidence of symptomatic antibiotic-treated urinary tract infection during the 12-month treatment period. Cost-effectiveness was assessed by incremental cost per quality-adjusted life-year gained, extrapolated over the patient's expected lifetime using a Markov cohort model. Secondary outcomes included post-treatment urinary tract infections, total antibiotic use, microbiologically proven urinary tract infections, antimicrobial resistance, bacteriuria, hospitalisations and treatment satisfaction. RESULTS: Primary modified intention-to-treat analysis comprised 205 (85%) randomised participants [102/120 (85%) participants in the antibiotics arm and 103/120 (86%) participants in the methenamine hippurate arm] with at least 6 months' data available. During treatment, the incidence rate of symptomatic, antibiotic-treated urinary tract infections decreased substantially in both arms to 1.38 episodes per person-year (95% confidence interval 1.05 to 1.72 episodes per person-year) for methenamine hippurate and 0.89 episodes per person year (95% confidence interval 0.65 to 1.12 episodes per person-year) for antibiotics (absolute difference 0.49; 90% confidence interval 0.15 to 0.84). This absolute difference did not exceed the predefined, strict, non-inferiority limit of one urinary tract infection per person-year. On average, methenamine hippurate was less costly and more effective than antibiotics in terms of quality-adjusted life-years gained; however, this finding was not consistent over the longer term. The urinary tract infection incidence rate 6 months after treatment completion was 1.72 episodes per year in the methenamine hippurate arm and 1.19 in the antibiotics arm. During treatment, 52% of urine samples taken during symptomatic urinary tract infections were microbiologically confirmed and higher proportions of participants taking daily antibiotics (46/64; 72%) demonstrated antibiotic resistance in Escherichia coli cultured from perineal swabs than participants in the methenamine hippurate arm (39/70; 56%) (p-value = 0.05). Urine cultures revealed that during treatment higher proportions of participants and samples from the antibiotic arm grew E. coli resistant to trimethoprim/co-trimoxazole and cephalosporins, respectively. Conversely, post treatment, higher proportions of participants in the methenamine hippurate arm (9/45; 20%) demonstrated multidrug resistance in E. coli isolated from perineal swabs than participants in the antibiotic arm (2/39; 5%) (p = 0.06). All other secondary outcomes and adverse events were similar in both arms. LIMITATIONS: This trial could not define whether or not one particular antibiotic was more beneficial, and progressive data loss hampered economic evaluation. CONCLUSIONS: This large, randomised, pragmatic trial in a routine NHS setting has clearly shown that methenamine hippurate is not inferior to current standard care (daily low-dose antibiotics) in preventing recurrent urinary tract infections in women. The results suggest that antimicrobial resistance is proportionally higher in women taking prophylactic antibiotics. RECOMMENDATIONS FOR RESEARCH: Future research should include evaluation of other non-antibiotic preventative treatments in well-defined homogeneous patient groups, preferably with the comparator of daily antibiotics. TRIAL REGISTRATION: This trial is registered as ISRCTN70219762 and EudraCT 2015-003487-36. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 23. See the NIHR Journals Library website for further project information.

Women with recurrent urine infections often require preventative treatment to reduce the frequency of infection episodes. Daily low-dose antibiotic medication is a guideline-recommended treatment option for these women. There is increasing concern globally regarding antibiotic-resistant infections, which has led researchers to look at alternative treatments. This trial was conducted to find out whether or not taking an alternative treatment that is not an antibiotic [i.e. methenamine hippurate (Hiprex^®; Mylan NV, Canonsburg, PA, USA)] was as effective as the standard daily low-dose antibiotics. A total of 240 women from across the UK took part in the trial. They were divided equally into two groups; half of the women were given methenamine hippurate and the other half were given standard low-dose antibiotics. Both treatments were prescribed to be taken every day for 1 year. To make a fair comparison, people were put into the two groups at random using a computer program. Aspects of the trial that could be improved were identified through telephone interviews with patients and recruiting staff. Feedback from these telephone interviews helped to ensure the successful conduct of the trial. Patients were followed up for 18 months, comprising the 12 months when they were taking treatment and a 6-month follow-up phase after they had finished treatment. We found that the non-antibiotic option of methenamine hippurate was no worse than the current standard treatment of daily antibiotics in preventing urinary tract infection episodes in adult women. For both treatments, patients expressed high levels of satisfaction. One advantage of the methenamine hippurate treatment was that infecting bacteria were slightly less likely to develop resistance to antibiotics. We also evaluated health-care costs of both treatments and found that methenamine hippurate seemed worthwhile to the NHS in the short term, but there was uncertainty over longer-term costs and benefits. These results will help patients with repeated urinary tract infections to decide on treatment options, particularly if they want to avoid prolonged courses of preventative antibiotics.

Preventing Health Care-Associated Infections Through Implementation of an Interprofessional Visual Management Safety Tracker.

