REVIEW URRENT C OPINION
An update on prevention and treatment of catheter-associated urinary tract infections Peter Tenke a, Be´la Ko¨ves a, and Truls E.B. Johansen b
Purpose of review Catheter-related urinary tract infections (UTIs) are among the most important nosocomial infections. This review summarizes the latest advances in the field of catheter care and the management of catheterassociated UTIs. Recent findings The most efficient methods to prevent catheter-associated UTIs are to avoid unnecessary catheterizations and to remove catheters as soon as possible. The use of different reminder systems and implementation of infection control programs can effectively decrease catheter-associated UTIs, although their introduction can be challenging. There is still no evidence to support the routine use of antimicrobial-impregnated catheters, but the use of hydrophilic-coated catheters for clean intermittent catheterization can effectively reduce infections. Preliminary results with chlorhexidine-coated catheters are promising. In cases of serious catheter-associated UTI in patients with a history of previous antibiotic therapy or healthcare-associated bacteraemia, empirical antibiotic treatment should be initiated with activity against multiresistant uropathogens. Suprapubic catheterization is not superior to urethral catheters in terms of reducing the rate of catheter-related bacteriuria. Summary A technology to prevent catheter-associated UTIs is still not available; however, there are promising results with new approaches such as the use of reminder systems and infection control programs, which can effectively decrease the rate of catheter-associated UTIs. There is evidence supporting the use of hydrophilic coated catheters for clean intermittent catheterization, but an optimal catheter material or coating still has to be developed. Evidence-based catheter management is crucial for every patient in need of a catheter. Keywords bacteriuria, catheter, catheter-associated UTI, infection, prevention
INTRODUCTION Urinary catheters are among the most commonly used devices in hospitals, especially in perioperative and intensive care units. Up to 25% of hospitalized patients experience catheterization for different reasons [1,2]. As more people are living longer, catheters are also used more frequently in the elderly population residing in nursing homes and in private homes. With the worldwide increase in the rate of antibiotic resistance and limited number of antibiotics, appropriate surveillance of healthcare-associated infections (HAIs) is of utmost importance. The urinary tract is considered as one of the most important sources of HAIs [3] and the presence of a urinary catheter is one of the major risk factors, as it is associated with up to 80% of healthcare-associated urinary tract infections (UTIs) [4]. Furthermore, www.co-infectiousdiseases.com
catheter-associated UTIs were found to be the most preventable type of HAIs [5]. The case fatality rate of catheter-associated UTIs had been estimated around 2.3% in US hospitals [5], and a mortality rate of 9% was reported in cases of bacteraemic catheter-associated UTIs [6 ], and 25–60% in cases of urosepsis [7]. Hospitalization resulting from catheter-related complications shows an increasing trend, with &&
a
Department of Urology, South-Pest Hospital, Budapest, Hungary and Department of Urology, Oslo University Hospital, Oslo, Norway
b
Correspondence to Peter Tenke, Department of Urology, South-Pest Hospital, Ko¨ves Str.1, 1204, Budapest, Hungary. Tel: +3612396200; e-mail: [email protected] Curr Opin Infect Dis 2014, 27:102–107 DOI:10.1097/QCO.0000000000000031 Volume 27 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Catheter-associated urinary tract infections Tenke et al.
KEY POINTS Catheter-associated UTI is a major source of healthcareassociated infections with significant morbidity and costs. It is important to avoid unnecessary catheterizations and to remove catheters as soon as possible; the use of reminder systems and implementation of infection control programs can help achieving these goals. Recent evidence does not support the routine use of antimicrobial-impregnated catheters. The use of hydrophilic-coated catheters for clean intermittent catheterization can effectively reduce the rate of catheter-associated UTIs. Suprapubic catheterization is not superior to urethral catheters in terms of reducing the rate of catheter related bacteriuria.
