The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care

OBJECTIVE: To determine the additional direct costs of hospitalization attributable to catheter-associated urinary tract infection (CAUTI) in 1,497 newly catheterized patients. DESIGN: Prospective observational and laboratory study. SETTING: University hospital. METHODS: Data were collected on risk factors for CAUTI (defined as > 10(3) colony-forming units [CFU]/mL), severity of illness, and diagnostic and therapeutic interventions in consenting newly catheterized patients. Daily urine cultures were obtained from each newly catheterized patient, but the results of these cultures were not revealed to his or her physician. During the study, one of the investigators (DGM) reviewed each patient's record and made a judgment as to which of the diagnostic tests and treatments ordered and what incremental length of stay could reasonably be ascribed to his or her CAUTI. The total hospital costs for each patient were also obtained. RESULTS: Overall, 235 patients acquired CAUTIs during the study; most of the CAUTIs were completely asymptomatic, and only 52% were diagnosed by the patients' physicians using the hospital laboratory. Only 1 patient with a CAUTI had a secondary bloodstream infection. Thirty-three (13%) of the CAUTIs were caused by Escherichia coli; 63 (25%) by Klebsiella, Enterobacter, Citrobacter, Pseudomonas aeruginosa, or other antibiotic-resistant, gram-negative bacilli; 87 (35%) by enterococci or staphylococci; and 67 (27%) by Candida species. The 123 CAUTIs diagnosed by the hospital laboratory were judged to have been responsible for an additional $20,662 in extra costs of diagnostic tests and $35,872 in extra medication costs, a mean of $589 (median, $356) per CAUTI. CAUTIs caused by E. coli cost considerably less than infections caused by other gram-negative bacilli ($363.3 +/- $228.2 vs $690.4 +/- $783.7; P =.02) or yeasts ($821.2 +/- $2,169.9). There were less striking differences in the costs per CALM caused by staphylococci or enterococci ($387.1 +/- $434.8). CONCLUSIONS: The extra direct costs associated with nosocomial CALM found in this prospective study, which was done in the era of managed care during the late 1990s, are substantially lower than those reported in the largest comparable studies done more than 15 years ago, most of which were retrospective, reflecting the powerful impact of cost-containment measures that are now implemented in managed care.