European and Asian guidelines on management and prevention of catheter-associated urinary tract infections

Replacement of Urinary Catheter for Urinary Tract Infections: A Prospective Observational Study

OBJECTIVES

To assess whether catheter replacement is associated with better clinical outcomes in individuals with long-term urinary catheters.

DESIGN

Prospective, noninterventional study.

PARTICIPANTS

Individuals (mean age 79.2±11.5) who had had an indwelling urinary catheter for longer than 7 days and a symptomatic urinary tract infection (UTI) (N=315).

MEASUREMENTS

The exposure assessed was replacement of the indwelling urinary catheter within 6 hours. The primary outcome was clinical failure at day 7. We developed a propensity score model for catheter replacement to match participants. Multivariate analysis was conducted to adjust for other risk factors.

RESULTS

The catheter was replaced in 98 participants and not in 217. More than half of the participants resided in long-term care facilities and had high Charlson comorbidity scores. The rate of clinical failure on day 7 was 35.2% (108/306). The 30-day fatality rate was 30.8% (96/315). We found no statistically significant association between catheter replacement and clinical failure (propensity-adjusted odds ratio (OR)=0.90, 95% CI=0.50-1.63) or 30-day fatality (OR=0.76, 95% CI=0.40-1.44).

CONCLUSION

We found no clinical benefit of replacing a long-term catheter at the onset of the catheter-associated UTI. Further research is needed through randomized controlled trials.

A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection

Objective

Catheter-associated urinary tract infections (CAUTIs) are common and preventable hospital-acquired infections, yet their rate continues to rise nationwide. We describe the implementation of a multifaceted program to reduce catheter use and CAUTI rates while simultaneously addressing barriers to long-term success.

Design/Setting/Participants

Pre-post study of medical inpatient veterans between December 2012 and February 2015.

Intervention

Five component intervention: (i) a bedside catheter reminder; (ii) multidisciplinary educational campaign; (iii) structured catheter order set with clinical decision support; (iv) automated catheter discontinuation orders; and (v) protocol for post-catheter removal care.

Main Outcome Measure(s)

Catheter utilization rates and CAUTI rates on the study ward were followed during the 14-week baseline period, the 27-week transition/intervention period and the 70-week period of full implementation/sustainability. Rates of patient falls per bed days and catheter reinsertions were collected during the same time periods as balancing measures.

Results

Catheter use declined by 35% from the baseline period to the full implementation/sustainability period. This improvement was not realized until deployment of the structured electronic orders with automated catheter discontinuation and protocolized post-catheter care. The average number of days between CAUTIs on the study ward increased from 101 days in the baseline period to over 400 days in the full implementation/sustainability period. There was no significant change in the rates of falls or catheter reinsertions during the study period.

Conclusions

A multicomponent intervention aimed specifically at targeting local barriers was successful in reducing catheter utilization as well as CAUTIs in a veteran population without compensatory increase in patient falls or catheter replacement.

Comparative activity of silver-based antimicrobial composites for urinary catheters

Biomedical polymers are an integral component in a wide range of medical devices because of their many desirable properties. However, extensive use of polymer materials in medical devices has been associated with an increasing incidence of patient infections. Efforts to address this issue have included incorporating antimicrobial additives to develop novel antimicrobial polymeric materials. Silver, with its high toxicity towards bacteria, oligodynamic effect and good thermal stability, has been employed as an additive for polymeric medical devices. In the present study, commercially available elemental (Biogate) and ionic (Ultrafresh 16) silver additives were incorporated into a Polyamide 11 (PA 11) matrix using a compression press. These polymer composites were evaluated for their antimicrobial and ion-release properties. Elemental silver composites were shown to retain their antimicrobial properties for extended periods and actively released silver ions for 84 days; whereas ionic silver composites lost their ion-release activity and, therefore, their antibacterial activity after 56 days. Bacterial log reduction units of 3.87 for ionic silver and 2.41 for elemental silver were identified within 24 h, when tested in accordance with the ISO 22196 test standard; this indicates that ionic silver is more efficient for short-term applications than elemental silver.

Asymptomatic bacteriuria, to screen or not to screen - and when to treat?

PURPOSE OF REVIEW

Asymptomatic bacteriuria (ABU) is a common clinical condition that often leads to unnecessary treatment. The purpose of this review is to outline and evaluate the most recent literature on the management of ABU.

RECENT FINDINGS

The role of ABU management has been evaluated in several patient subgroups: healthy patients without identified risk factors, pregnant women, postmenopausal women, women with recurrent UTI, patients with diabetes, elderly institutionalized patients, patients with renal transplants, patients with indwelling catheters and prior to surgery. Available evidence only supports the need for screening and treatment of ABU in pregnant women and prior to urological procedures breaching the mucosa. In all the other conditions the treatment of ABU is not only useless but also harmful. A short course treatment in pregnant women is recommended; in patients with ABU prior to urological procedures breaching the mucosa the treatment should be given in line with antibiogram and in line with the recommendations of European Association of Urology guidelines.

SUMMARY

The approach to patients with ABU has changed completely during recent years. Today, screening and treatment of ABU is recommended only in pregnant women and in all patients who are candidates for urological procedures breaching the mucosa.