catheter-associated UTIs being the leading cause of admission in this category [8 ]. For these reasons, evidence-based catheter care and appropriate prevention and management of catheter-associated UTI are mandatory. The aim of this review is to summarize the latest advances in these fields. &
DEFINITION According to the National Healthcare Safety Network (NHSN), the patient safety surveillance system of the US Centers for Disease Control and Prevention (CDC), catheter-associated UTI is defined as a UTI (symptomatic UTI or asymptomatic bacteremic UTI) in which an indwelling catheter was in place for more than 2 days on the date of the event, with day of device placement being day 1, and an indwelling urinary catheter was in place on the date of the event or the day before. If an indwelling urinary catheter was in place for more than 2 calendar days and then removed, the UTI criteria must be fully met on the day of discontinuation or the next day (http://www.cdc.gov/nhsn/acute-carehospital/CAUTI/). This definition contains an important change that was applied in 2009, when asymptomatic bacteriuria was removed from the definition of catheter-associated UTI by NHSN, leading to a potential decrease in the incidence of the documented catheter-associated UTIs and catheterassociated UTI-related outcomes in the hospital systems. The first report confirming this effect has been published [9 ], underlining that this change should be considered in longitudinal monitoring and in &&
comparisons of the rates of catheter-associated UTIs in hospital systems in the recent years. In 2010, the European Association of Urology (EAU) published a new classification of urinary tract infections based on the clinical presentation of the UTI, categorization of risk factors and availability of appropriate antimicrobial therapy [10]. In this classification system, asymptomatic bacteriuria is regarded as a urological risk factor and not a separate type of UTI. Likewise, the presence of a long-term indwelling catheter represents a different group of risk factors (urinary catheter and nonresolvable urological risk factors with risk of more severe outcome).
PATHOGENESIS OF CATHETERASSOCIATED BACTERIURIA AND INFECTION The first step to a symptomatic catheter-associated UTI is the development of bacteriuria and the formation of biofilms on the inner and outer surfaces of urinary catheters. The catheter allows access of organisms into the urinary tract. There is a 3–10% risk of bacteriuria with every day of catheterization [11,12], and bacteriuria is considered universal after 30 days [13]. A biofilm is a structured community of microorganisms encapsulated within a self-developed polymeric matrix adherent to a surface. The first step in the formation of a biofilm is the deposition of a conditioning film produced by the host to the foreign body, followed by the attachment of microorganisms. The microbial adhesion and anchorage to the surface are made by exopolymer production. After this process, the bacteria start to multiply. The significance of biofilm formation is that bacteria in biofilms can be highly protected from and resistant to antibiotics, and it can be hard to detect them with conventional urine cultures.
PREVENTION OF CATHETER-ASSOCIATED BACTERIURIA URINARY TRACT INFECTION Many efforts have been made to try and prevent or delay catheter-associated bacteriuria or catheterassociated UTIs in the recent decades [14]. These efforts fall into the following main groups: (1) reminder systems to take catheters out when they are no longer indicated; (2) implementation of infection control programs; (3) reducing biofilm formation by means of new catheter surface materials;
0951-7375 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-infectiousdiseases.com
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Urinary tract infections
(4) reducing biofilm formation by means of impregnation of catheter surface with antimicrobial substances; (5) antibiotic prophylaxis; (6) other methods.
and physician engagement, the request of the patient or family for catheters, and catheter insertion practices in the emergency departments [24 ].
The most important measures of prevention of catheter-associated UTIs are as follows:
Surface modifications and catheter materials
(1) catheters should be introduced under antiseptic conditions; (2) the catheter system should remain closed; (3) unnecessary catheterizations should be avoided; (4) the duration of catheterization should be as short as possible; (5) the use of catheter reminding systems is recommended; (6) implementing infection control programs and catheter care practice bundles can reduce the rate of catheter-associated UTIs; (7) the use of hydrophilic-coated catheters is recommended for clean intermittent catheterisation. Recent achievements in each of these fields will be described below.
