TOPIC PAPER

Epidemiology, treatment and prevention of healthcare-associatedurinary tract infections

F. M. E. Wagenlehner • Mete Cek •

Kurt G. Naber • Hiroshi Kiyota •

Truls E. Bjerklund-Johansen

Received: 17 April 2011 / Accepted: 23 August 2011 / Published online: 7 September 2011

� Springer-Verlag 2011

Abstract

Objectives Healthcare-associated urinary tract infections

(HAUTIs) are the most frequent healthcare-associated

infections in general hospitals. They are almost exclusively

complicated UTIs, although complicating factors are very

heterogenous. HAUTIs are mainly catheter associated.

Most of them are asymptomatic and do not need antimi-

crobial therapy. However, cross-contamination and cross-

infection may contribute to distribution of resistant uro-

pathogens. The bacterial spectrum of HAUTI is broad, and

antibiotic resistance is common.

Methods The authors reviewed the literature from 2000

to 2010 to determine the epidemiology, prevention and best

treatment strategies for HAUTI. The recommendations

were summarized by determining the level of evidence and

grading each recommendation.

Results The treatment for HAUTI encompasses treatment

for complicating factors as well as antimicrobial chemo-

therapy. At least in serious UTI, adequate initial antibiotic

therapy results in lower mortality. Therefore, the initial

antibiotic regimen must provide sufficient antibiotic cov-

erage. This can only be achieved if the local or regional

bacterial spectrum and antibiotic resistance patterns of

uropathogens are followed continuously. Provisional

microbiological findings, such as reports on Gram-stain or

certain biochemical results, can lead to early stratification

of pathogens and allow a more tailored empiric antibiotic

therapy. Antibiotic therapy of HAUTI has to consider

therapeutic success in the individual patient and prevention

of emergence of antibiotic-resistant mutants. For both

aspects, adequate drug selection and dosing are paramount.

Discussion Antibiotic treatment for HAUTI should fol-

low prudent antibiotic use to prevent emergence of anti-

biotic resistance.

Keywords Healthcare-associated UTI �Nosocomial UTI �Antibiotic treatment for UTI � Emergence of

antibiotic-resistant uropathogens

Summary of recommendations

1. All urinary tract infections (UTI) acquired in an outpa-

tient or in an institutional care setting should be con-

sidered as healthcare-associated UTI (HAUTI) (GoR B).

2. Healthcare-associated asymptomatic bacteriuria

should not be treated with antimicrobials, except

before traumatizing interventions of the urinary tract

and in pregnant women (GoR A).

F. M. E. Wagenlehner

Department of Urology, University Giessen, Giessen, Germany

F. M. E. Wagenlehner (&)

Clinic of Urology, Pediatric Urology and Andrology,

Justus-Liebig-University, Rudolf-Buchheim-Str. 7,

35385 Giessen, Germany

e-mail: Wagenlehner@AOL.com

M. Cek

Department of Urology, Trakya University,

Edirne, Turkey

K. G. Naber

Technical University, Munich, Germany

H. Kiyota

Department of Urology, Jikei University Affiliated Aoto

Hospital, Tokyo, Japan

T. E. Bjerklund-Johansen

Urology Department, Aarhus University Hospital, Skejby,

Aarhus University, Aarhus, Denmark

123

World J Urol (2012) 30:59–67

DOI 10.1007/s00345-011-0757-1

3. In HAUTI, a wide spectrum of frequently also

multiresistant uropathogenic bacteria has to be con-

sidered (GoR B).

4. For rational empiric therapy, the local susceptibility

pattern of the uropathogens must be continuously

followed and considered (GoR A).

5. A urine specimen and in case of urosepsis also a

blood specimen for culture must be obtained before

initiation of any antibiotic therapy (GoR A).

6. Antibiotic treatment should be initiated after the

results of the susceptibility testing are available,

whenever possible (GoR B).

7. If empiric antibiotic treatment is warranted, it should

be tailored after the results of the susceptibility

testing are available (GoR B).

8. Antibiotics with best performance in biofilm infec-

tion should be selected, and the dosage should be

sufficiently high when treating HAUTI (GoR B).

9. Prevention of catheter-associated UTI is the gold

standard for prevention of HAUTI (GoR A).

10. For prevention of HAUTI in short-term catheteriza-

tion, the following recommendations are to be

considered: (i) staff education about catheter man-

agement; (ii) catheterization only when indicated and

prompt removal of indwelling catheters; (iii) hand-

washing; (iv) catheter insertion with aseptic tech-

nique and sterile equipment; and (v) maintenance of a

closed urinary drainage system (GoR A).

11. For prevention of HAUTI in long-term catheteriza-

tion, the following recommendations should be

considered: (i) hydration; (ii) appropriate catheter

exchange; and (iii) no antimicrobial prophylaxis for

catheter-associated bacteriuria (GoR B).

12. For avoidance of long-term bladder catheterization,

the following methods should be considered:

12.1 in case of incomplete emptying of the bladder:

(i) medications for complete emptying the

urinary bladder, such as cholinergic drugs

and/or alpha-1 adrenergic inhibitors; (ii)

operative deobstruction for benign prostatic

hyperplasia (BPH); and (iii) clean intermit-

tent catheterization (GoR B).

