(See the article by Tedja et al7 on pages 1330–1334.) Increasingly, payers, legislators, regulators, consumer groups, and the general public have become interested in the prevention of hospital-acquired infections (HAIs). Most states have mandated public reporting of HAIs, and some financial reimbursements are now linked to how effectively hospitals prevent infections.

For example, HAI prevention is a central part of the Centers for Medicare and Medicaid (CMS) Hospital-Acquired Condition (HAC) Reduction Program. In this program, 65% of a hospital’s total HAC score is based on the observedto-predicted number of central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). When a hospital falls in the highest quartile of HAC scores, a stiff financial penalty is imposed: CMS reduces the hospital’s reimbursements by 1%. Evaluating hospital quality, however, is fraught with difficulties. A good HAI metric should be objective, reflect a clear episode of patient harm, and be preventable through the implementation of evidence-based practices. The question at hand is whether these standards are met by the National Healthcare Safety Network (NHSN) surveillance definition for CAUTI as part of the HAC Reduction Program. Whether a NHSN-defined CAUTI represents an episode of patient harm is debatable. Because the surveillance definition does not coincide with physician practices, each CAUTI does not necessarily represent a preventable infection or antibiotic prescription. 1 Furthermore, because the criteria used to define a CAUTI are nonspecific, it is unclear what exactly the metric is measuring. To meet the current CAUTI definition, a patient must meet 3 simple criteria:(1) the presence of a Foley catheter for> 2 days;(2) a urine culture growing≥ 105 colony-forming units per milliliter (CFU/mL) of bacteria; and (3) signs or symptoms suggestive of a urinary tract infection (UTI). This final criterion has been met by a temperature> 38 C in 79.7% of cases reported to the NHSN. 2 The nonspecificity of the NHSN criteria is highlighted in the intensive care unit (ICU), where the simultaneous occurrence of these 3 findings is common. Foley utilization in the ICU ranges from 48% to 76% depending on the type of unit, while fever,