CATHETER ASSOCIATED URINARY TRACT INFECTION IN THE INTENSIVE

CARE UNIT: INCIDENCE, RISK FACTORS AND MICROBIOLOGIC PROFILE.

A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA, IN PART FULFILMENT OF THE REQUIREMENT FOR

THE AWARD OF FELLOWSHIP OF THE COLLEGE IN ANAESTHESIA.

BY

NWACHUKWU, MARTHA UGOCHI.

MBBS (NIG.) 1991.

i

DEDICATION

This dissertation is dedicated to the Almighty God who makes all things beautiful in His time. It

is also dedicated to my Lord and Saviour Jesus Christ, who ransomed me with His Precious

Blood.

iv

ACKNOWLEDGEMENT

I heartily wish to appreciate my project supervisors: Dr H. A. Ezike, Dr Ajuzieogu Obinna and

Dr (Mrs) Onyeka Tonia for their encouragement, support and painstaking efforts in guiding the

various aspects of this research work and proof-reading the manuscripts with admirable

promptness.

My gratitude also goes to the other consultant Anaesthetists who read through and made

necessary corrections in the work especially Drs Onyekwulu F. and Amucheazi A. I also wish to

appreciate Dr. P. Ufoegbunam who counseled me on the choice of research topic and provided

me with appropriate impetus for this work.

I am indebted to the resident doctors who assisted in the collection of some of the samples

especially Dr Solomon Akponye, who rendered this assistance as a friend indeed. I appreciate the

Medical Laboratory Scientists in both microbiology laboratories of the tertiary institutions where

I carried out my investigations for their understanding in receiving urine samples even at call

hours.

Finally, I wish to thank immensely, my husband Dr. Nwachukwu, E.N. and children - Daniel,

David and Deborah for their patience, understanding, love, care and many prayers while this

work persisted. May the good Lord reward you all for your sacrifice and labour of love on my

behalf.

v

TABLE OF CONTENTS

Title Page

Title page i

Declaration page ii

Attestation page iii

Dedication iv

Acknowledgement v

Table of contents vi

List of tables viii

List of figures ix

List of Abbreviations x

Summary 1

Chapter 1: Introduction 3

Aims and Objectives 6

Chapter 2: Literature Review 7

Chapter 3: Patients, Materials and Methods 18

Chapter 4: Results 23

Tables 26

Figures 30

Chapter 5 Discussion 36

vi

Conclusions 44

Recommendations 46

Limitations of the study 47

References 48

Appendices 57

Appendix I : Data collection form 57

Appendix 11: Patient informed consent 60

Appendix 111: UNTH Ethics Committee approval 62

Appendix 1V: FMC Ethics Committee approval 63

Appendix V: Registration of dissertation 64

vi

LIST OF TABLES

Table Title Page

Table1. Distribution of duration of admission/catheterization with CAUTI status 26

Table II .Antibiotic sensitivity pattern of bacterial isolates 27

Table III. Antibiotic resistant pattern of bacterial isolates 28

Table IV. Distribution of ICU fomites with their isolated organisms. 29

vii

LIST OF FIGURES

Figure Title Page

Figure1. Incidence of Catheter Associated Urinary Tract Infection 30

Figure2. Age group distribution of patients with their CAUTI status 31

Figure3. Gender distribution of patients with their CAUTI status 32

Figure4. Distribution of patients with comorbidities and CAUTI status 33

Figure 5.Clinical specialty distribution of subjects and CAUTI status 34

Figure 6.Distribution of various microbial isolates 35

viii

LIST OF ABBREVIATIONS

ABUTI -Asymptomatic bacteremia urinary tract infection

ASB- Asymptomatic bacteriuria

BMI- Body Mass Index

CAUTI-Catheter -Associated Urinary Tract Infection

CDC- Centre for Disease Control.

CFU- Colony Forming Unit

CONS- Coagulase Negative Staphylococcus.

CVP-Central Venous Pressure.

DA-HAI Device–Associated Hospital Acquired Infection.

ECG-Electrocardiography.

E coli- Escherichia coli.

EEG- Electroencephalography.

E R-Emergency Room.

FMC- Federal Medical Centre.

HAI-Hospital Acquired Infection.

HDU- High Dependency Unit.

HIV- Human Immunodeficiency Virus.

ICU-Intensive Care Unit.

ix

INICC- International Nosocomial Infection Control Consortium.

IUC-Indwelling Urethral Catheter

KISS-The Hospital Infection Surveillance.(German)

MRSA- Methicillin Resistant Staphylococcal Aureus

NHSN- NationalHealthcare Safety Network.

OR- Operating Room.

P aeruginosa- Pseudomonas aeruginosa

SPSS- Statistical Package for Social Sciences

SUTI- Symptomatic Urinary Tract Infection.

UCH- University College Hospital.

UICP- Universal Infection Control Precautions

UNTH- University of Nigeria Teaching Hospital.

USA-United States of America.

UTI- Urinary Tract Infection.

VRE- Vancomycin Resistant Enterococcus.

x

SUMMARY

Patients in the intensive care units often require the insertion of various invasive devices such as

peripheral venous lines, urinary catheters and tracheal tubes for therapy and monitoring. These

devices predispose them to a high risk of acquiring nosocomial infections. Catheter-associated

urinary tract infection (CAUTI) is one of the commonest types of hospital-acquired infection

(HAI) in the ICU, and increases cost, morbidity and mortality. This prospective observational

study was aimed at determining the incidence of catheter- associated urinary tract infection with

its risk factors and microbiologic profile among critically ill patients in two Intensive care units

in South East Nigeria. The study was conducted over a seven -month period in the Intensive

Care Units of University of Nigeria Teaching Hospital (UNTH) Ituku Ozalla , Enugu State and

Federal Medical Centre(FMC), Umuahia, Abia State. Both hospitals have four- bedded ICUs but

UNTH also has a four-bedded High Dependency Unit (HDU). Patients admitted into these ICUs

with indwelling urinary catheters inserted in the Emergency room(ER), Operating Room (OR) or

ICU who met the inclusion criteria were enrolled for the study.

The first catheter urine sample was collected aseptically from each patient and sent for

microscopy, culture and sensitivity (mcs) to ascertain the baseline urine status. The patients

whose base line samples had microbial growth were excluded as the study was aimed at UTI

acquired in the ICU. A total of ninety six patients were enrolled, 26 patients either had microbial

growth in their first samples or demised before the collection of the second sample and had to be

excluded from the study. Seventy patients concluded the study. A total of 25 (35.71%) of the 70

subjects had microbial growth in their second or third sample giving an incidence of 36%.Four

(13.79%) of 29 whose duration of admission/catheterization was 48 hours to 72 hours had

CAUTI, while 21(51.22%) of 41 whose duration of admission was up to 5-7days had CAUTI.

Twenty eight (28) organisms were isolated and include Candida species, 12(42.87);

Staphylococcus aureus, 4(14.29);Klebsiella species,3(10.71%); Escherichia coli 2(7.14%); others

7(25.00%). The bacterial isolates were mostly susceptible to Nitrofurantoin. The organisms

showed a high resistance to the antibiotics tested.

1

The most predominant organism grown from ICU fomites was Staphylococcus aureus and the

fomite most affected was the suction machine. This study showed a high incidence of CAUTI in

ICU with duration of admission /catheterization as the only statistically significant risk factor. It

also confirmed the presence of pathogens on ICU fomites which could be continuous sources of

cross-infection affecting both patients and health care givers. Institution guidelines for the care

and monitoring of urethral catheterization are therefore desirable and urinary catheters should be

removed once they are no longer needed. Nitrofurantoin can be used for the empirical treatment

of UTI in our environment while awaiting urine microscopy, culture and sensitivity results.

2

CHAPTER ONE

INTRODUCTION

The Intensive Care Unit (ICU) is an area of the hospital where facilities are concentrated for

treatment of critically ill patients1.The purpose of the ICU is to provide a level of care

unattainable in other areas of the hospital for patients suffering an acute illness from which they

have a realistic chance of recovery. In addition to nursing care, observation and monitoring, the

patient may also require mechanical ventilation and cardiovascular support. In some centres,

separate ICUs exist for specialized fields of medicine such as coronary care, neurosurgery,

paediatrics, and transplant surgery. However in the majority of hospitals, as obtainable in the

developing countries, a general ICU deals with critically ill patients from various specialties.1

Nosocomial infections, also called health care acquired or health care-associated infections

(HAI) is defined by the Centre for Disease Control (CDC) as a localized or systemic condition

resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) without

any evidence that the infection was present or incubating at the time of admission to the acute

care setting.2 Patients admitted into the ICU are especially susceptible to nosocomial infections

in view of the significant risk factors such as the use of invasive devices like central venous

catheterization, urethral catheterization, mechanical ventilation; stress ulcer prophylaxis, and

increased ICU stay.3-6 Nosocomial infections result in increased morbidity and mortality,

prolonged hospital stay and increased medical expenses.1

Hourly measurement of urine output is a routine procedure for the critically ill patient, the

amount of urine formed each hour being an indicator of the fluid status and renal function and a

reduction in the volume to less than a critical value is a matter of concern.7 An adequate urine

flow should be more than 500mls/24 hours per m2 or more than 20mls/hour/m2. Accurate hourly

measurements of urine output is therefore essential for evaluation of fluid status and renal

perfusion.7 The indwelling urethral catheter is passed to enable this urine monitoring. The

presence of an indwelling urethral catheter is often complicated by catheter-associated urinary

tract infection.