12.2 in case of incontinence: (i) medications for incon-

tinence and (ii) operative treatment for

incontinence (GoR B).

Introduction

A healthcare-associated infection is defined as a localized or

systemic condition that results from an adverse reaction to

the presence of an infectious agent or its toxin and was not

present or incubating prior to the initiation of a healthcare

encounter [1, 2]. The term ‘‘healthcare-associated infec-

tion’’ incorporates the term ‘‘nosocomial’’ or ‘‘hospital

acquired,’’ which refers to infections that occur as a result of

hospital care, but also any infection occurring in an insti-

tutional (long-term facilities, nursing home) or outpatient

care setting. Healthcare-associated urinary tract infections

(HAUTIs) are the most frequent healthcare-associated

infections and account for more than 40% of all healthcare-

associated infections in a general hospital [3, 4] (LoE 2b).

They are mainly catheter associated [3–5] (LoE 2b). Bac-

teriuria should be distinguished from urinary tract infection

and develops in up to 25% of patients who require a urinary

catheter for seven days or more, with a daily risk of 5% [5]

(LoE 3). Most of the catheter-associated bacteriuria are

asymptomatic [6] (LoE 3) and therefore do not need anti-

biotic therapy. However, the pathogens are fully exposed to

the healthcare setting (nosocomial) environment, including

the selective pressure of antibiotic or antiseptic substances.

Unfortunately, many studies do not differentiate between

symptomatic UTI and asymptomatic bacteriuria. HAUTI

comprises perhaps the largest institutional reservoir of

antibiotic-resistant pathogens [5] (LoE 3).

The aim of this review is to determine the epidemiology,

prevention and best treatment strategies for HAUTI and

provide evidence graded recommendations.

Methods

This manuscript was published in part originally in: Naber

KG, Schaeffer AJ, Heyns CF, Matsumoto T, Shoskes DA,

Bjerklund Johansen TE (eds) Urogenital Infections. Euro-

pean Association of Urology—International Consultation

on Urological Diseases, 1st edition 2010, Arnhem, The

Netherlands, ISBN:978-90-79754-41-0 [7]. The review is

based on a systematic literature search for the years

2000–2010 in PubMed. Two searches were performed

using Boolean logic structure: (1) surveillance AND sus-

ceptibility AND nosocomial urinary tract infection (for

search, the term ‘‘nosocomial’’ was used instead of

‘‘healthcare associated’’) and (2) randomized clinical trials

AND nosocomial urinary tract infection AND antibiotic

therapy. The first search revealed 55 publications. There

were several local or national surveillance studies, but only

three multinational studies were found and used for this

review. The second search revealed 15 publications. No

prospective controlled, randomized therapeutic study was

found, in which only patients with nosocomial UTI were

treated or such patients were substratified. Only one study

investigated the effect of antibiotic prophylaxis at urinary

catheter removal, which was included into this review, and

one study investigated the effect of an antibiotic-coated

60 World J Urol (2012) 30:59–67

123

urinary catheter on prophylaxis of nosocomial UTI, which

was included into this review. These publications were

augmented with publications known by the authors.

The studies were rated according to their level of evi-

dence, and the strength of the recommendations was graded

according to the standards of the International Consultation

on Urological Diseases [8, 9].

Epidemiology

The incidence of healthcare-associated infections has

stayed more or less stable over the last two decades.

However, certain aspects of patient care have changed

during this period. As minimally invasive techniques

develop and patient care improves, patients are being

treated either on an outpatient basis or they stay in hos-

pitals for shorter periods. Particularly in urology, there is a

wide range of operations, which allow the patient to be

discharged within 48 h of operations. This has two

important implications on the incidence of healthcare-

associated infections: (1) More elderly patients with

comorbidities are hospitalized [10, 11] and (2) shorter

hospital stays make it difficult to assess the true frequency

of healthcare-associated infections. The incubation periods

of certain infections (e.g., surgical site infections) are

sometimes longer than the hospital stay of patients. It is

thus more preferable to calculate the incidence of health-

care-associated infections on the basis of patient days,

rather than actual number of admissions [12]. The

denominator can also be the number of patients at risk, or

days of indwelling catheterization [13]. The rate of noso-

comial infections per 1,000 patients’ days in the USA was

calculated to be 9.8 in 1995 [12, 13]. More recent esti-

mates (for 2009) exhibit a much more detailed analysis and

are therefore not comparable to previous overall estimates

[14]. On the other hand, the incidence of nosocomial uri-

nary infections in European countries was found to be 3.55

episodes/1,000 patient days and the prevalence was esti-

mated to be 10.65/1,000 [15].

The prevalence of HAUTI in urological departments

was 11% in the combined analysis of the Pan European

Prevalence (PEP) study and the Pan Euro-Asian Prevalence

(PEAP) study [16]. The largest group was asymptomatic

bacteriuria (29%) followed by cystitis (26%), pyelone-

phritis (21%) and urosepsis (12%). The prevalence of

HAUTIs was found to be 14.7% in the Global Prevalence

Study on Infections in Urology (GPIU) 2008 also showing

a rising percentage of urosepsis from 9.3% in 2006 to

21.8% in 2008, while the prevalence of HAUTI stayed

more or less stable around 14% in the same period [17].

This suggests that prophylactic measures in various urol-

ogy clinics may not be appropriate [18].

