Evaluation of an office method of detecting bacteriuria.

Although catheter-associated UTI continues to be the leading cause of nosocomial infection, epidemiological investigation of catheter use in many hospitals may be precluded by the reluctance of the laboratory to process the large number of urine cultures. We have evaluated the use by Nurse Epidemiologists of Bacturcult tubes for such purposes. The urine of 111 catheterized patients was cultured daily using both the Bacturcult and streak plate method until significant bacteriuria developed (greater than 10(5) colonies/ml). Bacturcult proved as accurate as the conventional technique in detecting bacteriuria. In contrast to previous studies, the daily incidence of infection rose with increasing duration of catheterization. Concomitant antibiotic usage reduced the risk of infection but selected out multi-drug resistant organisms. Older age and procedural errors also increased the risk of infection. The study took 150 hours to complete and cost about $250. It is concluded that Bacturcult is an accurate, simple and relatively inexpensive method of detecting bacteriuria and could be useful for investigating the epidemiology of catheter-associated infections in community hospitals.     

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 10³ and 10⁵ 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.     

留置导尿管患者尿路感染的相关危险因素分析与护理措施探讨

目的探讨留置导尿管相关尿路感染（UTI）的危险因素分析及最佳护理措施。方法入选我院留置尿管患者100例,对中段尿（或膀胱尿）及尿道口处尿进行不同时段的采样及细菌培养,分析出现菌尿症的情况。结果留置导尿管期间,出现菌尿症67例,发生率为67％。导尿管不同留置时间UTI发生率差异有统计学意义（P〈0．05）。结论高龄、留置尿管时间过长是发生UTI的高危因素．规范留置导尿管管理、尽量缩短留置尿管时间、严格遵守无菌操作原则是留置导尿管相关尿路感染的重要护理及预防措施。     

Does catheter-associated urinary tract infection increase mortality in critically ill patients?

OBJECTIVE: To produce an accurate estimate of the association between catheter-associated urinary tract infection (UTI) and intensive care unit (ICU) and hospital mortality, controlling for major confounding factors. DESIGN: Nested case-control study in a multicenter cohort (the OutcomeRea database). SETTING: Twelve French medical or surgical ICUs. METHODS: All patients admitted between January 1997 and August 2005 who required the insertion of an indwelling urinary catheter. Patients who developed catheter-associated UTI (ie, case patients) were matched to control patients on the basis of the following criteria: sex, age (+/- 10 years), SAPS (Simplified Acute Physiology Score) II score (+/- 10 points), duration of urinary tract catheterization, and presence or absence of diabetes mellitus. The association of catheter-associated UTI with ICU and hospital mortality was assessed by use of conditional logistic regression. RESULTS: Of the 3,281 patients who had an indwelling urinary catheter, 298 (9%) developed at least 1 episode of catheter-associated UTI. The incidence density of catheter-associated UTI was 12.9 infections per 1,000 catheterization-days. Crude ICU mortality rates were higher among patients with catheter-associated UTI, compared with those without catheter-associated UTI (32% vs 25%, P=.02); the same was true for crude hospital mortality rates (43% vs 30%, P<.01). After matching and adjustment, catheter-associated UTI was no longer associated with increased mortality (ICU mortality: odds ratio [OR], 0.846 [95% confidence interval {CI}, 0.659-1.086]; P=.19 and hospital mortality: OR, 0.949 [95% CI, 0.763-1.181]; P=.64). CONCLUSION: After carefully controlling for confounding factors, catheter-associated UTI was not found to be associated with excess mortality among our population of critically ill patients in either the ICU or the hospital.     

Daily meatal care for prevention of catheter-associated bacteriuria: results using frequent applications of polyantibiotic cream

