Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention

Management of Asymptomatic Bacteriuria in Non-Catheterized Adults

Understanding the management of asymptomatic bacteriuria (ASB) is important given the prevalence of the condition, associated risks in certain patient populations, and the risks associated with inappropriate antibiotic administration. Generally, screening and treatment is only recommended in pregnant women and in those undergoing urologic procedures that will violate the urothelium. Knowing the appropriate time to screen and treat ASB is critical for managing high-risk patients and preventing the growth of antibiotic resistance. Recent research into the protective nature of avirulent strains of Escherichia coli might offer a new approach to management of ASB.

Development and evaluation of a model for predicting the risk of healthcare-associated infections in patients admitted to intensive care units

This retrospective study used 10 machine learning algorithms to predict the risk of healthcare-associated infections (HAIs) in patients admitted to intensive care units (ICUs). A total of 2,517 patients treated in the ICU of a tertiary hospital in China from January 2019 to December 2023 were included, of whom 455 (18.1%) developed an HAI. Data on 32 potential risk factors for infection were considered, of which 18 factors that were statistically significant on single-factor analysis were used to develop a machine learning prediction model using the synthetic minority oversampling technique (SMOTE). The main HAIs were respiratory tract infections (28.7%) and ventilator-associated pneumonia (25.0%), and were predominantly caused by gram-negative bacteria (78.8%). The CatBoost model showed good predictive performance (area under the curve: 0.944, and sensitivity 0.872). The 10 most important predictors of HAIs in this model were the Penetration Aspiration Scale score, Braden score, high total bilirubin level, female, high white blood cell count, Caprini Risk Score, Nutritional Risk Screening 2002 score, low eosinophil count, medium white blood cell count, and the Glasgow Coma Scale score. The CatBoost model accurately predicted the occurrence of HAIs and could be used in clinical practice.

Materials-based incidence of urinary catheter associated urinary tract infections and the causative micro-organisms: systematic review and meta-analysis

BACKGROUND

Both long (> 30 days) and short-term (≤ 30 days) catheterisation has been associated with urinary tract infections (UTIs) due to the invasive nature of device insertion through the urethra. Catheter associated Urinary Tract Infections (CAUTIs) are common (prevalence of ~ 8.5%) infections which can be treated with antibiotics; however, CAUTIs are both expensive to treat and contributes to the antibiotic usage crisis. As catheters are unlikely be replaced for the management of patients' urination, ways of reducing CAUTIs are sought out, using the catheter device itself. The aim of this review is to assess the incidence of CAUTI and the causative micro-organisms when different urinary catheter devices have been used by humans, as reported in published research articles.

METHODS

A Systematic Literature Review was conducted in Ovid Medline, Web of Science and PubMed, to identify studies which investigated the incidence of UTI and the causative micro-organisms, in patients with different urinary catheter devices. The articles were selected based on a strict set of inclusion and exclusion criteria. The data regarding UTI incidence was extracted and calculated odds ratio were compared across studies and pooled when types of catheters were compared. CAUTI causative micro-organisms, if stated within the research pieces, were also gathered.

RESULTS

A total of 890 articles were identified, but only 26 unique articles met the inclusion/exclusion criteria for this review. Amongst the large cohort there were catheters of materials silicone, latex and PVC and catheter modifications of silver nanoparticles and nitrofurantoin antibiotics. The meta-analysis did not provide a clear choice towards a single catheter against another although silver-based catheters, and silver alloy, appeared to statistically reduce the OR of developing CAUTIs. At genus level the three commonest bacteria identified across the cohort were E. coli, Enterococcus spp. and Pseudomonas spp. whilst considering only at the genus level, with E. coli, Klebsiella pneumonia and Enterococcus faecalis most common at the species-specific level.

CONCLUSIONS

There does not appear to be a catheter type, which can significantly reduce the incidence of CAUTI's in patients requiring catheterisation. Ultimately, this warrants further research to identify and develop a catheter device material that will reduce the incidence for CAUTIs.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients

Background

Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively.

Methods

Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics.

Results

Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02).

Conclusions

PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Reduced Sliding Friction of Lubricant-Impregnated Catheters

During urethral catheterization, sliding friction can cause discomfort and even hemorrhaging. In this report, we use a lubricant-impregnated polydimethylsiloxane coating to reduce the sliding friction of a catheter. Using a pig urethra attached to a microforce testing system, we found that a lubricant-impregnated catheter reduces the sliding friction during insertion by more than a factor of two. This suggests that slippery, lubricant-impregnated surfaces have the potential to enhance patient comfort and safety during catheterization.

An Observational Study from Northern India to Evaluate Catheter-associated Urinary Tract Infection in Medical Intensive Care Unit at a Tertiary Care Center

Background

Healthcare-associated infections are the leading cause of morbidity and mortality in hospitalized patients. Catheter-associated urinary tract infection (CAUTI) is a leading infection in ICU settings. This study aims to evaluate the patient and catheter-related factors contributing to the urinary tract infection as well as implementing the preventive measures ultimately curbing down the burden of healthcare-associated infections.

Material and methods

This is a hospital-based observational study conducted in Department of Microbiology, from October 2020 to September 2021. A total of 150 patients admitted to Medical Intensive Care Unit (MICU) with the indwelling urinary catheter were included. Urine samples were collected with proper aseptic precautions and processed within 2 hours of collection. Identification and antimicrobial susceptibility testing of the isolated pathogens was done as per CLSI guidelines 2019.

Results

In this study, the CAUTI rate was 9.4 per 1000 urinary catheter days, while the overall magnitude was 14.67%. It was predominantly reported in 51-70-years age group (34%), and females (63.63%) outnumbered males (36.36%), with Escherichia coli being the commonest pathogen. The highest incidence was reported in the 3rd week of catheterization with diabetes being a predominant risk factor (17.24%).

Conclusion

This study provides baseline data on CAUTI rate, pathogens isolated, and risk factors at our institute. The overall goal is to identify, educate, and implement best-practice measures for prevention and curbing down the incidence rates of catheter-associated urinary tract infections.

How to cite this article

Parihar S, Sharma R, Kinimi SV, Choudhary S. An Observational Study from Northern India to Evaluate Catheter-associated Urinary Tract Infection in Medical Intensive Care Unit at a Tertiary Care Center. Indian J Crit Care Med 2023;27(9):642-646.