BACKGROUND: The management of health care associated infections (HAIs) challenges acute care facilities due to variability in practices. The purpose of this quality improvement project was to decrease central line-associated bloodstream infection, catheter-associated urinary tract infection, and Clostridioides difficile infection in a high acuity care environment using a visual management (VM) tool to address practice variations. LOCAL PROBLEM: An acute care unit experienced increasing HAIs. METHODS: An interprofessional team used Lean methodology to implement a VM tool reflective of evidence-based HAI prevention practices that staff had frequently omitted. INTERVENTIONS: A VM tool called the Safety Tracker was created. RESULTS: In 12 months, HAIs decreased from 9 events to 1, with a corresponding reduction in indwelling urinary catheter utilization and central line utilization. More than $160 000 were avoided in health care costs. CONCLUSIONS: Creating an interprofessional VM Safety Tracker could significantly reduce HAIs.

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

BACKGROUND: Hospitals have implemented diverse quality improvement (QI) interventions to reduce rates of catheter-associated urinary tract infections (CAUTIs). The economic value of these QI interventions is uncertain. OBJECTIVE: To systematically review economic evaluations of QI interventions designed to prevent CAUTI in acute care hospitals. METHODS: A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, WorldCat, IDWeek conference abstracts and prior systematic reviews was conducted from January 2000 to October 2020.We included English-language studies of any design that evaluated organisational or structural changes to prevent CAUTI in acute care hospitals, and reported programme and infection-related costs.Dual reviewers assessed study design, effectiveness, costs and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net cost/savings per hospital over 3 years. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter days per study. RESULTS: Fifteen unique economic evaluations were eligible, encompassing 74 hospitals. Across 12 studies amenable to standardisation, QI interventions were associated with a 43% decline in infections (mean IRR 0.57, 95% CI 0.44 to 0.70) and wide ranges of net costs (mean US$52 000, 95% CI -$288 000 to $392 000), relative to usual care. CONCLUSIONS: QI interventions were associated with large declines in infection rates and net costs to hospitals that varied greatly but that, on average, were not significantly different from zero over 3 years. Future research should examine specific practices associated with cost-savings and clinical effectiveness, and examine whether or not more comprehensive interventions offer hospitals and patients the best value.

Urinary catheter policies in home healthcare agencies and hospital transfers due to urinary tract infection.

BACKGROUND: Urinary tract infections (UTIs) are a frequent cause of hospital transfer for home healthcare (HHC) patients, particularly among patients with urinary catheters. METHODS: We conducted a cross-sectional, nationally representative HHC agency-level survey (2018-2019) and combined it with patient-level data from the Outcome and Assessment Information Set (OASIS) and Medicare inpatient data (2016-2018) to evaluate the association between HHC agencies' urinary catheter policies and hospital transfers due to UTI. Our sample included 28,205 patients with urinary catheters who received HHC from 473 Medicare-certified agencies between 2016-2018. Our survey assessed whether agencies had written policies in place for (1) replacement of indwelling catheters at fixed intervals, and (2) emptying the drainage bag. We used adjusted logistic regression to estimate the association of these policies with probability of hospital transfer due to UTI during a 60-day HHC episode. RESULTS: Probability of hospital transfer due to UTI during a HHC episode ranged from 5.62% among agencies with neither urinary catheter policy to 4.43% among agencies with both policies. Relative to agencies with neither policy, having both policies was associated with 21% lower probability of hospital transfer due to UTI (P < .05). CONCLUSION: Our findings suggest implementation of policies in HHC to promote best practices for care of patients with urinary catheters may be an effective strategy to prevent hospital transfers due to UTI.

Gaps in infection prevention practices for catheter-associated urinary tract infections and central line-associated bloodstream infections as identified by the Targeted Assessment for Prevention Strategy.

BACKGROUND: Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of health care-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention Strategy is a quality improvement framework to reduce health care-associated infections. Data from the Targeted Assessment for Prevention Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI. METHODS: Data from 2,044 CAUTI and 1,680 CLABSI assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement. RESULTS: Across CAUTI and CLABSI assessments, lack of physician champions (<35% Yes) and nurse champions (<55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI. CONCLUSIONS: These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.

D-MannosE to prevent Recurrent urinary tract InfecTions (MERIT): protocol for a randomised controlled trial.

