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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 7-11

Catheter-associated urinary tract infection in a Tertiary Care Hospital


1 Department of Lab Medicine, Sahara Hospital, Lucknow, Uttar Pradesh, India
2 Department of Infection Control, Sahara Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication18-Aug-2017

Correspondence Address:
Areena Hoda Siddiqui
Department of Lab Medicine, Sahara Hospital, Viraj Khand, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_2_16

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  Abstract 


Background: Catheter-associated urinary tract infection (CAUTI) is due to inadvertent use of urinary catheter. This study was done to determine the confirmed CAUTI cases, infection rate, prevalence of organisms, and their sensitivity profile.
Materials and Methods: A total of 1874 Foleys catheter cases were followed for 3 months. Cases were confirmed as per the Centers for Disease Control and Prevention guideline.
Results: A total of 21 (6.93') CAUTI cases were confirmed from 303 culture positive samples. The most common isolate was Escherichia coli (28.57'). Isolates were found resistant to fluoroquinolones and decreased sensitivity was found to other urinary drugs with the exception being colistin which was 100' sensitive. Average infection rate was 1.78/1000 catheter days. Average of catheter days was 11825.
Conclusion: To reduce morbidity and length of hospital stay and costs to the patient, unnecessary catheter insertion should be avoided. If Foley catheter insertion is needed, aseptic precaution during catheter insertion must be practiced and removal of Foleys must be done as soon as possible. Continuous education and training of the health-care workers and surveillance by infection control team play an important role in improving the practice and reducing infection.

Keywords: Catheter-associated urinary tract infection, catheter days, healthcare-associated infection, infection rate


How to cite this article:
Siddiqui AH, Srivastava VK, Aneeshamol P P, Prakash C. Catheter-associated urinary tract infection in a Tertiary Care Hospital. J Patient Saf Infect Control 2017;5:7-11

How to cite this URL:
Siddiqui AH, Srivastava VK, Aneeshamol P P, Prakash C. Catheter-associated urinary tract infection in a Tertiary Care Hospital. J Patient Saf Infect Control [serial online] 2017 [cited 2017 Nov 23];5:7-11. Available from: http://www.jpsiconline.com/text.asp?2017/5/1/7/213283



Introductory statement

Catheter insertion should only be done after proper assessment and removal is warranted once it is not required. Catheter duration is directly proportional to infection.


  Introduction Top


Catheter-associated urinary tract infection (CAUTI) has become fourth important cause of healthcare-associated infection (HAI).[1] Data suggest that urinary tract infections (UTIs) account for more than 12% of infections in acute settings leading to increase hospital stay and also morbidity and mortality.[1] The more the number of catheter days the more is infection.[2] Data from India representing CAUTI as per the Centers for Disease Control and Prevention (CDC) guideline are very few.

An approach for identification of catheter-associated infection and its confirmation should be made, and at the same time, care should be taken to minimize the infection rate. Strategies should be planned and policies should be made. CAUTI are associated with blood stream infections and other complications such as prostatitis, epididymitis, orchitis in males, and cystitis, pyelonephritis, septic arthritis, meningitis to name a few of the complication resulting from CAUTI leading to grave consequences. These complications result in prolong hospital stay and cost to the patient.[3] In view of this, the following study has been done to find the infection rate and prevalence of organisms in CAUTI cases and their antibiotic sensitivity pattern and also measures to be taken to reduce the infection rate.


  Materials and Methods Top


A total of 1874 cases of Foleys catheter from the Intensive Care Unit (ICU) and ward were followed for 6 months from June 2015 to December 2015. Emergency ward was not included in the study. Infection control nurses (ICNs) during their round used to collect the data as shown in [Table 1]. Fever or change in consistency of urine or presence of any urinary symptom (suprapubic tenderness, costovertebral angle tenderness) if any were noted down. Cases were confirmed as per the CDC guideline for CAUTI detection, 2009.[4] Information regarding catheter days of each patient was entered in hospital information system (HIS) (infection control section). Information of each case is entered in HIS. A confirmed case is defined when it meets all the criteria for CAUTI as shown in [Figure 1] and [Figure 2].
Figure 1: Entry of data into hospital information system toward catheter-associated urinary tract infection for count >105 cfu/ml

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Figure 2: Entry of data into hospital information system toward catheter-associated urinary tract infection for count <105 cfu/ml

