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
 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
 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
 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 noninfectious 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
 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-UTI
 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
 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
 Role of the catheter
 Bacterial factors
 Pathways of infection
 Host factor
Pathogenesis
 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
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
 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
 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
 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
 ↑ 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)
CGH醫療照護相關感染微生物排名-UTI
排
98年度
名
99年度
100年度
1
E. coli
E. coli
E. coli
2
Fungi
P. aeruginosa
Fungi
3
P. aeruginosa
Fungi
P. aeruginosa
4
K. pneumoniae
K. pneumoniae
K. pneumoniae
5
E. faecalis
E. faecalis
E. faecalis
CGH加護單位醫療照護相關感染微生物排名-UTI
排
98年度
名
99年度
100年度
1
Fungi
E. coli
E. coli
2
E. coli
Fungi
Fungi
3
K. pneumoniae
S. marcescens
P. aeruginosa
4
P. aeruginosa
K. pneumoniae
E. faecalis
5
E. faecalis
E. faecalis
K. pneumoniae
TNIS(醫中)加護單位醫療照護相關感染微生物排名 -UTI
排
98年度
名
99年度
1
Fungi
Fungi
2
E. coli
E. coli
3
P. aeruginosa
P. aeruginosa
4
K. pneumoniae
K. pneumoniae
5
A. baumannii
A. baumannii
100年度
TNIS(區域）加護單位醫療照護相關感染微生物排名-UTI
排
98年度
名
99年度
1
Fungi
Fungi
2
E. coli
E. coli
3
K. pneumoniae
K. pneumoniae
4
P. aeruginosa
P. aeruginosa
5
A. baumannii
A. baumannii
100年度
E.coli
S%
98 98
100
89
80
79
82 82 80 80 81
93 91
86
60
85
83 82 82
80 81
86 84 85
2001年
75
74
64
89
95
2003年
67
2005年
52
2007年
43
40
2009年
24
2011年
20
0
GM
CF
CIP
CXM
CTX
抗生素
K.pneumoniae
S%
100
99
92
94
92 91 92
95 95
89
85
80
80
93 91
90
95
93
88
89
95
91 90 90
89
84 83 84
83
79
2001年
77
2003年
69
2005年
60
2007年
2009年
40
2011年
20
0
抗生素
GM
CF
CIP
CXM
CTX
E.cloacae
S%
100
80
95 96
93
91
88 90
92 92
95
2001年
90
78 79 79
78 78
2003年
76
72 72
2005年
66
58
60
61
53
2007年
51
44
2009年
40
2011年
17
20
12 11
7
3
6
0
GM
CF
CIP
CXM
CTX
抗生素
Ps.aeruginosa
S%
100
98 98
97 98 96
95
93
90 90 9190 90
96 97 95
94
92 92
97
94
97
91
99
99
97
95
92
89
87 8886
83 83
90
2001年
78
76
80
2003年
2005年
60
2007年
40
2009年
2011年
20
0
IPM
CIP
CAZ
ATM
FEP
LVX
抗生素
A.baumannii
S%
100
95
97
93
91 91
80
78
76
73
62
64 65 65
68
65
63
58
60
70
69
68
2001年
77
72 73
68
70
2003年
66
60
55
53
52
53
2007年
39
40
2005年
2009年
26
23
20
2011年
11 12
5
0
IPM
CIP
CAZ
ATM
FEP
LVX
抗生素
S.aureus
S%
100
100100
100100
100
100
9190
83
80
100
100100
100100
100
81
77
84
2001年
76
72
73
70
69
60
2003年
2005年
5354
43
2007年
39
40
34
35
2009年
2011年
20
3
5
3
5 4
1
0
SXT
E
P
CIP
VA
TEC
抗生素
S.pneumoniae
S%
100
100
100
98
100100100
100100100
100100
94
80
2001年
2003年
60
55
2005年
2007年
46
42
40
36
35
35
32
29
26
2009年
3130
29
25
26
2011年
21
16
20
7
3
0
SXT
E
P
CIP
VA
TEC
抗生素
GAS
S%
10010099 100100100
98
100
95
98 99
100100100100100100
96 97
93
90
2001年
83
80
2003年
61
2005年
60
2007年
2009年
40
21 22
20
2011年
23
9
0
SXT
E
P
CIP
VA
抗生素
GBS
S%
10010010099100100
100
95 95
98
100100100100100100
92
2001年
81
78
80
75
2003年
77
67 66
2005年
60
2007年
2009年
40
2011年
20
18
9
7
9
0
抗生素
SXT
E
P
CIP
VA
E.faecalis
S%
100
95
100100100 100
98
96
97 96 96
100100100
92
85
82
81
80
77
71
78
2001年
70
2003年
61
60
2005年
2007年
2009年
40
31
29
26
2011年
27
23
20
11 11
9
0
抗生素
SXT
E
P
CIP
VA
TEC
E.faecium
S%
100
100
96
100
100100
95
92
89
2001年
83
80
2003年
74
70
63
63
62
60
46
36
40
2007年
46
41
38
40
2009年
34
3029
23
20
2005年
53
2011年
22
17
14
6
3
0
SXT
E
P
CIP
VA
TEC
抗生素
2008年 ~ 2011年ESBL 比較(1)--數量
數量(株)
400
350
339
350
312
300
2008年
282
250
2009年
200
2010年
150
126 131
100
2011年
86
77
50
6
0
E.coli
K. pneumoniae
10 13
4
K. oxytoca
ESBL菌株
2008 ~ 2011 ESBL 比較(2)--百分比
百分比
25%
21.31%
2008年
20%
2009年
15%
2010年
11.32%
2011年
10.99%
10%
8.03%
6.90%
6.76% 6.72%
5.58%
5.94%
5.70% 5.72%
4.59%
5%
0%
E.coli
K. pneumoniae
K. oxytoca
ESBL菌株
ESBL
菌株
E.coli
Klebsiella pneumoniae
Klebsiella oxytoca
平均
年度
數量
ESBL
百分比
2584
97
ESBL
百分比
1105
339
6.76%
數量
126
5.70%
1105
35
2491
1057
43
350
6.72%
131
5.72%
2719
1233
48
2527
955
46
99
282
5.58%
86
4.59%
2523
920
15
2232
669
30
100
312
8.03%
1655
19165
77
5.94%
627
1283
6.69%
7671
ESBL
百分比
6
11.32%
6.47%
10
10.99%
6.47%
13
21.31%
5.45%
4
6.90%
7.50%
33
12.55%
6.47%
18
2434
98
平均
數量
28
420
5.48%
263
Therapeutic Plans
 Host risk-factor consideration
 Microbiologic factors
 Clinical essential data
 Recognizing situation where the usual treatment
may be inappropriate
 Trend of antimicrobial resistance and D.Dx
colonization or infection
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
 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
 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)