Nosocomial Urinary Tract Infections Research Articles

Reduction of ICU Nosocomial Catheter-Associated Urinary Tract Infections

Reduction of ICU Nosocomial Catheter-Associated Urinary Tract Infections

Reduction of ICU Nosocomial Catheter-Associated Urinary Tract Infections

ISSUE: The Infection Control Department is responsible for an annual review and update of the surveillance plan. Surveillance is extremely important in the context of continuous quality improvement because it makes use of objective data to improve organizational performance. Catheter-associated urinary tract infection (CA-UTI) rates were compared to data from the National Nosocomial Infection Surveillance System (NNIS). It was noted that infection rates in the intensive care unit (ICU) from October 2001 to September 2002 were consistently greater than the 90th percentile when compared to NNIS. PROJECT: An action plan was devised through a root-cause analysis identifying issues in practice, patient demographics, and human characteristics. The action plan included lecture and demonstration in handwashing techniques with a program that included the use of fluorescent lotion to help the staff with visualization of residue left on the hands after hand hygiene, encouraging the use of a waterless hand sanitizer (already available in all the ICU rooms), anonymous culturing of the hands of the ICU staff (for educational purposes), environmental culturing, trialing a new catheter securement device, and reviewing the CDC recommendations for prevention and/or reduction of CA-UTIs. RESULTS: The action plan was implemented from July through September 2002. The data collected from September 2002 to the present shows a consistent decline in the incidence of CA-UTIs in the ICU, with a rate of 2.8 infections per 1000 urinary catheter days, which falls between the 25th and 50th percentile when compared to NNIS. Annual statistics show a total of 13 infections per 1000 urinary catheter days from October 2001 to August 2002, and a total of 4 infections per 1000 urinary catheter days from September 2002 to September 2003, a decrease of 70%. LESSONS LEARNED: It is extremely important to continue to monitor and give feedback to the staff on all of the actions taken. Several monitoring systems were also put into place, one for the usage of the alcohol hand sanitizer and one for the use of the new catheter securement device.

Redefining Catheter-Associated Nosocomial Urinary Tract Infections: Are New Definitions Necessary?

ISSUE: Centers for Disease Control and Prevention (CDC) definitions of urinary tract infection (UTI) have not been updated since 1988 and are not designed specifically for surveillance of nosocomial catheter-association UTIs (CA-NUTIs). Given the emphasis on device-related infections, a specific algorithm was developed to address CA-NUTI surveillance. PROJECT: Surveillance data from 20 hospitals (over 5,000 records) was reviewed. Surveillance included laboratory data, physician progress notes and orders, pharmacy records, and nursing notes (including emergency and operating room records). Analysis of documented symptoms, clinical indicators, and treatment patterns was conducted to determine which criteria were most frequently found. After review of the data a group of nine infection control specialists, all with extensive experience in conducting CA-NUTI surveillance, met to discuss current CDC definitions and to develop new/revised definitions. Efforts were made to incorporate existing UTI definitions (CDC and Long-Term Care) when possible. RESULTS: Due to the presence of a Foley catheter, symptoms typically associated with UTI are rarely manifested (frequency, urgency, dysuria). While fever is often noted, it is not always present in CA-NUTI patients. Many indicators not presently used in the CDC definitions are triggers for CA-NUTI work-up. These indicators include cloudy or foul-smelling urine, leukocytosis, elevated temperature (not over 100.4), and change in mental status. Physicians are more likely to treat patients with low-colony counts who exhibit some indicator of infection and are less likely to treat those with high colony counts that have no indicators present. Discrepancies between current CDC definitions and lab practices make it difficult to apply certain definitions. LESSONS LEARNED: Current surveillance definitions do not address device-related UTIs. Development of an algorithm used specifically for CA-NUTIs has allowed us to more accurately assess infection rates based on symptoms, clinical indicators, laboratory data, and treatment patterns.