Risk factors

Several characteristics related to the healthcare provider,

the patient and the procedures are known to increase the risk

of HAUTI. The most important risk factors for HAUTI are

an indwelling catheter and the duration of catheterization

[19]. Other significant risk factors are (1) UTI during the

previous 12 months; (2) urinary tract obstruction; (3) uri-

nary stones; (4) previous antibiotic usage within the last

3 months; and (5) hospitalization within the last 6 months

due to any reason [19]. The study also showed that for

patients having more than three risk factors, there was a

significantly increased risk of having a Candida sp., Kleb-

siella sp. or Pseudomonas sp. as a causative pathogen, when

compared to those patients with three or less risk factors.

Another recent study also found strong evidence

between HAUTI and prolonged length of stay (OR 5.28),

urinary catheter (OR 5.16) [20], unresolved spinal injury

(OR 4.07), fracture/dislocation on admission (OR 3.34),

transfer to/from another hospital (OR 2.9), underlying

neurologic disease (OR 2.59), some assistance required

prior to admission (OR 2.58), previous stroke (OR 1.94)

and male sex was protective (OR 0.44) [20]. Information

on the effectiveness of risk-reducing strategies in those risk

groups is now warranted. Studies suggested also the

severity score of hospitalized patients as an important risk

factor for the development of HAUTI [11, 21]. On the

other hand, immunosuppressant therapy within 14 days,

history of malignancy, cigarette smoking in the past and

male sex are shown to be risk factors for healthcare-asso-

ciated urinary tract-related bacteremia [22].

Bacterial spectrum

Whereas community-acquired UTI are often uncompli-

cated, almost all HAUTIs are complicated infections with

structural or functional abnormalities within the urinary

tract, such as indwelling catheters or some kind of urinary

obstruction. The bacterial etiology of UTI differs markedly

between uncomplicated and complicated UTIs, which is

mainly due to the fact that bacteria causing uncomplicated

UTI are highly selected clones with an array of virulence

factors, which are not required to such an extent in bacteria

causing complicated UTI [23].

Bacterial spectrum in complicated HAUTI

The bacterial spectrum of complicated HAUTIs comprises

a wide range of Gram-negative and Gram-positive species.

The bacterial spectrum can vary geographically, over the

time and between distinct specialities at the same institu-

tion [24] (LoE 3).

World J Urol (2012) 30:59–67 61

123

Bacterial spectrum of HAUTI in North America

(SENTRY study)

The SENTRY antimicrobial surveillance program, initiated

in 1997, has chronologically examined urinary pathogens

collected from hospitalized patients from different hospital

departments across North America and thus provides

insight into pathogen frequency and resistance rates [25]

(LoE 3). A surveillance study based on 1998 data encom-

passed 31 North American institutions, which examined

1,510 urinary isolates from hospitalized patients from dif-

ferent departments [26] (Table 1).

Bacterial spectrum of HAUTI in Europe

(ESGNI-003 study)

A European multicenter one-day prevalence study on

HAUTI of patients from different hospital departments

tested 607 uropathogens from 228 hospitals throughout

Europe [27] (LoE 2b). Patients from different departments

throughout the hospital were evaluated (Table 1).

Bacterial spectrum of HAUTI in urological patients

in Europe (PEP-study)

A European multicenter one-day prevalence study on

HAUTI in urology tested 320 uropathogens from 232

urological departments throughout Europe [19] (LoE 3)

(Table 1).

Antibiotic resistance

Since antibiotics have been introduced into clinical medi-

cine, antibiotic-resistant bacteria have evolved. The epi-

demiology of antibiotic-resistant bacteria, however, varies

from region to region, from speciality to speciality, from

infection type to infection type and from time to time.

Antibiotic resistance in complicated HAUTI

Healthcare-associated uropathogens are frequently subject

to antibiotic pressure and cross-infection [28] (LoE 2b).

The influence of these parameters can vary between

regions and specialities [24] (LoE 3). Different species of

uropathogens show distinct abilities to develop antibiotic

resistance.

Antibiotic resistance in HAUTI in North America,

Latin America and Europe (SENTRY study)

In the SENTRY study, which was a laboratory-based study,

a central reference laboratory was employed using NCCLS

(National Committee for Clinical Laboratory Standards)

criteria [26] (LoE 3). Strains were sent from the local

microbiology laboratories. Global resistance rates (com-

bined resistance of E. coli, Klebsiella spp., P. aeruginosa

and Enterococci) in North America for Ampicillin,

Amoxicillin/clavulanate, Trimethoprim/Sulfamethoxazole

and Ciprofloxacin were 59, 31, 43 and 29%, respectively.

Global resistance rates in Latin America for Ampicillin,

Amoxicillin/clavulanate, Trimethoprim/Sulfamethoxazole

and Ciprofloxacin were 62, 36, 38 and 32%, respectively.

Global resistance rates in Europe for Ampicillin, Amoxi-

cillin/clavulanate, Trimethoprim/Sulfamethoxazole and

Ciprofloxacin were 62, 36, 38 and 32%, respectively

(Table 1).

Antibiotic resistance in HAUTI in Europe

(ESGNI-003 study)

The European Study Group on Nosocomial Infections

(29 countries) also evaluated antimicrobial susceptibility

against hospital-acquired urinary isolates [27] (LoE 2b).