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Table 1: Data for CAUTI

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Calculation was done by




  Results Top


A total of 1874 samples of patients where catheter was placed were sent to laboratory. Of which 303 (16.17%) samples were culture positive. When investigated for other criteria like fever, raised leukocyte count, suprapubic or costovertebral tenderness present at the time of collection of sample, cases where Foleys was not present; but before 48 h, it was removed along with frequency, urgency, and dysuria; a total of 21 cases (6.93%) came out to be confirmed CAUTI cases from culture positives. Isolates obtained in confirmed cases are shown in [Figure 3]. The most common isolate obtained being Escherichia coli. Sensitivity (%) of the isolates is shown in [Figure 4] and [Figure 5]. Klebsiella was more notorious being resistant of all the isolate. It was sensitive only to colistin and doxycycline.
Figure 3: Isolates obtained in confirm cases of catheter-associated urinary tract infection

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Figure 4: Sensitivity (') of Escherichia coli, Klebsiella pneumoniae, and Acinetobacter baumannii complex

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Figure 5: Sensitivity of Pseudomonas sp.

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Enterococcus sp was 100% sensitive to doxycycline and nitrofurantoin.

Enzymes present in the isolates are shown in [Table 2].
Table 2: Enzymes prevalent in the isolates

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Monthly and average catheter days and infection rate/1000 catheter days are shown in [Table 3].
Table 3: Monthly and average catheter days and infection rate/1000 catheter days

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Majority of confirmed cases were males being 85% (18), and samples were more from ward 52.38% (11) when compared to ICU 47.61% (10).

When analyzed, it was found that 16 (76.19%) isolates obtained had 105 colony-forming unit (cfu)/ml and 5 (23.81%) isolates had colony count of <105 cfu/ml. These samples with lower colony count were then looked for other criteria as defined by CDC in urine sample and another template in HIS was used for entry as shown in [Figure 2].


  Discussion Top


Catheter-associated UTI is the most common HAI accounting for about 12% of total infection. Catheterization is required at some point of time during treatment.[3],[5] UTI related to catheterization may occur with or without symptoms. Incidence of bacteriuria is 3%–8% per day in catheterized patient.[6],[7] Rates vary in other studies as from India.[8] The longer the duration more is the risk for developing bacteriuria accounting for around 3% to 7% per day increase in CAUTI.[5]

In this study, the most common isolate was E. coli (28.57%) followed by Klebsiella pneumoniae (19.05%) as seen in other studies.[9],[10],[11] Eradication of these microorganisms in the presence of urethral catheter is difficult and is often impossible due to antimicrobial resistance and the presence of biofilm on the inner surface of the catheter. Resistance to antimicrobial agents has been noted in this study similar to other studies since the first use of these agents and is an increasing worldwide problem.[12]

Antibiotic susceptibility pattern shows resistance in these organisms to almost all the antibiotics with the exception of colistin which showed 100% sensitivity as shown in this study. The use of colistin as a treatment modality in cases of urinary infection is questionable due to its pharmacokinetics.[13],[14]

HAI (CAUTI) could be either due to endogenous or exogenous organisms. Also with the use of higher end antibiotics, there is change in flora and harboring of resistant pathogens. These patients could be a source of multidrug-resistant organism and if there is a breech in aseptic technique by a healthcare worker the most important being hand hygiene, it could spread to other patient or environment. Hence, infection prevention program find their implication.[15]

Patient with Foleys catheter inserted must be monitored for sign and symptoms and in-charge nurse must be trained on for aseptic insertion of Foleys catheter. Days for catheter must be entered manually or in a system or electronic sources for denominator. Training must be given for catheter care, hand hygiene practice, and at the same time, urine sample should be sent for culture. According to new guideline, a blood culture should also be sent simultaneously if patient with Foleys catheter does not have signs or symptoms so in that case if organism identified from blood matches with that obtained in urine at ≥100000 cfu/ml, it is considered as CAUTI.[16]

It is recommended that catheters must be inserted only when it is indicated. There should be a policy for catheter insertion, maintenance, and removal. A checklist could be made for indication required for insertion and also removal. There are various methods which have been proposed to limit the CAUTI. These could be adopted and practiced.[17]

Training and education regarding implementation of policy should be imparted at institute level. Once inserted, they should daily be monitored for removal. It should be removed as early as the clinical condition improves. Nursing staff should be trained and vigilant enough to remind the physician for the removal. Studies report that 38%–50% of catheter were without any indication.[18],[19] Besides training to the staff, patients and their attendants should also be trained for catheter care.