Using an American Model To Reduce Catheter-Associated UTI in England with a Novel Silver Alloy Foley

ISSUE: Nosocomial catheter-associated UTI (CA-UTI) are the commonest and most costly healthcare-associated infection (HAI) in England. The recent introduction of the silver-alloy hydrogel-coated Foley catheter to UK healthcare provides an opportunity to reduce the incidence of this HAI should U.S. results be replicated (mean reduction in CA-UTI rate of 35% recorded from approximately 250 product evaluations). Surveillance of CA-UTI is the exception, as the Department of Health's priority has been methicillin-resistant Staphylococcus aureus bacteremia. Infection Control Teams (ICTs) have been overstretched and underresourced (one Infection Control Nurse per ∼800 beds). Recently, the Chief Medical Officer published a strategy to reduce HAI which increases the amount of surveillance to be undertaken. PROJECT: Learning from U.S. Specialists how successful Performance Improvement Programs (PIP) are developed, a Quality Improvement Program (QIP) Framework has been developed by the Infection Control Clinical Consultant who can assist ICTs at all stages of the QIP as they evaluate this novel Foley. The increased unit cost of the improved product means cost-benefit analysis is integral to each QIP. RESULTS: Data for the first QIP is currently being analyzed. Several other QIP teams are collecting their baseline data at the time of writing. LESSONS LEARNED: Adapting the successful USA PIP template and experience to the National Health Service's quest for quality improvement has illustrated the variation in emphases, yet similar aims, between the two countries' healthcare systems. Reduction in CA-UTI, device-associated bacteremia and microbial resistance are common aims on both sides of the Atlantic.

Redefining Catheter-Associated Nosocomial Urinary Tract Infections: Are New Definitions Necessary?

Redefining Catheter-Associated Nosocomial Urinary Tract Infections: Are New Definitions Necessary?

Nosocomial bacteremia and urinary tract infections caused by extended-spectrum beta -lactamase-producing Klebsiella pneumoniae with plasmids carrying both SHV-5 and TLA-1 genes.

We describe the prevalence and molecular characteristics of extended-spectrum beta -lactamase (ESBL)-producing Klebsiella pneumoniae causing nosocomial bacteremia and urinary tract infections in a Mexican general hospital. We analyzed 82 episodes of bacteremia (approximately 60% of episodes) and urinary tract infection (approximately 40% of episodes) due to K. pneumoniae during a 23-month surveillance period. The neonatal intensive care unit accounted for 49% of all episodes. All strains were imipenem susceptible; 62.2% of the strains were resistant to ceftazidime, cefotaxime, and aztreonam; 69.5% were resistant to amikacin; 58.5% were resistant to gentamicin; and 7.3% were resistant to ciprofloxacin. All strains were associated with 28 pulsed-field gel electrophoresis patterns, and dissemination of 2 ceftazidime-resistant clones produced 44% of the cases. The ESBL phenotype in these clones was transferred by identical or highly related megaplasmids. The ESBL activity corresponded to SHV-5 and TLA-1. Cross-transmission of 2 ceftazidime-resistant clones and the horizontal spread of identical or highly related megaplasmids explain the high prevalence of ESBL phenotype in these infections.

The impact of using silver alloy urinary catheters in reducing the incidence of urinary tract infections in the critical care setting

prospective study was undertaken on three critical care units to establish the efficacy of using a silver alloy urinary catheter in reducing the incidence of nosocomial urinary tract infections. Some 188 patients participated in the evaluation (94 in each group). A urine sample was obtained post insertion and every three days while on the critical care unit to detect bacteriuria. The infection rate was 12.65 in the standard group and 11.32 in the silver alloy group per 1000 catheter days respectively. The mean duration of catheterisation was 16 days (inter-quartile range 13). Gram positive cocci were responsible for 24.5% of the bacteriuria, Gram negatives 64.5% and yeasts accounted for 11%. Based on these results, routine use of silver alloy catheters cannot be justified for all patients, but may be suited to high-risk female patients.

Role of fluoroquinolones in the treatment of serious bacterial urinary tract infections.

