Author's Accepted Manuscript Risk Factors for Catheter-Associated Urinary Tract Infections in a Pediatric Institution Nora G. Lee , Daniel Marchalik , Andrew Lipsky , H. Gil Rushton , Hans G. Pohl , Xiaoyan Song
PII: DOI: Reference:
S0022-5347(15)03696-4 10.1016/j.juro.2015.03.121 JURO 12504
To appear in: The Journal of Urology Accepted Date: 30 March 2015 Please cite this article as: Lee NG, Marchalik D, Lipsky A, Rushton HG, Pohl HG, Song X, Risk Factors for Catheter-Associated Urinary Tract Infections in a Pediatric Institution, The Journal of Urology® (2015), doi: 10.1016/j.juro.2015.03.121. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain.
Embargo Policy All article content is under embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date. Questions regarding embargo should be directed to
[email protected].
ACCEPTED MANUSCRIPT
RI PT
Risk Factors for Catheter-Associated Urinary Tract Infections in a Pediatric Institution
Nora G. Lee MD1, Daniel Marchalik MD1, Andrew Lipsky MD3, H. Gil Rushton MD1, Hans G. Pohl MD1, Xiaoyan Song MD, PhD2
SC
Affiliations: Division of Urology, Children’s National Medical Center, Washington DC1; Division of Infectious Diseases, Children’s National Medical Center, Washington DC2; Department of Internal Medicine, Montefiore Medical Center, New York NY3
M AN U
Corresponding author: Nora G. Lee MD, 111 Michigan Ave. NW, Washington DC 20010;
[email protected]; 202-476-3262
Keywords: Catheter-associated urinary tract infection, pediatrics
AC C
EP
TE D
Word count: 2,493
ACCEPTED MANUSCRIPT
ABSTRACT Purpose: Catheter-associated urinary tract infections (CAUTI) are an essential measure for health
RI PT
care quality improvement that affects reimbursement through hospital-acquired condition reduction programs in adult patients. With the mounting importance of preventing
SC
CAUTI, we sought to evaluate risk factors for acquiring CAUTI in pediatric patients.
Methods:
M AN U
All CAUTIs were identified within one pediatric institution from September 2010 to August 2014 from a prospective database maintained by the Infection Control Office. To identify risk factors, CAUTI patients were individually matched to control patients with a urinary catheter but without CAUTI by age, sex, date, and hospital location of CAUTI in
Results:
TE D
a 1:2 fashion.
EP
Fifty patients with CAUTI were identified and were matched to 100 control patients. Compared to control patients, CAUTI patients were more likely to have catheters in place
AC C
for longer (2.9 days) (OR 1.08, 95%CI 1.01,1.15, p=0.02). They were also more likely to be on contact precautions (OR 4.00, 95%CI 1.73,9.26, p=0.001), have concurrent infections (OR 3.04, 95%CI 1.39,6.28, p=0.005) and have a history of prior catheterization (OR 3.24, 95%CI 1.55,6.77, p=0.002). Using a conditional multivariate regression model, the three most predictive variables were duration of catheter drainage, contact isolation status and history of prior catheterization.
ACCEPTED MANUSCRIPT
Conclusions: Longer duration of urinary catheter drainage, positive contact precautions status, and
RI PT
prior history of catheterization appear to be associated with a higher risk of CAUTI in hospitalized pediatric patients. Physicians should attempt to reduce the duration of
catheterization, especially in patients who meet these criteria, to minimize the risk of
AC C
EP
TE D
M AN U
SC
CAUTI.
ACCEPTED MANUSCRIPT
INTRODUCTION The prevalence of catheter-associated urinary tract infections (CAUTI) in the adult population is well established, comprising 34% of healthcare associated infections in the
RI PT
United States with more than 500,000 CAUTI reported annually.1 In light of the
significant morbidity and financial burden attributed to CAUTI, the Centers for Medicare and Medicaid Services amended its reimbursement policies in 2008 to omit coverage for
SC
certain healthcare associated infections, including CAUTIs, and a reduction in CAUTI has become one of the main targets in improving healthcare quality.2 Despite the
M AN U
comparably high incidence of CAUTI reported in the pediatric population, the true impact of these infections has only recently become recognized.3 The Ohio Children’s Hospitals’ Solutions for Patient Safety reveals that CAUTI is the third most frequent cause of pediatric healthcare associated infections, outnumbered by central line-
TE D
associated blood stream infections and surgical site infections.3 This data portrays a profound discrepancy between the impact of pediatric CAUTI on the healthcare system and the paucity of data on the relevant characteristics and risk factors of CAUTI in the
EP
pediatric population.
