Factors that affect nosocomial catheter-associated urinary tract infection in intensive care units: 2-year experience at a single center

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.

Urinary Stent Development and Evaluation Models: In Vitro, Ex Vivo and In Vivo-A European Network of Multidisciplinary Research to Improve Urinary Stents (ENIUS) Initiative

Background: When trying to modify urinary stents, certain pre-clinical steps have to be followed before clinical evaluation in humans. Usually, the process starts as an in silico assessment. The urinary tract is a highly complex, dynamic and variable environment, which makes a computer simulation closely reflecting physiological conditions extremely challenging. Therefore, the pre-clinical evaluation needs to go through further steps of in vitro, ex vivo and in vivo assessments. Methods and materials: Within the European Network of Multidisciplinary Research to Improve Urinary Stents (ENIUS), the authors summarized and evaluated stent assessment models in silico, in vitro, ex vivo and in vivo. The topic and relevant sub-topics were researched in a systematic literature search in Embase, Scope, Web of Science and PubMed. Clinicaltrials.gov was consulted for ongoing trials. Articles were selected systematically according to guidelines with non-relevant, non-complete, and non-English or Spanish language articles excluded. Results: In the first part of this paper, we critically evaluate in vitro stent assessment models used over the last five decades, outlining briefly their strengths and weaknesses. In the second part, we provide a step-by-step guide on what to consider when setting up an ex vivo model for stent evaluation on the example of a biodegradable stent. Lastly, the third part lists and discusses the pros and cons of available animal models for urinary stent evaluation, this being the final step before human trials. Conclusions: We hope that this overview can provide a practical guide and a critical discussion of the experimental pre-clinical evaluation steps needed, which will help interested readers in choosing the right methodology from the start of a stent evaluation process once an in silico assessment has been completed. Only a transparent multidisciplinary approach using the correct methodology will lead to a successful clinical implementation of any new or modified stent.

Catheter-Associated Urinary Tract Infection: Incidence, Associated Factors and Drug Resistance Patterns of Bacterial Isolates in Southern Ethiopia

Introduction

Catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infection and a leading cause of morbidity. The aim of this study was to determine the prevalence, associated factors and antibiogram of the bacterial isolates among CAUTIs patients.

Methods

A facility-based, cross-sectional study was conducted from March to December 2019 at Arba Minch General Hospital, Southern Ethiopia. Clinical and socio-demographic data were obtained using a questionnaire. Clean catch midstream urine samples were collected and inoculated onto blood agar, MacConkey agar, and cysteine lactose electrolyte deficient agar (CLED). The inoculated culture media were incubated in an aerobic atmosphere at 37°C for 24 h. After overnight incubation, the bacterial growth on the respective media was inspected visually and graded for the presence of significant bacteriuria. A significant bacteriuria was considered, if pure culture at a concentration of ≥10⁵ colony forming unit (CFU)/mL. All isolates were further identified using colony morphology and biochemical tests. Antimicrobial sensitivity was determined by modified Kirby–Bauer disc diffusion method. Data were analyzed using SPSS version 25. P-value less than 0.05 was used as statistical significance.

Results

The overall incidence of symptomatic CAUTIs was 39/231 (16.8%). Independent predictors of CAUTIs were prolonged (≥7 days) catheterization (AOR = 3.6, 95% CI = 1.0–12.2), diabetes mellitus (AOR = 5.3, 95% CI = 1.4–19.6) and insertion of catheter in surgical ward (AOR = 3.6, 95% CI = 1.08–12.28). The most common bacterial isolates were E. coli 17/42 (40.5%), Klebsiella species 9/42 (21.4%) and Enterococcus species 5/42 (11.9%). High (>80%) drug resistance was observed against cotrimoxazole, cefoxitin and tetracycline. Ciprofloxacin and nitrofurantoin were the most active drugs. The overall prevalence of MDR among isolates was 37/42 (88.1%). Most bacterial isolates 30/42 (71.4%) were biofilm producers.

Conclusion

High levels of drug resistance were observed to commonly used antibiotics. In our study, biofilm-producing bacterial isolates were the predominant cause of CAUTIs. Therefore, continuous surveillance of antimicrobial resistance patterns is necessary to help physicians in treatment and management of CAUTIs.

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.

Risk Factors Analysis for Catheter-Associated Urinary Tract Infection in Medan, Indonesia

BACKGROUND

Catheter-associated urinary tract infection (CAUTI) is one of the most common infections in health care caused by several risk factors.

AIM

This study aims at analysing the risky factors triggering CAUTI.

METHODS

This research was designed by applying prospective study. It was conducted from July to November 2018 by involving 82 patients attached to the catheter and treated in the General Hospital of Medan as the sample. The study instrument used observational sheets by measuring the occurrence of urinary tract infection using urine culture analysis ≥ 105 CFU/ml.

