_______________________________________________________________ Healthcare-Associated Infections
The NHSN survey in 2013 found the rate of catheter-associated urinary tract infections to be 7.4 to 11.5 infections per 1,000 catheter-days [147]. Catheter-associated urinary tract infections account for approximately 40% of all HAIs annually, with 75% to 80% of these attributable to indwelling urethral catheters [148]. The most recent NHSN survey observed a significant reduction (11%) in catheter-associated urinary tract infections in 2023, compared with 2022 [4; 17]. This improvement has been attributed in part to a reduction in urinary catheter use and to the implementation of a Comprehensive Unit Based Safety Program (focused on prevention of urinary infection) in 603 US hospitals between 2011 and 2013 [4]. As discussed, the COVID-19 pandemic affected the rate of HAIs across U.S. healthcare institutions. For example, data from acute care hospitals for 2023 indicate a 24% overall increase in catheter- associated urinary tract infections, with ICUs experiencing a 16% increase [17]. Risk Factors The duration of catheterization is the most important risk fac- tor for infection [32]. Studies have shown that catheterization for more than 2 days is a significant risk factor for urinary tract infection as well as increased 30-day mortality [149]. Other risk factors for catheter-related urinary tract infection include no treatment with systemic antimicrobial agents, positive results on culture of the urethral meatus, microbial colonization of the urinary drainage bag, insertion of the catheter outside the operating room, and nonadherence to guidelines for appro- priate catheter care. Patient-related risk factors include female gender, older age, diabetes, and an elevated level of serum creatinine at the time of catheterization [32]. Transmission and Common Pathogens Urinary tract infections can be caused by both endogenous and exogenous transmission. Normal flora from the gastrointestinal tract can spread to the urinary tract, or pathogens can be trans- mitted by caregivers carrying out tasks related to the catheter or drainage bag. Occasionally, pathogens are transmitted through urologic equipment that has not been adequately disinfected. Extraluminal ascension of bacteria along the catheter-urethral mucosa interface is the most common pathway of infection, accounting for approximately two-thirds of infections [32]. According to NHSN data for 2018–2021, the pathogens most commonly isolated from catheter-related urinary tract infec- tions are E. coli (33.5%), followed by Klebsiella spp. (24.5%), P. aeruginosa (13.4%), and Enterococcus species (12.4%) [146]. Infections related to short-term catheterization is usually caused by a single agent, whereas infections related to long-term cath- eterization (30 days or more) is typically caused by multiple pathogens. P. mirabilis , Morganella morganii , and P. stuartii are additional common pathogens in infections related to long- term catheterization [32].
With regard to antimicrobial-resistant pathogens, the percent- age of S. aureus infections resistant to oxacillins increased in 2018–2021 (45.5% vs. 41% in 2015–2017) [146]. The percent- age of Enterococcus faecium resistant to vancomycin increased, to 89.1% (from 82% in 2015–2017), as did the percentage of vancomycin-resistant E. faecalis (approximately 91.5% vs 12% in 2015–2017). The prevalence of multidrug-resistance among P. aeruginosa was 94.5% in 2018–2021 [146]. Prevention The principles of care required for prevention of catheter- associated urinary tract infection are well established: appro- priate use, sterile catheter placement, maintenance of a closed drainage system, avoidance of back-flow, and minimal duration of catheter insertion. In addition to these technical aspects, a systems approach that standardizes care, educates, and fosters an interprofessional culture of attentiveness is also necessary for optimal preventive care [23; 150]. The evidence-based guidelines for prevention of catheter- associated urinary tract infections were published by the CDC in 2009 ( Table 8 ). The IDSA has published evidence-based clinical practice guidelines on the prevention, diagnosis, and treatment of catheter-associated urinary tract infections in 2010 [23; 32]. According to both guidelines, the most impor- tant principles for prevention are:
• Limit the use of indwelling urinary catheters. • Use aseptic technique and sterile equipment when inserting a catheter. • Secure the catheter properly. • Use a closed sterile drainage system. • Maintain unobstructed urine flow. • Remove the catheter as soon as feasible.
As with prevention of all HAIs, handwashing is an essential ele- ment of aseptic technique and care of patients with catheters. In addition, healthcare staff should be educated and trained in proper techniques of catheter insertion and care. Alternatives to indwelling catheters have been evaluated as an approach to preventing catheter-related urinary tract infections. The IDSA guidelines note that a suprapubic catheter may be considered as an alternative to short-term catheterization (level III, C), but use of this type of catheter is limited because an invasive procedure is needed for insertion [32]. Intermittent catheterization may also be considered as an alternative to short-term (level I, C) or long-term (level III, A) catheteriza- tion, and, for men who have minimal postvoid residual urine, condom catheterization can be considered as an alternative to short-term (level II, A) or long-term (level II, B) catheterization in those who are not cognitively impaired [32]. The use of catheters coated with an antimicrobial surface has been evaluated, especially those coated with silver, a highly effective antibacterial substance. In one study, the addition of silver did not reduce the incidence of bacteriuria
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