Rapid Antibiotic Susceptibility Testing of Gram-Negative Bacteria Directly from Urine Samples of UTI Patients Using MALDI-TOF MS

Urinary tract infections (UTIs) are one of the most common human infections and are most often caused by Gram-negative bacteria such as Escherichia coli. In view of the increasing number of antibiotic-resistant isolates, rapidly initiating effective antibiotic therapy is essential. Therefore, a faster antibiotic susceptibility test (AST) is desirable. The MALDI-TOF MS-based phenotypic antibiotic susceptibility test (MALDI AST) has been used in blood culture diagnostics to rapidly detect antibiotic susceptibility. This study demonstrates for the first time that MALDI AST can be used to rapidly determine antibiotic susceptibility in UTIs directly from patients' urine samples. MALDI-TOF MS enables the rapid identification and AST of Gram-negative UTIs within 4.5 h of receiving urine samples. Six urinary tract infection antibiotics, including ciprofloxacin, cotrimoxazole, fosfomycin, meropenem, cefuroxime, and nitrofurantoin, were analyzed and compared with conventional culture-based AST methods. A total of 105 urine samples from UTI patients contained bacterial isolates for MALDI AST. The combination of ID and AST by MALDI-TOF allowed us to interpret the result according to EUCAST guidelines. An overall agreement of 94.7% was found between MALDI AST and conventional AST for the urinary tract pathogens tested.

Lens Free Holographic Imaging for Urinary Tract Infection Screening

OBJECTIVE

The diagnosis of urinary tract infection (UTI) currently requires precise specimen collection, handling infectious human waste, controlled urine storage, and timely transportation to modern laboratory equipment for analysis. Here we investigate holographic lens free imaging (LFI) to show its promise for enabling automatic urine analysis at the patient bedside.

METHODS

We introduce an LFI system capable of resolving important urine clinical biomarkers such as red blood cells, white blood cells, crystals, and casts in 2 mm thick urine phantoms.

RESULTS

This approach is sensitive to the particulate concentrations relevant for detecting several clinical urine abnormalities such as hematuria and pyuria, linearly correlating to ground truth hemacytometer measurements with R 2 = 0.9941 and R 2 = 0.9973, respectively. We show that LFI can estimate E. coli concentrations of 10 3 to 10 5 cells/mL by counting individual cells, and is sensitive to concentrations of 10 5 cells/mL to 10 8 cells/mL by analyzing hologram texture. Further, LFI measurements of blood cell concentrations are relatively insensitive to changes in bacteria concentrations of over seven orders of magnitude. Lastly, LFI reveals clear differences between UTI-positive and UTI-negative urine from human patients.

CONCLUSION

LFI is sensitive to clinically-relevant concentrations of bacteria, blood cells, and other sediment in large urine volumes.

SIGNIFICANCE

Together, these results show promise for LFI as a tool for urine screening, potentially offering early, point-of-care detection of UTI and other pathological processes.

A Velocity-Based Approach to Noninvasive Methodology for Urodynamic Analysis

PURPOSE

To date, invasive urodynamic investigations have been used to define most terms and conditions relating to lower urinary tract symptoms. This invasiveness is almost totally due to the urethral catheter. In order to remove this source of discomfort for patients, the present study investigated a noninvasive methodology able to provide diagnostic information on bladder outlet obstruction or detrusor underactivity without any contact with the human body.

METHODS

The proposed approach is based on simultaneous measurements of flow rate and jet exit velocity. In particular, the jet exit kinetic energy appears to be strongly related to bladder pressure, providing useful information on the lower urinary tract functionality. We developed a new experimental apparatus to simulate the male lower urinary tract, thus allowing extensive laboratory activities. A large amount of data was collected regarding different functional statuses.

RESULTS

Experimental results were compared successfully with data in the literature in terms of peak flow rate and jet exit velocity. A new diagram based on the kinetic energy of the exit jet is proposed herein. Using the same notation as a Schäfer diagram, it is possible to perform noninvasive urodynamic studies.

CONCLUSION

A new noninvasive approach based on the measurement of jet exit kinetic energy has been proposed to replace current invasive urodynamic studies. A preliminary assessment of this approach was carried out in healthy men, with a specificity of 91.5%. An additional comparison using a small sample of available pressure-flow studies also confirmed the validity of the proposed approach.

Racial Differences in Urinary Catheter Use Among Female Nursing Home Residents

OBJECTIVE

To assess racial differences in prevalence of indwelling urinary catheterization and intermittent catheterization among female NH residents in the United States (US).

METHODS

We performed a cross-sectional analysis using the 2019 Minimum Data Set 3.0 and developed a multivariable logistic regression model to examine the association between catheter use and race. Moderation analyses were performed to clarify significant associations.

RESULTS

Our study cohort was composed of 597,966 women, who were predominantly of White race with a median age of 80 years. Eight percent (n=47,799) of female residents had indwelling catheters, and 0.5% (n=2,876) used intermittent catheterization. Black residents had a 7% lower odds of having an indwelling catheter (aOR 0.93, 95% CI 0.90-0.96), and a 38% lower odds of utilizing intermittent catheterization (aOR 0.62, 95% CI 0.54-0.71) compared to White residents when controlling for common factors associated with catheter use. In moderation analyses, Black residents with age under 80 years and BMI of 35 kg/m2 or greater were less likely to have an indwelling catheter than age- and BMI-matched White residents.

CONCLUSION

Racial differences in both indwelling and intermittent catheterization prevalence exist in female NH residents. These disparities should be further clarified to reduce bias in NH care.

Asymptomatic bacteriuria in candidates for active treatment of renal stones: results from an international multicentric study on more than 2600 patients

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1-2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9-3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19-1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02-1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0-1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications.

A collaborative approach intended to reduce the duration of short term urinary catheters in adult patients at a tertiary care medical center also significantly reduced the duration of hospitalization

BACKGROUND

Urinary tract infections are the leading cause of nosocomial infections in the United States. The major contributing factor is the placement of indwelling urinary catheters.

METHODS

Following a chart review of adult patients hospitalized at a tertiary care medical center who required the use of a short-term (≤ 2 weeks) indwelling urinary catheter, a collaborative effort was initiated by an Infectious Diseases physician to develop protocols focused on the clinical service involved for the expeditious removal of short-term indwelling urinary catheters. The protocols relied in part on the standards of practice by pertinent medical/surgical subspecialty societies. Usage of urinary catheters and duration of hospitalization following implementation of the protocols was assessed.