It is also recommended that patient with catheter placed should be cohorted in conjunction with infection control department to limit the spread of organism.

Infection control plays a very important part in training, education, creating awareness for hand hygiene practice among healthcare workers. Data collection and analysis form an integral part of surveillance. Monthly infection rate is monitored and measures are taken if there is an increase in rate. Daily rounds, training, and education should be given by the ICNs. Here also comes the role of link nurse who is responsible for implementation of the policies to the patient level.


  Conclusion Top


A total of 1874 samples of Foleys catheter were followed for the presence of CAUTI. Of which 21 cases were confirmed. The most common isolate obtained was E. coli followed by K. pneumoniae. The only drug which was 100% sensitive was colistin. This shows that inadvertent use of catheter might result in harboring of resistant pathogens which are difficult to treat. With dearth of new antibiotics and increasing challenges in treatment, we should be vigilant toward catheter insertion and removal as early as possible. A pre-assessment of all the patients must be done to find whether the catheter is actually required or not. A policy should be made and guideline should be laid and followed. Regular training and education should be imparted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370:1198-208.  Back to cited text no. 1
    
2.
Jaggi N, Sissodia P. Multimodal supervision programme to reduce catheter associated urinary tract infections and its analysis to enable focus on labour and cost effective infection control measures in a tertiary care hospital in India. J Clin Diagn Res 2012;6:1372-6.  Back to cited text no. 2
    
3.
McGuckin M. The Patient Survival Guide: 8 Simple Solutions to Prevent Hospital and Healthcare-Associated Infections. New York: Demos Medical Publishing; 2012.  Back to cited text no. 3
    
4.
Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events. CDC; 2009. Available form: www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. [Last accessed on 2015 Dec 20].  Back to cited text no. 4
    
5.
Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:464-79.  Back to cited text no. 5
    
6.
Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med 1999;159:800-8.  Back to cited text no. 6
    
7.
Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis 2001;7:342-7.  Back to cited text no. 7
    
8.
Mehta Y, Jaggi N, Rosenthal VD, Kavathekar M, Sakle A, Munshi N, et al. Device-associated infection rates in 20 cities of India, data summary for 2004-2013: Findings of the International Nosocomial Infection Control Consortium. Infect Control Hosp Epidemiol 2016;37:172-81.  Back to cited text no. 8
    
9.
Danchaivijitr S, Pichiensatian W, Apisarnthanarak A, Kachintorn K, Cherdrungsi R. Strategies to improve hand hygiene practices in two university hospitals. J Med Assoc Thai 2005;88 Suppl 10:S155-60.  Back to cited text no. 9
    
10.
Bagchi I, Jaitly NK, Thrombare VR. Microbiological evaluation of catheter associated urinary tract infection in a tertiary care hospital. Peoples Journal of Scientific Research 2015;8:23-29.  Back to cited text no. 10
    
11.
Jayshri VD, Rakesh N, Sinha M. Antibiotic sensitivity pattern of bacteria isolated from catheter associated urinary tract infections in tertiary care hospital, Jamangar. Sch J Appl Med Sci 2015;3:1985-8.  Back to cited text no. 11
    
12.
Beyene G, Tsegaye W. Bacterial uropathogens in urinary tract infection and antibiotic susceptibility pattern in Jimma University specialized hospital, Southwest Ethiopia. Ethiop J Health Sci 2011;21:141-6.  Back to cited text no. 12
    
13.
Gobin P, Lemaître F, Marchand S, Couet W, Olivier JC. Assay of colistin and colistin methanesulfonate in plasma and urine by liquid chromatography-tandem mass spectrometry. Antimicrob Agents Chemother 2010;54:1941-8.  Back to cited text no. 13
    
14.
Michalopoulos AS, Falagas ME. Colistin: Recent data on pharmacodynamics properties and clinical efficacy in critically ill patients. Ann Intensive Care 2011;1:30.  Back to cited text no. 14
    
15.
Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63.  Back to cited text no. 15
    
16.
Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events. CDC; 2016. Available form: www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. [Last accessed on 2016 Mar 16].  Back to cited text no. 16
    
17.
Jacobsen SM, Stickler DJ, Mobley HL, Shirtliff ME. Complicated catheter-associated urinary tract infections due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev 2008;21:26-59.  Back to cited text no. 17
    
18.
Munasinghe RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol 2001;22:647-9.  Back to cited text no. 18
    
19.
Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA. Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 1998;6:99-102.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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