Evaluation of Antimicrobial Durability and Anti-Biofilm Effects in Urinary Catheters Against Enterococcus faecalis Clinical Isolates and Reference Strains

BACKGROUND

Enterococcus faecalis, Escherichia coli, Staphylococcus epidermidis, Pseudomonas aeruginosa and Candida albicans biofilms are major causes of catheter-associated urinary tract infections. Antimicrobial-coated or impregnated urinary catheters are seen as a possible way to prevent these infections.

AIMS

To determine the biofilm-forming ability of 89 E. faecalis isolates from urinary tract infections and to compare several urinary catheters for antimicrobial durability and the inhibitory effects on biofilm formation of different laboratory strains and clinical isolates of E. faecalis.

STUDY DESIGN

In vitro experimental study.

METHODS

The biofilm forming ability of E. faecalis isolates was determined by the crystal violet staining and plate counting methods. For comparison of urinary catheters, biofilms of 45 E. faecalis isolates from the catheter samples of hospitalized patients and five laboratory strains of E. coli ATCC25922, S. epidermidis ATCC35984, P. aeruginosa ATCC27853, E. faecalis ATCC29212 and C. albicans ATCC90028 were formed on the catheters in 24-well tissue culture plates. Scanning electron microscopy analysis was performed to observe biofilms.

RESULTS

All 89 E. faecalis isolates were found to be biofilm positive. Nitrofurazone-impregnated catheters significantly reduced the cell counts of E. faecalis isolates and completely inhibited the formation of P. aeruginosa and S. epidermidis biofilms compared with the others. Regarding reduction of biofilm cell counts, a hydrophilic-coated catheter was more effective against P. aeruginosa, whereas a silver-coated catheter was found to be more effective against S. epidermidis. The nitrofurazone-impregnated catheter had the best antimicrobial durability.

CONCLUSION

Urine isolates of E. faecalis had considerable ability with respect to biofilm formation. The nitrofurazone-impregnated catheter was the most effective against all tested bacteria; however, the effect of a hydrophilic or silver-coated catheter depends on the species present in it.

Modification of a conventional polyurethane composition provides significant anti-biofilm activity against Escherichia coli

Tecoflex-NH₃⁺ exhibited a contact-killing mechanism and showed excellent anti-biofilm properties against E. coli even after 5 days.

Reducing catheter-associated urinary tract infections in hospitals: study protocol for a multi-site randomised controlled study

INTRODUCTION

Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. A number of measures can be taken to reduce the risk of CAUTI in hospitals. Appropriate urinary catheter insertion procedures are one such method. Reducing bacterial colonisation around the meatal or urethral area has the potential to reduce CAUTI risk. However, evidence about the best antiseptic solutions for meatal cleaning is mixed, resulting in conflicting recommendations in guidelines internationally. This paper presents the protocol for a study to evaluate the effectiveness (objective 1) and cost-effectiveness (objective 2) of using chlorhexidine in meatal cleaning prior to catheter insertion, in reducing catheter-associated asymptomatic bacteriuria and CAUTI.

METHODS AND ANALYSIS

A stepped wedge randomised controlled trial will be undertaken in three large Australian hospitals over a 32-week period. The intervention in this study is the use of chlorhexidine (0.1%) solution for meatal cleaning prior to catheter insertion. During the first 8 weeks of the study, no hospital will receive the intervention. After 8 weeks, one hospital will cross over to the intervention with the other two participating hospitals crossing over to the intervention at 8-week intervals respectively based on randomisation. All sites complete the trial at the same time in 2018. The primary outcomes for objective 1 (effectiveness) are the number of cases of CAUTI and catheter-associated asymptomatic bacteriuria per 100 catheter days will be analysed separately using Poisson regression. The primary outcome for objective 2 (cost-effectiveness) is the changes in costs relative to health benefits (incremental cost-effectiveness ratio) from adoption of the intervention.

DISSEMINATION

Results will be disseminated via peer-reviewed journals and presentations at relevant conferences.A dissemination plan it being developed. Results will be published in the peer review literature, presented at relevant conferences and communicated via professional networks.

ETHICS

Ethics approval has been obtained.

TRIAL REGISTRATION NUMBER

12617000373370, approved 13/03/2017. Protocol version 1.1.

Spectrum and antibiotic resistance of catheter-associated urinary tract infections

Catheter associated urinary tract infections (CAUTIs) are amongst the most common nosocomial infections and are also considered among the most common complications associated with indwelling urinary catheters. Most catheter associated infections are derived from the patient's own perineal flora, however the presence of a catheter increases the chance of being colonised by cross transmission of nosocomial bacteria as well. Most episodes of short-term catheter-associated bacteriuria are asymptomatic and are caused by single organisms, while long-term catheterisation promotes multibacterial infections and colonization. With prolonged duration of catheterization bacteriuria is considered universal because of the formation of biofilms on the surface of the catheter. Chronic indwelling catheters are an important reservoir of different multiresistant gram-negative organisms, therefore they are frequently isolated from CAUTIs. Treatment of catheter associated asymptomatic bacteriuria is not recommended because it will only promote the emergence of resistant organisms without effectively clearing the urine of catheterised patients.