RESULTS

Based on a multivariate analysis controlling for demographic variables, comorbidities, medical vs surgical service, and indication for the urinary catheterization, the median duration of catheterization was significantly reduced from 6.7 days to 3.6 days after the protocols were initiated (P < .001), and the median duration of hospitalization was significantly reduced from 9.5 days to 5.9 days (P < .001). No patient had to have the urinary catheter reinserted.

CONCLUSIONS

Development of collaborative protocols for the removal of short-term indwelling urinary catheters significantly reduced both the duration of catheterization and the duration of hospitalization.

A Current Review of the Etiology, Clinical Features, and Diagnosis of Urinary Tract Infection in Renal Transplant Patients

Urinary tract infection (UTI) represents the most common infection after kidney transplantation and remains a major cause of morbidity and mortality in kidney transplant (KT) recipients, with a potential impact on graft survival. UTIs after KT are usually caused by Gram-negative microorganisms. Other pathogens which are uncommon in the general population should be considered in KT patients, especially BK virus since an early diagnosis is necessary to improve the prognosis. UTIs following kidney transplantation are classified into acute simple cystitis, acute pyelonephritis/complicated UTI, and recurrent UTI, due to their different clinical presentation, prognosis, and management. Asymptomatic bacteriuria (ASB) represents a frequent finding after kidney transplantation, but ASB is considered to be a separate entity apart from UTI since it is not necessarily a disease state. In fact, current guidelines do not recommend routine screening and treatment of ASB in KT patients, since a beneficial effect has not been shown. Harmful effects such as the development of multidrug-resistant (MDR) bacteria and a higher incidence of Clostridium difficile diarrhea have been associated with the antibiotic treatment of ASB.

Disparity in Microbiological Pattern of Cauti in Precisely Tribal Patients in Relation to Impacting Factors from the Known Pattern in the Medical Intensive Care Unit in a Tribal Tertiary Care Centre

The important risk factor for the development of CAUTI, especially in the intensive care units, is the presence, method and length of Duration of urinary catheterization. The other potential significant risk factors are gender, age, uncontrolled diabetes and long hospital stay. There have been no studies on Tribal patients describing the factors (Demographic as well as Risk factors) which influence the deviation in microbiological pattern of CAUTI in of the MICU, from the patients of other area studied till now. This prospective study was conducted over Tribal patients aged ≥ 18 years who developed features of symptomatic urinary tract infection following an indwelling urinary Foley’s catheter more than 48 hours, in the Medical Intensive Care Unit. Geographical and Clinical data were collected. The CAUTI rate in 33 Tribal patients was 19.2 per 1000 device days with an incidence of 17.3% in the MICU. The microbiological trend was Staphylococcus aureus 12 (26.0%), E. coli 11 (23.9%), Candida albicans 9 (19.5%), Klebsiella pneumoniae 5 (10.8%), CONS 3 (6.5%), Streptococcus pneumoniae 3(6.0%), Pseudomonas aeruginosa 2 (4.3%) and Acinetobacter baumannii 1 (2.1%). Staphylococcus aureus was the common cause of CAUTI in low and medium socioeconomic tribal patients of more than 20 to 40 years of age, as compared to E. coli in Nontribal Patients. E.coli was found in the dominated female patients and in age upto 20 years and more than 40to 60 years old patients and Klebsiella pneumonae in above 60 years age. High status group with Acinetobactor baumannii. Candida albicans was associated with use of urinary catheter less than 7 days. Length of ICU stay more than 14 days was associated with E. coli and Staphylococcus aureus in equally proportionately. CONS 2(50%) was found in type-2 Diabetes mellitus and Staphylococcus aureus 7 (53.8 %) with Sickle cell anemia in Tribal patients. Our analysis precisely of this Tribal patients, brings several important and unique findings, which will not only aid in the development of some new or update guidelines but also encourage the researcher to do more study, for the prevention of CAUTI in the MICU of Tribal tertiary care centre.

Antibiotic prophylaxis for urinary catheter manipulation following arthroplasty: a systematic review

BACKGROUND

Urinary catheter use in the peri- and post-operative phase following arthroplasty may be associated with urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on use of antibiotics for urinary catheter insertion and removal following arthroplasty.

METHODS

Electronic databases were searched using the Healthcare Databases Advanced Search interface. Grey literature was searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity, a narrative approach was adopted. Methodological quality of each study was assessed using the Critical Appraisal Skills Programme appraisal tool.

RESULTS

A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these, 1475 (31%) were on men and 3189 (68%) on women. The mean age of study participants was 69 years. Three thousand four hundred and eighty-nine cases (74.3%) were related to hip arthroplasty and 629 (13.4%) to knee arthroplasty. Five hundred and seventy-eight (12.3%) were either hip or knee arthroplasty. Forty-five PJIs were reported across all studies (0.96%). Two studies found either no PJI or no statistical difference in the rate of PJI when no antibiotic prophylaxis was used for catheter manipulation. Another study found no statistical difference in PJI rates between patients with or without preoperative bacteriuria. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Increased duration of urinary catheterization is positively associated with UTI.

CONCLUSION

It remains difficult to justify the use of prophylactic antibiotics for catheter manipulation in well patients. Their use is not recommended for this indication.

The cost-effectiveness of schistosomiasis screening and treatment among recently resettled refugees to Canada: an economic evaluation

BACKGROUND

Many refugees and asylum seekers from countries where schistosomiasis is endemic are infected with the Schistosoma parasite when they arrive in Canada. We assessed, from a systemic perspective, which of the following management strategies by health care providers is cost-effective: testing for schistosomiasis and treating if the individual is infected, treating presumptively or waiting for symptoms to emerge.

METHODS

We constructed a decision-tree model to examine the cost-effectiveness of 3 management strategies: watchful waiting, screening and treatment, and presumptive treatment. We obtained data for the model from the literature and other sources, to predict deaths and chronic complications caused by schistosomiasis, as well as costs and net monetary benefit.

RESULTS

Presumptive treatment was cost-saving if the prevalence of schistosomiasis in the target population was greater than 2.1%. In our baseline analysis, presumptive treatment was associated with an increase of 0.156 quality-adjusted life years and a cost saving of $405 per person, compared with watchful waiting. It was also more effective and less costly than screening and treatment.

INTERPRETATION

Among recently resettled refugees and asylum claimants in Canada, from countries where schistosomiasis is endemic, presumptive treatment was predicted to be less costly and more effective than watchful waiting or screening and treatment. Our results support a revision of the current Canadian recommendations.

