Diagnosis, Management, and Prevention of Catheter-Associated Urinary Tract Infections

Vaccines and monoclonal antibodies to prevent healthcare-associated bacterial infections

SUMMARYHealthcare-associated infections (HAIs) represent a burden for public health with a high prevalence and high death rates associated with them. Pathogens with a high potential for antimicrobial resistance, such as ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) and Clostridioides difficile, are responsible for most HAIs. Despite the implementation of infection prevention and control intervention, globally, HAIs prevalence is stable and they are mainly due to endogenous pathogens. It is undeniable that complementary to infection prevention and control measures, prophylactic approaches by active or passive immunization are needed. Specific groups at-risk (elderly people, chronic condition as immunocompromised) and also healthcare workers are key targets. Medical procedures and specific interventions are known to be at risk of HAIs, in addition to hospital environmental exposure. Vaccines or monoclonal antibodies can be seen as attractive preventive approaches for HAIs. In this review, we present an overview of the vaccines and monoclonal antibodies in clinical development for prevention of the major bacterial HAIs pathogens. Based on the current state of knowledge, we look at the challenges and future perspectives to improve prevention by these means.

Validity of urinary catheter specimens for diagnosis of urinary tract infection in patients with short-term catheterization

Current guidelines recommend urine culture after catheter replacement to diagnose catheter-associated urinary tract infections (CA-UTI) in patients with long-term catheters, but it's unclear if this applies to short-term catheterizations. We studied 52 patients with catheters for less than 28 days, showing symptoms of CA-UTI. We collected urine from the catheter port initially and from the new catheter within 2 hours of replacement. Positive culture rates were 36.5 % before and 28.8 % after replacement. Significant differences in urine culture results were observed in 32.7 % of cases postreplacement (P = .0184), increasing to 78.9 % after excluding negative pre-replacement cultures (P = 0.0003). Duration of catheterization didn't affect urine bacteriology changes post-replacement. This suggests that urine bacteriology often differs after catheter replacement in short-term catheterizations.

Urinary Catheter-Associated Infections

Catheter-associated urinary tract infections (CAUTIs) are common and costly hospital-acquired infections, yet they are largely preventable. The greatest modifiable risk factor for developing a CAUTI is duration of catheterization, including initial indwelling catheter placement when it may not otherwise be necessary. Alternatives to indwelling urinary catheters, including intermittent straight catheterization and the use of external catheters, should be considered in applicable patients. If an indwelling urinary catheter is required, aseptic insertion technique and maintenance should be performed. Through the use of collaborative, multidisciplinary intervention efforts, CAUTI rates can be successfully reduced.

Summer temperature and emergency room visits due to urinary tract infection in South Korea: a national time-stratified case-crossover study

BACKGROUND

Although urinary tract infection (UTI) is a common and severe public health concern, and there are clear biological mechanisms between UTI and hot temperatures, few studies have addressed the association between hot temperatures and UTI.

METHODS

We designed a time-stratified case-crossover study using a population-representative sample cohort based on the National Health Insurance System (NHIS) in South Korea. We obtained all NHIS-based hospital admissions through the emergency room (ER) due to UTI (using a primary diagnostic code) from 2006 to 2019. We assigned satellite-based reanalyzed daily summer (June to September) average temperatures as exposures, based on residential districts of beneficiaries (248 districts in South Korea). The conditional logistic regression was performed to evaluate the association between summer temperature and UTI outcome.

RESULTS

A total of 4,436 ER visits due to UTI were observed during the summer between 2006 and 2019 among 1,131,714 NHIS beneficiaries. For 20% increase in summer temperatures (0-2 lag days), the odd ratio (OR) was 1.06 (95% CI: 1.02-1.10) in the total population, and the association was more prominent in the elderly (people aged 65 y or older; OR:1.11, 95% CI: 1.05-1.17), females (OR: 1.12, 95% CI: 1.05-1.19), and people with diabetes history (OR: 1.14, 95% CI: 1.07-1.23). The effect modification by household income was different in the total and elderly populations. Furthermore, the association between summer temperature and UTI increased during the study period in the total population.

CONCLUSIONS

Our results are consistent with the hypothesis that higher summer temperatures increase the risk of severe UTIs, and the risk might be different by sub-populations.

Long-term antifouling surfaces for urinary catheters

The presence of a variety of bacteria is an inevitable/indispensable part of human life. In particular, for patients, the existence and spreading of bacteria lead to prolonged treatment period with many more complications. The widespread use of urinary catheters is one of the main causes for the prevalence of infections. The necessity of long-term use of indwelling catheters is unavoidable in terms of the development of bacteriuria and blockage. As is known, since a permanent solution to this problem has not yet been found, research and development activities continue actively. Herein, polyethylene glycol (PEG)-like thin films were synthesized by a custom designed plasma enhanced chemical vapor deposition (PE-CVD) method and the long-term effect of antifouling properties of PEG-like coated catheters was investigated against Escherichia coli and Proteus mirabilis. The contact angle measurements have revealed the increase of wettability with the increase of plasma exposure time. The antifouling activity of surface-coated catheters was analyzed against the Gram-negative/positive bacteria over a long-term period (up to 30 days). The results revealed that PE-CVD coated PEG-like thin films are highly capable of eliminating bacterial attachment on surfaces with relatively reduced protein attachment without having any toxic effect. Previous statements were supported with SEM, XPS, FTIR spectroscopy, and contact angle analysis.

Efficacy of expanded periurethral cleansing in reducing catheter-associated urinary tract infection in comatose patients: a randomized controlled clinical trial

BACKGROUND

The effect of the periurethral cleansing range on catheter-associated urinary tract infection (CAUTI) occurrence remains unknown. The purpose of this study was to evaluate the efficacy of expanded periurethral cleansing for reducing CAUTI in comatose patients.

METHODS

In this randomized controlled trial, eligible patients in our hospital were enrolled and allocated randomly to the experimental group (expanded periurethral cleansing protocol; n = 225) or the control group (usual periurethral cleansing protocol; n = 221). The incidence of CAUTI on days 3, 7, and 10 after catheter insertion were compared, and the pathogen results and influencing factors were analyzed.

RESULTS

The incidences of CAUTI in the experimental and control groups on days 3, 7, and 10 were (5/225, 2.22% vs. 7/221, 3.17%, P = 0.54), (12/225, 5.33% vs. 18/221, 8.14%, P = 0.24), and (23/225, 10.22% vs. 47/221, 21.27%, P = 0.001), respectively; Escherichia coli and Candida albicans were the most common species in the two groups. The incidences of bacterial CAUTI and fungal CAUTI in the two groups were 11/225, 4.89% vs. 24/221, 10.86%, P = 0.02) and (10/225, 4.44% vs. 14/221, 6.33%, P = 0.38), respectively. The incidences of polymicrobial CAUTI in the two groups were 2/225 (0.89%) and 9/221 (4.07%), respectively (P = 0.03). The percentages of CAUTI-positive females in the two groups were 9.85% (13/132) and 29.52% (31/105), respectively (P < 0.05). The proportion of CAUTI-positive patients with diabetes in the experimental and control groups was 17.72% (14/79), which was lower than the 40.85% (29/71) in the control group (P < 0.05).

CONCLUSION

Expanded periurethral cleansing could reduce the incidence of CAUTI, especially those caused by bacteria and multiple pathogens, in comatose patients with short-term catheterization (≤ 10 days). Female patients and patients with diabetes benefit more from the expanded periurethral cleansing protocol for reducing CAUTI.

