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Catheter-associated urinary tract infection is a common clinical condition among hospitalized patients with numerous health and economic implications. With judicious use of indwelling urinary catheters, along with strict adherence to basic infection prevention measures, such as hand hygiene and aseptic technique during catheter insertion, these infections are most often preventable. However, these devices continue to be used inappropriately or unnecessarily, which has led the Center for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and numerous infectious disease professional societies to focus attention on how these infections can be diagnosed, prevented, and managed. Despite these efforts, consensus on how best to identify cases of CAUTI has been elusive.
Perhaps the most widely used guidelines for the diagnosis, prevention, and treatment of CAUTI are those published in 2010 in the American Journal of Infection Control by Hooton and colleagues. These authors are very clear that CAUTI is a problem if, and only if, it is associated with clinical manifestations; the presence of urinary microorganisms alone is not a clear indication for antimicrobial therapy. Moreover, these authors provide a list of accepted clinical manifestations of CAUTI, which are substantially different from those in previous guidelines. Among others, the manifestations listed include: fever, suprapubic tenderness, flank tenderness, and delirium. However, these are supported by expert opinion only, and neither their diagnostic validity nor their inter-rater reliability have been reported in the literature.
The purpose of this study was to examine the diagnostic validity and inter-rater reliability of fever, suprapubic tenderness, flank tenderness, and delirium in hospitalized adult with an indwelling urinary catheter. Briefly, these clinical manifestations were compared against three diagnostic criteria for CAUTI based on microbiologic and molecular methods, and their inter-rater reliability was examined using assessments conducted by three advanced practice nurses.
Because significant microbial growth was only present in two urine samples, the diagnostic validity of these manifestations could not be established. However, it was possible to examine the inter-rater reliability of these manifestations. To summarize these findings, the nurse raters were in perfect agreement with the identification of fever, moderate agreement with the identification of delirium, and fair agreement with the identification of suprapubic tenderness and flank tenderness. With the exception of flank tenderness, these findings are statistically significant, and they provide evidence that nurses can consistently identify the presence and absence of fever, suprapubic tenderness, and delirium in hospitalized patients with indwelling urinary catheters. As CAUTI receives more attention from multiple stakeholders, nurses must take an active role in correctly identifying patients with this condition. However, this study had several limitations, and further research is necessary to understand the overall clinical utility and value of these manifestations in terms of patient outcomes and cost.