AC C
Recognizing this important issue, pediatric institutions are beginning to implement quality improvement initiatives to combat pediatric CAUTI. Specifically Children’s Hospital of Philadelphia recently showed that initiating a CAUTI prevention bundle reduced the mean monthly CAUTI rate by 50%. Their prevention bundle primarily included using catheters only when indicated and using aseptic techniques. However, the study evaluated interventions as a bundle and could not discern which of the individual
ACCEPTED MANUSCRIPT
interventions were most effective.4 Therefore, understanding pediatric CAUTI pathogenesis remains critically important given the distinct pathologic conditions and
risk factors for CAUTI in the pediatric population.
METHODS
RI PT
surgical interventions performed in pediatric patients. With this, we aimed to evaluate
SC
After institutional board review approval, all CAUTI were identified within one pediatric institution from September 2010 to August 2014 from a prospectively collected database
M AN U
maintained by the Office of Infection Control at a tertiary care children’s hospital. CAUTI was defined by the Centers for Disease Control and Prevention (CDC) definition of symptomatic UTI.5 Patients were excluded if they did not meet full CDC criteria for a symptomatic UTI or if they arrived to the hospital with a catheter in place due to baseline
TE D
status. To identify risk factors that may contribute to infection, CAUTI patients were individually matched 1:2 by gender and age (maximum 2 year difference) to those with a urinary catheter but without CAUTI. Patients were also matched by date of UTI
EP
hospitalization (maximum 18 month difference) and inpatient location of CAUTI given the majority occurred in an intensive care unit (ICU) setting and also to account for
AC C
differences in health status. The control patients were likewise identified from a prospective database collected by the Infection Control Office as part of the hospital’s quality control standards.
Urine specimens for all suspected UTIs were collected through the needleless port of the catheter drainage tubing, located in close proximity to the Foley catheter, per hospital
ACCEPTED MANUSCRIPT
protocol. The collection process did not interrupt the integrity of the drainage system. For patients with CAUTI, various parameters were evaluated including hospital location of the UTI episode, presence of fever, white blood cell (WBC) count, urinalysis findings,
RI PT
urine culture organism with colony count and antibiotic resistances, length of antibiotic therapy, use of intravenous versus oral antibiotics, and complications of UTI. For both cases and controls, additional parameters measured included duration of catheter
SC
drainage, presence of concurrent infections, contact precautions status, hospital location and reason of catheter placement, surgical procedures performed with operative times,
M AN U
antibiotic use prior to UTI, history of prior hospitalization, catheterization or UTI, and history of neuropathic bladder, constipation, or genitourinary anomalies. For CAUTI patients, duration of catheter drainage was counted from the day of catheter placement until the day of the UTI, whereas for control patients, the duration of catheter drainage
TE D
was the time of placement to the time of removal. Positive contact precautions status was defined as a patient who was flagged as having a prior infection with Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococcus, extended spectrum
EP
beta-lactamase-producing organisms, inducible beta-lactamase-producing organisms, or Clostridium difficile prior to the time of the UTI for cases or matched hospitalization for
AC C
controls. If a patient was cleared of the positive status prior to the hospitalization of interest, he/she was not considered positive for contact precautions status. Airborne precautions were not considered in our analysis. Prior catheterization was defined as one that occurred not necessarily during the hospitalization in question.
ACCEPTED MANUSCRIPT
Statistical analysis was performed using SPSS version 22 (SPSS Inc, Chicago, IL). The cohort and controls were paired as triplets (1:2) and were compared by using conditional logistic regression to preserve the case-control matching. A conditional multivariate
RI PT
logistical regression model was created using significant variables identified by
univariate analyses. A less conservative p (p < 0.1) was used for inclusion in multivariate analyses using forward selection. For all analyses, a p value of 200 beats/minute. The WBC count at the time of CAUTI diagnosis was in the hospital reference range for leukocytosis in 15 patients (30%) with a mean of
AC C
11.7x103/µL. Urinalysis findings were generally consistent with UTI, with 31 of 40 (78%) positive for leukocyte esterase, pyuria or both (Figure 1). Urinary pathogens seen in CAUTI patients varied (Figure 2). Fourteen of 50 patients (28%) demonstrated resistances of 3 or more organisms. All patients received antibiotics for their CAUTI for an average of 8.8 days, with 42 patients (78%) receiving intravenous antibiotics. Complications occurred in 5 of 50 (10%) patients; four occurred in the ICU comprised of
ACCEPTED MANUSCRIPT
pyelonephritis (1), sepsis (2), and death (1), and one floor patient required surgical intervention (1).