Medical Device-Associated Biofilm Infections and Multidrug-Resistant Pathogens

Medical devices such as venous catheters (VCs) and urinary catheters (UCs) are widely used in the hospital setting. However, the implantation of these devices is often accompanied by complications. About 60 to 70% of nosocomial infections (NIs) are linked to biofilms. The main complication is the ability of microorganisms to adhere to surfaces and form biofilms which protect them and help them to persist in the host. Indeed, by crossing the skin barrier, the insertion of VC inevitably allows skin flora or accidental environmental contaminants to access the underlying tissues and cause fatal complications like bloodstream infections (BSIs). In fact, 80,000 central venous catheters-BSIs (CVC-BSIs)-mainly occur in intensive care units (ICUs) with a death rate of 12 to 25%. Similarly, catheter-associated urinary tract infections (CA-UTIs) are the most commonlyhospital-acquired infections (HAIs) worldwide.These infections represent up to 40% of NIs.In this review, we present a summary of biofilm formation steps. We provide an overview of two main and important infections in clinical settings linked to medical devices, namely the catheter-asociated bloodstream infections (CA-BSIs) and catheter-associated urinary tract infections (CA-UTIs), and highlight also the most multidrug resistant bacteria implicated in these infections. Furthermore, we draw attention toseveral useful prevention strategies, and advanced antimicrobial and antifouling approaches developed to reduce bacterial colonization on catheter surfaces and the incidence of the catheter-related infections.

The Clinical Profile of Patients With Culture-Positive Urinary Tract Infections Admitting to a Tertiary Hospital in Sri Lanka

Introduction Urinary tract infections (UTIs) are globally prevalent. This study explores the clinical and pathological profile of culture-positive UTI patients at Sri Jayewardenepura General Hospital. Method In this descriptive cross-sectional study conducted at Sri Jayewardenepura General Hospital from December 2020 to May 2021, we evaluated patients over 14 years with positive urine culture reports. Excluding those with HIV, undergoing chemotherapy, or pregnant, we used consecutive sampling. Data were collected via interviewer-administered questionnaires and analyzed using SPSS version 21.0 (IBM Inc., Armonk, New York), employing descriptive statistics and Fisher's exact tests to identify factors associated with urinary tract infections. Results The study involved approximately 278 participants. The mean age remained 60 ± 20.279 years, with over half of the participants being female. Common symptoms like fever and lower abdominal pain were observed in 22.30% of cases. The incidence of acute kidney injury was 30.58%. Escherichia coli (36%) and Klebsiella pneumoniae (26%) were the predominant organisms found. Indwelling catheters and other urinary tract conditions were considered risk factors. Patients with at least one risk factor were more likely to receive antibiotics before the urine culture. Similarly, males exhibited a higher prevalence of at least a risk factor than females. Conclusion UTIs are a significant clinical issue in older populations, with females being more susceptible. Fever and abdominal pain were common symptoms. Escherichia coli and Klebsiella pneumoniae were the most frequent causative agents. Further research is necessary to identify risk factors and predictors of antimicrobial resistance in UTI patients.

Asymptomatic bacteriuria in patients with type 2 diabetes mellitus in rural southwestern Nigeria: a cross-sectional study

OBJECTIVES

We aimed to identify the prevalence, bacterial isolates, antimicrobial susceptibility profile, and factors associated with asymptomatic bacteriuria (ASB) in patients with type 2 diabetes mellitus (T2DM) in rural southwestern Nigeria.

METHODS

We performed a hospital-based cross-sectional study of patients with T2DM and ASB. Demographic and clinical data were collected using questionnaires. Urine samples were cultured using standard laboratory procedures, and bacterial colonies were isolated and antimicrobial sensitivity was performed using the disc diffusion technique. Relationships between variables were assessed using adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Of the 280 participants, 73 (26.1%) had ASB (95% CI: 20.9%-31.2%). The most commonly identified isolate was E. coli (45/73; 61.7%), 100.0% of which were sensitive to cefuroxime but resistant to ciprofloxacin. Female sex (AOR, 6.132; 95% CI: 2.327-16.157), living below the poverty line (AOR, 2.066; 95% CI: 1.059-4.029), uncontrolled blood glucose (AOR, 2.097; 95% CI: 1.000-4.404), and a history of indwelling urethral catheterization (AOR, 14.521; 95% CI: 4.914-42.908) were associated with ASB.

CONCLUSION

The findings suggest that cefuroxime should be used as an empirical treatment, pending urine culture and sensitivity, and that efforts should be made to prevent ASB in rural southwestern Nigeria.

Validation of measures for perioperative urinary catheter use, urinary retention, and urinary catheter-related trauma in surgical patients

BACKGROUND

The effects of non-infectious urinary catheter-related complications such as measurements of indwelling urinary catheter overuse, catheter-related trauma, and urinary retention are not well understood.

METHODS

This was a retrospective cohort study of 200 patients undergoing general surgery operations. Variables to measure urinary catheter use, trauma, and retention were developed, then surgical cases were abstracted. Inter- and intra-rater reliability were calculated for measure validation.

RESULTS

129 of 200 (65%) had an indwelling urinary catheter placed at the time of surgery. 32 patients (16%) had urinary retention, and variation was observed in the treatment of urinary retention. 12 patients (6%) had urinary trauma. Rater reliability was high (>90% agreement for all) for the dichotomous outcomes of urinary catheter use, urinary catheter-related trauma, and urinary retention.

CONCLUSIONS

This study suggests a persistent high rate of catheter use, significant rates of urinary retention and trauma, and variation in the management of retention.

Perfluoropolyether-incorporated polyurethane with enhanced antibacterial and anti-adhesive activities for combating catheter-induced infection

To avoid the undesired bacterial attachment on polyurethane-based biomedical devices, we designed a class of novel perfluoropolyether-incorporated polyurethanes (PFPU) containing different contents of perfluoropolyether (PFPE) segments. After blending with Ag nanoparticles (AgNPs), a series of bifunctional PFPU/AgNPs composites with bactericidal and anti-adhesion abilities were obtained and correspondingly made into PFPU/AgNPs films (PFPU/Ag-F) using a simple solvent-casting method. Due to its highest hydrophobicity and suitable mechanical properties, PFPU8/Ag-F containing 8 mol% of PFPE content was chosen as the optimized one for the next antibacterial assessment. The PFPU8/Ag-F can effectively deactivate over 99.9% of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) cells at 106 CFU mL-1 within 30 min. Furthermore, the PFPU8/AgNPs composite was used as painting material to form a protective coating for the commercial polyurethane (PU) catheter. The as-prepared PFPU8/Ag coating exhibits high resistance to bacterial adhesion in a continuous-flow artificial urine model in an 8 day exposure. Therefore, it can be expected that the proposed PFPE-containing films and coatings can effectively prevent bacterial colonization and biofilm formation on catheters or other implants, thereby reducing the risk of postoperative catheter-induced infection.

Prevention of urinary tract infection using a silver alloy hydrogel-coated catheter in critically ill patients: A single-center prospective randomized controlled study

Background

A new type of silver alloy hydrogel-coated (SAH) catheter has been shown to prevent bacterial adhesion and colonization by generating a microcurrent, and to block the retrograde infection pathway. However, these have only been confirmed in ordinary patients. This study aims to evaluate the effectiveness of a SAH catheter for preventing urinary tract infections in critically ill patients.

Methods

This was a prospective single-center, single-blind, randomized, controlled study. A total of 132 patients requiring indwelling catheterization in the intensive care unit (ICU) of the First Affiliated Hospital of the University of Science and Technology of China between October 2022 and February 2023 and who met the study inclusion/exclusion criteria were randomly divided into two groups. Patients in the SAH catheter group received a SAH catheter, while patients in the conventional catheter group received a conventional siliconized latex Foley catheter. The main outcome measure was the incidence of catheter-associated urinary tract infections (CAUTIs). Secondary outcome indicators included urine positivity for white blood cells and positive urine cultures on 3 days, 7 days, 10 days, and 14 days after catheterization, number of viable bacteria in the catheter biofilm on day 14, pathogenic characteristics of positive urine cultures, length of ICU stay, overall hospital stay, ICU mortality, and 28-day mortality. All the data were compared between the two groups.