INTRODUCTION: Recurrent urinary tract infections (RUTIs) have a significant negative impact on quality of life and healthcare costs. To date, daily prophylactic antibiotics are the only treatment which have been shown to help prevent RUTIs. D-mannose is a type of sugar which is believed to inhibit bacterial adherence to uroepithelial cells, and is already being used by some women in an attempt to prevent RUTIs. There is currently insufficient rigorous evidence on which to base decisions about its use. The D-mannose to prevent recurrent urinary tract infections (MERIT) study will evaluate whether D-mannose is clinically and cost-effective in reducing frequency of infection and symptom burden for women presenting to UK primary care with RUTI. METHODS AND ANALYSIS: MERIT will be a two-arm, individually randomised, double blind placebo controlled, pragmatic trial. Participants will be randomised to take D-mannose powder or placebo powder daily for 6 months. The primary outcome will be the number of medical attendances attributable to symptoms of RUTI. With 508 participants we will have 90% power to detect a 50% reduction in the chance of a further clinically suspected UTI, assuming 20% lost to follow-up. Secondary outcomes will include: number of days of moderately bad symptoms of UTI; time to next consultation; number of clinically suspected UTIs; number of microbiologically proven UTIs; number of antibiotic courses for UTI; quality of life and healthcare utilisation related to UTI. A within trial economic evaluation will be conducted to examine cost-effectiveness of D-mannose in comparison with placebo. A nested qualitative study will explore participants' experiences and perceptions of recruitment to, and participation in a study requiring a daily treatment. ETHICS AND DISSEMINATION: Ethical approval has been obtained from South West-Central Bristol Research Ethics Committee. Publication of the MERIT study is anticipated to occur in 2021. TRIAL REGISTRATION NUMBER: ISRCTN 13283516.

In silico analysis and in vivo assessment of a novel epitope-based vaccine candidate against uropathogenic Escherichia coli.

Uropathogenic Escherichia coli (UPEC) are common pathogens in urinary tract infections (UTIs), which show resistance to antibiotics. Therefore, there is a need for a vaccine to reduce susceptibility to the infection. In the present study, bioinformatics approaches were employed to predict the best B and T-cell epitopes of UPEC virulence proteins to develop a multiepitope vaccine candidate against UPEC. Then, the efficacy of the candidate was studied with and without Freund adjuvant. Using bioinformatics methods, 3 epitope-rich domains of IutA and FimH antigens were selected to construct the fusion. Molecular docking and Molecular dynamics (MD) simulation were employed to investigate in silico interaction between designed vaccine and Toll-like receptor 4 (TLR4). Our results showed that the levels of IgG and IgA antibodies were improved in the serum and mucosal samples of the vaccinated mice, and the IgG responses were maintained for at least 6 months. The fusion protein was also able to enhance the level of cytokines IFN.γ (Th1), IL.4 (Th2), and IL.17. In challenge experiments, all vaccine combinations showed high potency in the protection of the urinary tract even after 6 months post first injection. The present study indicates that the designed candidate is able to evoke strong protective responses which warrant further studies.

Device associated -health care associated infections monitoring, prevention and cost assessment at intensive care unit of University Hospital in Poland (2015-2017).

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) in intensive care unit (ICU) patients constitute a major therapeutic issue complicating the regular hospitalisation process and having influence on patients' condition, length of hospitalisation, mortality and therapy cost. METHODS: The study involved all patients treated > 48 h at ICU of the Medical University Teaching Hospital (Poland) from 1.01.2015 to 31.12.2017. The study showed the surveillance and prevention of DA-HAIs on International Nosocomial Infection Control Consortium (INICC) Surveillance Online System (ISOS) 3 online platform according to methodology of the INICC multidimensional approach (IMA). RESULTS: During study period 252 HAIs were found in 1353 (549F/804M) patients and 14,700 patient-days of hospitalisation. The crude infections rate and incidence density of DA-HAIs was 18.69% and 17.49 ± 2.56 /1000 patient-days. Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI) and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 12.63 ± 1.49, 1.83 ± 0.65 and 6.5 ± 1.2, respectively. VAP(137) constituted 54.4% of HAIs, whereas CA-UTI(91) 36%, CLA-BSI(24) 9.6%.The most common pathogens in VAP and CA-UTI was multidrug-resistant (MDR) Acinetobacter baumannii (57 and 31%), and methicillin-resistant Staphylococcus epidermidis (MRSE) in CLA-BSI (45%). MDR Gram negative bacteria (GNB) 159 were responsible for 63.09% of HAIs. The length of hospitalisation of patients with a single DA-HAI at ICU was 21(14-33) days, while without infections it was 6.0 (3-11) days; p = 0.0001. The mortality rates in the hospital-acquired infection group and no infection group were 26.1% vs 26.9%; p = 0.838; OR 0.9633;95% CI (0.6733-1.3782). Extra cost of therapy caused by one ICU acquired HAI was US$ 11,475/Euro 10,035. Hand hygiene standards compliance rate was 64.7%, while VAP, CLA-BSI bundles compliance ranges were 96.2-76.8 and 29-100, respectively. CONCLUSIONS: DA-HAIs was diagnosed at nearly 1/5 of patients. They were more frequent than in European Centre Disease Control report (except for CLA-BSI), more frequent than the USA CDC report, yet less frequent than in limited-resource countries (except for CA-UTI). They prolonged the hospitalisation period at ICU and generated substantial additional costs of treatment with no influence on mortality. The Acinetobacter baumannii MDR infections were the most problematic therapeutic issue. DA-HAIs preventive methods compliance rate needs improvement.