RI PT
In univariate analyses, compared to control patients, CAUTI patients were more likely to have catheters in place for a longer period of time at a mean difference of 2.9 days
(p=0.02) (Table 1). The odds of UTI increased by 8% for each additional day that the
SC
catheter remained in place. CAUTI patients were also more likely to be on contact
precautions (p=0.001) and had more overall concurrent infections (p=0.005). Specifically
M AN U
the rate of concurrent respiratory infections was higher in CAUTI patients (p=0.005). Interestingly, contact precautions were only weakly correlated to concurrent infections (r = 0.3). CAUTI patients were also more likely to have a history of prior catheterization (p=0.002). Hospital location of catheter placement did not appear to have an influence on
TE D
acquiring a CAUTI. The reason for catheter placement also did not affect rates of CAUTI except for urine output measurement that was more prevalent in CAUTI patients compared to controls. Of note, the apparent discrepancy in numbers of surgical
EP
procedures as the reason for catheterization (n=21 CAUTI and n=52 non-CAUTI patients) and the overall surgical procedures (n=25 CAUTI and n=59 non-CAUTI
AC C
patients) is due to the fact that not all patients who had a surgical procedure had a catheter placed for that reason. Surgical procedure and surgical times did not have an influence on acquiring a CAUTI with the exception of a decreased risk of CAUTI occurring in neurosurgical procedures (p=0.02). The odds ratio (OR) for history of prior hospitalization and neuropathic bladder were 2.00 (95% CI 0.94, 4.27, p=0.07) and 2.54 (95% CI 0.91, 7.06, p=0.07), but did not meet statistical significance. Presence of
ACCEPTED MANUSCRIPT
genitourinary anomalies that could increase the risk of UTI did not have an effect on CAUTI rates (Table 1).
RI PT
Using a conditional multivariate regression analysis, the three most predictive variables for acquiring a CAUTI were duration of catheter drainage (adjusted OR 1.09, 95% CI
1.02, 1.17), contact precautions status (adjusted OR 3.33, 95% CI 1.33, 8.35), and history
SC
of prior catheterization (adjusted OR 3.13, 95% CI 1.41, 6.96).
M AN U
DISCUSSION
Although there is a mounting emphasis on minimizing the risk for CAUTI in the pediatric population, only a few descriptive, epidemiological studies on pediatric CAUTI have been conducted.6, 7 Furthermore, according to a recent meta-analysis of pediatric
TE D
healthcare-related infections, only 1 of 84 studies explored the risk factors for CAUTI.8 In this retrospective study, Matlow et al evaluated 25 CAUTI patients admitted to the PICU to all PICU admissions during a 19-month period and found that previous heart
EP
surgery was the only risk factor for the infection.9 No other studies have been identified
AC C
to date regarding risk factors for CAUTI in pediatric patients.
In our study, the three most predictive variables for acquiring a CAUTI were duration of catheterization, positive contact precautions status, and prior history of catheterization in multivariate analysis. This observation of increased risk of CAUTI with prior catheterization is consistent with the fact that colonization of the urethra persists after catheter removal10 and may serve as a nidus for re-infection upon catheter placement due
ACCEPTED MANUSCRIPT
to the disruption of the urothelium and exposure of new binding sites for bacterial adhesins.11
RI PT
The duration of catheterization appeared to be contributing additively to the odds of the occurrence of CAUTI, with an 8% increase in odds for each consecutive day that the
catheter was left in place. This data is consistent with the adult studies revealing a 3 to
SC
7% risk of bacteriuria for each additional day that the catheter is left in place12 and the increased risk of CAUTI associated with increased duration of catheterization.13
M AN U
Decreasing the length of time that indwelling catheters remain in place is a major component of every quality-improvement initiative aimed at reducing pediatric CAUTI, and our findings support this intervention.