Results

A total of 68 patients in the conventional catheter group and 64 patients in the SAH catheter group were included in the study. On day 7 after catheter placement, the positivity rate for urinary white blood cells was significantly higher in the conventional catheter group than in the SAH catheter group (33.8% vs. 15.6%, P=0.016). On day 10, the rates of positive urine cultures (27.9% vs. 10.9%, P=0.014) and CAUTIs (22.1% vs. 7.8%, P=0.023) were significantly higher in the conventional catheter group than in the SAH catheter group. On day 14, the numbers of viable bacteria isolated from the catheter tip ([3.21±1.91]×106 colony-forming units [cfu]/mL vs. [7.44±2.22]×104 cfu/mL, P <0.001), balloon segment ([7.30±1.99]×107 cfu/mL vs. [3.48±2.38]×105 cfu/mL, P <0.001), and tail section ([6.41±2.07]×105 cfu/mL vs. [8.50±1.46]×103 cfu/mL, P <0.001) were significantly higher in the conventional catheter group than in the SAH catheter group. The most common bacteria in the urine of patients in both groups were Escherichia coli (n=13) and Pseudomonas aeruginosa (n=6), with only one case of Candida in each group. There were no significant differences between the two groups in terms of ICU hospitalization time, total hospitalization time, ICU mortality, and 28-day mortality.

Conclusion

SAH catheters can effectively inhibit the formation of catheter-related bacterial biofilms in critically ill patients and reduce the incidence of CAUTIs, compared with conventional siliconized latex Foley catheters; however, regular replacement of the catheter is still necessary.

Urinary Tract Infection in Children: A Narrative Review

This study investigates the susceptibility of different age groups and genders to urinary tract infections (UTIs) in pediatric populations, focusing on anatomical and behavioural factors. A systematic review of clinical data explores manifestations, accurate diagnosis methods, and antibiotic treatment regimens. Escherichia coli is a prevalent uropathogen, and the study addresses concerns about antibiotic resistance. The research aims to close knowledge gaps, influence guidelines, and enhance public health initiatives. Factors influencing UTI prevalence, such as age, gender, and structural abnormalities, are discussed. The review follows a robust search methodology, presenting a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. The included studies cover a wide range of topics related to pediatric UTIs, including aetiology, treatment, prevention, and diagnostic approaches. The study emphasizes the importance of understanding and addressing pediatric UTIs for effective management and prevention.

Engineered live bacteria as disease detection and diagnosis tools

Sensitive and minimally invasive medical diagnostics are essential to the early detection of diseases, monitoring their progression and response to treatment. Engineered bacteria as live sensors are being developed as a new class of biosensors for sensitive, robust, noninvasive, and in situ detection of disease onset at low cost. Akin to microrobotic systems, a combination of simple genetic rules, basic logic gates, and complex synthetic bioengineering principles are used to program bacterial vectors as living machines for detecting biomarkers of diseases, some of which cannot be detected with other sensing technologies. Bacterial whole-cell biosensors (BWCBs) can have wide-ranging functions from detection only, to detection and recording, to closed-loop detection-regulated treatment. In this review article, we first summarize the unique benefits of bacteria as living sensors. We then describe the different bacteria-based diagnosis approaches and provide examples of diagnosing various diseases and disorders. We also discuss the use of bacteria as imaging vectors for disease detection and image-guided surgery. We conclude by highlighting current challenges and opportunities for further exploration toward clinical translation of these bacteria-based systems.

CpxA/R-Controlled Nitroreductase Expression as Target for Combinatorial Therapy against Uropathogens by Promoting Reactive Oxygen Species Generation

The antibiotic resistances emerged in uropathogens lead to accumulative treatment failure and recurrent episodes of urinary tract infection (UTI), necessitating more innovative therapeutics to curb UTI before systematic infection. In the current study, the combination of amikacin and nitrofurantoin is found to synergistically eradicate Gram-negative uropathogens in vitro and in vivo. The mechanistic analysis demonstrates that the amikacin, as an aminoglycoside, induced bacterial envelope stress by introducing mistranslated proteins, thereby constitutively activating the cpxA/R two-component system (Cpx signaling). The activation of Cpx signaling stimulates the expression of bacterial major nitroreductases (nfsA/nfsB) through soxS/marA regulons. As a result, the CpxA/R-dependent nitroreductases overexpression generates considerable quantity of lethal reactive intermediates via nitroreduction and promotes the prodrug activation of nitrofurantoin. As such, these actions together disrupt the bacterial cellular redox balance with excessively-produced reactive oxygen species (ROS) as "Domino effect", accelerating the clearance of uropathogens. Although aminoglycosides are used as proof-of-principle to elucidate the mechanism, the synergy between nitrofurantoin is generally applicable to other Cpx stimuli. To summarize, this study highlights the potential of aminoglycoside-nitrofurantoin combination to replenish the arsenal against recurrent Gram-negative uropathogens and shed light on the Cpx signaling-controlled nitroreductase as a potential target to manipulate the antibiotic susceptibility.

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.

A systematic review and meta-analysis of cardiovascular diseases and associated factors among diabetes mellitus patients in Ethiopia

BACKGROUND

Cardiovascular disease (CVD) is the most prevalent complication and the leading cause of death and disability among patients with diabetes mellitus (DM). Over time, diabetes-related cardiovascular disease has become more common worldwide. The aim of this study was to determine the cumulative prevalence of cardiovascular disease and associated factors among diabetic patients in Ethiopia.

OBJECTIVE

The main aim of this review was to estimate the pooled prevalence of cardiovascular disease and its associated factors among diabetic patients in Ethiopia.

METHODS AND MATERIALS

This review was searched using PubMed, Google, and Google Scholar search engines, and was accessed using medical subject heading (MeSH) terms for studies based in Ethiopia. Excel was used to extract the data. With a random-effects model, STATA Version 14 was used for all statistical analyses. The studies' heterogeneity and funnel plot were both examined. The study domain and authors' names were used in the subgroup analysis.

RESULTS

In this systematic review, 12 studies totaling 2,953 participants were included. The estimated overall prevalence of cardiovascular disease among diabetic patients in Ethiopia was 37.26% (95% CI: 21.05, 53.47, I2 = 99.3%, P ≤ 0.001). Study participants' age older than 60 years (AOR = 4.74, 95%CI: 1.05, 8.43), BMI > 24.9kg/m2 (AOR = 4.12, 95% CI: 2.33, 5.92), triglyceride > 200mg/dl (AOR = 3.05, 95% CI: 1.26, 4.83), Hypertension (AOR = 3.26, 95% CI: 1.09, 5.43) and duration of DM > 4 years (AOR = 5.49, 95% CI: 3.27, 7.70) were significantly associated with cardiovascular disease.

CONCLUSIONS

In conclusion, diabetic patients face a serious public health risk from cardiovascular disease. This review found the following factors, which is independent predictors of cardiovascular disease in diabetic patients: age over 60, BMI > 24.9kg/m2, triglycerides > 200 mg/dl, hypertension, and diabetes duration > 4 years. The results emphasize the need for a prospective study design with a longer follow-up period to assess the long-term effects of CVD predictors in diabetic patients as well as the significance of paying attention to cardiovascular disease in diabetic patients with comorbidity.

APSIC guide for prevention of catheter associated urinary tract infections (CAUTIs)

BACKGROUND

The Asia Pacific Society of Infection Control launched the APSIC guide for prevention of catheter associated urinary tract infections in July 2022. It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities in the Asia Pacific region to achieve high standards in infection prevention and control practices during the management and care of patients with a urinary catheter.

METHODS

The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.

RESULTS

It recommends that healthcare institutions have a catheter associated urinary tract infection prevention program that includes surveillance and the use of the insertion and maintenance bundles. Implementation of the bundles is best done using a quality improvement approach with a multidisciplinary team.

CONCLUSIONS

Healthcare facilities should aim for excellence in care of patients with urinary catheters. It is recommended that healthcare facilities have a catheter associated urinary tract infection prevention program as part of their Infection Prevention and Control program.

