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Healthcare Associated Urinary Tract Infection Epidemiology And Pathogenesis. Cheng- Hua Huang, M.D. Vice-superintendent Cathay General Hospital. Definition of HAI-UTI. Asymptomatic UTI: bacteriuria/funguria + no constitutional symptoms

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healthcare associated urinary tract infection epidemiology and pathogenesis

Healthcare AssociatedUrinary Tract InfectionEpidemiology And Pathogenesis

Cheng-Hua Huang, M.D.


Cathay General Hospital

definition of hai uti
Definition of HAI-UTI
  • Asymptomatic UTI: bacteriuria/funguria + no constitutional symptoms
  • The presence of bacteria/fungi in the urine does not always imply infection or a clinically significant condition
  • HAI-UTI: indicating clinical, histologic or immunologic evidence of infection
pyuria vs bacteriuria
Pyuria vs Bacteriuria
  • Musher:100% of u/c >100000 CFU/ml with presence of pyuria
  • Musher: presence of pyuria in catheterized p’t, 30% U/C (-)
  • Intermittent cathetherized p’t (ICP) pyuria with 100% U/C >100000/ml
  • Tambyah: short-term catheterized

p’t :37% each pyuria vs Bacteriuria

infection vs colonization
Infection vs Colonization
  • Bacteriuria is present in almost all p’t with prolonged catheterization
  • The usual symptoms of dysuria, hesitancy, urgency are not seen in catheterized p’t
  • Fever, leukocytosis may also be caused by non-infectious conditions
  • Only 30% (2-4 days short-term catheterized) with presence of constitutional S/S
hai uti
  • HAI-UTI: 30-45% of total nosocomial infections
  • 80-85% HAI-UTI related to the use of urethral catheter
  • 5-10% caused by other genito-urethral procedures
important events on hai uti
Important Events on HAI-UTI
  • 1927: Frederick E. Foley: invested a retention balloon on indwelling catheter (control bleeding after prostate surgery)
  • 1950: Cuthbert Dukes: closed drainage system for better infection control (70-85% of UTI are preventable)
  • 1960s: Calvin Kunin stated the important issue of infection control
hai uti1
  • In US, 600,000 p’ts annually and occupy 15% of total hospital infection cost
  • Bacteriuria occur in 1-5% after single brief catheterization
  • Bacteriuria: 100% in indwelling catheter, no closed drainage< 4 days
  • 3-10%/ day of catheterized indwelling with closed drainage system(U/C +)
inappropriated bladder catheterization
Inappropriated Bladder Catheterization
  • 28% of physicians were not aware of bladder indwelling catheter
  • 41% of bladder catheter judged inappropriately
  • 69% of bladder catheter only for incontinence p’ts (31.7% by Dr and 37.3% by RN)
pathogenesis of hai uti
Pathogenesis of HAI-UTI
  • Role of the catheter
  • Bacterial factors
  • Pathways of infection
  • Host factor
  • Normal non-catheterized urethra and bladder with good defense function (epithelial cell)
  • Each urinations clears 99.9% of existed bladder organisms
  • Tamm-Horsfall protein and oligoSaccharide will bind the organism and suspended in urine
  • Bladder mucosa with bactericidal effect
  • Glycocalix/ Biofilm helps the bacteria survive
routes of infection in catheter associated uti 1 through insertion 2 intraluminal 3 extraluminal
Routes of Infection in Catheter Associated UTI:1 Through Insertion2 Intraluminal 3 Extraluminal
route of entry
Route of Entry
  • Tambyah: intra-luminal entry(23%)
  • Tambyah: extra-luminal route (34%)
  • Garibaldi et al : peri-urethral colonization

(GNB/ Enterococci) →UTI (18%);non-colonized(5%)

  • Removal of catheter with remain risk for 24 hours
indications of indwelling catheter
Indications of Indwelling Catheter
  • Acute urine retention/ outlet obstruction
  • For accurate measurement of urine output in critically ill p’t
  • Peri-operative use for selected surgery(uro, prolonged surgical time, or large amount of blood or fluid replacement)
  • To assist in healing of open wound at perineal region in incontinent p’t
  • P’t requires for prolonged immobilization
  • Others
inappropriate uses of indwelling catheter
Inappropriate Uses of Indwelling Catheter
  • As a substitute for nursing care for incontinent elderly
  • As a means of obtaining urine for culture or diagnosis need on p’t can voluntarily void.
  • For prolonged post-operation duration to recovery
alternatives for indwelling catheter
Alternatives for Indwelling Catheter
  • External catheter on non-retention or bladder outlet no obstruction
  • Intermittent catheterization (clean) in spinal cord injury
  • Frequent change of absorbed diaper and perineal hygiene care plan
risk factors for hai uti
Risk Factors for HAI-UTI
  • ↑ duration of use (catheter days)
  • Female gender
  • Delay recognized of systemic infection
  • DM/ Renal insufficiency
  • Advanced age
  • Severity of underlying disease
  • Meatal colonization(peri-urethral) (72% in female; 30% in male)
tnis uti1
therapeutic plans
Therapeutic Plans
  • Host risk-factor consideration
  • Microbiologic factors
  • Clinical essential data
  • Recognizing situation where the usual treatment may be inappropriate
  • Trend of antimicrobial resistanceand D.Dx colonization or infection
treatment goals
Treatment Goals
  • Draumatic reduce or eradicate pathogenic strains
  • Limit the extent and severity of HAI-UTI
  • Minimize alterations in normal flora(↓superinfection of candida and MDROs
  • ↑ hour urine amount 80-100ml/hr for washing out the organism and non-obstructionly
antimicrobial therapy in hai uti
Antimicrobial Therapy in HAI-UTI
  • Most authorities believe that antibiotics to postpone bacteriuria are not indicated, but exception on specific p’ts (renal transplant and febrile neutropenia)
  • Indication for HAI-UTI with antibiotics is a subject of debate and controversy but also is virtually universal
  • Routine therapy for culture is not only cost-waste but also increasing adverse reaction and selective of MDROs
mortality related to hai uti
Mortality Related to HAI-UTI
  • Uncertain, but <10% Bacteremia from pre-existence of HAI-UTI
  • 0.3-3.9% total HAI-UTI may progress into sepsis and /or mortality
  • Transient Bacteremia (6.5%) may occur after bladder catheterization, or removal of catheter (within 24 hours)