TE D
Additionally, patients on contact precautions were more likely to develop a CAUTI in our study. This finding is interesting as patients with a history of contact precautions may represent a select population who has sustained a shift in their microbiome that facilitates
EP
an increased risk of UTI, as well as a demonstrated history of prior exposure to the healthcare system. The CDC recognizes impaired immunity as a risk factor for CAUTI in
AC C
adults5, and it may be feasible that in some pediatric patients, multiple hospitalizations with a predisposition for positive contact precautions status may indicate a chronically ill, immunocompromised child. As an independent risk factor, prior hospitalization approached, but did not reach, significance, demonstrating that contact precautions may signify more than a marker of prior hospitalization. The majority of the organisms necessitating patient isolation were not the causative agent of the CAUTI. This suggests
ACCEPTED MANUSCRIPT
that contact precautions status confers a risk of CAUTI that is distinct from mere infectious dissemination.
RI PT
In univariate analysis, our data showed an increased risk associated with a concomitant
respiratory infection. Unlike patients on isolation precaution, patients with concurrently occurring non-genitourinary infections more frequently had the same pathogen cause
SC
both the non-genitourinary infection and the CAUTI itself. This pathogenic overlap occurred in 6 of 25 (24%) of patients with concurrent infections suggesting a likely
M AN U
multimodal effect of concurrent infection, both as a direct pathogen and as a marker (or cause) of compromised host immunity.
Although we found no difference in CAUTI risk depending on the hospital location of
TE D
catheter placement, our data showed a statistically significantly lower risk of CAUTI in patients undergoing neurologic surgery. This difference may possibly be due to the extreme sterile barrier precautions exercised during those procedures. Similarly adult
EP
CAUTI data has shown a protective effect of catheter placement within the operating suites (compared to other locations), likely linked to augmented barrier precautions.14
AC C
However, it is important to note that a subsequent prospective trial attempting to elucidate the protective effect of aseptic (gown and sterile gloves) versus nonsterile/clean technique (hand washing, non-sterile gloves) within surgical suites revealed no difference in risk of catheter-associated bacteriuria in the adult population.15
ACCEPTED MANUSCRIPT
Currently, the evidence-based risk factors for adult CAUTI established by the CDC include prolonged catheterization, female sex, older age, and impaired immunity.16 Overall, our data appear to reflect many of the findings previously reported in adult
RI PT
CAUTI literature: namely, the profound importance of minimizing the length of
catheterization. This well-established risk factor has led to the inclusion of daily review of catheter necessity with early-as-possible removal of catheters in almost every CAUTI
SC
quality improvement initiative.17 By demonstrating this effect in the pediatric population, we can provide evidence for the emphasis on early catheter removal in all pediatric
M AN U
patients. Furthermore, additional precautionary measures may be warranted for the at-risk pediatric groups: specifically, those with a history of contact isolations and prior catheterization. Antibiotic-impregnated catheters have been shown to potentially reduce UTI rates;18 more importantly, a Cochrane review noted that clean intermittent
TE D
catheterization (CIC), in select populations, demonstrates a decreased risk of UTI compared with indwelling catheters.19
EP
A particular strength of this study is that cases and controls were prospectively identified by trained infection control professionals using a standard definition. This method
AC C
insured that all patients with CAUTI were identified, thereby providing a complete cohort and helping minimize the selection bias of the control group inherent to retrospective studies. Furthermore, a common difficulty in studying CAUTI is the lack of uniformity in defining CAUTI events.20 In our hospital, the CDC criteria were employed, minimizing the risk of inconsistent data collection and misclassification bias. Other study strengths
ACCEPTED MANUSCRIPT
included controlling for confounding by matching controls by age, gender, date and location of CAUTI.
RI PT
A limitation of this study is its retrospective design. Even though the database from
which the patients were identified was prospectively maintained, the chart review was
conducted in a retrospective fashion. Due to this limitation, it was difficult to evaluate the
SC
true numbers of prior hospitalizations, catheterizations, and UTIs especially if patients sought their care at alternative institutions or with their primary care doctor. Although
M AN U
CAUTI patients were found to have fever and positive urine cultures with presumed CAUTI, it is not clearly certain these patients had true UTIs as opposed to incidental bacteriuria with fever due to other sources. However by matching patients to hospital location of UTI, we aimed to control for the confounding factor of severity of illness and
TE D
risk of concurrent infection from ICU status. Finally, matching by age, gender, date and hospital location of UTI for the control group prevented us from studying the effects of
EP
those variables on CAUTI – a risk that may very well exist within this population.