Need to clamp indwelling urinary catheters before removal after different durations: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate the effect of bladder training by clamping on bladder urethral function in patients with indwelling urinary catheters used for different durations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The UpToDate, Cochrane Library, OVID, PubMed, China National Knowledge Infrastructure, CINAHL and Embase were screened from 1 January 2000 to 28 February 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) or quasi-experimental designs comparing the efficacy of bladder training in patients with an indwelling urinary catheter by clamping or free drainage before urinary catheter removal were published in English or Chinese.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted the data and assessed the quality of studies. Continuous variables were analysed using mean difference and standardised mean difference (SMD) values with a 95% CI. Categorical variables were analysed using relative risk (RR) and 95% CI.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was urinary tract infection incidence, and secondary outcomes included hours to first voiding, incidence of urinary retention and recatheterisation and residual urine volume.

RESULTS

Seventeen papers (15 RCTs and 2 quasi-RCTs) comprising 3908 participants were included in the meta-analysis. The pooled results of the meta-analysis showed that the clamping group had a significantly higher risk of urinary tract infections (RR=1.47; 95% CI 1.26 to 1.72; p<0.00001) and a longer hour to first void (SMD=0.19; 95% CI 0.08 to 0.29; p=0.0004) compared with the free drainage group. Subgroup analysis of indwelling urinary catheter use durations of ≤7 days indicated that clamping significantly increased the risk of urinary tract infection (RR=1.69; 95% CI 1.42 to 2.02, p<0.00001) and lengthens the interval to first void (SMD=0.26, 95% CI 0.11 to 0.41, p=0.0008) compared with free drainage.

CONCLUSIONS

Bladder training by clamping indwelling urinary catheters increases the incidence of urinary tract infection and lengthens the hours to first void in patients with indwelling urinary catheters use durations of ≤7 days compared with the free drainage. However, the effect of clamping training on patients with an indwelling urinary catheter use duration of >7 days is unclear.

Do postoperative infectious complications really affect long-term survival in colorectal cancer surgery? A multicenter retrospective cohort study

Aim

To investigate the impact of postoperative infection (PI), surgical site infection, and remote infection (RI), on long-term outcomes in patients with colorectal cancer (CRC).

Methods

The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 1817 curative stage I/II/III CRC patients from April 2013 to March 2015. Patients were divided into the No-PI group and the PI group. We examined the association between PI and oncological outcomes for cancer-specific survival (CSS) and overall survival (OS) using Cox proportional hazards models and propensity score matching.

Results

Two hundred and ninety-nine patients (16.5%) had PIs. The 5-year CSS and OS rates in the No-PI and PI groups were 92.8% and 87.6%, and 87.4% and 83.8%, respectively. Both the Cox proportional hazards models and propensity score matching demonstrated a significantly worse prognosis in the PI group than that in the No-PI group for CSS (hazard ratio: 1.60; 95% confidence interval: 1.10-2.34; P = .015 and P = .031, respectively) but not for OS. RI and the PI severity were not associated with oncological outcomes. The presence of PI abolished the survival benefit of adjuvant chemotherapy.

Conclusions

These results suggest that PI after curative CRC surgery is associated with impaired oncological outcomes. This survival disadvantage of PI was primarily derived from surgical site infection, not RI, and PI induced lower efficacy of adjuvant chemotherapy. Strategies to prevent PI and implement appropriate postoperative treatment may improve the quality of care and oncological outcomes in patients undergoing curative CRC surgery.

A single institution pre-/post-comparison after introduction of an external urinary collection device for female medical patients

Background

External urinary collection devices (EUCDs) may serve as an alternative to indwelling urinary catheters (IUCs) and decrease the rate of catheter associated urinary tract infections (CAUTIs). PureWick® is a novel female EUCD; however, no study has definitively proven benefit regarding reduction of CAUTIs.

Aim

We sought to compare the CAUTI rate and IUC days before and after availability of the PureWick® EUCD at a single institution. We provide a descriptive analysis of female medical patients receiving an EUCD.

Methods

A retrospective review of adult female patients admitted to a single institution on a medical service who received an IUC and/or an EUCD was performed. Patients who received an IUC in the 3 months before EUCD availability (PRE) were compared to patients who received an IUC and/or EUCD in the 12 months after (POST).

Results

Out of 848 female patients, 292 received an EUCD in the POST cohort and overall, 656 received an IUC (259 (100%) PRE vs. 397 (67.4%) POST). Compared to the PRE cohort, the POST cohort had a higher number of IUC days (median, 3 vs 2 days, p = 0.001) and a higher rate of CAUTI (infections per 1000 catheter days, 9.3 vs 2.3, p = 0.001). The rate of UTI associated with EUCD use was 9.8 infections per 1000 device days.

Discussion

While EUCDs might appear to be a promising alternative to IUCs for female patients, this single center pre-/post-analysis found that both the number of IUC days and the CAUTI rate increased after introduction of a female EUCD.

How to Prevent Catheter-Associated Urinary Tract Infections: A Reappraisal of Vico's Theory-Is History Repeating Itself?

New, contextualized modern solutions must be found to solve the dilemma of catheter-associated urinary infection (CAUTI) in long-term care settings. In this paper, we describe the etiology, risk factors, and complications of CAUTI, explore different preventive strategies proposed in literature from the past to the present, and offer new insights on therapeutic opportunities. A care bundle to prevent CAUTI mainly consists of multiple interventions to improve clinical indications, identifying a timeline for catheter removal, or whether any alternatives may be offered in elderly and frail patients suffering from chronic urinary retention and/or untreatable urinary incontinence. Among the various approaches used to prevent CAUTI, specific urinary catheter coatings according to their antifouling and/or biocidal properties have been widely investigated. Nonetheless, an ideal catheter offering holistic antimicrobial effectiveness is still far from being available. After pioneering research in favor of bladder irrigations or endovesical instillations was initially published more than 50 years ago, only recently has it been made clear that evidence supporting their use to treat symptomatic CAUTI and prevent complications is needed.

Prevention and Treatment of Side Effects of Immunotherapy for Bladder Cancer

Bladder cancer (BC) is one of the most important tumors of the genitourinary system, associated with high morbidity and mortality rates. Over the years, various antitumor treatments have been developed, and immunotherapy is one of the most effective methods. Immunotherapy aims to activate the body’s immune system to kill cancer cells. It has been established that immunotherapy drugs can be classified into “non-targeted” and “targeted” drugs depending on their site of action. Immunotherapy is reportedly effective for BC. Even though it can attack cancer cells, it can also cause the immune system to attack healthy cells, which can occur at any time during treatment and sometimes even after immunotherapy is stopped. Importantly, different types of immunotherapies can cause different side effects. Side effects may manifest themselves as signs or as symptoms. The prevention and treatment of side effects caused by immunotherapy is an important part of cancer patient management.

Catheter-Associated Urinary Tract Infections: Current Challenges and Future Prospects

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and cause of secondary bloodstream infections. Despite many advances in diagnosis, prevention and treatment, CAUTI remains a severe healthcare burden, and antibiotic resistance rates are alarmingly high. In this review, current CAUTI management paradigms and challenges are discussed, followed by future prospects as they relate to the diagnosis, prevention, and treatment. Clinical and translational evidence will be evaluated, as will key basic science studies that underlie preventive and therapeutic approaches. Novel diagnostic strategies and treatment decision aids under development will decrease the time to diagnosis and improve antibiotic accuracy and stewardship. These include several classes of biomarkers often coupled with artificial intelligence algorithms, cell-free DNA, and others. New preventive strategies including catheter coatings and materials, vaccination, and bacterial interference are being developed and investigated. The antibiotic pipeline remains insufficient, and new strategies for the identification of new classes of antibiotics, and rational design of small molecule inhibitor alternatives, are under development for CAUTI treatment.

Urinary catheter alleviation navigator protocol (UCANP): Overview of protocol and review of initial experience

BACKGROUND

Given the associated morbidity, mortality, and financial consequences of catheter associated urinary tract infections (CAUTIs), efforts should be made to mitigate the risk. We sought to describe, and report results for a post-catheter removal bladder management protocol focused on decreasing catheter reinsertion, catheter days, and overall CAUTI risk.