Sensitivity assays were not performed in a central labora-

tory, and local results of susceptibility testing were taken at

face value. During 1999, 607 organisms from 522 patients

with HAUTI were tested. For E. coli, resistance rates were

comparable to those observed from the North American

SENTRY experience (Table 1): TMP/SMX (28%), ampi-

cillin (55%), ciprofloxacin (9%) and gentamicin (6%).

However, it is worth noting that non-European Union

countries tended to have higher rates of E. coli resistance

than European Union countries.

In particular, amikacin, ceftazidime and cefepime were

the most active agents ([90% susceptible), imipenem and

tobramycin were moderately active ([85% susceptible)

and ciprofloxacin and gentamicin were the least active

(*75% susceptible). In contrast, P. aeruginosa isolates

from non-European Union countries (e.g., Estonia, Serbia)

showed resistance rates of over 50% for fluoroquinolones

and non-amikacin aminoglycosides. The authors specu-

lated that this high rate of resistance to pseudomonal

strains might be explained by the lack of strict antimi-

crobial policies in hospitals within non-European Union

countries.

Antibiotic resistance in HAUTI in urological patients

in Europe (PEP-study)

The PEP-study also evaluated resistance rates of uropath-

ogens causing HAUTI in urological patients [19] (LoE 3).

However, there was no reference laboratory, and different

standards were employed for testing of the strains (178

hospitals employed NCCLS criteria, 34 DIN (Deutsches

Institut fur Normung) criteria, and 20 other criteria) and not

62 World J Urol (2012) 30:59–67

123

all hospitals have tested all antibiotics. Global resistance

rates for the total bacterial spectrum were as follows

(Table 1): Ampicillin 51%, ampicillin ? beta-lactamase

inhibitor 30%, piperacillin 21%, piperacillin/tazobactam

15%, cefazolin 44%, cefuroxime 25%, ceftazidime 17%,

cefepime 21%, imipenem 7%, gentamicin 34%, amikacin

14%, ciprofloxacin 34% and TMP/SMZ 45%.

In all these studies, increasing resistance rates were

found for some species like E. coli, but not for all uro-

pathogens. However, resistance rates may vary substan-

tially between regions. Additionally, the results of those

studies were published almost 10 years ago, and more

recent published data on HAUTI are missing. Therefore,

timely, local, hospital-based surveillance of the bacterial

spectrum and antibiotic sensitivity is paramount for a

rational empiric therapy.

Treatment for HAUTI

As mentioned earlier, HAUTI is mainly catheter associated.

HAUTI has to be distinguished from asymptomatic bacte-

riuria, which does not need antibiotic therapy according to

the current guidelines, except before an traumatizing inter-

vention of the urinary tract and in pregnant women [29, 30]

(LoE 1a). However, by cross-contamination and cross-

infection healthcare-associated asymptomatic bacteriuria

may also contribute significantly to the distribution of

Table 1 Antimicrobial spectrum of healthcare-associated uropathogens (C2%) from distinct surveillance studies

Name of study SENTRY [33] SENTRY [33] SENTRY [33] ESGNI-003 [27] PEP-study [19]

Regions of the world North America Latin America Europe Europe Europe

Year of surveillance 2000 2000 2000 2000 2003

Type of surveillance Longitudinal Longitudinal Longitudinal Cross-section Cross-section

Origin of samples Microbiology

laboratories

Microbiology

laboratories

Microbiology

laboratories

Different departments in the

hospital

Urology

departments

Number of pathogens n = 1,466 n = 531 n = 783 n = 607 n = 320

Species %

E. coli 43 60 46 36 35

Klebsiella spp. 12 12 9 8 10

Pseudomonas spp. 7 6 9 7 13

Proteus spp. 6 7 10 8 7

Enterobacter spp. 3 4 4 4 3

Citrobacter spp. 4 2 2 2 n.r.

Enterococcus spp. 16 4 13 16 9

Staphylococcus spp. 6 3 3 4 4

Candida spp. n.r. n.r. n.r. 9 4

Resistance rates of

antibiotics %

Ampicillin 59e 62e 65e 66a 51

Ampicillin ? BLI 31e 36e 36e 29a 30

TMP/SMZ 43e 38e 48e 32a 45

Ciprofloxacin 29e 32e 29e 17b 34

Gentamicin n.r. n.r. n.r. 18 34

Ceftazidime n.r. n.r. n.r. 13c 17

Amikacin n.r. n.r. n.r. 19c 14

Piperacillin/tazobactam n.r. n.r. n.r. n.r. 15

Imipenem n.r. n.r. n.r. 14c 7

Vancomycin n.r. n.r. n.r. 1d n.r.

n.r. Not reporteda Gram-negative bacteria excluding P. aeruginosab Gram-negative bacteriac P. aeruginosad Enteroccocie E. coli, Klebsiella spp., P. aeruginosa, Enterococci

World J Urol (2012) 30:59–67 63

123

resistant uropathogens throughout the institution (nursing

home and hospital) [28] (LoE 2b) and also throughout the

community in case of an outpatient care setting. Therefore,

healthcare-associated asymptomatic bacteriuria may be an

important factor for the spread of resistant uropathogens and

should therefore be included into a systematic (not routine)

surveillance. But in general, antibiotic therapy should only

be considered for symptomatic HAUTI. In some situations,

however, the distinction between healthcare-associated

asymptomatic bacteriuria and symptomatic HAUTI may be

difficult, e.g., intensive care medicine, patients with spinal

cord injury, physically and mentally handicapped (geriatric)

patients or children in young age. Careful consideration of all

clinical parameters is necessary in those instances before

antibiotic therapy is initiated. On the other hand, if systemic

signs or symptoms such as fever or chills appear the urinary

tract should be thoroughly investigated.