CONCLUSION
AC C
CAUTI have, to date, been poorly categorized on the pediatric population, making evidence-based interventions difficult. Our findings of the risk associated with length of catheterization, history of contact precautions, and prior catheterization are important in identifying high-risk groups. By stratifying patients into higher-risk categories for CAUTI, healthcare providers may begin implementing targeted interventions such as the
ACCEPTED MANUSCRIPT
use of CIC, increased vigilance, and decreased duration of catheterization for these
AC C
EP
TE D
M AN U
SC
RI PT
patients.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
REFERENCES 1. Fink, R., Gilmartin, H., Richard, A. et al.: Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals. Am J Infect Control, 40: 715, 2012 2. Meddings, J. A., Reichert, H., Rogers, M. A. et al.: Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med, 157: 305, 2012 3. Rebmann, T., Greene, L. R.: Preventing catheter-associated urinary tract infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide. Am J Infect Control, 38: 644, 2010 4. Davis, K. F., Colebaugh, A. M., Eithun, B. L. et al.: Reducing catheter-associated urinary tract infections: a quality-improvement initiative. Pediatrics, 134: e857, 2014 5. CDC: Catheter-associated urinary tract infection (CAUTI) event: Centers for Disease Control and Prevention, vol. 2014, 2014 6. Langley, J. M., Hanakowski, M., Leblanc, J. C.: Unique epidemiology of nosocomial urinary tract infection in children. Am J Infect Control, 29: 94, 2001 7. Davies, H. D., Jones, E. L., Sheng, R. Y. et al.: Nosocomial urinary tract infections at a pediatric hospital. Pediatr Infect Dis J, 11: 349, 1992 8. Mello, M. J., Albuquerque Mde, F., Lacerda, H. R. et al.: Risk factors for healthcare-associated infection in pediatric intensive care units: a systematic review. Cad Saude Publica, 25 Suppl 3: S373, 2009 9. Matlow, A. G., Wray, R. D., Cox, P. N.: Nosocomial urinary tract infections in children in a pediatric intensive care unit: a follow-up after 10 years. Pediatr Crit Care Med, 4: 74, 2003 10. Hartstein, A. I., Garber, S. B., Ward, T. T. et al.: Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients. Infect Control, 2: 380, 1981 11. Jacobsen, S. M., Stickler, D. J., Mobley, H. L. et al.: Complicated catheterassociated urinary tract infections due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev, 21: 26, 2008 12. Lo, E., Nicolle, L. E., Coffin, S. E. et al.: Strategies to prevent catheterassociated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol, 35 Suppl 2: S32, 2014 13. Crouzet, J., Bertrand, X., Venier, A. G. et al.: Control of the duration of urinary catheterization: impact on catheter-associated urinary tract infection. J Hosp Infect, 67: 253, 2007 14. Shapiro, M., Simchen, E., Izraeli, S. et al.: A multivariate analysis of risk factors for acquiring bacteriuria in patients with indwelling urinary catheters for longer than 24 hours. Infect Control, 5: 525, 1984
ACCEPTED MANUSCRIPT
18.
19.
AC C
EP
TE D
20.
RI PT
17.
SC
16.
Carapeti, E. A., Andrews, S. M., Bentley, P. G.: Randomised study of sterile versus non-sterile urethral catheterisation. Ann R Coll Surg Engl, 78: 59, 1996 Gould, C. V., Umscheid, C. A., Agarwal, R. K. et al.: Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol, 31: 319, 2010 Meddings, J., Rogers, M. A., Krein, S. L. et al.: Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf, 23: 277, 2014 Pickard, R., Lam, T., MacLennan, G. et al.: Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring shortterm catheterisation in hospital: a multicentre randomised controlled trial. Lancet, 380: 1927, 2012 Jamison, J., Maguire, S., McCann, J.: Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders. Cochrane Database Syst Rev, 11: CD004375, 2013 AUA-Staff: AUA White Paper on CATHETER-ASSOCIATED URINARY TRACT INFECTIONS: DEFINITIONS AND SIGNIFICANCE IN THE UROLOGIC PATIENT, 2014
M AN U
15.