METHODS

This was a quality improvement initiative implemented over a 3-month period at a single urban, tertiary health care center. Patients with an indwelling urinary catheter deemed eligible for removal were followed and cared for according to the study protocol. Rates of catheter reinsertion, catheter days, and assessment of CAUTI risk were compared between cohorts.

RESULTS

A total of 173 patients were eligible for protocol enrollment. Catheter reinsertion rate was 16% during the pilot, compared to 21% and 27% for the historical cohorts, (P = .02). The mean number of catheter day's during the study was 1.4 days, compared to 9.5 and 5.6 days in the historical cohorts (P = .004). Catheter hours (OR 1.010 95% CI 1.005 - 1.015 P < .0001.) was a predictor of catheter reinsertion during the pilot.

CONCLUSIONS

Our protocol resulted in a reduction of catheter reinsertion rates and number of catheter days. Expansion of this protocol to a larger patient cohort is required.

The Impact of Differences in Surveillance Definitions of Hospital Acquired Urinary Tract Infections (HAUTI)

Hospital-acquired urinary tract infections (HAUTI) are common and most cases are related to catheters (CAUTI). HAUTI and CAUTI surveillance is mandatory in many countries as a measure to reduce the incidence of infections and appropriately direct the allocation of preventable resources. The surveillance criteria issued by the Israeli Ministry of Health (IMOH), differ somewhat from that of the U.S. Centers for Disease Control and Prevention (CDC). Our study aims were to query and quantify the impact of these differences. In a retrospective cohort study conducted at Shamir Medical Center, for calendar year 2017, the surveillance criteria of both IMOH and CDC were applied on 644 patient-unique adults with “positive” urine cultures (per similar definitions). The incidence of HAUTI per IMOH was significantly higher compared to CDC (1.24/1000 vs. 1.02/1000 patient-days, p = 0.02), with no impact on hospitalization’s outcomes. The agreement rate between methods was high for CAUTI (92%), but much lower for all HAUTI (83%). The major error rate, i.e., patients diagnosed with HAUTI per IMOH but had no UTI per CDC, was 31%. To conclude, in order for surveillance to reflect the relative situation and direct allocation of preventable resources based on scientific literature, the process should be uniform worldwide.

Prospective assessment of catheter-associated bacteriuria clinical presentation, epidemiology, and colonization dynamics in nursing home residents

BACKGROUND

Catheterization facilitates continuous bacteriuria, for which the clinical significance remains unclear. This study aimed to determine the clinical presentation, epidemiology, and dynamics of bacteriuria in a cohort of long-term catheterized nursing home residents.

METHODS

Prospective urine culture, urinalysis, chart review, and assessment of signs and symptoms of infection were performed weekly for 19 study participants over 7 months. All bacteria ≥ 1 × 10³ cfu/mL were cultured, isolated, identified, and tested for susceptibility to select antimicrobials.

RESULTS

In total, 226 of the 234 urine samples were polymicrobial (97%), with an average of 4.7 isolates per weekly specimen. A total of 228 urine samples (97%) exhibited ≥ 1 × 10⁶ CFU/mL, 220 (94%) exhibited abnormal urinalysis, 126 (54%) were associated with at least 1 possible sign or symptom of infection, and 82 (35%) would potentially meet a standardized definition of catheter-associated urinary tract infection (CAUTI), but only 3 had a caregiver diagnosis of CAUTI. Bacterial isolates (286; 30%) were resistant to a tested antimicrobial agent, and bacteriuria composition was remarkably stable despite a combined total of 54 catheter changes and 23 weeks of antimicrobial use.

CONCLUSION

Bacteriuria composition was largely polymicrobial, including persistent colonization by organisms previously considered to be urine culture contaminants. Neither antimicrobial use nor catheter changes sterilized the urine, at most resulting in transient reductions in bacterial burden followed by new acquisition of resistant isolates. Thus, this patient population exhibits a high prevalence of bacteriuria coupled with potential indicators of infection, necessitating further exploration to identify sensitive markers of true infection.

FUNDING

This work was supported by the NIH (R00 DK105205, R01 DK123158, UL1 TR001412).

Efficacy of three lytic bacteriophages for eradicating biofilms of multidrug-resistant Proteus mirabilis

Proteus mirabilis is one of the most frequent causes of catheter-associated urinary tract infections (CAUTIs) owing to its capability to colonize and develop crystalline multidrug-resistant (MDR) biofilms. Here, we report the isolation and partial characterization of three novel bacteriophages, vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, which were active against the planktonic form and biofilms of the MDR P. mirabilis strain ES01, isolated from CAUTIs in Egypt. The antibiotic susceptibility profile of the P. mirabilis isolates showed resistance to most of the antibiotics tested. The isolated phages were identified morphologically using TEM, and each appeared to have myovirus-like morphology. The three phages displayed strong lytic activity and a narrow host range, and they were stable at different ranges of temperatures and pH values. One-step growth kinetics showed a lysis time of 180 min with a burst size of 99.6, 95, and 86 PFU/cell for phage vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, respectively. The three phages exhibited different digestion patterns using different restriction enzymes. The genome size was estimated to be 59.39 kb, 62.19 kb, and 52.07 kb for phage vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, respectively. A phage cocktail including the three phages showed a potential ability to reduce and eradicate a biofilm formed by the MDR Proteus mirabilis EG-ES1. Accordingly, a phage cocktail of vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c is considered a promising candidate for use as a biocontrol agent against MDR Proteus mirabilis bacteria.

Healthcare-associated urinary tract infections in urology

The purpose of the present review is to report the incidence and characteristics of healthcare-associated urinary tract infections (HAUTIs) in urology with their microbiological and resistance patterns. Urinary tract infections are the main type of healthcare-associated infection in patients hospitalized in a urology ward. Patients admitted to urology departments report a high prevalence of urinary tract catheterization, up to 75% during the hospitalization period, and up to 20% had a urinary catheter before admission. An endourological surgical procedure is another risk factor for HAUTIs. Other risk factors for HAUTIs are the presence of immunosuppression and previous urinary tract infections.

In urological patients, Enterobacterales are the principal causative agent of HAUTIs, and E. coli is the most frequently isolated microorganism. However, there is also a high rate of microorganisms other than E. coli such as Klebsiella spp. and Enterococcus spp. Non-E. coli microorganisms show a higher prevalence in immunosuppressed patients and those with urinary catheters before admission. High resistance patterns are reported in patients with HAUTIs, and ESBL-producing bacteria are frequently described. Moreover, the isolation of multidrug-resistant microorganisms is more common in immunosuppressed patients, those with previous urinary tract infections, and urinary catheters into the upper urinary tract. Treatment must be tailored according to patient characteristics and patient profiles, bearing in mind the ORENUC classification for risk factors (no risk factors (O), recurrent urinary tract infections risk factors (R), extraurogenital risk factors (E), nephropathic disease (N), urological risk factors (U), permanent urinary catheter and non-resolvable urological risk factors (C)).

Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI.

OBJECTIVE

The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI.

METHODS

A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis.

RESULTS

Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without.

CONCLUSIONS

Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.

Behind Every Great Infection Prevention Program is a Great Microbiology Laboratory: Key Components and Strategies for an Effective Partnership

A great clinical microbiology laboratory supporting a great infection prevention program requires focusing on the following services: rapid and accurate identification of pathogens associated with health care-associated infections; asymptomatic surveillance for health care-acquired pathogens before infections arise; routine use of broad and flexible antimicrobial susceptibility testing to direct optimal therapy; implementation of epidemiologic tracking tools to identify outbreaks; development of clear result communication with interpretative comments for clinicians. These goals are best realized in a collaborative relationship with the infection prevention program so that both can benefit from the shared priorities of providing the best patient care.