3

Catheter-Associated Urinary Tract Infection (CAUTI) is urinary tract infection in a patient who

had an indwelling urinary catheter (IUC) in place at the time of or within 48 hours prior to

infection onset.8 Catheter associated urinary tract infection complicates 14 -100% of all catheters

passed depending on the duration of use.9 They account for 32% of all health care associated

infections in the intensive care units in the United States of America9 and has been associated

with a three-fold increased risk for mortality in hospital-based studies with estimates of more

than 50,000 excess deaths occurring per year in the United State of America(USA) as a result of

these infections.10 Chukwuocha in Owerri, South East of Nigeria found a prevalence of 44% of

bacteriuria among catheterized patients in various hospital wards11. In a study conducted at the

University College Hospital (UCH) Ibadan, Western Nigeria, CAUTI accounted for 43.96% of

HAI.12 Rosenthal et al. in a study of 55 ICUs in 8 developing countries discovered that CAUTI

was responsible for 29% of device-associated nosocomial infections, giving prevalence of

4.2%.13 Catheter-associated urinary tract infection can lead to such complications as cystitis,

pyelonephritis, gram negative bacteriuria, prostatitis, epididimytis and orchitis in the male;

endocarditis, vertebral osteomyelitis, septic arthritis, endolphthalmitis, and meningitis in all

patients14.These complications associated with CAUTI cause discomfort to the patient,

prolonged hospital stay, increased cost and mortality.14The daily rate of bacteriuria in

catheterized patients increases by about 5% with the incidence directly related to the duration of

catheterization.15 Among the patients with bacteriuria, 10 to 25% will develop symptoms of

urinary tract infection such as suprapubic or loin pain16. Bacteraemia results from catheter-

related bacteriuria in approximately 3% of patients and invariably represents a serious

complication.15 Risk factors for acquiring CAUTI include, duration of catheterization, female

sex (because of the short and wide urethra and its proximity to the anus), extended ICU stay,

colonization of the drainage bag, diarrhea, diabetes mellitus, renal insufficiency and errors in

catheter care.15The predominant organisms causing CAUTI in ICU are enteric gram negative

bacilli, enterococci, pseudomonas aeruginosa and Candida species.16

4

ICU treatment is quite expensive both in the developed and developing countries of the world.

Okafor estimated the daily ICU cost in Eastern Nigeria at about $85 (about 13,000 naira).17 The

cost is further increased when there is an added burden of CAUTI which is reasonably

preventable. Estimates from one university hospital in Kuwait based on data for almost twenty

years showed that CAUTI led to approximately $204,000 in additional expenses per year,18

despite their importance, there have been very few studies focused on CAUTI in the critically ill.

No study has been done evaluating CAUTI in the Intensive care unit in South Eastern Nigeria.

This study therefore, was aimed at determining the incidence and risk factors associated with

CAUTI and the microbiologic profile with their sensitivity pattern in the ICUs of two tertiary

health care facilities in South Eastern Nigeria.

5

AIMS AND OBJECTIVES

AIM:

The aim of this prospective study was to determine the incidence of Catheter- Associated

Urinary Tract Infection (CAUTI), the risk factors and microbiologic profile among critically ill

patients on admission in two Intensive Care Units (ICUs) in South East of Nigeria.

SPECIFIC OBJECTIVES:

The specific objectives were the following:

1. To determine the incidence of CAUTI in the ICU.

2. To determine the risk factors associated with CAUTI in the ICU.

3. To determine the microbiologic profile of CAUTI in the ICU.

4. To determine the antibiotic sensitivity pattern of CAUTI in the ICU.

5. To determine the resident microorganisms in the ICU.

6

CHAPTER TWO

LITERATURE REVIEW

Definition of Catheter Associated Urinary Tract Infection (CAUTI)

Urinary tract infection (UTI) is an inflammatory response to the colonization of the urinary tract,

(which may involve the bladder (cystitis), renal pelvis (pyelitis),or renal parenchyma

(pyelonephritis)) from a bacteria or fungal pathogen.19 Catheter-associated urinary tract infection

(CAUTI) is urinary tract infection in a patient who had an indwelling urinary catheter in place at

the time of or within 48 hours prior to onset of infection.8 An ICU- acquired UTI was defined

using a modification of the criteria of Costel 20and colleagues as those patients with a positive

urine culture (at least 105colony forming units/ml(cfu/ml) of one or two organisms first identified

on ICU day 3 (48 hours) or later.20 Patients with positive urine culture within 48 hours of ICU

discharge were also considered to have ICU-acquired UTIs. Asymptomatic bacteriuria is the

isolation of a specified quantitative count of bacteria in an appropriately collected urine

specimen obtained from an individual without symptoms and signs of UTI.21Acute

uncomplicated UTI is a symptomatic bladder infection characterized by frequency, urgency,

dysuria, or suprapubic pain in a woman with normal genitourinary tract and is associated with

both genetic and behavioral determinants.22 Uncomplicated urinary tract infections rarely occur

in men and urinary infection in men is usually considered complicated.22 Pyuria is the presence

of increased numbers of polymorph nuclear leucocytes in the urine and is evidence of an

inflammatory response in the urinary tract23

Epidemiology of Catheter-Associated Urinary Tract Infection

Prevalence and Incidence

Device-Associated Hospital Acquired Infection (DA-HAI) rates in the ICU of countries with

limited resources are 3-5 times higher than rates in the high-income countries as reported from

hospitals by International Nosocomial Infections Control Consortium (INICC).24

7

In a prospective study conducted in an adult surgical ICU of a tertiary University Hospital in

Lebanon, incidence of CAUTI was 13.07 per 1000 urinary catheter days which was about ten-

fold higher than the US rate of 1.5 CAUTI rate per 1000 urinary catheter days determined by the

CDC/NHSN25and 2.5CAUTI rate determined by KISS.26 Prevalence of asymptomatic bacteriuria

in patients with short-term urethral catheterization is 9-23%, while that for long term

catheterization is 100 %.27

Daily risk of developing CAUTI is 3-7% in acute hospital settings.28Abaeze in Abeokuta,

Western Nigeria in a cross-sectional study with 200 catheterized patients, in a tertiary health

institution, found an incidence of CAUTI as 40%29 This rate was quite high compared to what

was obtainable in developed countries as the United States where a surveillance study of CAUTI

in the ICUs gave incidences of 3.1-7.4 per 1000 catheter days.30Abaeze however, attributed the

high incidence to the possibility of non-observance of sterile precautions during catheterization

and technical errors by health care givers. The mode of collection of the samples was not

mentioned as samples collected from the drainage bag will yield a higher incidence and health

care givers involved in urethral catheterization are usually trained and are aware that it is a sterile

procedure. This high incidence could also be as a result of the non-ICU location of the patients as

catheter care is not optimal on the general wards. The study also failed to mention the cut off for

significant bacteriuria as the incidence will be lower if ≥105 is used as against ≥103. They were

also silent on their criteria for diagnosis (symptomatic or asymptomatic or both. Karina et al.31

in a prospective study of medical patients in both ICU and non ICU wards, also recorded a very

high incidence (51.4%) in the Philippines General Hospital31.This high incidence could have

been as a result of a lower (≥103) cut-off for significant bacteriuria used in this study, though

their criterion for using that was based on some recommendations that for complicated UTI as in

catheterized patients, levels below 103 can be representative of true infection. The researchers

failed to mention if their result included both symptomatic and asymptomatic cases. However,

Alavaren et al.28 studying in the same region,-the Philippines, among 178 non-ICU medical and

surgical adult patients, also using ≥103as the value for significant bacteriuria, had a lower

incidence of 24.7%. This is probably because they excluded patients with confirmed UTI and

their study was conducted on non-critically ill patients, as infection rates are higher among the

critically ill. 8

Indranil Bagchi et al.32 studying 220 adult patients without recent history of UTI in both medical

and surgical wards and ICUs in a tertiary health facility in Maharashtra India found an incidence

of 29.09% which is slightly higher than Alavaren’s result.28 They also excluded patients with

recent UTI showing that excluding patients with UTI from the study, can reduce the incidence of

CAUTI. Duo-shuang33in a cohort study in the ICU in China, found an incidence rate for CAUTI

as 15.8. This rate is lower than others cited 28,29,31,32 probably because it is an ICU-specific study

as ICU patients although critically ill, usually attract better nursing care including better urinary

catheter care as patient to nurse ratio is smaller.

Pathogenesis

Urinary tract infection is inflammatory responses to the colonization of the urinary tract from a

bacterial or fungal pathogen.19 Most bacteria causing CAUTI gain access to the urinary tract

either extraluminally or intraluminally.34 Extra luminal contamination may occur during

insertion from contamination of the catheter from any source. It is also thought to occur when the

microorganisms ascend from the perineum along the surface of the catheter. It is commoner in

women because of the shorter length of the urethra and its proximity to the anus.35 Intraluminal

contamination occurs by ascent of bacteria from a contaminated catheter drainage tube or urine

drainage bag.36 There are three main catheter-associated entry points for bacteria.(1)The urethral

meatus, with the introduction of bacteria during insertion of the catheter.(2)The junction

(connection) of the catheter with the drainage bag especially when a break in the close catheter

system occurs and (3)the drainage port of the collection. All these mechanisms involved in the

pathogenesis of colonization and infection of the urinary tract combine to make CAUTI very

difficult to prevent in patients with indwelling catheter in place for more than two weeks.