Glycopyrrolate and Post-Operative Urinary Retention: A Narrative Review

The use of non-depolarizing neuromuscular blockade (NDNMB) necessitates the use of reversal agents. Glycopyrrolate, an anticholinergic agent, is commonly used in combination with neostigmine, an anticholinesterase, for the reversal of neuromuscular blockade medications. Glycopyrrolate is known to effect on the genitourinary system adversely with an inhibitory effect on bladder contraction, bladder hypotonia, and increase in the frequency of urinary retention. Many studies analyzing the association between glycopyrrolate and urinary retention are outdated and published over a decade ago. The decade old studies were retrospective and did not consider post-operative urinary retention (POUR) as a primary outcome. The purpose of this manuscript is to review the association between glycopyrrolate administration and post-operative urinary retention in the perioperative setting.

Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections on a medical hospital unit

BACKGROUND

Urinary tract infections (UTI) are one of the most common hospital-acquired infections with 80% as a result of urinary catheterisation.

AIM/OBJECTIVE

This study examined the impact of a simple intervention consisting of a daily chart reminder in patients with indwelling urinary catheters (IUC) on the duration of catheter use and the incidence of catheter-associated UTIs (CAUTIs).

METHODS

The trial used a prospective pretest-post-test design with a control group over a six-month period conducted on two medical units of a community teaching hospital. We included all patients admitted to two medical units between 1 June and 30 November 2016 who had an IUC inserted at the study site. During the intervention phase, a sticker was placed in the charts of patients with urinary catheters reminding physicians to assess for catheter removal if not clinically necessary.

RESULTS

A total of 195 patients participated in this study (112 control unit, 83 intervention unit). There was a decrease in the duration of IUC use on the intervention unit from 11.7 days to 7.5 days (P = 0.0028). There was a decrease in repeated catheterisation from 11.1% to 2.1% (P = 0.0882), and CAUTIs from 17.5% to 4.6% (P = 0.0552) but this did not reach statistical significance.

DISCUSSION

The implementation of a daily IUC reminder sticker in patient charts was associated with a significant reduction in the mean duration of indwelling catheter use with a trend towards a reduction in the frequency of repeated urinary catheterisation and rate of CAUTIs.

Detection of biofilm among uropathogenic Escherichia coli and its correlation with antibiotic resistance pattern

BACKGROUND:

Escherichia coli accounts for 70%–95% of urinary tract infections (UTIs). UTI is a serious health problem with respect to antibiotic resistance and biofilms formation being the prime cause for the antibiotic resistance. Biofilm can restrict the diffusion of substances and binding of antimicrobials. In this context, the present study is aimed to perform in vitro detection of biofilm formation among E. coli strains isolated from urine and to correlate their susceptibility pattern with biofilm formation.

MATERIALS AND METHODS:

A total of 100 E. coli strains isolated from patients suffering from UTI were included in the study. The identification of E. coli was performed by colony morphology, Gram staining, and standard biochemical tests. The detection of biofilm was carried out by Congo Red Agar (CRA) method, tube method (TM), and tissue culture plate (TCP) method. Antimicrobial sensitivity testing was performed by Kirby–Bauer disc diffusion method on Muller–Hinton agar plate.

RESULTS:

Of the 100 E. coli strains, 49 (49%) and 51 (51%) were from catheterized and noncatheterized patients, respectively. Biofilm production was positive by CRA, TM, and TCP method were 49 (49%), 55 (55%), and 69 (69%), respectively. Biofilm producers showed maximum resistance to co-trimoxazole (73.9%), gentamicin (94.2%), and imipenem (11.6%) when compared to nonbiofilm producers. Significant association was seen between resistance to antibiotic and biofilm formation with a P = 0.01 (<0.05).

CONCLUSION:

A greater understanding of biofilm detection in E. coli will help in the development of newer and more effective treatment. The detection of biofilm formation and antibiotic susceptibility pattern helps in choosing the correct antibiotic therapy.

The Urine Microbiome of Healthy Men and Women Differs by Urine Collection Method

PURPOSE

Compared to the microbiome of other body sites, the urinary microbiome remains poorly understood. Although noninvasive voided urine specimens are convenient, contamination by urethral microbiota may confound understanding of the bladder microbiome. Herein we compared the voiding- versus catheterization-associated urine microbiome of healthy men and women.

METHODS

An asymptomatic, healthy cohort of 6 women and 14 men underwent midstream urine collection, followed by sterile catheterization of the bladder after bladder refilling. Urine samples underwent urine dipstick testing and conventional microscopy and urine cultures. Samples also underwent Illumina MiSeq-based 16S ribosomal RNA gene amplification and sequencing.

RESULTS

All organisms identified by urine culture were also identified by 16S amplification; however, next-generation sequencing (NGS) also detected bacteria not identified by cultivation. Lactobacillus and Streptococcus were the most abundant species. Abundances of the 9 predominant bacterial genera differed between the urethra and bladder. Voided and catheterized microbiomes share all dominant (>1%) genera and Operational Taxonomic Units but in similar or different proportions. Hence, urethra and bladder microbiomes do not differ in taxonomic composition, but rather in taxonomic structure. Women had higher abundance of Lactobacillus and Prevotella than men.

CONCLUSION

Our findings lend credence to the hypothesis that Lactobacilli are important members of the healthy urine microbiome. Our data also suggest that the microbiomes of the urethra and bladder differ from one another. In conclusion, urine collection method results in different 16S-based NGS data, likely due to the sensitivity of NGS methods enabling detection of urethral bacteria present in voided but not catheterized urine specimens.

Pilot Ex Vivo and In Vitro Evaluation of a Novel Foley Catheter with Antimicrobial Periurethral Irrigation for Prevention of Extraluminal Biofilm Colonization Leading to Catheter-Associated Urinary Tract Infections (CAUTIs)

CAUTI remains a serious healthcare issue for incontinent patients whose urine drainage is managed by catheters. A novel double-balloon Foley catheter was developed which was capable of irrigating the extraluminal catheter surfaces within the periurethral space between the urethral-bladder junction and meatus. The catheter has a retention cuff that is inflated to secure the catheter in the bladder and a novel irrigation cuff proximal to the urethral-bladder junction capable of providing periurethral irrigation from the urethral-bladder junction to the meatus. Uniform periurethral irrigation was demonstrated in an ex vivo porcine model by adding a dye to the antimicrobial urethral irrigation solution. An in vitro biofilm colonization model was adapted to study the ability of periurethral irrigation with a newly developed antimicrobial combination consisting of polygalacturonic acid + caprylic acid (PG + CAP) to prevent axial colonization of the extraluminal urethral indwelling catheter shaft by common uropathogens. The extraluminal surface of control catheters that were not irrigated formed biofilms along the entire axial urethral tract after 24 hours. Significant (p < 0.001) inhibition of colonization was seen against multidrug-resistant Pseudomonas aeruginosa (PA), carbapenem-resistant Escherichia coli (EC), and carbapenem-resistant Klebsiella pneumoniae (KB). For other common uropathogens including Candida albicans (CA), Proteus mirabilis (PR), and Enterococcus faecalis (EF), a first irrigation treatment completely inhibited colonization of half of the indwelling catheter closest to the bladder and a second treatment largely disinfected the remaining intraurethral portion of the catheter towards the meatus. The novel Foley catheter and PG + CAP antimicrobial irrigant prevented biofilm colonization in an in vitro CAUTI model and merits further testing in an in vivo CAUTI prevention model.