OBJECTIVE: To determine the efficacy of meatal treatment with a polyantibiotic cream in the prevention of bacteriuria during transurethral bladder catheterization. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: Adult patients who underwent closed urinary catheter drainage for short and intermediate durations (two to 30 days). INTERVENTION: Polyantibiotic cream containing polymyxin B sulfate, neomycin sulfate, and gramicidin was applied to the urethral meatus-catheter interface three times daily from the first day of catheterization until bacteriuria was found. The onset of bacteriuria was defined as the day the colonizing species first achieved a colony count of greater than or equal to 1000 colonies/ml. Patients randomized to the control group received routine meatal care with cleansing of the meatal surface during daily bathing. RESULTS: Among 2,923 patients who were randomly allocated to receive either the protocol meatal care or routine care, the evaluable study population consisted of 747 patients who were nonbacteriuric and who remained catheterized for more than two days. Overall, 26 (6.8%) of 383 patients given the polyantibiotic treatment acquired bacteriuria, as compared to 37 (10.1%) of 364 patients not given this treatment (p = .167). A Cox proportional hazards regression analysis showed that, among putative risk factors including lack of meatal care, only female gender, a meatal swab culture yielding gram-negative rods or enterococci, and lack of antibiotic use during catheterization were independently associated with the development of bacteriuria. CONCLUSIONS: The adverse effect of meatal care noted in earlier studies of a disinfectant ointment applied twice daily was not found in this study of an antimicrobial preparation in a cream vehicle applied three times daily. However, the results do not support meatal care as an efficacious method to prevent catheter-associated bacteriuria in all patients.     

Appropriate and inappropriate use of indwelling urinary catheters

- Many hospitalized patients receive a urinary catheter during their stay. In 21-54% of patients, however, there is no appropriate indication for this.- The most significant complication caused by the use of urinary catheters is the development of a urinary tract infection (UTI), one of the most common nosocomial infections. - In 71-80% of hospital acquired UTIs a urinary catheter is present. - The duration of the presence of a catheter is the major risk factor for catheter-associated UTI.- Reducing the number of inappropriate catheterisations is an effective way of preventing catheter-related UTIs. - Inapprpriate use of indwelling urinary catheters can be reduced by maintaining strict guidelines on justifiable indications for inserting a urinary catheter, verifying daily whether the indication still applies, and by timely removal of the catheter when it is not or no longer needed.     

Could the incidence of postoperative urinary tract infection be reduced by reversing the sequence of vaginal cleansing and urethral catheterization?

Postoperative urinary tract infection (UTI) is a common hospital infection after gynaecological operations. A prospective randomized study was performed to examine whether the incidence of UTI could be reduced by reversing the sequence of vaginal cleansing and urethral catheterization. Subjects were randomly allocated to: (1) urethral catheterization before vaginal cleansing; and (2) urethral catheterization after vaginal cleansing. Urine cultures were performed immediately after the procedures as the baseline, on the day of catheter removal, and two days after catheter removal. Patients were examined daily after the operation for any urinary symptoms and fever. The incidences of preoperative asymptomatic bacteriuria were similar in both groups, seven of 84 in group 1 vs. eight of 83 in group 2. Among those with negative urine culture before the operation, 77 in group 1 and 75 in group 2, there was no significant difference in postoperative bacteriuria at catheter removal (23 vs. 22) and two days later (35 vs. 42). No significant difference was noted in the incidence of UTI (5 vs. 10, P = 0.25), with a trend towards less UTI in group 1. Voiding discomfort was more common, and fever less common in group 1. There were significant associations between urine culture results at three different occasions. Bacteriuria at catheter removal is associated with a 7.2 times risk of bacteriuria two days later, 2.4 times risk of urinary symptoms and 3.2 times risk of UTI. Routine surveillance at catheter removal is not cost-effective.We conclude that postoperative bacteriuria and UTI are common. Reversing the sequence of the procedures cannot reduce the incidence. There is no evidence to change the status quo.     

Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina.

OBJECTIVE: To evaluate the effect of education and performance feedback regarding compliance with catheter care and handwashing on rates of catheter-associated urinary tract infection (UTI) in intensive care units (ICUs). SETTING: Two level III adult ICUs in a private healthcare facility in Argentina. PATIENTS: All adult patients admitted to the study units who had a urinary catheter in place for at least 24 hours. METHODS: A prospective, open trial in which rates of catheter-associated UTI determined during a baseline period of active surveillance without education and performance feedback were compared with rates of catheter-associated UTI after implementing education and performance feedback. RESULTS: There were 1,779 catheter-days during the baseline period and 5,568 catheter-days during the intervention period. Compliance regarding prevention of compression of the tubing by a leg improved (from 83% to 96%; relative risk [RR], 1.15; 95% confidence interval [CI95], 1.03 to 1.28; P = .01) and so did compliance with handwashing (from 23.1% to 65.2%; RR, 2.82; CI95, 2.49 to 3.20; P < .0001). Catheter-associated UTI rates decreased significantly from 21.3 to 12.39 per 1,000 catheter-days (RR, 0.58; CI%, 0.39 to 0.86; P = .006). CONCLUSION: Implementing education and performance feedback regarding catheter care measures and handwashing compliance was associated with a significant reduction in catheter-associated UTI rates. Similar programs may help reduce catheter-associated UTI rates in other Latin American hospitals.     