Reminder systems Early removal of the catheter is important to reduce the rate of catheter-related infections [15] and to reduce discomfort for the patients [16 ]. The use of nurse-based or electronic reminder systems to remove unnecessary catheters and decrease the duration of catheterization is recommended in guidelines developed by major international associations [17,18]. Recent evaluations of these monitoring systems for catheter care report on reduced periods of indwelling catheterization and a reduction in the incidence of catheter-associated UTIs [19 –21 ]. &
&
&
Infection control programs Implementing different infection control programs and catheter care practice bundles (improving hand hygiene, education for catheter insertion, management, and removal; alternatives to indwelling catheters, among others) also resulted in a decrease in the rate of catheter-associated UTIs [19 ,22 ,23]. On the other hand, the introduction of such systems can be challenging, and requires commitment from the involved personnel on all levels. The main barriers for implementing such programs have been identified as difficulty with nurse &
104
&
Many efforts have been made to modify the biomaterial surface in order to delay bacteriuria, the formation of biofilms, and infections. Most of the modifications can decrease the development of bacteriuria in cases of short-term catheterization (
An update on prevention and treatment of catheter-associated urinary tract infections Peter Tenke a, Be´la Ko¨ves a, and Truls E.B. Johansen b
Purpose of review Catheter-related urinary tract infections (UTIs) are among the most important nosocomial infections. This review summarizes the latest advances in the field of catheter care and the management of catheterassociated UTIs. Recent findings The most efficient methods to prevent catheter-associated UTIs are to avoid unnecessary catheterizations and to remove catheters as soon as possible. The use of different reminder systems and implementation of infection control programs can effectively decrease catheter-associated UTIs, although their introduction can be challenging. There is still no evidence to support the routine use of antimicrobial-impregnated catheters, but the use of hydrophilic-coated catheters for clean intermittent catheterization can effectively reduce infections. Preliminary results with chlorhexidine-coated catheters are promising. In cases of serious catheter-associated UTI in patients with a history of previous antibiotic therapy or healthcare-associated bacteraemia, empirical antibiotic treatment should be initiated with activity against multiresistant uropathogens. Suprapubic catheterization is not superior to urethral catheters in terms of reducing the rate of catheter-related bacteriuria. Summary A technology to prevent catheter-associated UTIs is still not available; however, there are promising results with new approaches such as the use of reminder systems and infection control programs, which can effectively decrease the rate of catheter-associated UTIs. There is evidence supporting the use of hydrophilic coated catheters for clean intermittent catheterization, but an optimal catheter material or coating still has to be developed. Evidence-based catheter management is crucial for every patient in need of a catheter. Keywords bacteriuria, catheter, catheter-associated UTI, infection, prevention
INTRODUCTION Urinary catheters are among the most commonly used devices in hospitals, especially in perioperative and intensive care units. Up to 25% of hospitalized patients experience catheterization for different reasons [1,2]. As more people are living longer, catheters are also used more frequently in the elderly population residing in nursing homes and in private homes. With the worldwide increase in the rate of antibiotic resistance and limited number of antibiotics, appropriate surveillance of healthcare-associated infections (HAIs) is of utmost importance. The urinary tract is considered as one of the most important sources of HAIs [3] and the presence of a urinary catheter is one of the major risk factors, as it is associated with up to 80% of healthcare-associated urinary tract infections (UTIs) [4]. Furthermore, www.co-infectiousdiseases.com
catheter-associated UTIs were found to be the most preventable type of HAIs [5]. The case fatality rate of catheter-associated UTIs had been estimated around 2.3% in US hospitals [5], and a mortality rate of 9% was reported in cases of bacteraemic catheter-associated UTIs [6 ], and 25–60% in cases of urosepsis [7]. Hospitalization resulting from catheter-related complications shows an increasing trend, with &&
a
Department of Urology, South-Pest Hospital, Budapest, Hungary and Department of Urology, Oslo University Hospital, Oslo, Norway
b
Correspondence to Peter Tenke, Department of Urology, South-Pest Hospital, Ko¨ves Str.1, 1204, Budapest, Hungary. Tel: +3612396200; e-mail: [email protected] Curr Opin Infect Dis 2014, 27:102–107 DOI:10.1097/QCO.0000000000000031 Volume 27 Number 1 February 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Catheter-associated urinary tract infections Tenke et al.
KEY POINTS Catheter-associated UTI is a major source of healthcareassociated infections with significant morbidity and costs. It is important to avoid unnecessary catheterizations and to remove catheters as soon as possible; the use of reminder systems and implementation of infection control programs can help achieving these goals. Recent evidence does not support the routine use of antimicrobial-impregnated catheters. The use of hydrophilic-coated catheters for clean intermittent catheterization can effectively reduce the rate of catheter-associated UTIs. Suprapubic catheterization is not superior to urethral catheters in terms of reducing the rate of catheter related bacteriuria.