General aspects of antibiotic therapy of UTI

In the antimicrobial treatment of uncomplicated UTIs, the

rapid elimination of the pathogen is most important. In

complicated HAUTIs, the primary goal of antibiotic ther-

apy is to limit the infection and prevent the emergence of

resistant mutants.

Drusano and Craig determined four parameters for the

rational dosing of an antibiotic in a population [31]:

1. the minimal inhibitory concentration (MIC) of the

clinical isolates.

2. the pharmacokinetic (pk) profile.

3. the pharmacodynamic (pd) profile.

4. the protein binding of the applied antibiotic.

The distribution of the MIC values of nosocomial clin-

ical isolates is the greatest variable parameter, and the

MICs vary geographically and by time [32, 33] (LoE 2b).

The other three parameters are usually determined from

Phase I to III studies. There is, however, a surprisingly high

interindividual variation. Certain subgroups of patients,

however, are not studied, and recommendations for anti-

biotic therapy must be extrapolated from the results of

other related groups. An additional 5th parameter is

extremely important for the treatment of HAUTI. In many

cases of complicated UTIs, biofilm infection is predomi-

nant, which leads to reduced susceptibility of the pathogens

[34] (LoE 2b). Antimicrobial therapy in complicated UTIs

may only kill the bacteria dissolved from the biofilm

(planktonic form) and thus inhibits the spread of the

infectious process. An accompanying urological therapy

must aim to remove the biofilm. In any case, antibiotics

with best performance in biofilm infection should be

selected and the dosage should generally be high when

treating complicated HAUTIs [35]. The dosage should

even be sufficiently high enough to eradicate also the first

step resistant mutants [36] (LoE 3).

At least in severe UTIs, adequate initial antibiotic

therapy results in lower mortality compared with inade-

quate antibiotic treatment [37] (LoE 3). Susceptibility

testing should be carried out in any case of HAUTI, and if

possible, the results should be awaited before treatment.

However, in severe infections, an initial empiric therapy

must be instigated immediately after microbiological

sampling. Susceptibility testing can serve in these cases to

narrow the antibiotic coverage. Provisional microbiological

findings, such as reports on Gram-stain or certain bio-

chemical results, such as oxidase, coagulase and catalase,

can lead to early stratification of pathogens and allow a

more tailored empiric antibiotic therapy [38] (LoE 3).

Prudent use of antimicrobials may also help to reduce the

selection of resistant pathogens to a minimum.

Antibiotic selection for therapy of complicated HAUTI

and urosepsis

Antibiotics with an enlarged antibacterial spectrum are

necessary for initial empiric treatment in severe cases [39]

(LoE 4). The empiric parenteral treatment could start with

a cephalosporin group 3a, a fluoroquinolone with good

renal excretion or with an aminopenicillin in combination

with a beta-lactamase inhibitor. If clinical improvement

fails after 2–3 days, treatment should be switched to a

pseudomonas active acylaminopenicillin/beta-lactamase

inhibitor, a group 3b cephalosporin or a group 1 carbape-

nem. Other reasons for treatment failure, such as persistent

complicating factors, other infections or non-infectious

sources, should also be taken into account and be

re-evaluated. Local and regional variations in resistance

must be also considered for empiric treatment.

The use of parenteral antibiotics is determined by the

general condition of the patient (e.g., nausea and vomiting)

and the severity of the infection; oral antibiotics can be

continued as soon as the clinical situation has improved.

After the results of the susceptibility testing have arrived,

the antibiotic treatment should be aligned accordingly.

Treatment duration should continue for at least 3–5 days

beyond defervescence, dependent on the removal of the

complicating factor. However, this recommendation does

not hold true for the treatment of pyelonephritis with

abscess formation or chronic bacterial prostatitis, which

should usually continue for several weeks.

Prevention of HAUTI

The best treatment is prevention; this is also true for

HAUTI. Since most HAUTIs are catheter associated,

64 World J Urol (2012) 30:59–67

123

optimal management of any indwelling catheter and pre-

vention of catheter-associated UTI should be of highest

priority in urology.

Prevention of HAUTI in short-term indwelling

catheterization

According to CDC guidelines, prevention of catheter-

associated UTI is the gold standard for prevention of

HAUTI [40]. The following have to be considered:

1. staff education about catheter management,

2. catheterization only when indicated and prompt

removal of indwelling catheters,

3. Handwashing,

4. catheter insertion with aseptic technique and sterile

equipment,

5. maintenance of a closed urinary drainage system,

6. silver- or antibiotic-coated urinary catheter may reduce

the risk of catheter-associated bacteriuria [41, 42]

(LoE 1b), but whether this also holds true for episodes

of symptomatic catheter-associated UTI, needs to be

shown, and

7. a short-term antibiotic prophylaxis at urinary catheter

removal may prevent UTI after short-term indwelling

catheterization [43] (LoE 1b), however may increase

the total antibiotic selection pressure for the develop-

ment of antibiotic resistance.