Catheter-associated bacteriuria may be symptomatic or asymptomatic. 20-30% of patients with

bacteriuria will present with symptoms of CAUTI.37-38

Most CAUTI involve multiple organisms and resistant bacteria from catheter-associated

biofilms, and include enterobacteriaciae other than E coli, (e.g. klebsiella, enterobacter, proteus

and citrobacter), pseudomonas aeruginosa, enterococci, staphylococci and Candida.

9

The infecting organism depends on the hospital unit35. The predominant organisms causing

CAUTI in ICU are the enteric gram-negative bacilli, enterococci, Candida species and P.

aeruginosa.35 Candiduria is especially common in individuals on broad spectrum antibiotic

therapy,35 because of increased use of antibiotics, resistant microorganisms particularly

Pseudomonas aeruginosa and Candida albicans are too frequently involved in device- associated

nosocomial infections35.

Broad spectrum antibiotic use is likely to contribute to colonization by candida species by

suppressing endogenous bacterial flora, primarily in the gut and lower genital tract and possibly

in the superficial area adjacent to the urethral meatus. It may interfere with phagocyte function

and antibody formation with subsequent impaired host defense mechanism against candida

infections.39-41 Candiduria is increasingly becoming an important subgroup of nosocomial UTI

(10-15%) and almost all are caused by candida albicans.40-42The prevalence varies in hospital

settings and is most prevalent among patients in the Intensive care units, more especially surgical

ICU, leukaemia and bone marrow transport units.43,44 Previous studies showed that the common

risk factors were urinary tract instrumentation, previous surgical procedures, recent use of

antibiotics, advanced age, female sex, diabetes mellitus, immunosuppressive therapy and

prolonged hospital stay.40,42-44,46-48 In a recent case controlled study, it was shown that the risk

factor to develop candiduria was increased by 12-fold after urinary catheterization, six fold each

after use of broad spectrum antibiotics and presence of urinary tract abnormalities, four-fold

following abdominal surgeries, two-fold in the presence of diabetes mellitus and one-fold with

the use of corticosteroids.39The study found no significant difference between the groups

compared in terms of female sex and age.39

Catheter -Associated Biofilms

Catheters are a good medium for bacterial growth because once they gain access to the urinary

tract, bacteria produce various adhesions including hair-like fimbrae that allow them to attach

firmly to the catheter wall. These bacteria up-regulate their expression of certain genes resulting

in altered phenotypes that ultimately lead to biofilms (living layers of organisms).49

10

Urine contains protein that adheres to and primes the catheter surface. Microorganisms bind this

protein layer and attach to the surface. Such bacteria are different from fleeting planktonic

bacteria (bacteria that float in urine). Indwelling urinary catheter biofilms may initially be

comprised of a single organism, but can lead to multiorganism biofilms because the presence of

biofilms inhibits antimicrobial activity.49 The presence of urinary catheter biofilms has important

implications for antimicrobial resistance, diagnosis, prevention and treatment of CA-UTIs.49

Clinical Presentation of CAUTI

From the Centre for Disease Control Criteria, CAUTI may present as symptomatic urinary tract

infection (SUTI) or Asymptomatic Bacteriuria (ASB).24-25 SUTI must meet the following

criteria; 1. Patient had an indwelling urinary catheter in place at the time of specimen collection,

or onset of symptoms and signs and at least one of the following signs or symptoms with no

other recognized cause. Fever (>380C), suprapubic tenderness, costovertebral angle pain or

tenderness and positive urine culture of ≥105 colony forming units (cfu)/ml with no more than

two species of organisms, or patient had an indwelling urinary catheter removed within 48 hours

prior to urine collection or onset of symptoms and at least one of the following signs or

symptoms with no other recognized cause; fever (>380C), urgency, frequency, dysuria,

suprapubic tenderness, costovertebral angle pain or tenderness. A positive urine culture of ≥ 103

and<105 colony forming units (cfu)/ml with >2 species of microorganisms.24-25

Asymptomatic Bacteremic UTI (ABUTI):Patient with an indwelling urinary catheter or had one

in ICU in the past 48 hours with no symptom but has a positive urine culture >105 cfu/ml with

not more than two species of uropathogenic organisms and a positive blood culture with at least

one matching uropathogen microorganism to urine culture.24

11

Risk Factors

Various studies have identified the significant risk factors for CAUTI as being, the female

gender,35prolonged duration of catheterization29and prolonged duration of ICU

admission.29Alavaren et al28 in their study identified risk factors, as open drainage system,

prolonged catheterization and daily meatal care. In this study, open drainage system was used in

31.5% while closed drainage was used in 68.5%. Bacteriuria was present in 88.5% of those on

open drainage by the 3rd day and 100% on the 6th day, while among those with closed drainage

system, only 38% had bacteriuria on the 6th day of catheterization. Daily meatal care and

application of antimicrobial ointments and solutions theoretically should prevent or delay onset

of infection. This study showed that bacteriuria was higher in patients with daily meatal care

compared to those without catheter care. This could have resulted from the fact that mobilization

of catheter during catheter care irritates the bladder mucosa there by encouraging

microorganisms to ascend and invade the mucosal epithelium and proliferate50. The average

daily incidence of bacteriuria was 9.5%. This increasing incidence of bacteriuria with increasing

duration was valid up to the 6th day of catheterization beyond which 100% of the patients had

bacteriuria. Ekrem Temiz51 in Zongudal Kaemas University Hospital found that immune

suppression, previous antibiotic usage and the presence of other site nosocomial infection were

risk factors for acquiring CAUTI. In the absence of other site infection, the female gender and

duration of catheterization were the risk factors for CAUTI alone. Karina Billote Domingo31 in

the Philippines studying both ICU and non-ICU medical patients with indwelling Foley catheters

inserted within 24 hours (in the emergency room) of admission found duration of catheterization,

the female gender and diabetes mellitus as unalterable risk factors for CAUTI. In their study,

bacteriuria developed at an average of 4.1 days. After two days of catheterization, 20.6% of the

patients had acquired CAUTI, 36% after 4 days and 46.7% after 7days. Duration of

catheterization was the most significant risk factor. Increasing duration of catheterization

increases the likelihood of microbes ascending to the bladder either via the intra or extra luminal

route. The female gender probably because of the anatomy was the next risk factor leading to

easier access of the perineal flora to the bladder along the catheter as it traverses the shorter

female urethra. 12

Diabetes mellitus was the third risk factor.Diabetics are at an increased risk of acquiring

infections because of increased prevalence of perineal colonization by potential pathogens and an

increased ability of the urine to support microbial growth31. Indranil Bagchi et al32 in their study

found increasing age, female gender, diabetes mellitus and duration of catheterization as risk

factors for CAUTI in ICU. This study revealed that maximum incidence occurred in people

above 75 years of age with an incidence of 66.67%( 2 out of 3) while the minimum incidence

was found in the age group 18-25 years with an incidence of 11.76% (2 out of 17).In the same

study, CAUTI occurred in 36 out of 105 females (34.29%) while the incidence in males was

24.35% (28 out of 115) showing that females were more vulnerable to acquiring CAUTI than

males as already indicated. The study also found that out of the 64 cases of CAUTI, 10 (15.63%)

were detected on the third day, 22 (34.38%) within 5 days and 32 (50%) within 7 days. The 50%

incidence on the 7th day is close to Domingo’s 46.7% on the same day in their study31. Indranil’s

study40 also showed that 14 (21.88%) out of the 64 cases of CAUTI recorded were diabetic

patients. In that same study,only 10 diabetic patients were free from CAUTI showing that

diabetes mellitus predisposes a patient to developing CAUTI.

Microorganisms involved in Catheter associated urinary tract infection.

Abaeze et al29 in Abeokuta, Western Nigeria and Indranil et al32 in India, in their various studies

isolated E coli as the commonest organism causing CAUTI both in ICU and non ICU settings

while Taiwo et al52 in Osogbo, Western Nigeria and Mahshid53in Iran found Klebsiella species as

the commonest organisms causing CAUTI. Mindy et al 54 in Singapore and Duo-shuang33 in

China isolated Candida species as the commonest organisms in their independent studies.

Abaeze et al29 in their study with 200 patient samples showed that 82 (41%) yielded bacterial

growth while 118 (59%) were sterile. 29(37.37%) of the isolates were E coli, 17(20.73%) were

Klebsiella Pneumoniae, 13(15.85%) were Staphylococcus aureus, 10(12.2%) were Pseudomonas

aeruginosa, 8(9.75%) were Proteus mirabilis while 5(6.1%) were Candida albicans. The

commonest organisms in this study were enterobacteriaceae group (E. coli and Klebsiella) which

are organisms in the bowel and may have ascended into the urinary tract following

contamination.