Early removal of urinary drainage in patients receiving epidural analgesia after colorectal surgery within an ERAS protocol is feasible

BACKGROUND

ERAS guidelines recommend early removal of urinary drainage after colorectal surgery to reduce the risk of catheter-associated urinary tract infections (CAUTI). Another recommendation is the postoperative use of epidural analgesia (EA). In many types of surgery, EA was shown to increase the risk of postoperative urinary retention (POUR). This study determines the impact of early urinary catheter removal on the incidence of POUR and CAUTI under EA after colorectal surgery.

METHODS

Eligible patients were scheduled for colorectal surgery within the local ERAS protocol between April 2015 and September 2016. Urinary drainage was removed on the first postoperative day while EA was still in place (early removal group (ER)). The incidences of POUR and CAUTIs were recorded prospectively. Results were compared with a historical control (CG), which was operated between October 2013 and March 2015.

RESULTS

POUR occurred significantly more often in the ER (ER 7.8%; CG 2.6%), while CAUTIs were significantly less frequent in the ER (13.8%) compared with the CG (30.4%). Patients who developed POUR were characterised by a significantly higher rate of abdominoperineal resections, by a higher frequency of rectal cancer, and a higher male-to-female ratio compared with patients who did not develop POUR.

CONCLUSION

Early removal of urinary drainage after colorectal surgery while EA is still in place is feasible; it reduces the incidence of CAUTI but increases the risk of POUR. Thus, screening for POUR in patients with failure to void after six to 8 h is mandatory under these clinical conditions.

A Pilot Study of Postoperative Animal Welfare as a Guidance Tool in the Development of a Kidney Autotransplantation Model With Extended Warm Ischemia

This pilot study aimed to maintain acceptable animal welfare in the development of a porcine autotransplantation model with severe and incremental renal ischemic injury, a model for usage in future intervention studies. Secondary aims were to develop and test methods to collect blood and urine without the need to restrain or use sedative and avoid transportation to optimize welfare of the pig.

Prevention of Nosocomial Catheter-Associated Urinary Tract Infections Through Computerized Feedback to Physicians and a Nurse-Directed Protocol

Catheter-associated urinary tract infections (CAUTIs) represent the most common nosocomial infection. The authors' baseline rate of CAUTI for general medical service was elevated at 36 per 1000 catheter-days. The medical literature has consistently linked inappropriate catheter use with the development of CAUTI. The baseline data also revealed a high rate of inappropriate use of indwelling urinary catheters. Using the dual modalities of technology through prompts in the computerized order/entry system and handheld bladder scanners, as well as in combination with staff education and nurse empowerment, the authors were successful in reducing the use and duration of urinary catheters as well as the incidence of CAUTI. In subsequent data collection cycles over the following 2 years, 81% reduction in device use and a 73% reduction in the clinical end point of nosocomial CAUTI (36/1000 catheter-days to 11/1000 catheter-days; P < .001) was demonstrated.

An In Vitro Bladder Model for Studying Catheter-Associated Urinary Tract Infection and Associated Analysis of Biofilms

Urethral catheters are among the most widely used medical devices, applied to manage a wide range of conditions in hospital, community, and care home settings. In long-term catheterized individuals, infection with Proteus mirabilis frequently complicates the care of patients owing to formation of extensive crystalline biofilms. Here we describe the use of an in vitro bladder model of the catheterized urinary tract and associated analyses to study P. mirabilis crystalline biofilm formation. The model originally described by Stickler et al. (1999, 310:494-501, Methods Enzymol) replicates a complete sterile closed drainage system as used in clinical practice, and permits formation of biofilms directly on catheters under conditions representative of those encountered in vivo. Models may be used to replicate either established infection or early stage colonization, and we describe a range of associated methods for quantification and visualization of biofilms formed on catheters. These methods are also easily adapted to study catheter-associated biofilm formation by other urinary tract pathogens.

National Survey of Bladder and Gastrointestinal Dysfunction in People with Spinal Cord Injury

Small-scale studies indicate that spinal cord injury (SCI) may lead to significant gastrointestinal and bladder dysfunction. However, how the prevalence of chronic disease related to these dysfunctions compares with non-SCI individuals and whether there are robust relationships to level and severity of injury are still unclear. Here, our goal was to provide high-level evidence on the association between bladder and gastrointestinal dysfunction and SCI using population-level data from the Canadian Community Health Survey (CCHS) and the SCI Community Survey. Data from more than 60,000 individuals in the 2010 CCHS and 1500 individuals with SCI from the SCI Community Survey were analyzed. We used bi-variable and multi-variable logistic regression to examine relationships between explanatory and outcome variables. We found that SCI was associated with increased odds of urinary incontinence (adjusted odds ratio [aOR] = 5.0, 95% confidence interval [CI]: 3.4-7.1), bowel disorders (aOR = 2.3, CI: 1.5-3.4), as well as gastric ulcers (aOR: 3.3, CI: 2.1-4.8), even after adjusting for key confounding variables. Additionally, we found that complete SCI was associated with increased odds of urinary tract infections (aOR = 2.0, CI: 1.6-2.5) and bowel incontinence (aOR = 2.1, CI: 1.7-2.6). Individuals with SCI are at increased odds for having bladder and gastrointestinal dysfunction, certain aspects of which are dependent on the level and severity of injury. Targeted intervention and prevention strategies to manage bladder and bowel problems after SCI should be a priority for both caregivers and policy makers.