Prevention of HAUTI in long-term indwelling

catheterization

The CDC guidelines mentioned earlier have been developed

only for the patients with short-term indwelling urethral

catheterization. Catheter-associated bacteriuria is ultimately

not avoidable in patients with long-term indwelling cathe-

terization. Since most catheter-associated bacteriuria with

long-term indwelling catheterization are asymptomatic [44]

(LoE 3), prevention of symptomatic episodes is the aim to

look for. The following practical points are recommended,

but the level of evidence is low (LoE 4).

1. Hydration—the increase in urine volume by hydration

results in washout of bacteria from the urinary bladder

and thus inhibiting bacterial growth in the urinary

bladder. Hydration also prevents obstruction of the

urethral catheter due to encrustation.

2. Catheter exchange—routine catheter exchange is usually

performed every 4–6 weeks. However, the optimal

frequency of catheter exchange depends on the individual

patient, because the catheter encrustation sometimes

happens in shorter periods. In these cases, catheter

exchange should be performed more frequently.

3. No antimicrobial prophylaxis—antimicrobial prophy-

laxis can delay the occurrence of catheter-associated

bacteriuria. However, the incidence of drug-resistant

bacteria increases in the presence of antimicrobial

prophylaxis. Therefore, antimicrobial prophylaxis for

prevention of catheter-associated bacteriuria should be

avoided [5] (LoE 4).

Avoidance of long-term indwelling catheterization

To prevent catheter-associated UTI, long-term indwelling

catheterization should be avoided at the first place. There

are two frequent indications for long-term bladder

catheterization:

• incomplete emptying of the bladder

and

• non-obstructive incontinence.

In both indications attempts, such as (1) medications for

complete emptying the urinary bladder, (2) operative tech-

niques such as deobstruction in case of prostatic obstruction

in males [45, 46], or pelvic floor reconstruction in case of

pelvic floor disorders, such as cystocele formation, (3) clean

intermittent catheterization; or (4) urethral stent for benign

prostatic enlargement [47, 48] (LoE 3), [49, 50] (LoE 3) may

be considered. There is little evidence whether clean inter-

mittent catheterization prevents symptomatic UTIs [51]

(LoE 4). The frequency of clean intermittent catheterization

may be important for the prevention of UTIs.

Further research

In the past most studies did not distinguish between

healthcare-associated symptomatic UTI and asymptomatic

bacteriuria. There is now agreement that healthcare-asso-

ciated asymptomatic bacteriuria should not be treated with

antimicrobials; therefore, routine screening for bacteriuria

seems to be not indicated. However, its impact to induce

infections when spread to other patients is not well

understood. Prospective studies are needed to clarify,

whether systematic surveillance of healthcare-associated

asymptomatic bacteriuria is recommended and if so, at

what time intervals.

Conclusions

HAUTIs are almost exclusively complicated UTI and

mainly catheter associated. Healthcare-associated asymp-

tomatic bacteriuria should not be treated with antimicrobials

World J Urol (2012) 30:59–67 65

123

except before traumatizing interventions of the urinary

tract and in pregnant women. Besides of an adequate

antibiotic therapy, the complicating factors need to be

treated effectively. For initial empiric therapy, the local

susceptibility profile of common uropathogens such as

E. coli must be known to choose the most appropriate

antibiotic. In case of severe, bacteremic UTI, it has been

shown that an inadequate initial antibiotic regimen has an

elevated mortality. Before initiation of antibiotic therapy, a

urine specimen for culture must be obtained to be able to

adapt the antibiotic regimen to the susceptibility profile.

Increasing antibiotic resistance requires a more prudent use

of antimicrobial drugs also in the treatment of HAUTI.

Conflict of interest The authors declare that they have no conflict

of interest.

References

1. Hooton TM, Carlet JM, Duse AG, Krieger JN, Steele L, Sunak-

awa K (2001) Definitions and epidemiology. In: Naber KG,

Pechere JC, Kumazawa J, Khoury S, Gerberding JL, Schaeffer AJ

(eds) Nosocomial and Health Care Associated Infections in

Urology. Health Publication, Plymouth

2. Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveil-

lance definition of health care-associated infection and criteria for

specific types of infections in the acute care setting. Am J Infect

Control 36(5):309–332

3. Gastmeier P, Kampf G, Wischnewski N, Hauer T, Schulgen G,

Schumacher M et al (1998) Prevalence of nosocomial infections

in representative German hospitals. J Hosp Infect 38(1):37–49

4. Ruden H, Gastmeier P, Daschner FD, Schumacher M (1997)

Nosocomial and community-acquired infections in Germany.