13

The most sensitive drug was ofloxacin with a sensitivity of 52.9% for Klebsiella pneumonia and

13.8% for E coli. Gentamycin was the next sensitive drug with a sensitivity of 41.17% for

Klebsiella and 13.79% for E coli. Augmentin had the highest (41.17%) sensitivity for E coli, the

commonest organism and 12.5% for Proteus mirabilis probably because these drugs are not

easily abused. The commonly used antibiotics (Cotrimoxazole and Amoxycillin) had 100%

resistance likely because of inappropriate uses and abuse. In Indranil’s study32 of 200 adult

patients in the ICU in Maharashtra India, 64 patients developed CAUTI with 66 isolates. 72.73%

were caused by gram negative bacilli, 16.67% by gram positive cocci, and 10.6% by fungal,

23(34.85%) were caused by E coli, 13(19.7%) by Klebsiella, 8(12.2%) by

Pseudomonas,7(10.6%) by Candida, 4(6.06%) by Enterococcus, 4(6.06%) by CONS, 2(3.03%)

by Citrobacteria and Proteus. In this study, all gram negative isolates were sensitive to

Imipenem, E coli and pseudomonas species showed maximum sensitivity to Piperacillin and

Tazobactam. Klebsiella showed maximum sensitivity to Ceftazidime. All gram positive isolates

were sensitive to Vancomycin. CONS, Staphylococcus aureus and enterococcus species showed

maximum sensitivity towards Linezolidine and Ciprofloxacin. Both groups of isolates showed

the least sensitivity to Ampicillin likely because the common antibiotics like Ampicillin are often

abused. In Taiwo’s study52 122 patient samples were studied out of which 108 had significant

bacteriuria with 126 microbial isolates. Klebsiella was the commonest organism isolated

46(36.6%), Pseudomonas was the next 34(27.0%), E. coli was the third 26(20.6), Staphylococcus

aureus 12(9.5%), Candida 4(3.2%).Many of these organisms are part of the patient’s endogenous

bowel flora, and some may have been acquired from cross contaminations from other patients or

the hands of health care givers. Isolating 126 organisms from 108 patient samples implies that

some infections were either monomicrobial or polymicrobial. The organisms were most sensitive

to Ciprofloxacin (83.3%) and Pefloxacin (66.7%) and exhibited multiple resistance to commonly

used antibiotics such as Ampicillin (100%), Gentamycin (90.9%), Tetracycline (89.9%),

Cotrimoxazole (87.3%). The emergence of multiresistant pathogens could be as a result of

prophylactic antibiotic use or abuse of commonly used antibiotics as all the patients were on

prophylactic antibiotic.

14

ICU Resident Organisms

Studies, 55,56 have shown that hospital surfaces and frequently used medical equipments become

contaminated by a variety of pathogenic and non-pathogenic organisms. In a study by Kramer et

al56 in which literature was systematically reviewed in Medline, cited articles were assessed and

standard text books on the topic were reviewed, they discovered that most gram positive bacteria

such as Enterococcus specie including Vancomycin Resistant Enterococcus (VRE),

Staphylococcus aureus including Methicillin Resistant Staph aureus (MRSA),and Streptococcus

pyogenes survive for months on dry surfaces. Many gram negative organisms such as E coli,

Klebsiella, Pseudomonas aeruginosa, Acinobacter, and Shigella specie can also survive for

months on dry surfaces. Candida albicans which is the most important nosocomial fungal

pathogen can survive for four months on surfaces. These imply that the most common

nosocomial pathogens can survive or persist for prolonged periods in hospital surfaces and

formites,56 thereby becoming continuous sources of infection transmission if no regular

preventive measure is applied.56 The mode of transmission from inanimate surfaces to

susceptible patients can be direct or indirect through the hand of the health care worker, but this

can be reduced to 50% through compliance with hand hygiene.56 Sung-on Teng and colleagues

in Taiwan determining the degree of bacterial contamination of patient’s files in the surgical ICU

and surgical ward and found that 90 % (81 out of 90) of charts in ICU and 72.2 %( 65 out of 90)

from surgical wards were contaminated with pathogenic or potential pathogenic bacteria

(p=0.0023).57 Coagulase negative staphylococci (CONS) were the most commonly isolated

bacteria both in surgical ICU( n=40, 44.44%) and surgical ward( n=48, 53.33%). Several

bacteria isolated from the chart had the same antibiogram as that isolated from the patient.57

Contaminated patients’ charts, can therefore serve as a source of cross infection. In surgical ICU,

Klebsiella pneumonia isolated from two of three charts was also isolated from corresponding

patients. Compliance with hand hygiene by health workers is critical to reducing this. Hand

washing remains the cornerstone of Infection control in the ICU.58 In a study conducted by

Tamberker58 in Amravati India, 400 swab samples were collected from the hands of 100 students

15

before and after hand washing and analyzed to see the effect of hand washing on

microbial flora of the hand. Prior to hand washing the hands of all the students were found to

harbor pathogens which include Staphylococcus species 23%, E coli 20%, Klebsiella 10%,

Micrococcus specie 9%, Proteus sp, Citrobacter and Streptococcus 7% each Enterobacter 6%,

Enterococcus 4%, Pseudomonas 3%, Salmonella species 2%. After hand washing there was 54%

reduction in microbial flora. Salmonella had 100% reduction, Staphylococcus 88%. E coli 59%,

Enterococcus 59%, Proteus 55%, Streptococcus 54%, Citrobacter 45% and Klebsiella 39%.This

indeed shows that compliance to hand washing by health care personnel reduces transmission of

nosocomial infections.

Infection Control in the Intensive Care Unit

Infection control is an application of scientific and epidemiological principles for infection

prevention and reduction. Hand washing, aseptic techniques and environment cleaning are

perhaps the most important infection control measures. Infection control programs have become

a requirement for hospital accreditation by the Joint Commission on Accreditation of Healthcare

Organizations59. The first formal US infection control hospital surveillance project initiated it as

a result of the 1950s Staphylococcus aureus pandemic. The Institute for Healthcare Initiatives

(IHI) is a not-for-profit organization reports how greater than 100,000 annual deaths can be

avoided by quality initiative infection control measures. Infection control consists of standard

precautions with or without transmission-based isolation precautions depending upon site/type of

infection. The infection control committee typically includes an infection control practitioner

(physician or nurse), trained ICU epidemiologist, and infectious disease or microbiology

specialist. The committee aims to develop infection control policies, educate hospital personnel,

provide wound-infection feedback to surgeons, and investigate suspected outbreaks. Standard

(universal) precautions are recommended for all hospitalized patients and consist of hand

hygiene and respiratory hygiene with cough etiquettes. This also includes safe disposal of

instruments and soiled linens. Hand hygiene, perhaps the most effective method for infection

control, can be done with 60-95% alcohol-based hand rub or soap.

16

Hand hygiene is recommended before clean/ aseptic procedures, before and after touching a

patient or patient surroundings, and after body fluid exposure.60 Infection control bundles

example, urinary catheter bundles can be used to reduce the incidence of CAUTI and this

includes;

Daily surveillance regarding further need of catheter

Proper securing of catheter on body

Maintenance of closed sterile drainage tubes

Aseptic techniques for obtaining urine samples

Meticulous Hand hygiene

Avoidance of prophylactic antibiotics and regular urine culture.

17

CHAPTER THREE

PATIENTS, MATERIALS AND METHODS

Study Locations

This study was conducted on critically ill patients admitted into the Intensive Care Units (ICUs)

of the University of Nigeria Teaching Hospital (UNTH), Ituku Ozalla, Enugu State and Federal

Medical Centre (FMC), Umuahia, Abia State. Both hospitals are tertiary health institutions with

multidisciplinary Intensive Care Units in the South East, Nigeria.

UNTH is a 450-bedded hospital in Enugu state serving Enugu, Anambra, Ebonyi, Abia, Imo and

some states in the South South zone of Nigeria. FMC Umuahia is a 304-bedded hospital in Abia

State and serves Abia, Imo, Ebonyi and Akwa Ibom States. Both hospitals have four-bedded

ICUs. UNTH in addition has a 4 bedded- high dependency unit to which patients are stepped-

down before they are discharged to the ward.

Ethical Clearance

Ethical clearance was obtained from Health Ethics Research Committees (HERC) of both

hospitals. Informed consent was obtained from the patients or relatives for the study. One

patient declined the collection of her third sample and was allowed to opt out.

Study Design

This was a prospective cross-sectional descriptive study in which patients who met the inclusion

criteria were included.

Sample Size Estimation

The sample size was calculated using the formula for determining the minimum sample size for

the prevalence rate of a condition in a population, assuming a confidence level of 95% and

degree of accuracy of 0.05.

18

The formula is as follows:

n=Z2 P (1-P)/d2

Where:

n= the desired sample size when the population is greater than 10,000.

z=1.96 (a standard normal deviate, usually set at 1.96, which corresponds to the 95% confidence

level).

P=the proportion in the target population estimated to have a particular characteristic. This is the

proportion of catheterized ICU patients estimated to have CAUTI. From a previous study carried

out in the ICU of 8 developing countries, the prevalence of CAUTI among critically ill patients

admitted into the ICU was 4.2%44. So P =4.2% was assumed ( i.e. 0.042).

1-P=1-0.042=0.958

d=0.05(degree of accuracy desired)

Therefore substituting the figures into the formula, the minimum sample size was n=Z2P (1-P)/d2

=1.962 x 0.042 x0.958/0.052 = 61.83 approximately 62. An attrition of 10% gave 6.18

approximately 6 giving a sample size of 68.