气囊尿管外固定囊对预防男性导尿患者泌尿道感染的临床研究

目的探讨气囊尿管外固定囊对减少男性留置导尿患者泌尿道感染的作用。方法将肿瘤内科男性导尿患者按导尿先后顺序随机分为观察组（100例）和对照组（100例）。对照组患者导尿成功后只应用导尿管的气囊进行导尿管膀胱内固定，不行尿管外固定；观察组患者在使用导尿管气囊进行膀胱内固定的同时，再应用气囊尿管外固定囊进行导尿管外固定，观察并比较两组患者留置尿管后第3、5、7天泌尿道感染发生情况。结果留置尿管后第3、5、7天，观察组患者的无症状菌尿症和泌尿道感染发生率分别为1.00%、0.00%，4.00%、2.00%，9.00%、3.00%；而对照组无症状菌尿症和泌尿道感染发生率分别为7.00%、3.00%，13.00%、7.00%，21.00%、13.00%，观察组的无症状菌尿症和泌尿道感染发生率均显著低于对照组（均P＜0.01）。结论气囊尿管外固定囊用于男性留置导尿患者，可以避免导尿管移动，有效降低泌尿道感染的发生，值得临床推广。     

预防性过程监控对留置导尿泌尿系感染控制作用的研究 FREE

目的在“过程监控”基础上提出“预防性过程监控”概念及可行的监控方法,实验性应用于留置导尿相关泌尿系感染的控制中,评价监控方法的有效性。方法将某院神经内科2007年1-7月留置导尿的155例患者设为对照组,2007年8月-2008年2月留置导尿的141例患者设为实验组;对照组执行留置导尿常规护理,实验组除进行常规护理外,采用评估督促和宣传教育等方法进行预防性过程监控。结果实验组留置导尿相关泌尿系感染率为4.26%,明显低于对照组的16.13%（χ2=11.10,P＜0.01）;两组患者留置导尿的时间比较,实验组70%的患者留置导尿时间在13.10 d内,明显低于对照组的18 d;留置导尿11～30 d、＞30 d时,实验组导尿相关泌尿系感染率分别为6.67%、16.67%,明显低于对照组的30.77%、57.89%（分别χ2=8.27,P＜0.01;χ2=5.13,P＜0.05）。结论评估督促和宣传教育等预防性过程监控可有效预防医院感染。     

碘伏扩大消毒预防留置尿管尿路感染120例的效果

目的探讨碘伏扩大范围消毒预防留置尿管相关医院泌尿道感染（UTI）的效果。方法实验组以0.5%碘伏在尿管植入、留置尿管护理时扩大消毒范围,对外阴、会阴体、肛周、尿管的前端尿管接头处及尿袋排尿口进行彻底的消毒,每天2次;对照组按常规消毒处理。结果实验组120例,UTI发生率（5.0%）与对照组102例UTI发生率（18.63%）比较,P〈0.01,差异有统计学意义。结论留置导尿时碘伏扩大范围消毒可有效预防尿管相关医院UTI。     

Hospital-acquired infections in Italy: a region wide prevalence study

Between October and December 2000, a region-wide prevalence study of hospital-acquired infections (HAI) was conducted in all public hospitals (59 facilities with ca. 16000 beds; 560000 admission yearly) in Piemonte Region, Italy, and in the one hospital of the neighbouring autonomous region of Valle d'Aosta. The study population comprised a total of 9467 patients hospitalized for at least 24 h. The prevalence of HAI was 7.84%, with marked differences in prevalence among the participating hospitals (range: 0-47.8%). The higher relative frequency of urinary tract infections (UTI; 52.7%) was due to the inclusion of urine cultures obtained on the day of the study from asymptomatic UTI in catheterized patients. A significant correlation was found with major risk factors related to medical procedures (urinary catheter, mechanical ventilation, surgical drainage, intravascular catheters). Patients with HAI were found to be older and to have a greater mean length of stay in hospital. Multiple logistic regression analyses showed that lack of independence, indwelling urinary catheter and mechanical ventilation were the risk factors more significantly associated with HAI. The use of antibiotics, in particular prophylactic agents used in surgery (cephalosporins, glycopeptides), provided an incentive for corrective intervention in antibiotic administration and in training of healthcare workers.     