A qualitative study exploring the value of a catheter passport

Many patients leaving hospital with a catheter do not have sufficient information to self-care and can experience physical and psychological difficulties.

AIM

This study aimed to explore how a patient-held catheter passport affects the experiences of patients leaving hospital with a urethral catheter, the hospital nurses who discharge them and the community nurses who provide ongoing care for them.

METHOD

Qualitative methods used included interviews, focus groups and questionnaires, and thematic analysis.

FINDINGS

Three major themes were reported-informing patients, informing nurses; improving catheter care, promoting self-management; and supporting transition.

CONCLUSION

The catheter passport can bridge the existing information gap, improve care, promote self-care and help patients adjust to their catheter, especially if complemented by ongoing input from a nurse or other health professional.

Development and characterization of a stable adhesive bond between a poly(dimethylsiloxane) catheter material and a bacterial biofilm resistant acrylate polymer coating

Catheter associated urinary tract infections are the most common health related infections worldwide, contributing significantly to patient morbidity and mortality and increased health care costs. To reduce the incidence of these infections, new materials that resist bacterial biofilm formation are needed. A composite catheter material, consisting of bulk poly(dimethylsiloxane) (PDMS) coated with a novel bacterial biofilm resistant polyacrylate [ethylene glycol dicyclopentenyl ether acrylate (EGDPEA)-co-di(ethyleneglycol) methyl ether methacrylate (DEGMA)], has been proposed. The coated material shows excellent bacterial resistance when compared to commercial catheter materials, but delamination of the EGDPEA-co-DEGMA coatings under mechanical stress presents a challenge. In this work, the use of oxygen plasma treatment to improve the wettability and reactivity of the PDMS catheter material and improve adhesion with the EGDPEA-co-DEGMA coating has been investigated. Argon cluster three dimensional-imaging time-of-flight secondary ion mass spectrometry (ToF-SIMS) has been used to probe the buried adhesive interface between the EGDPEA-co-DEGMA coating and the treated PDMS. ToF-SIMS analysis was performed in both dry and frozen-hydrated states, and the results were compared to mechanical tests. From the ToF-SIMS data, the authors have been able to observe the presence of PDMS, silicates, salt particles, cracks, and water at the adhesive interface. In the dry catheters, low molecular weight PDMS oligomers at the interface were associated with poor adhesion. When hydrated, the hydrophilic silicates attracted water to the interface and led to easy delamination of the coating. The best adhesion results, under hydrated conditions, were obtained using a combination of 5 min O₂ plasma treatment and silane primers. Cryo-ToF-SIMS analysis of the hydrated catheter material showed that the bond between the primed PDMS catheter and the EGDPEA-co-DEGMA coating was stable in the presence of water. The resulting catheter material resisted Escherichia coli and Proteus mirabilis biofilm colonization by up to 95% compared with uncoated PDMS after 10 days of continuous bacterial exposure and had the mechanical properties necessary for use as a urinary catheter.

[Community acquired urinary tract infections - association with risk factors : Changes in causative organisms and resistance over time]

BACKGROUND

Published studies on community-acquired urinary tract infections (UTI) often do not link microbiological findings with clinical risk factors and patient data.

MATERIALS AND METHODS

We retrospectively correlated clinical findings of all patients with UTI of a urological outpatient clinic with the respective microbiological analysis of their urine samples over 2 periods of time: (A: 2005-2006 and B: 2011-2012). Patients were stratified to the following risk groups: uncomplicated cystitis, diabetes mellitus type 2, nursing home resident, prostatitis/epidydimitis, permanent catheter.

RESULTS

The incidence of Escherichia coli (p < 0.001) and proteus (p < 0.001) significantly decreased from period A to B, while enterococci (p = 0.003) and staphylococci (p < 0.001) significantly increased. Antibiotic sensitivity to fosfomycin (p < 0.001), doxycycline (p < 0.001), nitrofurantoin (p < 0.001), and nitroxoline increased (p < 0. 001) and sensitivity to amoxicillin (p < 0.001) and gentamicin decreased (p < 0.001). Patients with a permanent catheter had significantly poorer sensitivity rates (50% and less) for almost all antibiotics tested compared to the overall group. The risk of a UTI with 3MRGN or MRSA bacteria was significantly higher for catheter carriers and nursing home residents.

CONCLUSIONS

Empiric antibiotic first-line therapy with nitrofurantoin and fosfomycin for uncomplicated community acquired UTIs are well indicated in conformity with guidelines. The accumulation of multiresistant pathogens in patients with a permanent bladder catheter requires restrictive use of any permanent catheter drainage.

Characterisation of polyamide 11/copper antimicrobial composites for medical device applications

Direct incorporation of antimicrobial additive into the polymer matrix is a cost effective approach for the development of polymer/metal antimicrobial composites. Application of these antimicrobial composite systems for manufacturing medical devices addresses the issue of device related infections. In the present study, commercially available inorganic copper based additive, Plasticopper, was incorporated into a Polyamide 11(PA 11) matrix during the polymer processing stage. These polymer composites were evaluated for their morphological, mechanical, antimicrobial and ion release properties. Isothermal crystallisation studies showed that the copper additive acted as a nucleating agent and promoted faster crystallisation. Short term mechanical studies confirmed that the incorporation of copper has reinforcing effect on the composites with 5 and 10% copper loadings and did not adversely affect the short-term mechanical performance of the polymer composites. These composite systems were shown to be active against Escherichia coli ATCC 8739 with >99.99% reduction in bacterial population. Corresponding ion release profiles for these composites indicated long term antimicrobial activity.

Prevention of nosocomial infections in critically ill patients with lactoferrin (PREVAIL study): study protocol for a randomized controlled trial

BACKGROUND

Nosocomial infections remain an important source of morbidity, mortality, and increased health care costs in hospitalized patients. This is particularly problematic in intensive care units (ICUs) because of increased patient vulnerability due to the underlying severity of illness and increased susceptibility from utilization of invasive therapeutic and monitoring devices. Lactoferrin (LF) and the products of its breakdown have multiple biological effects, which make its utilization of interest for the prevention of nosocomial infections in the critically ill.

METHODS/DESIGN

This is a phase II randomized, multicenter, double-blinded trial to determine the effect of LF on antibiotic-free days in mechanically ventilated, critically ill, adult patients in the ICU. Eligible, consenting patients will be randomized to receive either LF or placebo. The treating clinician will remain blinded to allocation during the study; blinding will be maintained by using opaque syringes and containers. The primary outcome will be antibiotic-free days, defined as the number of days alive and free of antibiotics 28 days after randomization. Secondary outcomes will include: antibiotic utilization, adjudicated diagnosis of nosocomial infection (longer than 72 h of admission to ICU), hospital and ICU length of stay, change in organ function after randomization, hospital and 90-day mortality, incidence of tracheal colonization, changes in gastrointestinal permeability, and immune function. Outcomes to inform the conduct of a larger definitive trial will also be evaluated, including feasibility as determined by recruitment rates and protocol adherence.

DISCUSSION

The results from this study are expected to provide insight into a potential novel therapeutic use for LF in critically ill adult patients. Further, analysis of study outcomes will inform a future, large-scale phase III randomized controlled trial powered on clinically important outcomes related to the use of LF.

TRIAL REGISTRATION

The trial was registered at www.ClinicalTrials.gov on 18 November 2013.

TRIAL REGISTRATION NUMBER

NCT01996579 .

Is Bladder Training by Clamping Before Removal Necessary for Short-Term Indwelling Urinary Catheter Inpatient? A Systematic Review and Meta-analysis

PURPOSE

Urinary catheterization is a common technique in clinical practice. There is, however, no consensus on management prior to removal of the indwelling catheter for short-term patients. This systematic review examined the necessity of clamping before removal of an indwelling urinary catheter in short-term patients.

METHODS

A systematic literature review was conducted using eight databases and predetermined keywords-guided searches. Some 2,515 studies were evaluated. Ten studies that met the inclusion criteria were selected.

RESULTS

The quality of the studies was assessed using the Jadad scoring system. Only 40.0% of studies were rated as high quality. This review found that catheter clamping prior to removal was not necessary for the short-term patient. When made a comparison with the unclamping group, there was no significant difference in recatheterization risk, risk of urine retention, patients' subjective perceptions and rate of urinary tract infection.

CONCLUSIONS

This review indicated that bladder training by clamping prior to removal of urinary catheters is not necessary in short-term catheter patients. In addition, clamping carries the risk of complications such as prolonging urinary catheter retention and urinary tract injury. Further investigation requires higher quality methodologies and more diverse study designs.

External Collection Devices as an Alternative to the Indwelling Urinary Catheter: Evidence-Based Review and Expert Clinical Panel Deliberations

Multiple evidence-based guidelines have suggested clinicians consider external collection devices (ECD) as alternatives to indwelling catheters. Nevertheless, there is a dearth of evidence-based resources concerning their use. An expert consensus panel was convened to review the current state of the evidence, indications for ECDs as an alternative to an indwelling urinary catheter, identify knowledge gaps, and areas for future research. This article presents the results of the expert consensus panel meeting and a systematic literature review regarding ECD use in the clinical setting.

Recommended Initial Antimicrobial Therapy for Emphysematous Pyelonephritis: 51 Cases and 14-Year-Experience of a Tertiary Referral Center

The aim of this study was to investigate the profiles of pathogens and patterns of antibiotic resistance of emphysematous pyelonephritis (EPN), offering recommendations for initial antibiotic treatment.Between January, 2001, and November, 2014, demographic data, presenting clinical features, management strategies, and treatment outcomes of 51 patients with EPN were retrospectively reviewed, analyzing microbiological characteristics of causative pathogens and patterns of antibiotic resistance.Overall survival rate was 90.2% (46/51). Pathogens isolated most frequently were Escherichia coli (49.0%), Klebsiella pneumoniae (19.6%), and Proteus mirabilis (17.7%). Approximately 24% of E coli isolates and 22% K pneumoniae isolates were resistant to fluoroquinolones. Improper empiric antibiotic use (P = 0.02) and third-generation cephalosporin-resistant pathogens (G3CRP) (P = 0.01) were significantly more common in cases of patient fatality. Prior hospitalization and antibiotic use within past year (P = 0.03), need for emergency hemodialysis (P = 0.03), and development of disseminated intravascular coagulation (DIC) (P = 0.03) were factors correlating significantly with microbial resistance to third-generation cephalosporins. The area under the receiver operating characteristic curve was 0.91. The cut-off point determined by the maximum Youden index for 2 of these 3 factors yielded a sensitivity of 0.8 and specificity of 0.93.Third-generation cephalosporins are recommended as initial treatment of EPN. In patients with histories of prior hospitalization and antibiotic use and in those needing emergency hemodialysis or developing DIC, carbapenem is the empiric antibiotic of choice. Patients presenting with 2 or more factors carry the highest risk of G3CRP involvement. Fluoroquinolone and gentamicin should be avoided.

Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults

BACKGROUND

Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death.

OBJECTIVES

To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required.

MAIN RESULTS

In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis.

AUTHORS' CONCLUSIONS

Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Laparoscopic and cystoscopic-assisted suprapubic catheter insertion: A case study and technical note

OBJECTIVE

To describe a new technique for suprapubic urinary catheterisation that can be used in selected patients with high anaesthetic risk, and previous lower abdominal surgery and bowel adhesions.

PATIENT AND METHODS

In a 33-year-old woman, laparoscopic guidance with cystoscopic vision was used to ensure the safe passage of a suprapubic catheter.

RESULTS

The suprapubic catheter was successfully inserted in this challenging patient; release of adhesions allowed for the passage of the catheter without bowel injury.

CONCLUSION

Laparoscopic and cystoscopic-assisted suprapubic catheter insertion is a novel technique to avoid significant morbidity and mortality in selected patients with high anaesthetic risk, and previous lower abdominal surgery and bowel adhesions.

[Prevention of catheter-associated urinary tract infections: established and new aspects for the clinical routine : Revised recommendations on "prevention and control of catheter-associated urinary tract infections" of the commission for hospital hygiene and infection prevention at the Robert Koch Institute]

Catheter-associated urinary tract infections (CAUTI) are one of the most common healthcare-associated infections (HAI) in Germany and are of particular relevance for intensive and standard care units. The revised guidelines of the commission for hospital hygiene and infection prevention (KRINKO) provide an update on prevention of CAUTI. The guidelines consider and evaluate the new literature published after the initial publication in 1999. The KRINKO recommendations should be implemented to protect patients from such infections, especially as CAUTIs are one of the most preventable types of HAI. In this respect tailor-made infection prevention bundles seem to be most effective and continuous infection surveillance procedures are of particular importance. Thus, a comparison with the reference data provided by the (German) National Reference Center for surveillance of nosocomial infections is possible. This article explains the recommendations for prevention measures included in the new KRINKO guidelines.

Using quality improvement methods to prevent catheter-associated UTI

Catheter-associated urinary tract infection (CAUTI) is considered to be reasonably preventable and there is an abundance of published guidance, all of which details similar CAUTI-prevention strategies. Many strategies and methods have been applied to reduce CAUTI; this article describes a quality improvement (QI) approach to the implementation of CAUTI prevention strategies, which can provide better patient experience and outcomes for patients.

[Urinary tract infections in the elderly]

Acute infection of the urinary tract is one of the most commonly encountered bacterial infections in the frail elderly population and is responsible for substantial morbidity and recurrent infections with antibiotic resistance. Although generally considered to be self-limiting without treatment or easily treated with a short antibiotic regime, urinary tract infections (UTIs) often have a dramatic history, associated with incomplete resolution and frequent recurrence. The biological complexity of the infections combined with a dramatic rise in antibiotic-resistant pathogens highlight the need for an anticipating strategy for therapy necessary for a rapid recovery. The first crucial step is the classification in asymptomatic bacteriuria or complicated pyelonephritis, on which the decision for the intensity of treatment and diagnostic effort is based. For the selection of empiric antibiotic therapy, knowledge about the predominant uropathogens as well as local resistance patterns is important. In this manner, most urinary tract infections in the elderly can be treated without greater expense.

The emerging threat of multidrug-resistant Gram-negative bacteria in urology

Antibiotic resistance in Gram-negative uropathogens is a major global concern. Worldwide, the prevalence of Enterobacteriaceae that produce extended-spectrum β-lactamase or carbapenemase enzymes continues to increase at alarming rates. Likewise, resistance to other antimicrobial agents including aminoglycosides, sulphonamides and fluoroquinolones is also escalating rapidly. Bacterial resistance has major implications for urological practice, particularly in relation to catheter-associated urinary tract infections (UTIs) and infectious complications following transrectal-ultrasonography-guided biopsy of the prostate or urological surgery. Although some new drugs with activity against Gram-negative bacteria with highly resistant phenotypes will become available in the near future, the existence of a single agent with activity against the great diversity of resistance is unlikely. Responding to the challenges of Gram-negative resistance will require a multifaceted approach including considered use of current antimicrobial agents, improved diagnostics (including the rapid detection of resistance) and surveillance, better adherence to basic measures of infection prevention, development of new antibiotics and research into non-antibiotic treatment and preventive strategies.

Bacteruria and Urinary Tract Infections in the Elderly

Both urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) are common problems among elderly adults and represent a significant health care burden. Despite their frequency, differentiating between ASB and true UTI remains controversial among health care providers. Several challenges exist in the evaluation of urinary symptoms in the elderly patient. Symptoms of UTI are variable; problems are encountered in the collection, testing, and interpretation of urine specimens; and results of urinalysis are often misinterpreted and mishandled. Multiple studies have shown no morbidity or mortality benefit to antibiotic therapy in either community or long-term care facility residents with ASB.

The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method

Interventions to reduce urinary catheter use involve lists of "appropriate" indications developed from limited evidence without substantial multidisciplinary input. Implementing these lists, however, is challenging given broad interpretation of indications, such as "critical illness." To refine criteria for appropriate catheter use-defined as use in which benefits outweigh risks-the RAND/UCLA Appropriateness Method was applied. After reviewing the literature, a 15-member multidisciplinary panel of physicians, nurses, and specialists in infection prevention rated scenarios for catheter use as appropriate, inappropriate, or of uncertain appropriateness by using a standardized, multiround rating process. The appropriateness of Foley catheters, intermittent straight catheters (ISCs), and external condom catheters for hospitalized adults on medical services was assessed in 299 scenarios, including urinary retention, incontinence, wounds, urine volume measurement, urine sample collection, and comfort. The scenarios included patient-specific issues, such as difficulty turning and catheter placement challenges. The panel rated 105 Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain), 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncertain), and 97 external catheter scenarios (30 appropriate, 51 inappropriate, 16 uncertain). The refined criteria clarify that Foley catheters are appropriate for measuring and collecting urine only when fluid status or urine cannot be assessed by other means; specify that patients in the intensive care unit (ICU) need specific medical indications for catheters because ICU location alone is not an appropriate indication; and recognize that Foley and external catheters may be pragmatically appropriate to manage urinary incontinence in select patients. These new appropriateness criteria can inform large-scale collaborative and bedside efforts to reduce inappropriate urinary catheter use.

[Incidence of urinary tract infections after cardiac surgery: comparative study accordind to catheterization device]

INTRODUCTION

Urinary tract infections (UTI) associated with urethral catheterization are the second cause of nosocomial infections in Intensive care units. We confirm a UTI when we get a result of 100,000 CFU/ml with at least one microorganism in a urine culture.

MAIN OBJECTIVE

Compare and determine the incidence of UTI in cardiac surgery postpoperative patients according to the catheterization device.

METHODS

A prospective, randomized analytical observational study of patients in the immediate cardiac surgery postoperative period. One group was probed with catheter Foley and one was inserted the catheter BIPFoley-Bactiguard® (CBF). The CBF is coated with noble metals (silver, gold and palladium) and biocompatible antimicrobial properties, covering the entire surface of the device and prevents the formation of biofilm, microbial adherence and colonization.

RESULTS

116 cases, 59.5% (69 cases) were negative for UTI and 40.5% (47 cases) were positive. Out of the positive UTI results, 25% were carriers of catheter Foley and 15.5% of CBF. Most common etiologic microorganisms: Escherichia coli 29.8% Klebsiella pneumonia 29.8%, Klebsiella oxytoca 9%.

CONCLUSION

With the data we have observed that patients catheterized BIPfoley-Bactiguard® are infected to a lesser extent than Foley carriers.

Shortening the course of antibiotic treatment in the intensive care unit

Effective antimicrobial stewardship is an increasingly important concern for healthcare providers globally. Antibiotics are frequently prescribed for patients who develop sepsis in the intensive care unit and traditionally courses are prolonged, with uncertain benefit and probable harm. There is little evidence to support many guidelines recommending between 10 and 14 days, and a number of studies suggest substantially shorter courses of less than 7 days may suffice. Safely reducing course length is likely to depend on a number of preconditions, including thorough eradication of any septic foci; optimization of serum antibiotic concentrations, particularly when there is physiological derangement; and use of novel biomarkers such as procalcitonin. The critical care environment is well suited to this aim as patients are closely monitored. With these measures in place, it is reasonable to believe short antibiotic courses can safely be used for the majority of intensive care infections.

Prevention of Bacterial Biofilms Formation on Urinary Catheter by Selected Plant Extracts

In this study, we investigated the feasibility of using Psidium guajava, Mangifera indica and Ocimum gratissimum leaf extracts in preventing Escherichia coli biofilm formation. The plants extractions were done with methanol under cold extraction. The various concentrations 5.0, 10.0 and 20.0 mg mL(-1) were used to coat 63 catheters under mild heat from water bath. Biofilm formation on the catheter was induced using cultures of E. coli. Biofilm formation was evaluated using aerobic plate count and turbidity at 600 nm. From the obtained results, Psidium guajava, Mangifera indica and Ocimum gratissimum delayed the onset of biofilm formation for a week. Ocimum gratissimum coated catheter had the highest inhibitory effect at 5.0, 10.0 and 20.0 mg mL(-1) with bacterial count ranging from 2.2 x 10(5)-7.0 x 10(4) and 5.7 x 10(5)-3.7 x10(5) for 120 and 128 h, respectively. The Psidium guajava coated catheter had the lowest inhibitory effect at 5.0, 10.0 and 20.0 mg mL(-1), with bacterial count ranging between 4.3 x 10(5)-1.9 x 10(3) and 7.7 x 10(5)-3.8 x 10(5) for 120 and 128 h, respectively. Despite the antimicrobial activities, the differences in the activity of these plant extracts were statistically not significant (p < 0.05).