ACCEPTED MANUSCRIPT
P-value
1.11 (0.60 to 2.07) N/A 1.08 (1.01 to 1.15)
0.74 0.02
0.62 (0.30 to 1.31) 1.36 (0.54 to 3.40) 1.06 (0.48 to 2.31) 0.03 (0.00 to 601.02) -
0.21 0.52 0.89 0.47 -
SC
RI PT
Odds ratio (95% CI)
0.62 (0.30 to 1.31) 2.34 (1.03 to 5.29) 0.78 (0.33 to 1.84) 0.02 (0.00 to 19.97) 0.66 (0.32 to 1.38) 0.40 (0.05 to 3.42) 0.21 (0.06 to 0.74) 2.24 (0.79 to 6.34) 0.77 (0.11 to 4.48) 0.53 (0.11 to 2.53) 0.67 (0.69 to 6.41)
0.21 0.04 0.57 0.26 0.27 0.40 0.02 0.13 0.77 0.43 0.67
1.00 (0.99 to 1.00)
0.20
4.00 (1.73 to 9.26) 3.04 (1.39 to 6.28) 3.21 (1.42 to 7.26) 1.33 (0.23 to 7.98) 0.63 (0.25 to 1.58) 2.00 (0.94 to 4.27) 3.24 (1.55 to 6.77) 1.91 (0.73 to 4.98) 2.54 (0.91 to 7.06) 1.42 (0.73 to 2.80)
0.001 0.005 0.005 0.75 0.32 0.07 0.002 0.19 0.07 0.30
6.00 (0.62 to 57.68) 3.35 (0.59 to 18.88) 4.00 (0.36 to 44.11)
0.11 0.17 0.26
AC C
EP
TE D
M AN U
Table 1. Risk factors for CAUTI from univariate analysis. CAUTI Non-CAUTI patients patients (n=50) (n=100) Mean age (years) 6.8±6.1 6.8±6.0 Gender M:F 2:3 2:3 Mean length of catheter (days) 7.4±7.9 4.4±5.2 Location of catheter placement Operating room 21 (42%) 52 (52%) Emergency room 8 (16%) 12 (12%) ICU 18 (36%) 31 (31%) Floor 2 (4%) 5 (5%) Unknown 1 (2%) 0 (0%) Reason for catheter placement Surgical procedure 21 (42%) 52 (52%) Urine output measure 17 (34%) 19 (19%) Intubation 9 (18%) 22 (22%) Urinary retention 0 (0%) 7 (7%) Trauma 2 (4%) 0 (0%) Hematuria 1 (2%) 0 (0%) Surgical procedures 25 (50%) 59 (59%) General 2 (4%) 5 (5%) Neurosurgery 2 (4%) 15 (15%) Orthopedics/spine 12 (24%) 15 (15%) Otolaryngology/oral maxillofacial 2 (4%) 6 (6%) Cardiothoracic or vascular 6 (12%) 15 (15%) Urology 1 (2%) 3 (3%) Mean length of surgical 295.5±224.6 301.6±140.3 procedures (minutes) Contact precautions/isolation 21 (42%) 14 (14%) Concurrent infection 25 (50%) 27 (27%) Respiratory 22 (44%) 24 (24%) Blood 2 (4%) 2 (2%) Respiratory and blood 1 (2%) 1 (1%) Antibiotic use prior to UTI 42 (84%) 90 (90%) Prior hospitalization 39 (78%) 63 (63%) Prior catheterization 26 (52%) 25 (25%) Prior UTI 10 (20%) 12 (12%) History of neuropathic bladder 13 (26%) 15 (15%) History of constipation 21 (42%) 35 (35%) Genitourinary anomalies with increased risk of UTI Hydronephrosis 3 (6%) 1 (1%) Vesicoureteral reflux 4 (8%) 3 (3%) Posterior urethral valve 2 (4%) 1 (1%) Urolithiasis 2 (4%) 1 (1%) Data presented as mean ± standard deviation
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
Figure 1. Urinalysis findings in patients with CAUTI (n=50).
AC C
EP
TE D
Figure 2. Pie graph demonstrating pathogens causing CAUTI (n=50). Colony counts ranged from 50,000 to >100,000 CFU/HPF.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
CAUTI – catheter-associated urinary tract infection CDC – Centers for Disease Control and Prevention CIC – intermittent catheterization ICU – intensive care unit MRSA – Methicillin-resistant Staphylococcus aureus OR – odds ratio PICU – pediatric intensive care unit UTI – urinary tract infection WBC – white blood cell
RI PT
Abbreviations: