_______________________________________________________________ Healthcare-Associated Infections
when compared with silicone-based, hydrogel-coated urinary catheters with and without silver impregnation [151]. One meta-analysis (12 trials; 13,392 patients or catheters) showed that antimicrobial-coated catheters prevented or delayed the onset of bacteriuria in select patients, but the magnitude of the effect varied substantially according to several variables, including catheter type and publication year [152]. A subse- quent systematic review (eight studies) found a favorable trend toward a lower rate of infection with silver alloy (vs uncoated) catheters, but the quality of some studies was poor and there was significant heterogeneity among the studies [153]. Coating urinary catheters with synthesized silver nanoparticles using green chemistry is an area of research showing promise in inhib- iting microbial migration and biofilm formation [154; 155]. The 2009 CDC guidelines state that antimicrobial/antiseptic- impregnated catheters can be considered if the rate of catheter- associated urinary tract infections does not decrease after a comprehensive prevention strategy has been implemented [23]. The guidelines add that further research is needed to determine the effect of these catheters in reducing the risk of symptomatic infection, their inclusion among the primary interventions, and the patient populations most likely to benefit from them [23]. Similarly, the IDSA states that catheters coated with an antimi- crobial surface may be considered to reduce the risk of infection for patients who are to have short-term catheterization (level II, B), but notes that the data on the effectiveness of this strategy are insufficient [32]. The IDSA guidelines note several prevention strategies that should not be used routinely, primarily because of insufficient data [32]: • Systemic antimicrobials in patients with short-term (level III, A) or long-term (level II, A) catheterization • Antimicrobials or antiseptics added to the drainage bag (level I, A) • Catheter irrigation with antimicrobials (level II, A) or normal saline (level II, B) • Enhanced meatal care (level I, A) • Cranberry products • Methenamine salts (although prophylaxis with
The IDSA notes that catheter-associated urinary tract infection is defined by the presence of signs or symptoms compatible with a urinary tract infection with no other identified source, and at least one bacterial species at a count of ≥10 3 cfu/mL in one urine specimen (level III, A) [32]. This threshold dif- fers from that defined by the CDC (≥10 5 cfu/mL), which is intended for infection control surveillance rather than detec- tion of infection in an individual patient [129]. In addition, the 2009 CDC guidelines define the criteria for symptomatic catheter-associated urinary tract infection as symptoms plus a positive urine culture at the threshold of ≥10 5 cfu/mL; if the urine culture result is between ≥10 3 and ≤10 5 cfu/mL, a posi- tive urinalysis is needed to meet the diagnostic criteria [23].
According to the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), signs and symptoms compatible with catheter associated-urinary tract infection include new onset or worsening
of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness. (https://academic.oup.com/cid/article/50/5/625/ 324341. Last accessed January 26, 2025.) Strength of Recommendation/Level of Evidence : AIII (Good evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees) Urine specimens for culture should not be obtained from the drainage bag; instead, a sample should be taken through the catheter port with use of aseptic technique [32]. If there is no port, a needle and syringe can be used to puncture the cath- eter tubing and collect the specimen [32]. For patients with a long-term indwelling catheter, the IDSA recommends replacing the catheter and collecting the specimen from the newly placed catheter [32]. Signs and symptoms suggestive of catheter-associated urinary tract infections include fever (new or worsening), flank pain, hematuria, pelvic discomfort, altered mental status, and malaise or lethargy not attributable to another cause; among patients without a current indwelling catheter, dysuria, urgency, and frequent urination are other symptoms [32]. However, studies have shown that the classic symptoms of urinary tract infection are uncommon among patients with a catheter-associated infection [32]. Pyuria is not diagnostic of catheter-associated urinary tract infection in patients with an indwelling catheter [32]. Asymptomatic bacteriuria is defined as the presence of signifi- cant bacteriuria with no signs or symptoms referable to the urinary tract [32].
methenamine salts may be considered after gynecologic surgery for women who have a catheter for less than 1 week) (level 1, C)
Diagnosis The CDC and the IDSA classify catheter-associated urinary tract infections as symptomatic urinary tract infection, asymp- tomatic bacteriuria, or other infection of the urinary tract. Urine samples for urinalysis and quantitative urine culture (using a clean catch technique or catheterization) are necessary for accurate diagnosis [32; 129].
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