Urinary-tract infection and bacteraemia in hospitalized medical patients--a European multicentre prevalence survey on nosocomial infection

A co-ordinated survey of 3899 medical patients in 169 wards, performed simultaneously in eight countries, showed a point-prevalence of urinary-tract infection (UTI) and bacteraemia of 12.6 and 1.6 per cent, respectively. One-half of the infections were acquired after the patients' admission. The bacteriological patterns of hospital- vs community-acquired infections were different, but showed no unexpected features. Antibiotic treatment was recorded in 22.3 per cent of the patients in this study, urinary-tract disinfectants, sulphonamides or penicillins being used in 95 per cent of those treated for UTI. The overall prevalence of urinary-tract drainage was 11.0 per cent with no significant difference between the two sexes. At ward level the rate of catheterized patients varied from below 5 per cent to more than 25 per cent, indicating--besides variations in the ward populations--differences in policies. The association between nosocomial UTI and the presence of an indwelling catheter and/or female sex was confirmed, while high age appeared to be a secondary risk factor among catheterized patients. The prevalence of nosocomial bacteraemia in patients with UTI was five times higher than in those without urinary-tract involvement, and a significant part of the nosocomial cases of both UTI and bacteraemia was clearly device-related. Guidelines for the use of indwelling catheters should be restrictive and provide for prompt removal. When introduced and followed they will effectively reduce nosocomial UTI and bacteraemia.     

A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals.

OBJECTIVE: Although urinary tract infection (UTI) is the most common hospital-acquired infection, there is little information about why hospitals use or do not use a range of available preventive practices. We thus conducted a multicenter study to understand better how US hospitals approach the prevention of hospital-acquired UTI. METHODS: This research is part of a larger study employing both quantitative and qualitative methods. The qualitative phase consisted of 38 semistructured phone interviews with key personnel at 14 purposefully sampled US hospitals and 39 in-person interviews at 5 of those 14 hospitals, to identify recurrent and unifying themes that characterize how hospitals have addressed hospital-acquired UTI. RESULTS: Four recurrent themes emerged from our study data. First, although preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early removal of a urinary catheter for patients. Second, those hospitals that made UTI prevention a high priority also focused on noninfectious complications and had committed advocates, or "champions," who facilitated prevention activities. Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial-impregnated catheters. Finally, external forces, such as public reporting, influenced UTI surveillance and infection prevention activities. CONCLUSIONS: Clinicians and policy makers can use our findings to develop initiatives that, for example, use a champion to promote the removal of unnecessary urinary catheters or exploit external forces, such public reporting, to enhance patient safety.     

Evolution of closed urinary drainage systems use and associated factors in Spanish hospitals

Although closed urinary drainage systems (CUDS) reduce the risk of catheter-associated urinary tract infection (CAUTI), open systems are still used in Spain. The object of this work was to describe the progress of CUDS use and factors associated with the drainage system type used in Spanish hospitals. The databases of the EPINE study (Study of Prevalence of Nosocomial Infections in Spain) from 1990 to 2000 were used. The EPINE study includes hospitalized patients of all ages in acute-care Spanish hospitals. Seventy-six thousand, seven hundred and eighty-eight catheterized patients were studied, and the whole database was used for the trend analysis of global hospital-acquired infection (HAI). The patient and the hospital were the two units of observation used in the analysis. Full implementation was defined as 90% CUDS use. A logistic regression model was applied to study factors influencing the use of CUDS and to determine prevalence trend. An odds ratio (OR) >1 indicates an incremental trend. The Pearson correlation coefficient between annual percentage of CUDS use and CAUTI prevalence was calculated. Variables for the year 2000 were compared using the Mann-Whitney U test between hospitals with and without full implementation. The prevalence of urinary catheterized patients in Spain increased from 12.4% in 1990 to 15.2% in 2000 (OR 1.019, 95% CI 1.016-1.021). The proportion of CUDS used increased from 50.6% in 1990 to 70% in 2000 (OR 1.1, 95% CI 1.095-1.104) and correlated with a significant decrease of UTIs (r = 0.65, P = 0.03). In 1990, 28.5% of hospitals had full implementation of CUDS and by 2000 this had risen to 40.3% (OR 1.093, 95% CI 1.06-1.127). Patients in medium (200-500 beds) and large (>500 beds) hospitals, as well as those with three of more diagnoses and two or more intrinsic risk factors had an increased probability of having a CUDS, whereas being hospitalized in areas other than intensive care, being male and less than 65 years old were associated with a lower probability of CUDS use. The median prevalence of catheterized patients in hospitals with full implementation, was significantly lower than in those without it (P = 0.049). Although CUDS use is increasing, there is still much work required to reach full implementation. Keeping CUDS for more severely ill patients may reflect a higher concern over the consequences of UTI in these patients. Nevertheless, it is necessary to change a practice that exposes patients to a known UTI risk factor and reach a consensus on indications for catheter insertion.     