The antimicrobial efficacy of zinc doped phosphate-based glass for treating catheter associated urinary tract infections

In this study, a series of phosphate-based glasses; (P₂O₅)₅₀(Na₂O)₂₀(CaO)_30-x (ZnO)_x were prepared with increasing concentration of zinc oxide to determine the antimicrobial effect against clinically relevant microorganisms. The addition of 1 and 3 mol% zinc oxide decreased glass degradation however a higher dissolution rate was observed for 5 and 10 mol% ZnO. The antimicrobial results showed a concentration dependent effect on the viability of microorganisms. When in direct contact zinc doped glasses showed a complete kill, within 24 h, against Escherichia coli and a significant (p < 0.01) kill was observed against Staphylococcus aureus however the effect of dissolution products was not seen until 48 h. Furthermore, the cytotoxic studies showed no toxic effects on the viability of uroepithelial cells. This study has shown that zinc doped phosphate-based glasses can potentially be used to prevent/treat catheter associated urinary tract infections.

Predicting the risk of sepsis and causative organisms following urinary stones removal using urinary versus stone and stent cultures

The association between foreign objects in the urinary system and urinary tract infections (UTI) is well established. The incidence of bacteriuria in patient with urinary catheters increases as dwelling time lengthens. The presence of ureteral stents and kidney stones is also associated with increased risk for bacteriuria and urinary tract infection. The aim of this study was to assess the bacterial characteristics of urine culture (UC) and foreign body culture (FBC), the concordance between them, and to identify risk factors for postoperative infections, in order to improve the treatment in these patients, using a prospectively collected database of patients who underwent ureteroscopy or percutaneous nephrolithotomy (PCNL) for the treatment of urinary stones between 2005 and 2016 at our institute. Preoperative UC was obtained from voided mid-stream urine for all patients. FBCs were obtained from ureteral stents removed and stones collected during the surgery. The cohort included 1011 patients. Mean age was 53 (SD 15.8), and 679 (67.2%) patients were male. Two hundred eighteen (21.6%) had a UTI in the year prior to the surgery. Among 795 patients who had sterile UC, 98 (12.3%) patients had positive FBC. Positive FBC was found in 53.7% of the patients with positive UC; however, FBC pathogens were similar to those identified in UC in 31% patients. The sensitivity of UC to detect FBC pathogens was 31.3%, and the PPV was 0.31. Urine cultures do not recognize all cases of pathogens colonizing foreign bodies in the urinary system. The colonization may be associated with an increased risk for SIRS. In more than one-quarter of the patients, the causative pathogen of sepsis is identified by FBC, but not by UC.

Nanopillared Surfaces Disrupt Pseudomonas aeruginosa Mechanoresponsive Upstream Motility

Pseudomonas aeruginosa is an opportunistic, multidrug-resistant, human pathogen that forms biofilms in environments with fluid flow, such as the lungs of cystic fibrosis patients, industrial pipelines, and medical devices. P. aeruginosa twitches upstream on surfaces by the cyclic extension and retraction of its mechanoresponsive type IV pili motility appendages. The prevention of upstream motility, host invasion, and infectious biofilm formation in fluid flow systems remains an unmet challenge. Here, we describe the design and application of scalable nanopillared surface structures fabricated using nanoimprint lithography that reduce upstream motility and colonization by P. aeruginosa. We used flow channels to induce shear stress typically found in catheter tubes and microscopy analysis to investigate the impact of nanopillared surfaces with different packing fractions on upstream motility trajectory, displacement, velocity, and surface attachment. We found that densely packed, subcellular nanopillared surfaces, with pillar periodicities ranging from 200 to 600 nm and widths ranging from 70 to 215 nm, inhibit the mechanoresponsive upstream motility and surface attachment. This bacteria-nanostructured surface interface effect allows us to tailor surfaces with specific nanopillared geometries for disrupting cell motility and attachment in fluid flow systems.

Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

The effect of bladder catheterization on the incidence of urinary tract infection in laboring women with epidural analgesia: a meta-analysis of randomized controlled trials

INTRODUCTION AND HYPOTHESIS

There is conflicting evidence on whether intermittent catheterization (IC) is less associated with urinary tract infection (UTI) and more likely to prevent urinary retention than continuous catheterization (CC). We aimed to compare the effect of IC with that of CC on the incidence of postpartum UTI, urinary retention and hemorrhage in laboring women with epidural analgesia.

METHODS

Electronic searches were performed in PubMed, EMBASE and Cochrane Library from their inception to October 2018. We selected RCTs comparing IC with CC in laboring women with epidural analgesia. A meta-analysis was performed using the RevMan software, and a random-effects model was used to pool the effect size. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence.

RESULTS

Six RCTs (N = 850) were included in this review. The meta-analyses indicated that there was no significant difference between the IC and CC group in the incidence of postpartum UTI (RR = 1.25, 95% CI: 0.91 to 1.71, P = 0.16), postpartum urinary retention (RR = 0.76, 95% CI: 0.21 to 2.77, P = 0.68) and postpartum hemorrhage (RR = 1.72, 95% CI: 0.60 to 4.95, P = 0.31). GRADE assessment results showed that the quality of evidence was low.

CONCLUSIONS

Based on the available evidence, there is no measurable difference in rates of UTI between CC and IC, not that neither stragety decreases UTI, since the included trials do not address this.

Pre-operative screening for asymptomatic bacteriuria and associations with post-operative outcomes in patients with spinal cord injury

CONTEXT

Screening for asymptomatic bacteriuria (ASB) before non-urologic surgery is common but of unclear benefit. Our aim was to describe pre-operative ASB screening and post-operative outcomes in patients with neurogenic bladder due to spinal cord injury (SCI).

METHODS

This was a descriptive retrospective cohort study of adults with SCI undergoing neurosurgical spine or orthopedic lower limb surgery from 10/1/2012-9/30/2014 at Veterans Affairs (VA) medical centers. National VA datasets and medical record review was used to describe frequency of pre-operative ASB screening, presence of ASB, and association with post-operative surgical site infection, urinary tract infection, and hospital readmission.

RESULTS

175 patients were included. Although over half of patients had pre-operative ASB screening, only 30.8% actually had pre-operative ASB. 15.2% of patients screened were treated for ASB with antibiotics before surgery. Post-operative urinary tract infection (UTI) or surgical site infection (SSI) occurred in 10 (5.7%) patients, and 20 patients (11.4%) were readmitted within 30 days. Neither ASB screening nor the presence of pre-operative ASB were associated with these post-op outcomes (p > 0.2 for all).

CONCLUSION

Pre-operative ASB screening is common in patients with SCI undergoing elective spine and lower limb surgery, although ASB occurs in less than 1/3rd of cases. There were no associations between pre-operative ASB and outcomes. Further studies evaluating the clinical benefit of this practice in patients with SCI should be performed.

Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals

MOTIVATION

Catheter-associated urinary tract infections (CAUTI) are a common and serious healthcare-associated infection. Despite many efforts to reduce the occurrence of CAUTI, there remains a gap in the literature about CAUTI risk factors, especially pertaining to the effect of catheter dwell-time on CAUTI development and patient comorbidities.

OBJECTIVE

To examine how the risk for CAUTI changes over time. Additionally, to assess whether time from catheter insertion to CAUTI event varied according to risk factors such as age, sex, patient type (surgical vs medical) and comorbidities.

DESIGN

Retrospective cohort study of all patients who were catheterised from 2012 to 2016, including those who did and did not develop CAUTIs. Both paediatric and adult patients were included. Indwelling urinary catheterisation is the exposure variable. The variable is interval, as all participants were exposed but for different lengths of time.

SETTING

Urban academic health system of over 2500 beds. The system encompasses two large academic medical centres, two community hospitals and a paediatric hospital.

RESULTS

The study population was 47 926 patients who had 61 047 catheterisations, of which 861 (1.41%) resulted in a CAUTI. CAUTI rates were found to increase non-linearly for each additional day of catheterisation; CAUTI-free survival was 97.3% (CI: 97.1 to 97.6) at 10 days, 88.2% (CI: 86.9 to 89.5) at 30 days and 71.8% (CI: 66.3 to 77.8) at 60 days. This translated to an instantaneous HR of. 49%-1.65% in the 10-60 day time range. Paraplegia, cerebrovascular disease and female sex were found to statistically increase the chances of a CAUTI.

CONCLUSIONS

Using a very large data set, we demonstrated the incremental risk of CAUTI associated with each additional day of catheterisation, as well as the risk factors that increase the hazard for CAUTI. Special attention should be given to patients carrying these risk factors, for example, females or those with mobility issues.

The new perspective of old antibiotic: In vitro antibacterial activity of TMP-SMZ against Klebsiella pneumoniae

BACKGROUND/PURPOSE

Trimethoprim-sulfamethoxazole (TMP-SMZ) is broadly administered to treat multiple infections, and the paucity of effective treatment alternatives for infections caused by Klebsiella pneumoniae has led to a renewed interest in TMP-SMZ. The aim of this study is to evaluate the antibacterial efficacy of TMP-SMZ against K. pneumoniae.

METHODS

The resistance genes of K. pneumoniae clinical isolates were investigated by PCR, followed by conjugation experiments and multilocus sequence typing.

RESULTS

The resistance rate of K. pneumoniae to TMP-SMZ decreased over the collection period from 26.7% (88/330) to 16.9% (56/332). The high carrying rates (173/175, 98.9%) of resistance determinants (sul genes or dfr genes) were the main mechanisms of TMP-SMZ resistance isolates, with sul1 (142/175, 81.1%) and dfrA1 (119/175, 68.0%). Only class 1 integron was detected, the prevalence of which in TMP-SMZ resistant K. pneumoniae was 63.4% (111/175).

CONCLUSION

These results provided insights into the antimicrobial efficacy of TMP-SMZ against K. pneumoniae, also illustrating the wide distribution of SMZ and TMP resistance genes among resistant K. pneumoniae. Simultaneously, the present study highlights the significance of reasonable administration and effective continued monitoring.

Health care-associated infections - an overview

Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. Multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, HCAIs, and surgical complications. The US Center for Disease Control and Prevention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. Several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and minimize health care costs. Routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. In support of this, the WHO has produced guidelines to promote hand-washing practices among member countries.

Catheter-Associated Urinary Tract Infection and Obstinate Biofilm Producers

Background

Biofilms, or colonies of uropathogen growing on the surface of indwelling medical devices, can inflict obstinate or recurring infection, thought-provoking antimicrobial therapy.

Methods

This prospective analysis included 105 urine samples from catheterized patients receiving intensive care. Ensuing phenotypic identification, antibiotic sensitivity test was performed by modified Kirby-Bauer disc diffusion method following CLSI guidelines; MDR isolates were identified according to the combined guidelines of the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC). Biofilm-forming uropathogens were detected by the tissue culture plate (TCA) method.

Results

The predominant uropathogen in catheter-associated UTIs (CAUTIs) was Escherichia coli 57%, followed by Klebsiella pneumonia 15%, Pseudomonas aeruginosa 12%, Staphylococcus aureus 8%, Enterobacter spp. 3%, Enterococcus faecalis, Acinetobacter spp., and Proteus mirabilis 1.5%, of which 46% isolates were biofilm producers. Prime biofilm producers were Escherichia coli 33%, followed by Klebsiella pneumoniae 30%, Pseudomonas aeruginosa 20%, Staphylococcus aureus 10%, Acinetobacter, and Enterobacter 3.33%. Multidrug resistance associated with biofilm producers were greater than biofilm nonproducers. The Gram-negative biofilm producers found 96.15%, 80.76%, 73.07%, 53.84%, 53.84%, 46.15%, 19.23%, and 11.5% resistant to amoxyclave, ceftazidime, tetracycline, gentamicin, meropenem, nitrofurantoin, amikacin, imipenem, and fosfomycin, respectively. Gram-positive biofilm producers, however, were found 100% resistant to tetracycline, cloxacillin, and amoxyclave: 66.67% resistant to ampicillin while 33.33% resistant to gentamicin, ciprofloxacin, and nitrofurantoin.

Conclusion

High antimicrobial resistance was observed in biofilm producers than non-biofilm producers. Of recommended antimicrobial therapies for CAUTIs, ampicillin and amoxicillin-clavulanate were the least active antibiotics, whereas piperacillin/tazobactam and imipenem were found as the most effectual for gram-negative biofilm producer. Likewise, amoxicillin-clavulanate and tetracycline were the least active antibiotics, whereas vancomycin, fosfomycin, piperacillin-tazobactam, and meropenem were found as the most effective antibiotic for Gram-positive biofilm producer. In the limelight, the activity fosfomycin was commendable against both Gram-positive and Gram-negative biofilm producers.

Comparison of uropathogens and antibiotic susceptibility patterns in catheterized ambulant middle-aged and elderly Nigerian patients with bladder outlet obstruction

OBJECTIVE

Advanced age is one of the notable risk factors for catheter-associated urinary tract infections (CAUTIs), and differences between middle aged and elderly men with CAUTIs is poorly understood. This study aimed at comparing the pattern of urinary pathogens and antibiotic susceptibility in ambulant catheterized middle-aged and elderly Nigerian men.