RESULTS

The results showed that there was a relationship (p < 0.05) amongs age (p = 0.01; RR = 0.51), diabetes mellitus (p = 0.00; RR = 7.61), duration of catheterization (p = 0.00; RR = 0.01), indications for catheter use (p = 0.00; RR = 0.34) with CAUTI, and there were not significant relationship (p > 0.05) amongs genre (p = 0.06; RR = 1.72), drainage system (p = 0.43; RR = 0.43) and catheter care (p = 0.08; RR = 0.50) with CAUTI. Diabetes mellitus (p = 0.00; OR = 8.92 95% CI = 1.02-11.83) and duration of catheterization (p = 0, 00; OR = 32.84 95% CI = 3.81-322.74) were the most significant factor related to CAUTI.

CONCLUSION

CAUTI is influenced by various factors, and it can be controlled by understanding those factors so that the right interventions to prevent the infections can be taken and the quality of nursing care can be increased as well.

Magnitude of Biofilm Formation and Antimicrobial Resistance Pattern of Bacteria Isolated from Urinary Catheterized Inpatients of Jimma University Medical Center, Southwest Ethiopia

Biofilm formation is one of the features of most bacteria. Catheterization in medicine is a source of highly resistant bacterial infections, and those bacteria respond poorly to antimicrobial therapy. Bacterial biofilm features were not described from catheterized inpatients in Ethiopia as its formation is known to afford antimicrobial resistance and challenge patient management. The aim of this study was to isolate catheter-associated urinary bacterial pathogens, their biofilm formation, and antimicrobial susceptibility pattern among inpatients of Jimma University Medical Center (JUMC) in Southwest Ethiopia. A prospective cross-sectional study was conducted among urinary catheterized inpatients of JUMC from February to August 2016. A total of 143 study participants were enrolled consecutively in this study. Urine samples were collected from catheterized patients and processed using a standard bacteriological protocol for isolation and identification. Evaluation of in vitro biofilm formation and antimicrobial susceptibility pattern of uropathogenic bacteria was done using microtiter plates and disk diffusion method, respectively. Data were cleaned, coded, and entered into SPSS version 20 for analysis. All statistical test values of p < 0.05 were considered statistically significant. From all study participants, mean age was 44 years. Sixty bacterial strains were recovered from 57 urinary catheterized inpatients among which 54 of them were monomicrobial (94.7%). The remaining six bacterial strains were recovered from three study participants each with two bacterial isolates. The predominant bacterial isolates were Gram-negative bacteria with E. coli turning out first. About 80% of bacterial isolates were biofilm formers. The majority of the bacteria were resistant to commonly prescribed antimicrobial agents. In conclusion, the majority of bacterial uropathogen isolates were Gram-negative, biofilm formers, and resistant to commonly prescribed antimicrobial agents. Relatively ciprofloxacin, nitrofurantoin, and amikacin were highly effective against most isolated bacteria.

Risk factors for catheter-associated urinary tract infection among hospitalized patients: A systematic review and meta-analysis of observational studies

AIMS

The study aimed to identify the risk factors for catheter-associated urinary tract infection among hospitalized patients. We also tried to explore its potential effect on patient outcomes if possible.

BACKGROUND

Catheter-associated urinary tract infection accounts for a large proportion of healthcare-associated infections and remains a considerable threat to patient safety worldwide.

DESIGN

A systematic review and meta-analysis of observational studies.

DATA SOURCES

We conducted an electronic search in PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews for studies published between January 2008-January 2018.

REVIEW METHODS

Two reviewers searched the articles and extracted the data independently. The quality of the studies was assessed with the Newcastle-Ottawa Scale. RevMan 5.3 was used to perform the meta-analysis.

RESULTS

Ten studies involving a total of 8785 participants with or without catheter-associated urinary tract infection were included. The average incidence of catheter-associated urinary tract infection was 13.79 per 1000 catheter days, with a prevalence rate of 9.33%. The meta-analysis demonstrated that patients at high risk for catheter-associated urinary tract infection were female, had a prolonged duration of catheterization, had diabetes, had previous catheterization, and had longer hospital and ICU stays. Additionally, catheter-associated urinary tract infection was also accompanied by an increase in mortality.

CONCLUSIONS

Healthcare staff should focus on the identified risk factors for catheter-associated urinary tract infection. Further research is needed to investigate the microbial isolates and focus on the intervention strategies of catheter-associated urinary tract infection, so as to reduce its incidence and related mortality.

Decreasing Catheter-Associated Urinary Tract Infections in the Neurological Intensive Care Unit: One Unit's Success

BACKGROUND

Catheter-associated urinary tract infections are preventable adverse outcomes that increase hospital morbidity, mortality, and costs. These infections are particularly prevalent in intensive care units.