Serious urinary tract infections (UTIs) in adults--defined as acute complicated UTIs or pyelonephritis requiring initial intravenous antimicrobials and/or hospitalisation and nosocomial infections--cause significant morbidity and economic burden. In the US, UTIs are responsible for nearly 7 million outpatient physician office visits, 1 million emergency room visits and over 100 000 hospital admissions annually. Complicated UTIs often affect patients with underlying functional, metabolic or anatomical defects of the urinary tract, whereas most nosocomial UTIs (~80%) are related to short- or long-term catheterisation. Serious UTIs are often difficult to treat because infection involves a diverse array of Gram-negative and Gram-positive bacteria, coupled with increasing antimicrobial resistance in some uropathogens, and a higher rate of recurrent infections. Although Escherichia coli remains a common aetiology (< or =60%), other Enterobacteriaceae, Gram-negative bacilli (e.g. Pseudomonas aeruginosa), and Gram-positive bacteria (e.g. Staphylococcus aureus) are frequently isolated. Patients with long-term catheterisation have UTIs typically caused by organisms that produce biofilms making eradication even more difficult. Overall, aetiology and resistance patterns are not predictable for those with serious UTIs, necessitating confirmation by culture and susceptibility testing.Numerous intravenous and oral antimicrobial treatment options are available and the majority of patients with serious UTIs will need initial intravenous therapy because of the possibility of bacteraemia/sepsis or impaired gastrointestinal absorption. Many experts concur that empirical therapy for the institutionalised or hospitalised patient with a serious UTI should include an intravenous antipseudomonal agent because of an increased risk of urosepsis. While state-of-the-art treatment guidelines are lacking for these infections, targeted therapy should be initiated once susceptibility data are known. The use of targeted therapy--emphasising the "correct antibacterial spectrum" and pharmacodynamic superiority--is likely to provide important benefits (e.g. reduced morbidity and associated costs, reduced emergence of resistance). Agents commonly prescribed include aminoglycosides, beta-lactam/beta-lactamase inhibitor combinations, imipenem, advanced-generation cephalosporins and fluoroquinolones. Fluoroquinolones are often recommended when conventional agents have failed or are less desirable (e.g. toxicity/hypersensitivity concerns), or when resistance is high. Several pivotal clinical trials support the use of fluoroquinolones for serious UTIs with most experience garnered with ciprofloxacin, including a new once-daily extended-release tablet formulation.Treatment of patients with serious UTIs remains challenging. Physicians should choose empirical therapy based on patient demographics/medical history, presumed aetiology and local resistance patterns until more definitive guidelines become available.

Independent prognostic factors for fatality in patients with urinary tract infection caused by Serratia marcescens.

In a retrospective study of 329 cases of nosocomial urinary tract infection caused by Serratia marcescens, 16 (4.9%) were fatal. Female gender (OR, 3.9; CI95, 1.3-11.7; P = .014) and secondary S. marcescens bacteremia (OR, 6.5; CI95, 1.5-28.6; P = .013) were independent prognostic factors for fatality.

Risk factors of nosocomial catheter-associated urinary tract infection in a polyvalent intensive care unit.

Due to a regrettable technical error, the article was published twice. The editorial office and the publisher present their apologies to the authors and the readers for this mistake.

Infections urinaires nosocomiales en réanimation : moyens de prévention et mise en application

Nosocomial urinary tract infection (NUTI) is the second most frequent nosocomial infection in ICU. Decreasing the infectious risk can only be achieved by targeting indications, and duration of catheterizing. Inserting a urinary catheter is often performed under aseptic surgical conditions even though the efficacy of this procedure has not been demonstrated in ICU. Several studies have reported that using catheters coated with antiseptics or antibiotics decreases the frequency of UTIs, but induces overcosts. The closed system remains a reference technique. Basic body hygiene seems to be efficient enough for daily care. To conclude, the prevention of UTIs is linked to the quality of care, especially nursing care, and for some a marker of the quality of care.

Maîtrise des moyens de prévention de l’infection urinaire nosocomiale : sondes et techniques

Nosocomial urinary tract infection is the most typical device-associated infections. Although, it is the most frequent nosocomial infection, its prevention has not been a strong priority for health care workers because of its relative mildness. But multiresistant bacteria have emerged, because of the frequency of NUTIs, associated to the selective pressure of antibiotic therapy. This urinary reservoir is a potential source of endogenous complication and cross transmission in wards. Except for closed drainage system, the efficacy of preventive measures has not been well documented because of the varying importance of risk factors in the studied populations and the use of different criteria for evaluation. Using data provided by these trials is subject to caution and requires stratification according to risk factors (sex, duration of catheterism) and analyzing misleading factors such as antibiotic treatment. Preventives measures are reviewed.