Preventing Catheter-Associated Urinary Tract Infections with Incontinence Management Alternatives: PureWick and Condom Catheter

Catheter-associated urinary tract infections (CAUTI) have a high financial and human impact on patients and society at large, making CAUTI prevention strategies essential. A shift has occurred where nurses play an increased role in infection prevention. Nurses promote staff and patient education on CAUTI prevention, identification of appropriate urinary incontinence management, and implementation of bundles and patient care strategies to minimize complications from urinary incontinence management. Because they understand the severity of CAUTI and current recommendations, nurses at the bedside are in the best position to identify appropriate indications of indwelling urinary catheters and external urine collection devices for patients.

Prevention and Management of Infectious Complications of Retrograde Intrarenal Surgery

Kidney stone disease (KSD) is a commonly encountered ailment in urologic practice. Urinary tract infection (UTI) is commonly associated with KSD, both as an etiology (e.g., struvite and carbonate apatite stones), and as a complication (i.e., obstructive pyelonephritis and post-operative UTI). Indeed, a significant portion of the economic burden of KSD is skewed toward stones associated with infection. UTI is the most common post-operative complication related to stone intervention with progression to urosepsis as a rare but serious consequence. Risk for infection is influenced by a variety of factors including co-morbid conditions, anatomic abnormalities, prior surgical procedures, and local anti-microbial susceptibility. Understanding these risks and the proper steps to mitigate them is an essential component in reducing post-operative morbidity and mortality. Retrograde intrarenal surgery is routinely used for the treatment of KSD. The objective of this review article is to examine the current literature and guidelines for the prevention and management of stone-related infectious complications associated with retrograde intrarenal surgery. Special attention will be given to the incidence, etiology, and antibiotic prophylaxis choice in the management of stone-related infections. Intraoperative risk mitigation techniques will be discussed in conjunction with the management of post-operative infections. Antibiotic stewardship and the potential benefits of reduced empiric antibiotic treatment will also be discussed.

Ciprofloxacin-Releasing ROS-Sensitive Nanoparticles Composed of Poly(Ethylene Glycol)/Poly(D,L-lactide-co-glycolide) for Antibacterial Treatment

Since urinary tract infections (UTIs) are closely associated with oxidative stress, we developed ROS-sensitive nanoparticles for ciprofloxacin (CIP) delivery for inhibition of UTI. Poly(D,L-lactide-co-glycolide) (PLGA)- selenocystamine (PLGA-selenocystamine) conjugates were attached to methoxypoly(ethylene glycol) (PEG) tetraacid (TA) (TA-PEG) conjugates to produce a copolymer (abbreviated as LGseseTAPEG). Selenocystamine linkages were introduced between PLGA and TA to endow reactive oxygen species (ROS) sensitivity to nanoparticles. CIP-incorporated nanoparticles of LGseseTAPEG copolymer were fabricated by W/O/W/W emulsion method. CIP-incorporated nanoparticles responded to H₂O₂ and then their morphologies were disintegrated by incubation with H₂O₂. Furthermore, particle size distribution of nanoparticles was changed from mono-modal distribution pattern to multi-modal distribution pattern by addition of H₂O₂. CIP release from nanoparticles of LGseseTAPEG copolymer was faster in the presence of H₂O₂ than in the absence of it. In antibacterial study using Escherichia coli (E. coli), free CIP and free CIP plus empty nanoparticles showed dose-dependent inhibitory effect against growth of bacteria while CIP-incorporated nanoparticles have less antibacterial activity compared to free CIP. These results were due to that CIP-incorporated nanoparticles have sustained release properties. When free CIP or CIP-incorporated nanoparticles were introduced into dialysis membrane to mimic in vivo situation, CIP-incorporated nanoparticles showed superior antibacterial activity compared to free CIP. At cell viability assay, nanoparticles of LGseseTAPEG copolymer have no acute cytotoxicity against L929 mouse fibroblast cells and CCD986sk human skin fibroblast cells. We suggest LGseseTAPEG nanoparticles are a promising candidate for CIP delivery.

Prospective cohort study on hospitalised patients with suspected urinary tract infection and risk factors por multidrug resistance

Urinary tract infections (UTIs) are among the most common bacterial infections and a frequent cause for hospitalization in the elderly. The aim of our study was to analyse epidemiological, microbiological, therapeutic, and prognostic of elderly hospitalised patients with and to determine independent risk factors for multidrug resistance and its outcome implications. A single-centre observational prospective cohort analysis of 163 adult patients hospitalized for suspected symptomatic UTI in the Departments of Internal Medicine, Infectious Diseases and Short-Stay Medical Unit of a tertiary hospital was conducted. Most patients currently admitted to hospital for UTI are elderly and usually present high comorbidity and severe dependence. More than 55% met sepsis criteria but presented with atypical symptoms. Usual risk factors for multidrug resistant pathogens were frequent. Almost one out of five patients had been hospitalized in the 90 days prior to the current admission and over 40% of patients had been treated with antibiotic in the previous 90 days. Infection by MDR bacteria was independently associated with the previous stay in nursing homes or long-term care facilities (LTCF) (OR 5.8, 95% CI 1.17–29.00), permanent bladder catheter (OR 3.55, 95% CI 1.00–12.50) and urinary incontinence (OR 2.63, 95% CI 1.04–6.68). The degree of dependence and comorbidity, female sex, obesity, and bacteraemia were independent predictors of longer hospital stay. The epidemiology and presentation of UTIs requiring hospitalisation is changing over time. Attention should be paid to improve management of urinary incontinence, judicious catheterisation, and antibiotic therapy.

Strategies to Tackle Antimicrobial Resistance: The Example of Escherichia coli and Pseudomonas aeruginosa

Traditional antimicrobial treatments consist of drugs which target different essential functions in pathogens. Nevertheless, bacteria continue to evolve new mechanisms to evade this drug-mediated killing with surprising speed on the deployment of each new drug and antibiotic worldwide, a phenomenon called antimicrobial resistance (AMR). Nowadays, AMR represents a critical health threat, for which new medical interventions are urgently needed. By 2050, it is estimated that the leading cause of death will be through untreatable AMR pathogens. Although antibiotics remain a first-line treatment, non-antibiotic therapies such as prophylactic vaccines and therapeutic monoclonal antibodies (mAbs) are increasingly interesting alternatives to limit the spread of such antibiotic resistant microorganisms. For the discovery of new vaccines and mAbs, the search for effective antigens that are able to raise protective immune responses is a challenging undertaking. In this context, outer membrane vesicles (OMV) represent a promising approach, as they recapitulate the complete antigen repertoire that occurs on the surface of Gram-negative bacteria. In this review, we present Escherichia coli and Pseudomonas aeruginosa as specific examples of key AMR threats caused by Gram-negative bacteria and we discuss the current status of mAbs and vaccine approaches under development as well as how knowledge on OMV could benefit antigen discovery strategies.

Epidemiological characteristics of uropatogenic isolates of Escherichia coli in hospitals

The aim of the study was to evaluate the genetic affinity of uropathogenic E. coli cultures (UPEC) and to identify the major types of extended spectrum beta-lactamases (ESBL) found among nosocomial isolates. A molecular typing of UPEC (n=93) isolated from patients with urinary tract infections (UTI) who were hospitalised in nine medical facilities (MO) in Perm was performed. It was found that 69.89% of the cultures had individual RAPD/ERIC profiles, the remaining 30.10% were distributed among 13 genome groups. Most frequently blaCTX-M-1 was detected individually or in combination with other beta-lactamase genes (n=23, 79.31% of ESBL phenotype-positive isolates), genes were detected in seventeen cases (58.62%) blaTEM and/or blaOXA, the blaCMY fragment was found in only three isolates (10.34%), blaSHV was missing in this isolates. It was shown that in two thirds of the cases the pathogens of the infection process are representatives of the endogenous intestinal microbiota of the patients, in other cases an exogenous infection occurs. The proportion of "circulating" (possibly hospital) isolates in the spectrum of UTI increased in the series: therapy departments - surgery departments - intensive care units. In addition, in multidisciplinary hospitals there are conditions for cross-infections of patients, but the epidemiological chains of episodes of UTI are short and concise. It has been shown that the probability of infection with E. coli producing CTX-M or OXA enzymes is significantly higher in the intensive care unit than in surgery or therapy departments. The data obtained complement the understanding of the epidemiology of UTI caused by E. coli and can be used as an aid in the planning and implementation of methods for the prevention and control of nosocomial UTI.