Bacteremia and Mortality with Urinary Catheter–Associated Bacteriuria

Objective.

Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.

Design.

We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.

Setting.

A large tertiary care facility.

Patients.

All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.

Results.

We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.

Conclusions.

Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.

Healthcare-Associated Bloodstream Infections Secondary to a Urinary Focus The Québec Provincial Surveillance Results

Objective.

Urinary tract infections (UTIs) are an important source of secondary healthcare-associated bloodstream infections (BSIs), where a potential for prevention exists. This study describes the epidemiology of BSIs secondary to a urinary source (U-BSIs) in the province of Québec and predictors of mortality.

Design.

Dynamic cohort of 9,377,830 patient-days followed through a provincial voluntary surveillance program targeting all episodes of healthcare-associated BSIs occurring in acute care hospitals.

Setting.

Sixty-one hospitals in Québec, followed between April 1, 2007, and March 31, 2010.

Participants.

Patients admitted to participating hospitals for 48 hours or longer.

Methods.

Descriptive statistics were used to summarize characteristics of U-BSIs and microorganisms involved. Wilcoxon and X2 tests were used to compare U-BSI episodes with other BSIs. Negative binomial regression was used to identify hospital characteristics associated with higher rates. We explored determinants of mortality using logistic regression.

Results.

Of the 7,217 reported BSIs, 1,510 were U-BSIs (21%), with an annual rate of 1.4 U-BSIs per 10,000 patient-days. A urinary device was used in 71% of U-BSI episodes. Identified institutional risk factors were average length of stay, teaching status, and hospital size. Increasing hospital size was influential only in nonteaching hospitals. Age, nonhematogenous neoplasia, Staphylococcus aureus, and Foley catheters were associated with mortality at 30 days.

Conclusion.

U-BSI characteristics suggest that urinary catheters may remain in patients for ease of care or because practitioners forget to remove them. Ongoing surveillance will enable hospitals to monitor trends in U-BSIs and impacts of process surveillance that will be implemented shortly.

Nosocomial urinary tract infections: A review

Nosocomial urinary tract infections are a common complication in healthcare systems worldwide. A review of the literature was performed in June 2014 using the Medical Literature Analysis and Retrieval System Online (MEDLINE) database, through either PubMed or Ovid as a search engine, to identify publications regarding nosocomial urinary tract infections (NUTIs) definition, epidemiology, etiology and treatment.According to current definitions, more than 30% of nosocomial infections are urinary tract infections (UTIs). A UTI is defined 'nosocomial' (NUTI) when it is acquired in any healthcare institution or, more generally, when it is related to patient management. The origin of nosocomial bacteria is endogenous (the patient's flora) in two thirds of the cases. Patients with indwelling urinary catheters, those undergoing urological surgery and manipulations, long-stay elderly male patients and patients with debilitating diseases are at high risk of developing NUTIs. All bacterial NUTIs should be treated, whether the patient is harboring a urinary catheter or not. The length of treatment depends on the infection site. There is abundance of important guidance which should be considered to reduce the risk of NUTIs (hand disinfection with instant hand sanitizer, wearing non-sterile gloves permanently, isolation of infected or colonized catheterized patients). Patients with asymptomatic bacteriuria can generally be treated initially with catheter removal or catheter exchange, and do not necessarily need antimicrobial therapy. Symptomatic patients should receive antibiotic therapy. Resistance of urinary pathogens to common antibiotics is currently a topic of concern.

Factors associated with specific uropathogens in catheter-associated urinary tract infection: Developing a clinical prediction model

Objectives

To identify characteristics associated with particular groups of uropathogens in catheter-associated urinary tract infection (CA–UTI) and to develop clinical prediction rules for identifying these groups.

Methods

Demographic, clinical and microbiological data were analysed from patients with CA–UTI. Infections were categorized into enteric Gram-negative rods, nonfermenters, Gram-positive cocci and fungal. Variables were analysed using univariate and multiple logistic regression analyses, and were used to develop clinical prediction rules.

Results

A total of 492 patients were included in the study. Candida species were the most common uropathogens (30.7%), followed by enterococci (17.3%), Escherichia coli (12.0%), Pseudomonas spp. (10.8%), Klebsiella spp. (7.9%) and staphylococci (6.5%). Clinical prediction rules for the bacterial uropathogenic groups showed poor-to-fair discriminatory power, with sensitivities of <40% and specificities of >90%. However, clinical prediction rules showed good discriminatory power for fungal infections, with a sensitivity of 67.3% and a specificity of 78.1%.