OBJECTIVES

To describe the success of an 18-bed neurological intensive care unit in using several nurse-implemented strategies that reduced the number of catheter-associated urinary tract infections.

METHODS

A prospective, interventional design with application of evidence-based practices to reduce catheter-associated urinary tract infections was used.

RESULTS

Before implementation of the strategies, 40 catheter-associated urinary tract infections were reported for 2012 and 38 for 2013. The standardized infection ratio was 2.04 for 2012 (95% CI, 1.456-2.775) and 2.34 (95% CI, 1.522-3.312) for 2013. After implementation of the strategies, significantly fewer catheter-associated urinary tract infections were reported. In 2014, a total of 15 infections were reported, and the standardized infection ratio was less than 1.0 (95% CI, 0.685-1.900).

CONCLUSIONS

Application of current evidence-based practices resulted in a substantial decrease in the number of catheter-associated urinary tract infections and a lower standardized infection ratio. These findings support current recommendations for "bundling" to maximize outcomes.

High Glucose Concentration Promotes Vancomycin-Enhanced Biofilm Formation of Vancomycin-Non-Susceptible Staphylococcus aureus in Diabetic Mice

We previously demonstrated that vancomycin treatment increased acquisition of eDNA and enhanced biofilm formation of drug-resistant Staphylococcus aureus through a cidA-mediated autolysis mechanism. Recently we found that such enhancement became more significant under a higher glucose concentration in vitro. We propose that besides improper antibiotic treatment, increased glucose concentration environment in diabetic animals may further enhance biofilm formation of drug-resistant S. aureus. To address this question, the diabetic mouse model infected by vancomycin-resistant S. aureus (VRSA) was used under vancomycin treatment. The capacity to form biofilms was evaluated through a catheter-associated biofilm assay. A 10- and 1000-fold increase in biofilm-bound bacterial colony forming units was observed in samples from diabetic mice without and with vancomycin treatment, respectively, compared to healthy mice. By contrast, in the absence of glucose vancomycin reduced propensity to form biofilms in vitro through the increased production of proteases and DNases from VRSA. Our study highlights the potentially important role of increased glucose concentration in enhancing biofilm formation in vancomycin-treated diabetic mice infected by drug-resistant S. aureus.

Compliance With Guideline Statements for Urethral Catheterization in an Iranian Teaching Hospital

BACKGROUND

It is believed that healthcare staff play an important role in minimizing complications related to urethral catheterization. The purpose of this study was to determine whether or not healthcare staff complied with the standards for urethral catheterization.

METHODS

This study was conducted in Imam Reza teaching hospital, Tabriz, Iran, from July to September 2013. A total of 109 catheterized patients were selected randomly from surgical and medical wards and intensive care units (ICUs). A questionnaire was completed by healthcare staff for each patient to assess quality of care provided for catheter insertion, while catheter in situ, draining and changing catheter bags. Items of the questionnaire were obtained from guidelines for the prevention of infection. Data analysis was performed with SPSS 16.

RESULTS

The mean age of the patients was 50.54±22.13. Of the 109 patients, 56.88% were admitted to ICUs. The mean duration of catheter use was 15.86 days. Among the 25 patients who had a urinalysis test documented in their hospital records, 11 were positive for urinary tract infection (UTI). The lowest rate of hand-washing was reported before bag drainage (49.52%). The closed drainage catheter system was not available at all. Among the cases who had a daily genital area cleansing, in 27.63% cases, the patients or their family members performed the washing. In 66.35% of cases, multiple-use lubricant gel was applied; single-use gel was not available. The rate of documentation for bag change was 79%.

CONCLUSION

The majority of the guideline statements was adhered to; however, some essential issues, such as hand hygiene were neglected. And some patients were catheterized routinely without proper indication. Limiting catheter use to mandatory situations and encouraging compliance with guidelines are recommended.

Urinary tract infections in patients with type 2 diabetes mellitus: review of prevalence, diagnosis, and management

Urinary tract infections are more common, more severe, and carry worse outcomes in patients with type 2 diabetes mellitus. They are also more often caused by resistant pathogens. Various impairments in the immune system, poor metabolic control, and incomplete bladder emptying due to autonomic neuropathy may all contribute to the enhanced risk of urinary tract infections in these patients. The new anti-diabetic sodium glucose cotransporter 2 inhibitors have not been found to significantly increase the risk of symptomatic urinary tract infections. Symptoms of urinary tract infection are similar to patients without diabetes, though some patients with diabetic neuropathy may have altered clinical signs. Treatment depends on several factors, including: presence of symptoms, severity of systemic symptoms, if infection is localized in the bladder or also involves the kidney, presence of urologic abnormalities, accompanying metabolic alterations, and renal function. There is no indication to treat diabetic patients with asymptomatic bacteriuria. Further studies are needed to improve the treatment of patients with type 2 diabetes and urinary tract infections.