MATERIAL AND METHODS

One hundred and fifty-four patients catheterized for >48 hours had provided clean catch mid-stream urine samples for microscopic analysis, culture and sensitivity tests. Eighty-two men aged <65, and 72 men aged ≥65 years matched for age, level of education, occupation and marital status were compared.

RESULTS

Prevalence of CAUTIs among middle-aged men was middle-aged men was higher than the elderly (90.2% and 80.6% respectively) but this was not statistically significant (p=0.086). CAUTIs in middle-aged men with suprapubic catheters were significantly more frequent than those with urethral catheters (p=0.000). The prevalence of CAUTIs in middle-aged men with urethral stricture was different from other causes of bladder outlet obstruction (p=0.004). Men with indwelling catheters longer than 2 weeks had higher CAUTIs (p=0.000). Escherichia coli was the commonest pathogen in both groups while nitrofurantoin was the most sensitive drug.

CONCLUSION

There are differential rates of CAUTIs in both the middle-aged men and the elderly with bladder outlet obstruction in our environment. The knowledge of the common pathogens and the antibiotic susceptibility will prevent irrational antibiotic use. Middle-aged men had higher prevalence of CAUTIs when Proteus spp. was the infectious agent. However, E. coli was the commonest pathogen of CAUTIs in all men. Also, middle- aged men with suprapubic catheters had higher rates of CAUTIs. Nitrofurantoin was the best drug in all men with CAUTIs but elderly men had higher rates of multi-resistance.

Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI.

RECENT FINDINGS

Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.

Incidence and Risk Factors of Postoperative Urinary Retention and Bladder Catheterization in Patients Undergoing Fast-Track Total Joint Arthroplasty: A Prospective Observational Study on 371 Patients

BACKGROUND

Postoperative urinary retention (POUR) appears to be a common complication in lower limb joint arthroplasty; however, reports on its incidence vary. There is no general consensus on its definition and there is no scientific evidence on treatment principles. We performed a prospective observational study to establish the incidence of POUR and its risk factors, including the preoperative postvoid residual urine volume and the perioperative fluid balance, in fast-track total joint arthroplasty (TJA). The preoperative residual urine volume and the perioperative fluid balance have not been studied in previous literature in the context of TJA and POUR.

METHODS

Three hundred eighty-one patients who underwent TJA of the lower limb were observed on developing POUR according to our local treatment protocol. Data on possible risk factors for POUR were collected including the perioperative fluid balance and the preoperative residual urine volume.

RESULTS

In total, 46.3% of patients were catheterized. A preoperative postvoid urine retention is a significant predictor of catheterization for postoperative residual urine (P = .03). Spinal anesthesia was correlated with urinary retention (P = .01). There was no cause-effect relationship between POUR and the perioperative fluid balance.

CONCLUSION

This study underlines POUR as a common complication in fast-track lower limb arthroplasty, with spinal anesthesia as a risk factor. A higher preoperative residual urine volume leads to higher postoperative residual volume, but not to a higher change in urinary retention. Increased perioperative fluid administration is not correlated with the incidence of POUR. Furthermore, there seems to be little rationale for monitoring residual urine volume both preoperatively and postoperatively.

Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury

PURPOSE

To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice.

METHODS

Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR).

RESULTS

Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy.

CONCLUSION

Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.

Role of neomycin polymyxin sulfate solution bladder wash for prevention of catheter associated urinary tract infection in traumatic brain injury patient admitted to Intensive Care Unit: A prospective randomized study

BACKGROUND

Catheter - associated urinary tract infection (CAUTI) remains a critical threat for patients in intensive care unit especially in traumatic brain injury patients with low Glasgow coma score (GCS). Almost all patients in ICU receive antibiotic either prophylactic or therapeutic based on local antibiogram of particular ICU or hospital. For prophylaxis, systemic antibiotics are used. It will be helpful to avoid systemic side effects by introducing antibiotics locally through bladder irrigation. The indwelling urinary catheter is an essential part of modern medical care.

AIMS AND OBJECTIVES

The primary objective was to study the effect of Neomycin and Polymyxin sulphate solution for bladder wash on CAUTI in traumatic brain injury patients. The secondary objectives was to study the various organisms causing CAUTI and their antibiotic sensitivity and resistance pattern.

MATERIALS AND METHODS

This was a prospective randomized controlled study performed on 100 patients who met the inclusion criteria at the trauma intensive care unit of Banaras Hindu University between September and February 2016. The patients were randomized into two groups - one was the study group which received Neomycin and Polymyxin Sulphate solution bladder wash, while the other was the control group that received Normal saline bladder wash. Urine samples were collected at certain days and sent for culture and sensitivity.

RESULTS

There was significant reduction in the incidence of CAUTI in neomycin/polymyxin test group in comparison to normal saline irrigated control group. Out of 50 patients in test group 8 patients and in control group 26 patients was identified as CAUTI positive and they were statistically significant. In our study pseudomonas aeruginosa (51%) was the commonest isolated pathogen.

CONCLUSIONS

Neomycin and Polymyxin Sulphate bladder wash was effective in preventing CAUTI. It can thus decrease the antibiotic usage thereby preventing the emergence of antibiotic resistance.

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.

Chlorhexidine sustained-release varnishes for catheter coating - Dissolution kinetics and antibiofilm properties

Catheter-associated urinary tract infections are difficult to eradicate or prevent, due to their biofilm-related nature. Chlorhexidine, a widely used antiseptic, was previously found to be effective against catheter-related biofilms. For the present study, we developed sustained-release chlorhexidine varnishes for catheter coating and evaluated their antibiofilm properties and chlorhexidine-dissolution kinetics under various conditions. The varnishes were based on ethylcellulose or ammonio methacrylate copolymer type A (Eudragit® RL). Chlorhexidine was released by diffusion from a heterogeneous matrix in the case of the ethylcellulose-based formulation, and from a homogeneous matrix in the case of Eudragit® RL. This dictated the release pattern of chlorhexidine under testing conditions: from film specimens, and from coated catheters in a static or flow-through system. Momentary saturation was observed with the flow-through system in Eudragit® RL-based coatings, an effect that might be present in vivo with other formulations as well. The coatings were retained on the catheters for at least 2weeks, and showed prolonged activity in a biological medium, including an antibiofilm effect against Pseudomonas aeruginosa. The current study demonstrates the potential of catheter coatings with sustained release of chlorhexidine in the prevention of catheter-associated urinary tract infections.