96 patients who met the inclusion criteria were initially enrolled into the study. 26 patients had to

be excluded as some of them demised while some had microbial growth in their first samples

leaving only 70.

Inclusion Criteria

Adult patients (18 years and above) admitted into the ICU with IUC inserted in the ICU or

elsewhere without signs and symptoms of UTI.

19

Exclusion Criteria

Paediatric patients (less than 18 years)

Patients with features of UTI prior to ICU admission as this was an incidence study based on

ICU- acquired infection.

Patients whose ICU admission was anticipated to be very brief (24 hours or less)

Patients with renal impairment.

Patients who demised before their second sample could be collected.

Procedure

A total of 96 patients were enrolled into the study. Twenty six (26) patients were excluded

while 70 were recruited. The researcher aseptically collected urine specimens from the

disinfected urinary catheter ports into sterile containers some of which contained boric acid (to

prevent multiplication of bacteria). The samples were sent to the microbiology laboratories for

microscopy, culture and sensitivity. The first sample was collected within 24 hours of ICU

admission from 96 patients. The second was collected at 48 to 72 hours (day 3-day 4) of

admission while the third sample was collected on day 5-7 of ICU admission. Only two samples

were collected from 29 patients while those from whom only baseline samples were collected

either because of their demise or presence of microbial growth were excluded from the study.

Forty one (41) patients also had their third samples collected on days 5-7 of ICU admission.

Patients discharged from the ICU before 72 hours of admission were followed up on the ward to

collect the second sample (as ICU- acquired CAUTI may still be incubating).

Urine specimen was cultured with the semi-quantitative method in the microbiology laboratories

of both hospitals. Significant bacteriuria was regarded as the growth of ≥103colony forming units

(cfu) /ml of urine. The results of full blood counts and blood culture of patients with evidence of

systemic infection (requested by the managing physicians) were reviewed to rule out bacteremia

though bacteremia was outside the scope of this study.

20

Swabs of regularly used equipments in the ICU (such as suction machines, mechanical

ventilators, patient’s monitors, beds and side tables) were also taken and sent for microscopy,

culture and sensitivity to determine the resident organisms in these ICUs. This was done twice

(in the first and last months) during data collection in both ICUs. A data collection form was

used to document the patient’s demographic characteristics and results of the investigations.

Statistical Analysis

Data were collected on forms specifically designed for the study. Data were presented in tables

expressed as mean (±SD) and figures (pie and bar charts). Statistical association was determined

using the Chi-square test for categorical variables and Student’s t-test for numerical variables. A

p-value of <0.05 was considered significant. Statistical analyses were performed using Statistical

Package for Social Sciences (SPSS) version 20, 2011.

Risk factors were determined with multinomial logistic regression analysis

21

CHAPTER FOUR

RESULTS

The baseline urine sample was collected from all 96 patients but only results of 70 patients were

analysed. The second samples were collected from the seventy recruited patients 48-72 hours of

ICU admission. Twenty nine (41.43%) of the 70 patients studied had only their second samples

collected 48 to 72 hours of ICU admission, while 41(58.57%) patients whose ICU admission

was longer also had their third samples collected on or after the 5th day (5-7 days) of ICU

admission. A total of 25 (35.71%) of the 70 patients recruited had microbial growth in their

samples giving a CAUTI incidence of 35.71%.

Table 1 shows the effect of duration of catheterization and admission on CAUTI status. In this

study, 29 of the 70 patients recruited exited after the collection of the second sample. Four

(13.73%) of the 29 patients developed CAUTI while 25(86.21%) did not. Twenty one (51.22%)

of the 41 patients whose third samples were collected were positive for CAUTI on or after the

fifth day of catheterization and admission while 20(48.75%) did not acquire CAUTI. The

incidence of CAUTI in this study was 35.71%. Duration of catheterization and admission was

the only statistically significant factor in this study with a p-value of 0.001 and x2 as 10.363.

Table II shows the antibiotic sensitivity pattern of isolated bacteria. Nitrofurantoin had the

highest sensitivity being sensitive to 11(68.75%) of 16 organisms, the quinolones were sensitive

to 6(37.50%) organisms while Augmentin and the cephalosporins were sensitive to 3(18.75%)

each. Imipenem was sensitive to only one (50%) of two organisms tested. Staphylococcus

aureus, E coli, Lactose fermenting organisms isolated were all susceptible to Nitrofurantoin

(100%). Klebsiella was only 33.3% sensitive to Nitrofurantoin, quinolones and Imipenem.

Table III shows the antibiotic resistant pattern of isolated bacteria. Staphylococcus aureus,

Klebsiella species and E coli were all 100% resistant to the Quinolones, Gentamicin and

Cephalosporins. They were also 75% and 100% each respectively to Augmentin. Pseudomonas

species were resistant to all the four antimicrobials tested. Fifteen (93.75%) of the sixteen

bacteria isolated were resistant to both Gentamycin and cephalosporins.

23

Eleven (68.50%) were resistant to Augmentin while 5(31.25%) were resistant to Nitrofurantoin.

All six organisms tested against the penicillins were resistant to them.

The isolated candida species were not tested against any antifungal drug for sensitivity and

resistance pattern.

Table IV shows various ICU fomites and the microorganisms isolated. A total of thirteen (13)

microorganisms were isolated: Staphylococcus aureus,7(53.85%);Klebsiella species,

2(15.39%);Staphylococcus epidermidis,1(7.69%); Coliform bacilli,1(7.69%); Proteus, 1(7.69%);

spore forming organism,1(7.69%).There was growth on six(60%) of the ten fomites. Three

fomites had mixed organisms while the other three had single organisms. Multiparameter

patients’ monitors had no growth on both cultures. Swabs from patients’ beds side tables and

suction machines showed microbial growth on both cultures. The ventilators and bedside tables

showed growth on one of the two swabs taken.

Figure 1 is a pie chart showing the incidence of catheter-associated urinary tract infection.

Twenty five (36%) of the 70 patients recruited had microbial growth while 45(64%) were free

from CAUTI.

Figure 2 is a bar chart representing the age group distribution of the patients with their CAUTI

status. The age range of patients studied was 18-75 years with a mean age of 36.99, (Standard

Error of mean-SEM of 1.881 and standard deviation-SD of 15.740). The most frequent age group

was 18-27 with 24 patients and 8(33.33%) being CAUTI positive. Age group 28-37 had a

frequency of 21 with 7 (33.33%) being CAUTI positive. 38-47 years had a frequency of 6 with

4(66.67) being CAUTI positive giving the highest occurrence of CAUTI. Only four patients

were of 68-77 age group and all were free from CAUTI.

Figure 3 is a bar chart showing gender distribution of respondents with their CAUTI status. In

this study, 49(70%) of the 70 patients studied were males while 21(30.00%) were females with a

male to female ratio of 2.33:1.00. Fourteen (28.57%) of the 49 male patients had CAUTI as well

as 11(52.38%) of the 21 female patients.

24

Figure 4 is a bar chart representing the effect of comorbidity on CAUTI. Eight (61.54%) of 13

patients with comorbidity had CAUTI while only 17(29.83%) out of 57 patients without

comorbidity had CAUTI. Three (50%) of 6 patients with Diabetes mellitus had CAUTI. Five

(71.43%) of 7 patients with other comorbidities had microbial growth. The other comorbidities

mentioned above include obesity, fecal incontinence, Human immune deficiency virus infection

and pulmonary tuberculosis.

Figure 5 is a bar chart representing the clinical specialties and CAUTI status of patients studied.

Neurosurgical admissions with 31(44.29%) patients had the highest frequency. Twelve (38.71%)

of these 31 patients had CAUTI. Neurology unit had 7 patients out of which 4(57.14%) had

microbial growth giving the highest incidence of CAUTI among the clinical specialties.

Cardiothoracic and General Surgical units each had 10(14.29%) patients with CAUTI incidence

of 20%. Obstetrics and Gynaecology unit had 9(12.86%) patients of which 4 (44.44%) were

CAUTI positive. The other subspecialties that accounted for the remaining 3(4.29%) patients

were Cardiology, Orthopaedic and Plastic.

Figure 6 shows the proportion of various microbial isolates. Twenty eight (28) microorganisms

were isolated from the urine samples of 25 patients with Candida species having the highest

frequency 12(42.86%) while 16 were bacteria isolates with Staphylococcus aureus being the

most preponderant with 4(14.29%) organisms. Klebsiella had 3(10.71%) organisms while

Escherichia coli, Coliform bacilli, Lactose fermenting organisms, each had 2(7.14%) organisms.

Pseudomonas, Streptococcus faecalis and Citrobacter freundi each had 1 (3.57%) organism.

Gram negative organisms accounted for 75 % of the bacterial isolates.

25

TABLE 1; Distribution of duration of Admission/ Catheterization and CAUTI Status

---------------------------------------------------------------------------------------------------------------------

DURATION CAUTI STATUS OF SUBJECTS Total

Positive (+) Negative (-)

48-72 hours (day 3-4) 4 (13.79%) 25(86.21%) 29(100.00%)

Day 5-7 21(51.22%) 20(48.78) 41(100.00%)

--------------------------------------------------------------------------------------------------------------------

TOTAL 25(35.71) 45(64.29%) 70(100.00%)

--------------------------------------------------------------------------------------------------------------------

X2 =10.363a while the p value =0.001

26

Table II: Antibiotic sensitivity pattern of bacterial isolates

Antibiotic Nit (%) Pen Qui Gen Tet Cep Col Ery Aug Imi Cot

Bacterial Isolate

Staph aureus (n=4) 4(100) 1(25.0) 1 (25.0)

Klebsiella (n=3) 1(33.3) 1 (33.3) 1 (33.33)

E coli (n=2) 2(100) 2 (100)

Coliform bacilli (n=2) 1(50) 2 (100) 1(50)

Lactose Fermenting

organism(n=2)

2(100) 2 (100)

Pseudomonas (n=1)

Streptococcus faecalis (n=1) 1(100) 1(100)

Citrobacter freundi n=1 1(100)

All Isolates n=16 11(68.75) 6 (37.50) 3(18.75) 3(18.75) 1(6.25)

Nit- Nitrofurantoin

Pen- Penicillins

Qui -Quinolones

Tet- Tetracycline

Gen-Gentamycin

Cep- Cephalosporins

Col- Colistin

Ery- Erythromycin

27

Aug-Augmentin

Imi- Imipenem

Cot- Cotrimoxazole

Table III: Antibiotic resistant pattern of bacterial isolates

Antibi

otic

Nit Pen Qui Gen Tet Cep Col Ery Aug Imi Cot

Bacterial

Isolate

Staph aureus

(n=4)

2 (50) 4 (100) 4 (100) 4(100) 1 (25) 1 (25) 3 (75) 2 (50)

Klebsiella

(n=3)

2(66.7) 1(33.3) 3(100) 3(100) 1(33.3) 3(100) 3(100) 1(33.3)

E coli (n=2) 2(100) 2(100) 2(100) 2(100)

Coliform

bacilli (n=2)

1 (50) 2 (100) 2 (100) 2 (100) 1 (50)

Lactose

Fermenting

organism(n=2)

2(100) 2(100) 2(100) 2(100) 2(100) 2(100) 2(100)

Pseudomonas

(n=1)

1(100) 1(100) 1(100) 1(100)

Streptococcus

faecalis (n=1)

1(100) 1(100)

Citrobacter

freundi (n=1)

1(100) 1(100) 1(100) 1(100) 1(100)

All Isolates

(n=16)

5(31.25) 6(37.50) 15(93.75) 4(25.00) 15(93.75) 1(6.25) 1(6.25) 11(68.75) 1(6.25) 5(31.25)

28

Table IV: Distribution of fomites and the isolated organisms.

Fomite Micro-organism 1st culture

(Number)

Micro-organism

2ndculture

(Number)

Patients’

beds

Staphylococcus aureus(2) Staphylococcus

epidermidis(1)

Patients’

Monitors

None None

Ventilators Staphylococcus

aureus(1),Klebsiella(1),proteus(1)

&Coliform bacilli(1)

None

Bedside

tables

Staphylococcus aureus(1) None

Suction

Machines

Staphylococcusaureus(2),&

Klebsiella(1)

Staphylococcus

aureus(1)&Spore

forming

organisms(1)

29

Figure 1: Incidence of CAUTI

30

Figure 2: Age group distribution of patients with their CAUTI status

8 7

4 5 5

0

1 6

1 4

2

7

2

4

0

5

1 0

1 5

2 0

2 5

3 0

1 8 -2 7 2 8 -3 7 3 8 -4 7 4 8 -5 7 5 8 -6 7 6 8 -7 7

n o n c a u t i

c a u t i

Age- group distribution

31

Num

ber

of

pat

ients

Figure 3: Gender distribution of patients and CAUTI status

3 5

1 0

1 4

1 1

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

4 5

5 0

M a le F e m a le

C a u t i

N o c a u t i

Gender

32

Num

ber

of

pat

ients

Figure 4: Distribution of patients with comorbidities and CAUTI status

Comorbid state

33

Num

ber

of

pat

ients

Figure 5: Clinical specialty distribution of subjects and CAUTI status

31 7 9 23

12 4

4 5

19 3

5 18

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Neurosurg Neurology O& G others

cauti-

cauti+

all patients

Clinical specialty

34

Per

centa

ge

Figure 6: Distribution of various microbial isolates

35

CHAPTER FIVE

DISCUSSION

The incidence of Catheter-associated urinary tract infection in this study was 35.71% .This is

comparable to the findings of Alaveren et al29 and Parlek et al, 61 whose incidences were 38%

with a closed system on the 6th day and 39.1% in asymptomatic patients respectively. Abaeze29

in Abeokuta, Western Nigeria also found an incidence of 40% although his study was not ICU -

based. The incidence in this study was however, lower than the findings of Karina et al.31 in the

Philippines which gave an incidence of 51.4% among medical patients in ICU and non-ICU

wards and Onipede et al.62 in Ile Ife, Western Nigeria with an incidence of 60.9% .This incidence

of 35.71 is however much higher than results of various studies28,32,33,63 in other countries of the

world probably because urinary catheter care bundle is not strictly adhered to in our centers.

Alavaren et al.28among the Philippines found an incidence of 24.70% among non-ICU

catheterized patients although they also excluded patients with UTI just as was done in this

study. Duo-shuang 33 in an ICU-based study in China had a much lower incidence (15.8%). The

incidence of CAUTI is even lower when the study is based only on symptomatic cases as Melaku

et al.64in Ethiopia studying catheterized patients in surgical, obstetric and gynaecological wards

found an incidence of 9.4%. Mahsheed,53 also studying symptomatic cases in the ICU found an

incidence of 9.15%. The incidence is even much lower among cardiac patients in ICU in which

Mirinazhad et al.65found an incidence of 1.6% by the third day, without the exclusion of patients

with previous UTI implying that patients with cardiac diseases may have a low incidence of

CAUTI in the ICU.

The peak age group in this study was 18-27 with a frequency of 24 (34.29%) patients. This is

similar to the finding of Okon et al66in Maiduguri, North East Nigeria with a peak age-group of

16-30 years. The highest CAUTI rate in this study occurred in patients of 38-47 age group, with

4(66.67%) of 6 having significant bacteriuria. This could be because this is a reproductive age

group with increased sexual activity. The lowest rate was found in the oldest age group (68-77

years) with four patients and none acquiring CAUTI.

36

Nineteen (37.26%) of 51 who were below 47 years had CAUTI while 6(31.58%) of 19 patients

who were above 47 also had CAUTI implying that CAUTI acquisition could be age-related as

already. In Kulkarni’s63study, 84% of the patients above 40 years had CAUTI which differs

from the findings of this study in which more of the younger age group acquired CAUTI and

four patients who were above 67 years old, although male were CAUTI-free. This is uncommon,

as elderly men are prone to prostatic hypertrophy with bladder outlet obstruction, which is a

major predisposing factor to the development of asymptomatic bacteriuria. In Abaeze’s study29,

the most affected age-group was 26-35years with 31.50% while the least affected age-group was

also the elderly 86-95 years (5.00%).This is somewhat similar to the findings of this study

probably because both were Nigerian-based studies and CAUTI distribution could be

geographical.

Significant bacteriuria occurred in 11 (52.40%) of 21 females and 14 (28.57%) of 49 males

This higher incidence of CAUTI in the female gender has been well documented.11,35,67,68 The

anatomy of the female urogenital tract predisposes her to the acquisition of CAUTI (the short

and wide urethra, which is close to the anus makes it susceptible to faecal contamination.) The

female urine is also said to have more suitable pH and osmolality for the growth of E coli.69

Certain studies have also shown a male preponderance to CAUTI. Mahshed et al53 had 75% of

CAUTI cases as male, Taiwo et al.52 also had a male preponderance. Older men are prone to

bladder outlet obstruction secondary to prostatic hyperplasia and malignancy and this

predisposes them to the acquisition of urinary tract infection.

Duration of catheterization was the only risk factor in this study which was statistically

significant. It is known as the most important modifiable risk factor in the acquisition of

CAUTI.15 Studies have shown that the daily risk for acquiring CAUTI is 3-6% and cumulatively

increases the longer the catheter remains in situ35,36 . By the 30th day of catheterization, infection

rates are close to 100%.9 This study showed that 4 (13.79%) patients had significant bacteriuria

by the 4th day while 25(35.71%) had acquired CAUTI by the 7th day. This is similar to the

findings of Karina et al.31 and Indranil et al.32 in which bacteriuria was 46.7% and 50%,

37

respectively by the 7th day but higher than the findings of Taiwo et al.52 who found an incidence

of 20% by the 7th day. This higher incidence may have resulted from the fact that this study was

ICU-based and CAUTI is commoner among critically ill patients. The result here is however

lower than that of Kulkarni et al.63in which 15(34.09%) had significant bacteriuria by the 3rd day

and 29 (65.90%) by the 7th day.

Neurosurgical unit had the highest frequency of admissions with 31(44.29%) patients, probably

because patients with severe traumatic brain injury are usually unconscious and are admitted into

the ICU for airway management and ventilatory support. They also had a high incidence of

CAUTI as 12(38.71%) had significant bacteriuria. This could be because unconscious patients

are usually catheterized for a longer duration predisposing them to the acquisition of CAUTI.

