The prevention of hospital-acquired urinary tract infection.

Received 2 October 2007; accepted 4 October 2007; electronically published 4 December 2007. Reprints or correspondence: Dr. Lindsay E. Nicolle, Dept. of Internal Medicine and Medical Microbiology, University of Manitoba, Health Sciences Centre, Rm. GG443, 820 Sherbrook St., Winnipeg, MB R3A 1R9, Canada (lnicolle@hsc.mb.ca). Clinical Infectious Diseases 2008; 46:251–3 2007 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2008/4602-0014$15.00 DOI: 10.1086/524663 The prevention of hospital-acquired infection has recently received increased prominence as infection rates have been propelled into the spotlight of mandated public reporting, together with expectations of “getting to zero” as the benchmark for infection incidence. These revolutionary initiatives were initially directed toward surgical site infection, ventilator-associated pneumonia, and bloodstream infection. The fourth leg of the tetrad of major hospital-acquired infections—urinary tract infection—has received relatively little attention. This neglect seems exceptional, because urinary infection is the single most common hospital-acquired infection [1]. Health care–acquired urinary infection is a substantial burden for patients and the health care system [1]. They constitute 40% of all hospital-acquired infections, and fully 80% of these infections are attributable to indwelling urethral catheter use. Twelve percent to 16% of hospital inpatients will have an indwelling catheter placed at some time during hospitalization. While the catheter remains in situ, 3%–7% of patients will acquire a urinary infection each day. Catheter-associated bacteriuria has harmful outcomes beyond infection, including catheter or stent obstruction caused by biofilm formation, which usually requires removal and reinsertion of the device [2] and provision of an environmental reservoir for drugresistant organisms, which may be transferred between patients, occasionally causing outbreaks [3–5]; and life-threatening complications, such as bacteremia and sepsis syndrome [6]. There are also adverse effects of urethral catheters unrelated to infection, such as trauma to the bladder and urethral mucosa, immobility and discomfort for patients, and reactions to catheter materials, including hypersensitivity reactions to latex or inflammatory responses leading to urethral strictures [7–9]. The national survey reported by Saint et al. [10] suggests that many American hospitals are not paying attention to the substantial problems attributable to indwelling urethral catheter use. The insertion of a urethral catheter is an invasive procedure with negative consequences for patient safety, yet less than one-half of hospitals responding to the survey monitored whether patients had a urinary catheter in place. Only one-quarter of facilities documented the duration of catheterization. The most important strategies for prevention of catheter-related urinary infection are to avoid insertion of a catheter and, if a catheter must be used, to limit the duration to as short a time as possible. It is remarkable that so few facilities measure this risk exposure. The survey also reports no consistent approach in the use of other potential preventive strategies, such as use of antimicrobial-coated catheters, catheter reminders, or bladder scanners. Although the majority of hospitals reported that they had some program for surveillance for urinary infection, the methods used and the perceived efficacies are not addressed. The report also does not discuss the adherence of facilities to the Centers for Disease Control and Prevention’s guidelines for preventing health care–acquired urinary infection. Why is there this apparent neglect of programs to prevent adverse effects attributable to the urethral catheter, given that use of such catheters is a common intervention with well-documented negative outcomes? Several considerations are likely relevant. There is limited morbidity attributable to hospital-acquired urinary tract infection relative to that reported for surgical site infections, pneumonia, and bacteremia [11]. Death directly attributable to hospital-acquired urinary tract infection is also uncommon. Catheteracquired urinary infection is usually asymptomatic; if symptomatic infection occurs, treatment is generally straightforward. In addition, the estimated costs of hospital-acquired urinary tract infection are markedly lower than those for the other major health care–associated infections [12]. Thus, health care professionals