Summary of the results of the First National Prevalence Study

(NIDEP). Infection 25(4):199–202

5. Maki DG, Tambyah PA (2001) Engineering out the risk for

infection with urinary catheters. Emerg Infect Dis 7(2):342–347

6. Tambyah PA, Knasinski V, Maki DG (2002) The direct costs of

nosocomial catheter-associated urinary tract infection in the era

of managed care. Infect Control Hosp Epidemiol 23(1):27–31

7. Wagenlehner FME, Cek M, Kiyota H, Bjerklund-Johansen TE

(2010) Epidemiology, treatment and prevention of health-care

associated urinary tract infections. In: Naber KG, Schaeffer AJ,

Heyns C, Matsumoto T, Shoskes D, Bjerklund-Johansen TE

(eds) Urogenital infections. European Association of Urology—

International Consultation on Urological Diseases, Arnhem,

pp 575–588

8. US Department of Health and Human Services, Public Health

Service, Agency for Health Care Policy and Research (1992)

pp 115–127

9. Abrams P, Khoury S, Grant A (2007) Evidence–based medicine

overview of the main steps for developing and grading guideline

recommendations. Prog Urol 17(3):681–684

10. Levy SB, Marshall B (2004) Antibacterial resistance worldwide:

causes, challenges and responses. Nat Med 10(12 Suppl):S122–

S129

11. Safdar N, Maki DG (2002) The commonality of risk factors for

nosocomial colonization and infection with antimicrobial-resis-

tant Staphylococcus aureus, enterococcus, gram-negative bacilli,

Clostridium difficile, and Candida. Ann Intern Med 136(11):

834–844

12. Weinstein RA (1998) Nosocomial infection update. Emerg Infect

Dis 4(3):416–420

13. National Nosocomial Infections Surveillance (NNIS) (2004)

System Report, data summary from January 1992 through June

2004, issued October 2004. Am J Infect Control 32(8):470–485

14. Cited 2011 02.06.2011. Available from: http://www.cdc.gov/

nhsn/PDFs/dataStat/2010NHSNReport.pdf

15. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J (2001) A

European perspective on nosocomial urinary tract infections II.

Report on incidence, clinical characteristics and outcome (ES-

GNI-004 study). European Study group on nosocomial infection.

Clin Microbiol Infect 7(10):532–542

16. Bjerklund Johansen TE, Cek M, Naber K, Stratchounski L,

Svendsen MV, Tenke P (2007) Prevalence of hospital-acquired

urinary tract infections in urology departments. Eur Urol

51(4):1100–1112

17. Tandogdu Z, Cek M, Tenke P, Naber K, Bjerklund Johansen TE

(2010) Prevalence of nosocomial urinary tract infections: what

has changed in years. In: European Urology Supplements. 25th

Anniversary EAU congress 2010. European Association of

Urology, Barcelona, p 171

18. Naber KG (2006) Urogenital infections: the pivotal role of the

urologist. Eur Urol 50(4):657–659

19. Johansen TE, Cek M, Naber KG, Stratchounski L, Svendsen MV,

Tenke P (2006) Hospital acquired urinary tract infections in

urology departments: pathogens, susceptibility and use of anti-

biotics. Data from the PEP and PEAP-studies. Int J Antimicrob

Agents 28(Suppl 1):S91–S107

20. Graves N, Tong E, Morton AP, Halton K, Curtis M, Lairson D

et al (2007) Factors associated with health care-acquired urinary

tract infection. Am J Infect Control 35(6):387–392

21. Leone M, Albanese J, Garnier F, Sapin C, Barrau K, Bimar MC

et al (2003) Risk factors of nosocomial catheter-associated uri-

nary tract infection in a polyvalent intensive care unit. Intensive

Care Med 29(7):1077–1080

22. Saint S, Kaufman SR, Rogers MA, Baker PD, Boyko EJ, Lipsky

BA (2006) Risk factors for nosocomial urinary tract-related

bacteremia: a case-control study. Am J Infect Control 34(7):

401–407

23. Dobrindt U, Chowdary MG, Krumbholz G, Hacker J (2010)

Genome dynamics and its impact on evolution of Escherichiacoli. Med Microbiol Immunol 199(3):145–154

24. Tambic A, Tambic T, Kucisec-Tepes N (1996) Prevalence and

antibiotic sensitivity pattern variations of bacterial isolates in

different settings and different periods of time. Acta med Croatica

50:5–10

25. Jones RN, Kugler KC, Pfaller MA, Winokur PL (1999) Charac-

teristics of pathogens causing urinary tract infections in hospitals

in North America: results from the SENTRY Antimicrobial

Surveillance Program, 1997. Diagn Microbiol Infect Dis

35(1):55–63

26. Mathai D, Jones RN, Pfaller MA (2001) Epidemiology and fre-

quency of resistance among pathogens causing urinary tract

infections in 1,510 hospitalized patients: a report from the

SENTRY Antimicrobial Surveillance Program (North America).

Diagn Microbiol Infect Dis 40(3):129–136

27. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J (2001) A

European perspective on nosocomial urinary tract infections I.

Report on the microbiology workload, etiology and antimicrobial

susceptibility (ESGNI-003 study). European Study Group on

Nosocomial Infections. Clin Microbiol Infect 7(10):523–531

28. Wagenlehner FM, Krcmery S, Held C, Klare I, Witte W,

Bauernfeind A et al (2002) Epidemiological analysis of the

spread of pathogens from a urological ward using genotypic,

phenotypic and clinical parameters. Int J Antimicrob Agents

19(6):583–591

66 World J Urol (2012) 30:59–67

123

29. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton

TM (2005) Infectious Diseases Society of America guidelines for

the diagnosis and treatment of asymptomatic bacteriuria in adults.