The role of meatal disinfection in preventing catheter-related bacteriuria in an intensive care unit: a pilot study in Turkey

The purpose of this study was to investigate the efficacy of antiseptics meatal care in preventing catheter-related urinary tract infections (UTIs) in patients with an indwelling urinary catheter in the intensive care unit of Osmangazi University Medical School. One hundred patients were divided into four groups (25 per group) and treated with once or twice daily application of chlorhexidine gluconate or povidone-iodine. A control group was also studied (N=30). Urine samples were taken weekly and cultures were evaluated quantitatively. Meatal swabs were obtained on the first, fifth, and 10th day and determinated semiquantitatively. UTI was defined as bacteriuria with 10(5)cfu/L. Cultures showing no growth or mixed growths were stated as negative for UTI. UTI developed in 16 patients on days two, three, four, five and seven (including control group). Dominant micro-organisms in the meatal area were found to be Candida species. In nine cases the causative agents of UTI were Candida species. It was therefore decided that the use of antiseptics to clean the periurethral area provides no benefit in decreasing the rate of bacteriuria.     

A randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter.

We have evaluated the effect of povidone-iodine (PVP-I) bladder irrigation prior to catheter removal on subsequent bacteriuria. Of 264 patients, 138 received PVP-I irrigation and 126 were controls. Both groups were similar with respect to duration of catheterization and bacteriuria before removal of the catheter. Of 497 cultures taken after catheter removal 99 (20%) were positive. This included 52 of 233 in the control group (22%) and 47 of 264 in the study group (18%). Patients with positive cultures had a significantly longer period of catheterization. Our trial did not demonstrate that PVP-I bladder irrigation before catheter removal reduces subsequent bacteriuria.     

“洁悠神”用于预防男性经尿道手术后尿路感染的研究

目的评价“洁悠神”对预防男性经尿道手术后留置导尿期间尿路感染的效果。方法128例患者随机分成两组,对照组术后仅给予常规尿道口护理,实验组术后给予常规尿道口护理后在尿道口及周围区域喷洒“洁悠神”,观察两组尿培养菌尿发生情况。结果对照组术后置管期间菌尿发生率明显高于文献报道水平,而实验组菌尿率显著低于对照组（P〈0．01）。结论经尿道手术可能增加术后置管期间尿路感染几率,而术后用洁悠神对患者进行导尿管表面和尿道口喷洒,可有效降低尿路感染的发生。     

The effect on bacteriuria of removal of indwelling catheters and treatment with co-trimoxazole

After removal of an indwelling cathether from 54 geriatric patients, 14 became non-bacteriuric during treatment with absorbent pads. The remaining 40 patients with bacteriuria showed a significant reduction in the number of Gram-negative strains of probable nosocomial type in their urine when compared to the previous period of catheter treatment. Of these 40 patients, 27 were non-bacteriuric after a week's treatment with cotrimoxazole. Seven weeks after treatment, 15 of these patients were still non-bacteriuric. This two-step model, removal of the indwelling catheter followed by a short course of treatment with a suitable antibiotic, demonstrates a possible approach to the problem of incontinence and hospital-acquired bacteriuria in long-term care.     

不同尿液引流方法的尿液检查分析

目的探讨不同引流方法引起菌尿症的机率。方法通过对留置尿管持续引流、留管后膀胱冲洗及肾盂输尿管支架导管引流三组患者的尿液，在即刻、第２、４、７、１０、１４天后进行细菌培养、药敏和检查分析。结果持续引流组较膀胱冲洗组尿培养出现菌尿的机率稍低，７天菌尿出现率分别为３３．３％和４６．７％，两组比较无显著性差异，但支架管引流组出现菌尿例数明显要少，７天菌尿出现率仅７．１％，与前两组比较有显著性差异，培养出的细菌对大多数抗生素不敏感。结论留置尿管期间膀胱冲洗并不降低菌尿的发生率，细菌通过尿管周围间隙侵入是尿管相关性感染的重要途径，尿液中的细菌对多种抗生素耐药，应引起重视。