Prévention des infections urinaires nosocomiales chez le patient ayant une vessie neurologique

Nosocomial urinary tract infection are common in patients with a neurogenic bladder due to the modification of physiology. These patients frequently require catheterization to empty the bladder. Bacteriuria and pyuria are common in this population, even in asymptomatic patients, and symptoms frequently reported are not specific. Self catheterization seems to be the best treatment for the prevention of UTI and resuming continence. However, there is no evidence to support the claim that such prophylaxis has been associated with a reduced number of symptomatic infections in the general populations that have been studied. Oral antibiotic prophylaxis, when efficient, leads to increased bacterial resistance.

Extended epidemic of nosocomial urinary tract infections caused by Serratia marcescens.

In recent years a significant increase in the incidence of Serratia marcescens infections was noted at the Chang Gung Memorial Hospital, Taoyuan, Taiwan. A review of laboratory (1991 to 2002) and infection control (1995 to 2002) records showed the possibility of an extended epidemic of nosocomial urinary tract infections (UTIs) caused by S. marcescens. Therefore, in 1998 and 1999, 87 isolates were collected from patients with such infections and examined and another 51 isolates were collected in 2001 and 2002. The patients were mostly elderly or the infections were associated with the use of several invasive devices. S. marcescens was usually the only pathogen found in urine cultures in our study. Neither prior infections nor disseminated infections with the organism were observed in these patients. Resistance to most antibiotics except imipenem was noted. Two genotyping methods, pulsed-field gel electrophoresis and infrequent-restriction-site PCR, were used to examine the isolates. A total of 12 genotypes were identified, and 2 predominant genotypes were found in 72 (82.8%) of the 87 isolates derived from all over the hospital. However, 63.9% of the isolates of the two genotypes were from neurology wards. A subsequent intervention by infection control personnel reduced the infection rate greatly. The number and proportion of the two predominant genotypes were significantly reduced among the 51 isolates collected in 2001 and 2002. Thus, a chronic and long-lasting epidemic of nosocomial UTIs caused by S. marcescens was identified and a successful intervention was carried out. Both a cautious review of laboratory and infection control data and an efficient genotyping system are necessary to identify such a cryptic epidemic and further contribute to the quality of patient care.

Prévention des risques d’infection urinaire nosocomiale dans les collectivités (hospitalières et extra-hospitalières) : l’isolement

Indwelling urinary catheters are the leading cause of nosocomial urinary tract infections. These invasive devices are generally contaminated by the hands of healthcare workers inserting or maintaining catheters. Isolation precautions such as “standard precautions” should be implemented to enhance the use of aseptic techniques when manipulating a device. Among standard precautions, improving hand hygiene by rubbing hands with alcohol-based hand antiseptic before patient care is the objective of a recent national policy. Hand rubbing is a technique replacing conventional hand washing that increases the accessibility of hand hygiene, the efficacy of antisepsis, and skin tolerance. Introduction of hand rubbing also improves hand hygiene compliance and induces a decrease of nosocomial infection rates. Such a technique should obviously be promoted for the prevention of urinary tract infections.

Infections urinaires nosocomiales chez l’immunocompétent en milieu médical : qui traiter, quand traiter et comment traiter ?

Guidelines for the treatment of nosocomial urinary tract infections (NUTI) have to take into account: i) the high prevalence of catheter-associated bacteriuria; ii) the lack of important clinical studies; iii) a variable bacterial count (between 10 3 and 10 5 mL –1) considered as significant by authors. NUTI without catheterization are clinically similar to UTI in outpatients, but more frequently due to multi-resistant bacteria. Among catheterized patients, the incidence of dysuria, pain, and urgency is not different between patients who develop bacteriuria and those who do not. However, fever has a high positive diagnostic value. Systematic treatment of NUTI is not recommended despite the morbidity because it reduces neither the incidence of febrile episodes, nor the rate of complications. Moreover, it promotes the selection of resistant bacteria. Exceptions to these recommendations are: treatment of asymptomatic NUTI in patients at high risk of severe complications (neutropenic patients, pregnant women, immunosuppressed patients, patients with diabetes mellitus), as part of a plan to control a cluster of multiresistant infections, before surgery (implantation of a prosthesis, urinary tract procedures), or persistent bacteriuria after catheter removal. All febrile NUTI should be treated given their specific morbidity and mortality. Empirical treatment depends on the local prevalence of resistant bacteria. In febrile NUTI, a 7 to 10 day antibiotic treatment is recommended, combined with the removal or the replacement of the catheter (immediately or after 48h of treatment). A longer treatment is necessary for complicated pyelonephritis or bacteremia, according to bacteria dissemination and urinary tract impairment.

Physiopathologie des infections urinaires nosocomiales

Nosocomial urinary tract infections (NUTI) are associated mostly with bladder catheterization, and to a lesser extent, with other genito-urinary procedures. In these cases, the normal defense mechanisms are overcome, so that micro-organisms usually little virulent for the urinary tract may induce an infection. Sometimes acquired early when inserting a catheter, NUTI mainly occur during the course of an indwelling catheterization, via an ascending route, either intraluminal or extraluminal peri-urethral. Whatever the route, the development of a biofilm around the foreign body rapidly induces a chronic colonization. The micro-organisms responsible for NUTI usually come from the fecal flora, either native or modified by hospital healthcare procedures. If most cases of catheter-associated bacteriuria remain asymptomatic, serious complications may occur, both for the patient (urosepsis, chronic obstructive infections in long term catheterization, etc.) and for the community (NUTI provide an important reservoir of antibiotic-resistant bacteria, responsible for cross infections).

Infections urinaires nosocomiales : qui traiter, quand traiter et comment traiter en gériatrie ?

Geriatric patient with nosocomial urinary tract infection (NUTI) frequently display an atypical clinical presentation. The diagnosis may be difficult because of the prevalence of asymptomatic bacteriuria among the elderly. Pyuria is not an accurate predictor of bacteriuria. Using a urinary reagent strip is far more useful in ruling out than in predicting NUTI. The diagnosis of NUTI is often a diagnosis of exclusion. A European study of febrile patients concluded that in only 10% of the cases, fever could be attributable to NUTI. Most institution considered counts > 10 4 CFU mL –1 as clinically significant, and for catheter associated UTI > 10 3 CFU mL –1. Sampling urine culture should be performed before choosing an antimicrobial therapy for UTI. Empiric management should be a 10 days systemic fluoroquinolone course for female patients, 14 to 28 days for male patients. Despite a high prevalence of NUTIs and particularly asymptomatic bacteriuria, numerous questions remain to be answered regarding their diagnosis and management.

Les infections urinaires nosocomiales de l’adulte

An average 40% of hospital-acquired infections are nosocomial urinary tract infections (NUTI). Their frequency depends on hospital ward type and specialty: from 30 to 49% in short stay units, and from 20 to 64% in long stay institutions for the elderly. Some specific risk factors have been identified in post-partum women. The most important risk factor is the duration of urinary catheterization, especially after the 5th day. Death rates are high in nosocomial bacteriema induced by NUTI and NUTI due to multi-drug resistant bacteria or fungi. The great number of NUTIs has a strong economic impact on hospital budgets and justifies implementing efficient prevention measures.

Outils du diagnostic biologique des infections urinaires nosocomiales (IUN) : analyse critique

Nosocomial urinary tract infections (NUTI) are the most frequent nosocomial infections. They are often associated with vesical catheterization. The current criteria of definition are based on the presence of symptoms, of vesical catheterization, and on the level of pyuria and bacteriuria determined by urinalysis. These definitions do not take into account all situations and must be reviewed. The conditions of sampling, transfer to the laboratory, and conservation of urines greatly influence the level of pyuria and the level and nature of bacteriuria. The interpretation of the urinalysis must take into account various clinical and epidemiological situations. Patients harboring an urinary catheter are often asymptomatic; they present a nonspecific pyuria all the more frequent that the duration of catheterization is long. Among these patients, the diagnosis of NUTI is based primarily on the level of the bacteriuria which is generally polymicrobial and always present after long-term catheterization. The absence of pyuria is a good negative predictor for non-catheterized symptomatic patients. Pyuria associated with bacteriuria, even low (10 3 to 10 5 cfu mL –1), proves the presence of UTI in these patients. Screening by urinary reagent strips cannot replace urinalysis for either symptomatic or catheterized patients. The systematic screening of UTI (using either a urinary reagent strips or urinalysis) is justified only when treatment is required in case of positive results.