Neurology patients had the highest incidence of CAUTI with 4 (57.14%) of 6 having significant

bacteriuria probably because they are often incontinent and perineal care may not be optimal

leading to extra luminal ascent of bacteria into the bladder. Cardiology had the lowest in

frequency of admissions with only one patient (1.43%) who was also CAUTI-free.

Cardiothoracic unit had a total of 10(14.28%) patients with just 2 (20.00%) having significant

bacteriuria. Patients in cardiac ICU have been documented to have low incidence of CAUTI.66

Obese and faecal incontinent patients had 100% CAUTI each although the number was

insufficient to draw conclusions. Patients with Human immunodeficiency Virus (HIV) had

66.67% with significant bacteriuria. Diabetes mellitus is a known risk factor for the acquisition

of CAUTI. The 50% incidence of CAUTI in hyperglycaemic patients in this study is higher than

the finding in Kulkarni’s63 study which had 39% incidence. In patients with diabetes mellitus,

impaired granulocyte function, increased adherence of uropathogens to the bladder epithelium

and the effect of glucosuria on the growth of uropathogens in diabetic patients contribute to a

higher urinary tract infection prevalence.70The immunocompromised state which is characteristic

of these patients allows bacteriuria to easily extend into the upper urinary tract. Patients with

diabetes especially those admitted into the ICU with indwelling urethral catheters are more

susceptible to the development of urosepsis, thus these patients require strict blood glucose

monitoring to prevent occurrence and progression.70

38

The only obese patient in this study was a polytraumatised female who was also CAUTI positive,

It is documented that the incidence of UTI is 2.5-5 fold higher among obese individuals (BMI

≥30 kg/m2) than among the non-obese. Obese females are even at a higher risk.71.Obesity has

been shown to predispose to UTI after traumatic injury.72,73 Patients with faecal incontinence in

this study also showed 100% CAUTI incidence, probably because meatal contamination

occurred leading to extra luminal ascent of pathogens into the urinary tract. Patients who were

HIV seropositive showed an incidence of 66.67% of bacteriuria in this study. This was high and

could be as a result of immunosuppression, however Asharak et al 74and Park75 in their different

studies showed no significant association between HIV infection and UTI. Park75however found

an association between the viral load and UTI. It should however be noted that the number of

comorbid patients in this study was too small to draw a conclusion. A study with a larger sample

size should give a more reliable result.

Consistent with some other studies both in the developed76 and developing33,77 countries of the

world, Candida specie was the most frequent pathogen isolated in this study accounting for

42.87%. This is similar to the finding in a multicenter study in ICUs in Turkey which had

candida as the commonest pathogen responsible for CAUTI with a frequency of 44.9%.78 Risk

factors for Candiduria (as prevalent in this study) include the presence of indwelling urinary

catheters, use of antibiotics (as all our patients were on various antibiotics), older age, previous

surgery and the presence of diabetes mellitus39. Candiduria may not be associated with

candidaemia and most cases are asymptomatic and are usually benign and do not require local or

systemic antifungal therapy. The infection needs to be confirmed by a second sterile sample.

Mortality can be high particularly in debilitating patients. In a recent case control study39, it was

shown that the risk of developing candiduria was increased by 12-fold after urinary

catheterization, six fold after use of broad spectrum antibiotics, and urinary tract abnormalities.

The prevalence of candiduria varies in hospital settings and is most prevalent among patients in

ICU especially surgical ICU and in leukaemia and bone marrow transplant units43,44.In a

multicenter study in ICUs in Turkey the most common pathogens responsible for CAUTI were

Candida species with a frequency of 44.9% which is quite close to that found in this study.78

39

The most prevalent bacterial isolates in this study were Staphylococcus aureus with a frequency

of 4(25.00%), Klebsiella species with a frequency of 3(18.75), E coli, coliform bacilli and

lactose fermenting organisms with frequencies of 2(12.5%) each. This differs from previous

studies which had E coli37,40,73, Klebsiella52,53 and Pseudomonas79 as the commonest organisms.

Most of these organisms are part of the patients’ endogenous bowel flora and some may have

been acquired through cross contamination from fomites or health care givers. The presence of

Staphylococcus aureus could mean a systemic infection affecting the urinary tract from the

haematogenous route.

All the patients in our ICUs were on various antibiotics prophylactically. A total of nineteen

antibiotics belonging to different classes were tested in this study against sixteen bacterial

pathogens. Nitrofurantoin had the highest sensitivity being sensitive to 11(68.75%) organisms.

This is similar to the findings of Awolude80 in Ibadan, Western Nigeria, Okon et al.66 in Northern

Nigeria and Kalkurni63 where most of the organisms were highly sensitive to Nitrofurantoin

among other antibiotics. This finding differs from that of Onyegbule81 et al. where the pathogens

were more sensitive to Augmentin. It also differs from Taiwo’s finding48 where most of the

organisms were poorly sensitive to Nitrofurantoin. This implies that Nitrofurantoin would be

effective for empirical antibiotic therapy in our environment. Imipenem was sensitive to 1 of 2

organisms tested.This is similar to Kulkarni’s63finding.This study also showed 50.00% resistance

to Imipenem. The quinolones showed sensitivity to 6 (37.50%) of the bacterial isolates, E coli

was susceptible to only 30% of the antibiotics tested, it was however 100% susceptible to

nitrofurantoin. Fifteen (93.75%) of 16 isolated bacteria were resistant to both Gentamicin and

Cephalosporins. While 11(68.75%) were resistant to Augmentin. All four Staphylococcus

aureus, all three Klebsiella, and both E coli isolates were resistant to the quinolones, Gentamicin

and Cephalosporins. This high resistance pattern is similar to that of Duo-shuang33 where

resistance was 88.00%. Multiresistant pathogens are common in CAUTI as a result of the

presence of biofilms. Staphylococcus aureus was susceptible to only 4 (26.67%) of 15 antibiotics

groups tested. It was 100% susceptible to Nitrofurantoin, 25% sensitive to, Gentamicin and

Augmentin each. Pseudomonas was resistant to all antibiotics tested.

40

This is similar to the finding of Duo-shuang33where Pseudomonas showed absolute resistance to

Ciprofloxacin, Amikacin, Ceftazidine and even Imipenem. All six pathogens tested against the

penicillins including Amoxicillin were resistant to it while Amoxicillin with Clavulinic acid

(Augmentin) gave a sensitivity of 15.39% confirming that augmenting Amoxicillin with

Clavulinic acid improves its efficacy.

Antibiotic resistance is a problem in the Intensive Care Unit especially as related to the

challenge of biofilms in catheter-associated urinary tract infection. Biofilms provide a sustained

reservoir for microorganisms that after detachment can infect the patient. These biofilms cause

further problems if the bacterium (e g P mirabilis) produces the enzyme urease.82The urine

becomes alkaline causing the production of ammonium ions followed by crystallization of

calcium and magnesium phosphate within the urine. These crystals are then incorporated into the

biofilm resulting in encrustation and blockade of the catheter over a period of time. The complex

structures of the biofilms promote bacterial proliferation and protect the bacteria from

destruction by cleaners, antiseptics, antibiotics, and the host’s immune system.82 Bacteria within

a biofilm exhibit greater ability to communicate and exchange genetic information than do free-

floating (planktonic) bacteria. This communication is hypothesized to promote antibiotic

resistance and spread of the biofilm to other surfaces of the catheter and urinary epithelium.

Biofilms can begin to develop within the first 24 hours after catheterization and has been

reported to grow so thick as to block a catheter lumen.83 The presence of urinary catheter

biofilms has important implications for antimicrobial resistance, diagnosis, prevention and

treatment of CAUTI. In those patients who need an IUC for long term bladder management,

prevention of complications relies on adherence to catheter care policies.84,85,86,87,88

Antibiotic use in ICU should be based on escalation and de-escalation mechanism whereby the

provision of effective initial antibiotic is achieved while avoiding unnecessary antibiotic use that

would promote development of resistance. It is a key element within antimicrobial stewardship

programs and treatment paradigm for serious sepsis. The embodiment of de-escalation is that

based on microbiology results around day three therapy.

41

The empiric antibiotics that were started are stopped or reduced in number and or narrowed in

spectrum. De-escalation is clinically effective and appropriate.89

Six different species of pathogens that were isolated from fomites had a preponderance of

Staphylococcus aureus with 7 (53.85%) of 13 pathogens. This is similar to Ike’s90 study

conducted on fomites in ICU in Jos, Nigeria, where staphylococcus aureus was the most

preponderous isolate. This is quite significant as Staphylococcus aureus including Methicillin

Resistant Staphylococcus Aureus (MRSA), Enterococcus species including Vancomycin

Resistant Enterococcus (VRE) and Streptococcus pyogenes, are known to persist for months on

dry surfaces and so can be sources of cross infection in the ICU56. The gram negative organisms,

Klebsiella (15.39%), coliform bacilli (7.69%), isolated are also known to survive for months on

dry surfaces. Proteus vulgaris, Vibrio cholera, Bordetella pertussis and Haemophilis influenza

are known to persist for days on fomites. Spore forming bacteria which constituted 7.69% of the

isolates are also known to persist for months on fomites becoming continuous sources of

infection if appropriate preventive measures are not adopted.56The mode of transmission of

infection can be direct or indirect through the hand of health care givers but this is reduced by

50% through compliance to hand hygiene.56 The isolation of Staph aureus as the most prevalent

organism both from patient’s samples and fomites suggest the possibility of cross infection.