Conclusions

Clinical prediction rules developed for identifying specific groups of bacterial uropathogens in patients with CA–UTI had a low sensitivity, whereas those for fungal infections showed good discriminatory power. Further studies to develop more refined and sensitive tools for predicting specific bacterial uropathogens in CA–UTI are warranted.

A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals

OBJECTIVES

Urinary tract infections (UTIs) account for over 30% of healthcare-associated infections. The aim of this study was to determine healthcare-associated UTI (HAUTI) and catheter-associated UTI (CAUTI) point prevalence in six Australian hospitals to inform a national point prevalence process and compare two internationally accepted HAUTI definitions. We also described the level and comprehensiveness of clinical record documentation, microbiology laboratory and coding data at identifying HAUTIs and CAUTIs.

SETTING

Data were collected from three public and three private Australian hospitals over the first 6 months of 2013.

PARTICIPANTS

A total of 1109 patients were surveyed. Records of patients of all ages, hospitalised on the day of the point prevalence at the study sites, were eligible for inclusion. Outpatients, patients in adult mental health units, patients categorised as maintenance care type (ie, patients waiting to be transferred to a long-term care facility) and those in the emergency department during the duration of the survey were excluded.

OUTCOME MEASURES

The primary outcome measures were the HAUTI and CAUTI point prevalence.

RESULTS

Overall HAUTI and CAUTI prevalence was 1.4% (15/1109) and 0.9% (10/1109), respectively. Staphylococcus aureus and Candida species were the most common pathogens. One-quarter (26.3%) of patients had a urinary catheter and fewer than half had appropriate documentation. Eight of the 15 patients ascertained to have a HAUTI based on clinical records (6 being CAUTI) were coded by the medical records department with an International Classification of Diseases (ICD)-10 code for UTI diagnosis. The Health Protection Agency Surveillance definition had a positive predictive value of 91.67% (CI 64.61 to 98.51) compared against the Centers for Disease Control and Prevention definition.

CONCLUSIONS

These study results provide a foundation for a national Australian point prevalence study and inform the development and implementation of targeted healthcare-associated infection surveillance more broadly.

A practical approach to difficult urinary catheterizations

Routine placement of transurethral catheters can be challenging in some situations, such as urethral strictures, severe phimosis and false passages. Intravaginal retraction of the urethral meatus can complicate Foley placement in postmenopausal females. In men, blind urethral procedures with mechanical or metal sounds without visual guidance or guidewire assistance are now discouraged due to the increased risk of urethral trauma and false passages. Newer techniques of urethral catheterization including guidewires, directed hydrophilic mechanical dilators, urethral balloon dilation, and direct vision endoscopic catheter systems are discussed, along with the new standardized protocol for difficult transurethral catheter insertions. Suprapubic catheter placement techniques, including percutaneous trocars and the use of the curved Lowsley tractor for initial suprapubic catheter insertion, are reviewed. Prevention and management of common catheter-related problems such as encrustation, leakage, Foley malposition, balloon cuffing and frequent blockages are discussed.

Preventable Infections in Children with Leukodystrophy

Children with inherited leukodystrophies have high hospitalization rates, often associated with infection. We studied whether potentially modifiable risk factors (pre-existing in-dwelling central intravenous access, urinary catheter, hardware, or mechanical ventilation; and influenza vaccine) were associated with infection-related hospitalization in children with leukodystrophy. Central intravenous access was associated with sepsis (odds ratio (OR) 9.8); urinary catheter was associated with urinary tract infections (OR 9.0); lack of seasonal vaccination was associated with influenza (OR 6.4); and mechanical ventilation was associated with pneumonia (OR 2.7). We conclude that potentially modifiable risk factors are significantly associated with infection and hospitalization in children with leukodystrophies.

Comparison of the risk of postoperative infection between transurethral vaporesection and transurethral resection of the prostate

BACKGROUND AND OBJECTIVE

We observed in our department at 3 months two episodes of bacteremia postoperatively to photoselective vaporization of the prostate (PVP). We decided to compare the frequency of postoperative urinary tract infections (POUTIs) in patients with preoperative bacterial colonization of urine between PVP and transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

From January 2010 to December 2011, we studied patients who underwent PVP or TURP for benign prostatic obstruction in our department. Preoperative urine culture (UC) was carried out for all patients and we included those with preoperative bacterial colonization of the urinary tract. Patients were treated preoperatively with an appropriate antibiotic treatment and/or inductive prophylactic antibiotics. Patients were diagnosed with POUTI if they had clinical signs of infections (e.g., fever) and a positive UC during the month after surgery.

RESULTS

Patients were treated by PVP in 49 cases and TURP in 62 cases. A preoperative indwelling urinary catheter was inserted in 80% of the patients. During the postoperative period, eight episodes of fever were identified in the PVP group (16%), five (8%) in the TURP group (P = 0.18). We then studied the subgroup of patients with multiple bacteria strains present in the preoperative UC and identified significant differences. The risk of POUTI was significantly higher in patients treated by PVP than in those treated by TURP (P = 0.018).

CONCLUSIONS

We found significant differences between subgroups of patients with positive preoperative cultures (containing various bacterial strains). The risk of POUTI was significantly higher in patients treated by PVP.