Clin Infect Dis 40(5):643–654

30. Nicolle LE, Zhanel GG, Harding GK (2006) Microbiological

outcomes in women with diabetes and untreated asymptomatic

bacteriuria. World J Urol 24(1):61–65

31. Drusano GL, Preston SL, Hardalo C, Hare R, Banfield C, Andes

D et al (2001) Use of preclinical data for selection of a phase II/

III dose for evernimicin and identification of a preclinical MIC

breakpoint. Antimicrob Agents Chemother 45(1):13–22

32. Kahlmeter G (2003) An international survey of the antimicrobial

susceptibility of pathogens from uncomplicated urinary tract

infections: the ECO.SENS project. J Antimicrob Chemother

51(1):69–76

33. Gordon KA, Jones RN (2003) Susceptibility patterns of orally

administered antimicrobials among urinary tract infection

pathogens from hospitalized patients in North America: com-

parison report to Europe, Latin America. Results from the

SENTRY Antimicrobial Surveillance Program (2000). Diagn

Microbiol Infect Dis 45(4):295–301

34. Goto T, Nakame Y, Nishida M, Ohi Y (1999) Bacterial biofilms

and catheters in experimental urinary tract infection. Int J Anti-

microb Agents 11(3–4):227–231 (discussion 37–39)

35. Pea F, Pavan F, Di Qual E, Brollo L, Nascimben E, Baldassarre

M et al (2003) Urinary pharmacokinetics and theoretical phar-

macodynamics of intravenous levofloxacin in intensive care unit

patients treated with 500 mg b.i.d. for ventilator-associated

pneumonia. J Chemother 5(6):563–567

36. Zhao X, Drlica K (2008) A unified anti-mutant dosing strategy.

J Antimicrob Chemother 62(3):434–436

37. Elhanan G, Sarhat M, Raz R (1997) Empiric antibiotic treatment

and the misuse of culture results and antibiotic sensitivities in

patients with community-acquired bacteraemia due to urinary

tract infection. J Infect 35(3):283–288

38. Wagenlehner E, Niemetz A, Naber G (2003) Spectrum of

pathogens and resistance to antibiotics in urinary tract infections

and the consequences for antibiotic treatment: study of urology

inpatients with urinary tract infections (1994–2001). Urologe A

42(1):13–25

39. Grabe M, Bishop M, Bjerklund-Johansen TE, Botto H, Cek M,

Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner F (2009)

Guidelines on urological infections. In: EAo Urology (ed)

European Association of Urology Guidelines. European Associ-

ation of Urology, Arnhem, pp 1–110

40. Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T,

Tambyah PA, Naber KG (2008) European and Asian guidelines on

management and prevention of catheter-associated urinary tract

infections. Int J Antimicrob Agents 31(Suppl 1):S68–S78

41. Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM (2000)

A randomized crossover study of silver-coated urinary catheters in

hospitalized patients. Arch Intern Med 160(21):3294–3298

42. Al-Habdan I, Sadat-Ali M, Corea JR, Al-Othman A, Kamal BA,

Shriyan DS (2003) Assessment of nosocomial urinary tract

infections in orthopaedic patients: a prospective and comparative

study using two different catheters. Int Surg 88(3):152–154

43. Pfefferkorn U, Lea S, Moldenhauer J, Peterli R, von Flue M,

Ackermann C (2009) Antibiotic prophylaxis at urinary catheter

removal prevents urinary tract infections: a prospective ran-

domized trial. Ann Surg 249(4):573–575

44. Tambyah PA, Maki DG (2000) Catheter-associated urinary tract

infection is rarely symptomatic: a prospective study of 1,497

catheterized patients. Arch Intern Med 160(5):678–682

45. Bach T, Netsch C, Haecker A, Michel MS, Herrmann TR, Gross

AJ (2010) Thulium: YAG laser enucleation (VapoEnucleation) of

the prostate: safety and durability during intermediate-term fol-

low-up. World J Urol 28(1):39–43

46. Lourenco T, Shaw M, Fraser C, MacLennan G, N’Dow J, Pickard

R (2010) The clinical effectiveness of transurethral incision of the

prostate: a systematic review of randomised controlled trials.

World J Urol 28(1):23–32

47. Oesterling JE (1991) A permanent, epithelializing stent for the

treatment of benign prostatic hyperplasia. Preliminary results.

J Androl 12(6):423–428

48. Gottfried HW, Schlmers HP, Gschwend J, Brandle E, Hautmann

RE (1994) Thermosensitive stent (Memotherm) for the treatment

of benign prostatic hyperplasia. Arch Esp Urol 47(9):933–943

49. Ala-Opas M, Talja M, Tiitinen J, Hellstrom P, Heikkinen A,

Nurmi M (1993) Prostakath in urinary outflow obstruction. Ann

Chir Gynaecol Suppl 206:14–18

50. Poulsen AL, Schou J, Ovesen H, Nordling J (1993) Memokath: a

second generation of intraprostatic spirals. Br J Urol 72(3):

331–334

51. Moore KN, Fader M, Getliffe K (2007) Long-term bladder

management by intermittent catheterisation in adults and chil-

dren. Cochrane Database Syst Rev (4):CD006008

World J Urol (2012) 30:59–67 67

123