Candida species, though the most prevalent organisms isolated from the patients in this study

were absent from the fomites, probably because the disinfection methods which include use of

soap and water for organic decontamination, antiseptics like alcohol, chlorhexidine, and iodine,

used in these centers were effective against them. Gram negative bacteria have been described to

persist longer than gram positive bacteria.91Humid conditions improved the persistence of some

types of bacteria such as Chlamydia trachomatis92and E coli93.Staph aureus is known to persist

longer at low humidity94.Methicillin Resistance Staphylococcus Aureus ( MRSA) has improved

survival under low temperature (40 or 60).94 Some authors described a longer persistence on

plastics95,96 while others see a survival advantage on steel.97 Longer persistence has been

described with higher innocular96,in the presence of protein,91Serum91and Sputum98.These could

be the reason why suction machines and ventilators had the highest growth of organisms, as the

42

suction bottles often contain fluid with organic matter which may not be discarded immediately

after each use, encouraging the growth of microorganisms.

The humidifiers attached to ventilators also do contain moisture. Patients on mechanical

ventilators are prone to acquiring ventilator associated pneumonia which is a common

nosocomial infection in ICU. The absence of microbial growth on patient’s monitors and

minimal growth on side tables could be explained that disinfection of such surfaces was easier

and organic matter could easily be visualized and removed and such surfaces disinfected.

Infection control in ICU

Isolation, the separation of an infectious patient from other people is probably the oldest form of

infection control still practiced.99The aim of isolation precaution is to reduce the risk of the

spread of infection, before and after diagnosis, to susceptible individuals including health care

workers. Health care givers are required to adopt the universal infection control precautions

(UICP). This requires clinical staff to wear, and change gloves in clearly defined clinical

situations.100They are also required to make a risk assessment of when additional protective

clothing is required. Additional protective clothing comes into play for infections spread by

droplets or airborne, and some that spread by contact. The universal infection control precautions

involve hand washing and the use of gloves when handling blood, body fluids, and contaminated

materials. These precautions are to be applied to all patients receiving care in a hospital,

regardless of their diagnosis or presumed infection status. If used wisely it can limit the need for

single room isolation.

A single room with shut doors is intended to prevent the transmission of organisms spread by the

airborne route and to prevent gross contamination of the environment outside of the room with

certain organisms spread by contact.101,99 For non-air-borne infections requiring a single room, it

is preferable to keep the door closed. Confinement to a single room can be an unpleasant

experience .While it is necessary to restrict the patient, it also discourages staff from entering the

room. The patient can feel deprived of human contact, so a single room should not be used if

airborne transmission is unlikely or if there is little risk of heavy environmental contamination.

43

The architectural design of the ICU has little influence on the infection rate and the dry

environment example walls, and ceilings do not require any particular attention.102

44

CONCLUSION

It was evident in this study that incidence of Catheter- associated urinary tract infection in the

Intensive Care Unit in South Eastern Nigeria was 35.71%. Duration of catheterization was found

to be a major risk factor for CAUTI and was statistically significant. The most prevalent

organism associated with CAUTI in the ICUs studied was Candida species while the commonest

bacteria was Staphylococcus aureus which was also the most predominant isolate from fomites.

The most sensitive antibiotic against CAUTI in these ICUs was Nitrofurantoin which can be

used empirically while awaiting the result of culture and sensitivity although treatment for

asymptomatic bacteriuria is discouraged. The Suction machine was the highest source of

microbes in the ICU.

45

RECOMMENDATIONS

Institution guidelines for the placement of urinary catheters in the ICU should be implemented

and surveillance studies frequently conducted to ensure compliance.

Each patient on admission in the ICU should have a dedicated suction machine to minimize

cross-infection to other patients. Diligent decontamination of the suction machines by discarding

the fluid in bottle after each suctioning section and the use of single use suction catheters would

help to reduce the number of pathogens present on the suction apparatus thereby reducing

nosocomial infections.

There should be strict compliance to disinfecting the ventilator corrugated tubings after each

patient use to minimise cross-infection to the next patient using the ventilator. Disposable

corrugated tubings should be used for each patient.

Training and re-training of health care-givers on hand hygiene compliance would reduce the

incidence of HAI in the ICU.

There should be regular surveillance of nosocomial infection in the ICU.

46

LIMITATIONS OF THE STUDY

The sample of our study was relatively small. A similar study with a larger sample size would be

desirable.

All our patients were on antibiotics and this may have affected the result of the study.

47

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inanimate surfaces. Infect Control Hosp Epidem 2000

98. Smith C R; Survival of tubercle bacilli: the viability of dried tubercle bacilli in unfiltered

roomlight and in the refrigerator. Am Rev of Tubercl.1942;5: 334-345.

99. Meers P, Jacobson W, McPherson M, Hospital infection control for Nurses.1st ed. London:

Chapman and Hall,1992.

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100. Centers for disease control. Update: universal precautions for prevention of transmission of

immunodeficiency virus, hepatitis B virus, and other blood borne pathogens in health

care settings. MMWR 1988; 37:377-388.

101. Hospital Acquired Infection Control. 1st ed. Oxford University Press,1992.

102. Heubner J,Frank U, Kappstein, I . Influence of architectural design on nosocomial

infections in intensive care units: a 2 year analysis. Int Care Med 1988;15: 179-183.

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APPENDIX I

Data collection form

Study Title;

Catheter associated urinary tract infection in ICU; Incidence, Risk factors and Microbiological

profile.

Date;

A. Patient’s demography and physical Data

Name;--------------------------------------------------

Hosp no;-------------------------------------------

Age in years;-----------------------------------------

Sex ; --------------------------------------------------

Diagnosis;-------------------------------------------------------------

B. ICU Admission.

Date of admission into ICU-----------------------------------------

Indication for ICU admission-------------------------------------------

Source of admission; A/E ; Theatre; Ward

Antibiotic therapy: Yes ; No

Baseline vital signs on admission; Pulse rate Bp Temp.-

C. Urethral catheterization history;

Date of 1st catheterization –; Place of catheterization:

Date of 1st change of catheter (if changed)

- Reason for change of catheter.

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D. Co- morbid state

Diabetes mellitus Yes ; No

Immuno compromised Yes ; No

Steroid Therapy Yes ; No

Antibiotics Yes ; No

E. Urine culture

1st sample ; ( Within 24 hours of ICU admission)

Results: Growth ; Yes ; No

Organisms grown; Sensitivity pattern;

2nd sample (48 to 72 hours of ICU admission)

Results: Growth Yes ; No

Microorganisms grown with sensitivity pattern.

3rd sample (5-7days of ICU admission).

Exact day; Day 5; Day 6 ; Day 7

Results: Growth; No Yes

Microorganisms grown with sensitivity pattern;

E. Evidence of bacteremia: Yes; No

If yes

Vital sign changes; Pulse - Temp.-

Blood culture result: Growth Yes No

Microorganisms and their sensitivity pattern.

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Full blood count

WBC; Total : Differentials

ICU FORMITES FOR CULTURE. Organism (s) grown

Suction Machine:

Ventilator:

Side table:

Patient’s bed:

Patient’s monitor;

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APPENDIX II

Patient Informed Consent

Dear patient,

You are being asked to participate in a research study. In order to decide whether or not you

should agree to be part of this research study, you should understand enough about the research

to make an informed judgment.

This consent form gives detailed information about the study which the investigator will discuss

with you. Once you understand this you will be asked to sign this form if you wish to participate.

The research being proposed to you is;

Catheter associated urinary tract infection in the ICU; incidence, risk factors and

microbiologic profile.

Purpose of the study:

The purpose of this study is to ascertain how the use of an indwelling urinary catheter in the ICU

contributes to acquiring urinary tract infection.

Description of the Study Procedures;

You are admitted into the ICU because you are critically ill and your body needs close

monitoring for a good outcome. Among these includes the insertion of a urinary catheter to

monitor your urine output which help us to know how your kidneys are functioning. This

catheter will be allowed to stay as long as it is needed. There may be need to change it whenever

we deem fit for your own good. Your urine sample will be examined about three times to check

for evidence of urinary tract infection contracted while in the ICU.

Risks; Your participation in this study will not expose you to further risks outside your illness.

Confidentiality: All the information obtained will be treated as confidential.

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Benefits: You will not be required to pay an extra cost for the investigations.

The result of the study will also help in better management of yourself and other patients in the

ICU.

You are at liberty to withdraw from this research if you so wish.

Feedback: The researcher will be available at any time to answer your questions on this

research. You can reach the researcher.Dr (Mrs.) Nwachukwu, M. U. Department of

Anaesthesia. UNTH Ituku-Ozalla/FMC, Umuahia.08034224246.

Response: I have read and understood the above and further explanations have cleared my

doubts. I fully understand the nature, risks and benefits of the study and hereby consent to take

part in it.

--------------------------------------- ----------------------------------------------

Name and signature of patient Name and signature of Researcher

Date -------------------------------- Date ---------------------------------

Name and signature of witness. Date ---------------------------------

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APPENDIX III

62

APPENDIX IV

6

3

APPENDIX V

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