catheter-associated UTIs being the leading cause of admission in this category [8 ]. For these reasons, evidence-based catheter care and appropriate prevention and management of catheter-associated UTI are mandatory. The aim of this review is to summarize the latest advances in these fields. &
DEFINITION According to the National Healthcare Safety Network (NHSN), the patient safety surveillance system of the US Centers for Disease Control and Prevention (CDC), catheter-associated UTI is defined as a UTI (symptomatic UTI or asymptomatic bacteremic UTI) in which an indwelling catheter was in place for more than 2 days on the date of the event, with day of device placement being day 1, and an indwelling urinary catheter was in place on the date of the event or the day before. If an indwelling urinary catheter was in place for more than 2 calendar days and then removed, the UTI criteria must be fully met on the day of discontinuation or the next day (http://www.cdc.gov/nhsn/acute-carehospital/CAUTI/). This definition contains an important change that was applied in 2009, when asymptomatic bacteriuria was removed from the definition of catheter-associated UTI by NHSN, leading to a potential decrease in the incidence of the documented catheter-associated UTIs and catheterassociated UTI-related outcomes in the hospital systems. The first report confirming this effect has been published [9 ], underlining that this change should be considered in longitudinal monitoring and in &&
comparisons of the rates of catheter-associated UTIs in hospital systems in the recent years. In 2010, the European Association of Urology (EAU) published a new classification of urinary tract infections based on the clinical presentation of the UTI, categorization of risk factors and availability of appropriate antimicrobial therapy [10]. In this classification system, asymptomatic bacteriuria is regarded as a urological risk factor and not a separate type of UTI. Likewise, the presence of a long-term indwelling catheter represents a different group of risk factors (urinary catheter and nonresolvable urological risk factors with risk of more severe outcome).
PATHOGENESIS OF CATHETERASSOCIATED BACTERIURIA AND INFECTION The first step to a symptomatic catheter-associated UTI is the development of bacteriuria and the formation of biofilms on the inner and outer surfaces of urinary catheters. The catheter allows access of organisms into the urinary tract. There is a 3–10% risk of bacteriuria with every day of catheterization [11,12], and bacteriuria is considered universal after 30 days [13]. A biofilm is a structured community of microorganisms encapsulated within a self-developed polymeric matrix adherent to a surface. The first step in the formation of a biofilm is the deposition of a conditioning film produced by the host to the foreign body, followed by the attachment of microorganisms. The microbial adhesion and anchorage to the surface are made by exopolymer production. After this process, the bacteria start to multiply. The significance of biofilm formation is that bacteria in biofilms can be highly protected from and resistant to antibiotics, and it can be hard to detect them with conventional urine cultures.
PREVENTION OF CATHETER-ASSOCIATED BACTERIURIA URINARY TRACT INFECTION Many efforts have been made to try and prevent or delay catheter-associated bacteriuria or catheterassociated UTIs in the recent decades [14]. These efforts fall into the following main groups: (1) reminder systems to take catheters out when they are no longer indicated; (2) implementation of infection control programs; (3) reducing biofilm formation by means of new catheter surface materials;
0951-7375 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-infectiousdiseases.com
103
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Urinary tract infections
(4) reducing biofilm formation by means of impregnation of catheter surface with antimicrobial substances; (5) antibiotic prophylaxis; (6) other methods.
and physician engagement, the request of the patient or family for catheters, and catheter insertion practices in the emergency departments [24 ].
The most important measures of prevention of catheter-associated UTIs are as follows:
Surface modifications and catheter materials
(1) catheters should be introduced under antiseptic conditions; (2) the catheter system should remain closed; (3) unnecessary catheterizations should be avoided; (4) the duration of catheterization should be as short as possible; (5) the use of catheter reminding systems is recommended; (6) implementing infection control programs and catheter care practice bundles can reduce the rate of catheter-associated UTIs; (7) the use of hydrophilic-coated catheters is recommended for clean intermittent catheterisation. Recent achievements in each of these fields will be described below.
Reminder systems Early removal of the catheter is important to reduce the rate of catheter-related infections [15] and to reduce discomfort for the patients [16 ]. The use of nurse-based or electronic reminder systems to remove unnecessary catheters and decrease the duration of catheterization is recommended in guidelines developed by major international associations [17,18]. Recent evaluations of these monitoring systems for catheter care report on reduced periods of indwelling catheterization and a reduction in the incidence of catheter-associated UTIs [19 –21 ]. &
&
&
Infection control programs Implementing different infection control programs and catheter care practice bundles (improving hand hygiene, education for catheter insertion, management, and removal; alternatives to indwelling catheters, among others) also resulted in a decrease in the rate of catheter-associated UTIs [19 ,22 ,23]. On the other hand, the introduction of such systems can be challenging, and requires commitment from the involved personnel on all levels. The main barriers for implementing such programs have been identified as difficulty with nurse &
104
&
Many efforts have been made to modify the biomaterial surface in order to delay bacteriuria, the formation of biofilms, and infections. Most of the modifications can decrease the development of bacteriuria in cases of short-term catheterization (