Sepsis after elective surgery - Incidence, aetiology and outcome

BACKGROUND

Sepsis requiring admission to intensive care (ICU) is a rare complication of elective surgery, but is associated with high morbidity and mortality. The aim of this study was to describe the incidence and outcome of sepsis following elective surgery.

METHODS

This was a retrospective, observational study where all admissions to Icelandic ICUs during calendar years 2006, 2008, 2010, 2012, 2014 and 2016 were screened, identifing patients with sepsis following elective surgery (ACCP/SCCM criteria). The number of elective operations performed at the largest center (Landspitali) during the study years were collected. Descriptive statistics were used to assess the incidence and outcome of patients with sepsis after elective surgery.

RESULTS

During the study years, 88 patients were admitted to Icelandic ICUs with sepsis following elective surgery. Of those, 80 were operated at Landspitali, where the incidence of sepsis was 0.19% per elective procedure, highest following pancreaticoduodenectomies (14%, CI 6-25) and esophagectomies (13%, CI 4-27), but the greatest number of patients (30% (26/88)) developed sepsis after a colorectal procedure. The most common infection sources were the abdomen (65% (57/88)) and lungs/mediastinum (22% (19/88)), frequently polymicrobial (58% (36/62) of patients with cultures). The incidence of insufficient empirical antibiotics was high (50% (30/60)). The median ICU and hospital length-of-stay were 5.5 and 26 days and the 28-day and 1-year mortality rates were 16% (14/88) and 41% (36/87), respectively.

CONCLUSIONS

Incidence of sepsis following elective surgery is low in Iceland but mortality is high. Initial antimicrobial therapy needs careful consideration in these hospital-acquired, often polymicrobial infections.

Biofilm-Producing Bacteria and Risk Factors (Gender and Duration of Catheterization) Characterized as Catheter-Associated Biofilm Formation

Background

A catheter-associated urinary tract infection (CA-UTI) is preceded by biofilm formation, which is related to several risk factors such as gender, age, diabetic status, duration of catheterization, bacteriuria before catheterization, virulence gene factor, and antibiotic usage.

Aims

This study aims to identify the microbial composition of catheter samples, including its corresponding comparison with urine samples, to determine the most important risk factors of biofilm formation and characterize the virulence gene factors that correlate with biofilm formation.

Methods

A longitudinal cross-sectional study was conducted on 109 catheterized patients from September 2017 to January 2018. The risk factors were obtained from the patients' medical records. All catheter and urine samples were cultured after removal, followed by biomass quantification. Isolate identification and antimicrobial susceptibility testing were performed using the Vitex2 system. Biofilm-producing bacteria were identified by the Congo Red Agar (CRA) method. A PCR test characterized the virulence genes of dominant bacteria (E. coli). All data were collected and processed for statistical analysis.

Results

Out of 109 catheterized patients, 78% of the catheters were culture positive, which was higher than those of the urine samples (37.62%). The most common species isolated from the catheter cultures were Escherichia coli (28.1%), Candida sp. (17.8%), Klebsiella pneumoniae (15.9%), and Enterococcus faecalis (13.1%). E. coli (83.3%) and E. faecalis (78.6%) were the main isolates with a positive CRA. A statistical analysis showed that gender and duration prior to catheterization were associated with an increased risk of biofilm formation (p < 0.05).

Conclusion

E. coli and E. faecalis were the most common biofilm-producing bacteria isolated from the urinary catheter. Gender and duration are two risk factors associated with biofilm formation, therefore determining the risk of CAUTI. The presence of PapC as a virulence gene encoding pili correlates with the biofilm formation. Biofilm-producing bacteria, female gender, duration of catheterization (more than five days), and PapC gene presence have strong correlation with the biofilm formation. To prevent CAUTI, patients with risk factors should be monitored by urinalysis tests to detect earlier the risk of biofilm formation.

Active surveillance of carbapenem-resistant Gram-negative healthcare-associated infections in a low-middle-income country city

Background

Carbapenem-resistance in healthcare-associated infections (HCAIs) is of great concern, and it is urgent to improve surveillance. We aimed to describe and analyze HCAIs trends on Gram-negative antimicrobial susceptibility in a city from a developing country, following the implementation of an active surveillance program.

Methods

This is an aggregated study describing data from 24 hospitals with intensive care units, including a trend analysis by Joinpoint regression between January 2012 and December 2017.

Results

There were 23,578 pathogens in 39,832 HCAIs, from which 16,225 were Gram-negatives (68.8%). Carbapenem susceptibility was lowest in A. baumannii (15.4–25.9%), K. pneumoniae (51.0–55.9%), and P. aeruginosa (64.9–84.1%) and highest in E. coli (96.5–99.2%). Only K. pneumoniae showed a significant Joinpoint at 95% confidence interval: −10.71% (−18.02; −2.75) from 2012 to 2014, p = 0.02, and 6.54% (−2.00; 15.83) from 2015 to 2017, p = 0.12, which was most influenced by urinary tract infections: −9.98% (−16.02; −3.48) from 2012 to 2014, p = 0.01, and 9.66% (−1.75; 22.39) from 2015 to 2017, p = 0.09.

Conclusion

Although we found a significant change toward an improvement in carbapenem susceptibility in K. pneumoniae, resistance is high for most pathogens. These data should encourage health institutions to improve their prevention and control strategies.

Open hepatic resection in the elderly at two tertiary referral centers

BACKGROUND

Surgeons are being increasingly called upon to operate on the very elderly. This study aimed to evaluate outcomes following hepatectomy in patients ≥80 years of age at two tertiary care centers.

METHODS

All adult patients who underwent liver resection from 2001 to 2017 were included. Primary outcome was 90-day postoperative mortality. Secondary outcomes included 30-day postoperative mortality and postoperative complications.

RESULTS

Between 2001 and 2017, 2397 patients underwent liver resection. On unadjusted analysis, patients ≥80 years of age had higher rates of 90-day mortality (13.3% vs. 3.6%, p < 0.001), 30-day mortality (5.6% vs. 1.8%, p = 0.01), MI (7.9% vs. 3.5%, p = 0.04), and UTI (10.0% vs. 4.5%, p = 0.02). On multivariable analysis, age ≥80 years was significantly associated with 90-day postoperative mortality (OR 4.51, 95%CI 2.11-9.67, p < 0.001).

CONCLUSIONS

Across these two major referral tertiary care centers, very elderly patients had higher rates of 90-day and 30-day postoperative mortality on both unadjusted and adjusted analyses.

Urinary Tract Infection After Midurethral Sling

OBJECTIVE

The aim of the study was to clarify which baseline, operative, and postoperative factors are associated with the development and recurrence of urinary tract infection (UTI) after midurethral sling (MUS).

METHODS

This is a retrospective analysis of patients who underwent a MUS from February 2010 to April 2014 within a single practice with 2 surgeons. Distribution of perioperative factors with relation to 6-week UTI occurrence (primary outcome) and recurrent UTI (secondary outcome) within a year after surgery were analyzed using Student's t test and χ2 test. Then, independent risk factors were determined using multiple logistic regression. A P value of less than 0.05 defined statistical significance.

RESULTS

From the 500 patients who underwent MUS, 79 (15.8%) developed a UTI within 6 weeks of surgery and 5.8% had recurrent UTI within a year. Looking at the independent effects, patients with a history of recurrent UTI and voiding dysfunction requiring catheterization more than 24 hours were at a higher risk of developing UTI within 6 weeks after surgery. In addition, having a history of recurrent UTI, asymptomatic bacteriuria, and postoperative UTI within 6 weeks after surgery were significantly associated with postoperative recurrent UTI.

CONCLUSIONS

In this study, we identified baseline and postoperative characteristics that are associated with greater risk of UTI within 6 weeks and recurrent UTI after MUS. These factors can be potentially modified or useful in counseling patients on personalized risks and benefits of the surgical procedure.

Cluster analysis identifies patients at risk of catheter-associated urinary tract infections in intensive care units: findings from the SPIN-UTI Network

BACKGROUND

Although preventive strategies have been proposed against catheter-associated urinary tract infections (CAUTIs) in intensive care units (ICUs), more efforts are needed to control the incidence rate.

AIM

To distinguish patients according to their characteristics at ICU admission, and to identify clusters of patients at higher risk for CAUTIs.

METHODS

A two-step cluster analysis was conducted on 9656 patients from the Italian Nosocomial Infections Surveillance in Intensive Care Units project.

FINDINGS

Three clusters of patients were identified. Type of admission, patient origin and administration of antibiotics had the greatest weight on the clustering model. Cluster 1 comprised more patients with a medical type of ICU admission who came from the community. Cluster 2 comprised patients who were more likely to come from other wards/hospitals, and to report administration of antibiotics 48 h before or after ICU admission. Cluster 3 was similar to Cluster 2 but was characterized by a lower percentage of patients with administration of antibiotics 48 h before or after ICU admission. Patients in Clusters 1 and 2 had a longer duration of urinary catheterization [median 7 days, interquartile range (IQR) 12 days for Cluster 1; median 7 days, IQR 11 days for Cluster 2] than patients in Cluster 3 (median 6 days, IQR 8 days; P<0.001). Interestingly, patients in Cluster 1 had a higher incidence of CAUTIs (3.5 per 100 patients) compared with patients in the other two clusters (2.5 per 100 patients in both clusters; P=0.033).

CONCLUSION

To the authors' knowledge, this is the first study to use cluster analysis to identify patients at higher risk of CAUTIs who could gain greater benefit from preventive strategies.

Risk Factors for Postoperative Urinary Tract Infections Following Anterior Lumbar Interbody Fusion

BACKGROUND

Although risk factors contributing to UTI have been studied in posterior approaches to lumbar fusion, there is a lack of literature on factors contributing to UTI in anterior lumbar interbody fusion (ALIF). Our purpose was to identify preoperative independent risk factors for postoperative urinary tract infection (UTI) following anterior lumbar interbody fusion (ALIF) so that surgeons may be able to initiate preventative measures and minimize the risk of UTI-related morbidity following ALIF.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify 10 232 patients who had undergone ALIF from 2005 to 2016; 144 patients (1.41%) developed a postoperative UTI while 10 088 patients (98.59%) did not. Univariate analyses were conducted to compare the 2 cohorts' demographics and preoperative comorbidities. Multivariate logistic regression models were then utilized to identify significant predictors of postoperative UTI following ALIF while controlling for differences seen in univariate analyses.

RESULTS

Age ≥ 60 years (P = .022), female sex (P < .001), alcohol use (P = .014), open wound or wound infections (P = .019), and steroid use (P = .046) were independent risk factors for postoperative UTI. Longer operative times were also independent predictors for developing UTI: 120 minutes ≤ x < 180 minutes (P = .050), 180 minutes ≤ x < 240 minutes (P = .025), and ≥ 240 minutes (P = .001). Postoperative UTI independently increased the risk for pneumonia, blood transfusions, sepsis, thromboembolic events, and extended length of stay as well.

CONCLUSIONS

Age ≥ 60 years, female sex, alcohol use, steroid use, and open wound or wound infections independently increased the risk for UTI following ALIF. Future work analyzing the efficacy of tapering alcohol and steroid use preoperatively and reducing procedural time with the aim of lowering UTI risk is warranted. Preoperative wound care is strongly encouraged to decrease UTI risk.

LEVEL OF EVIDENCE

III.

A systematic review comparing early with late removal of indwelling urinary catheters after pelvic organ prolapse surgery

BACKGROUND

An indwelling catheter is routinely used after pelvic organ prolapse surgery to prevent urinary retention. However, the timing of catheter removal remains controversial.

OBJECTIVES

To investigate the optimal timing of catheter removal following prolapse surgery.

METHODS

Electronic databases including the Cochrane Center Controlled Test Center, Embase, CINAHL, MEDLINE, PubMed, Web of Science and CNKI were searched up to January 2010. Randomized controlled trials (RCTs) comparing different timings of catheter removal after prolapse surgery were eligible. Results from RCTs comparing early versus late removal were pooled, and different durations of catheterization were divided into three sub-comparisons (≤ 2 days versus > 2 days; ≤ 1 day versus 2 days; < 1 day versus 1 day). Primary outcomes were urinary tract infection (UTI) and re-catheterization. Secondary outcomes were the length of hospital stay and patient-reported outcomes.

RESULTS

Seven RCTs with 964 women were involved in the analysis. Early catheter removal was associated with a reduced incidence of UTI (RR 0.46, 95% CI 0.24 to 0.9) but an increased risk of re-catheterization (RR 2.67, 95% CI 1.6 to 4.48). Significant differences in primary outcomes were found in the sub-comparison of ≤ 2 days versus > 2 days. Three of six trials found a significantly shorter length of hospital stay in the early removal group. The results for postoperative pain were mixed.

CONCLUSION

Among patients following pelvic organ prolapse surgery, early catheter removal is preferred. Moreover, the timing for removal is preferably within 2 days postoperatively.

Spectrum and Antibiotic Resistance of Uropathogens in Romanian Females

Urinary tract infections (UTIs) in women represent a common bacteriological finding, with negligible recent and consistent research on antimicrobial resistance (AMR) in the female population. We designed a retrospective study to observe the incidence of frequent uropathogens and their resistance rates to common antibiotics. We elaborated multicenter research in three different teaching hospitals in Romania, analyzing 13,081 urine samples, of which 1588 met the criteria of inclusion. Escherichia coli (58.37%) was the most frequent Gram-negative uropathogen, presenting high resistance rates to levofloxacin (R = 29.66%), amoxicillin–clavulanic ac. (R = 14.13%), and ceftazidime (R = 6.68%). We found good sensitivity to imipenem and meropenem (both 98.16%), amikacin (S = 96.0%), and fosfomycin (S = 90.39%). The second most prevalent uropathogen was Klebsiella (16.93%), with the highest resistance quota to amoxicillin–clavulanic ac. (R = 28.62%), levofloxacin and nitrofurantoin (both R = 15.61%), and ceftazidime (R = 15.24%), and good sensitivity to imipenem (S = 93.93%), meropenem (S = 91.91%), and amikacin (S = 88.47%). Enterococcus (13.35%) was the most encountered Gram-positive pathogen. It proved the highest resistance to levofloxacin (R = 32.07%), penicillin (R = 32.07%), and ampicillin (R = 14.62%) and good sensitivity to vancomycin (S = 91.98%), fosfomycin (S = 94.4%), and nitrofurantoin (S = 89.15%). Considering the lack of recent and consistent data on this topic, we find our survey a valuable starting research study in this area with high significance for an accurate clinical approach.

Phage Therapy as a Novel Strategy in the Treatment of Urinary Tract Infections Caused by E. Coli

Urinary tract infections (UTIs) are regarded as one of the most common bacterial infections affecting millions of people, in all age groups, annually in the world. The major causative agent of complicated and uncomplicated UTIs are uropathogenic E. coli strains (UPECs). Huge problems with infections of this type are their chronicity and periodic recurrences. Other disadvantages that are associated with UTIs are accompanying complications and high costs of health care, systematically increasing resistance of uropathogens to routinely used antibiotics, as well as biofilm formation by them. This creates the need to develop new approaches for the prevention and treatment of UTIs, among which phage therapy has a dominant potential to eliminate uropathogens within urinary tract. Due to the growing interest in such therapy in the last decade, the bacteriophages (natural, genetically modified, engineered, or combined with antibiotics or disinfectants) represent an innovative antimicrobial alternative and a strategy for managing the resistance of uropathogenic microorganisms and controlling UTIs.