State of the ScienceClinical and economic consequences of nosocomial catheter-related bacteriuria*,**,*
Section snippets
DEFINITIONS
The definition of catheter-related UTI used in published reports varies and, unfortunately, the terms “urinary tract infection” and “bacteriuria” are often used interchangeably. This practice leads to unnecessary confusion. In this report, “bacteriuria” will be used to indicate significant growth of bacteria in the urine not associated with symptoms. The amount of growth probably is not vital, inasmuch as low-level growth from a catheterized specimen (ie, 102 colony-forming units [CFU]/mL)
METHODS
Relevant reports were located by several methods. The computerized MEDLINE database of English language articles published between January 1966 and November 1998 was searched with use of the Medical Subject Headings (MeSH) “urinary tract infections” or “urinary tract,” combined with the keyword “catheter#.” The MEDLINE database also was searched for articles written by selected authorities in the field of catheter-associated infection. Finally, other potential references were identified by
INCIDENCE OF CATHETER-RELATED BACTERIURIA
Several prospective studies have assessed patients with indwelling catheters daily to ascertain the incidence of bacteriuria.14, 15, 16, 17, 18, 19, 20, 21, 22, 23 These studies, outlined in Table 1, are of two types: natural history evaluations and randomized trials using controls that compare various methods of preventing bacteriuria.Source Number of
INCIDENCE OF SYMPTOMATIC CATHETER-RELATED URINARY TRACT INFECTION
Most patients with catheter-related bacteriuria remain free of symptoms. In many patients, however, local and systemic symptoms occur that indicate the patient may have a UTI. The proportion of patients with bacteriuria in whom symptomatic UTI develops was estimated by combining the only 2 prospective studies that were found in which this outcome was reported.51, 54 Garibaldi and colleagues found that 25 of 77 patients (32%) with bacteriuria at the University of Utah Medical Center had
INCIDENCE OF BACTEREMIA IN PATIENTS WITH BACTERIURIA
Catheter-related bacteremia occurs infrequently; however, when it complicates bacteriuria it is invariably consequential. Urinary catheter-related bacteremia is diagnosed when the same organism is isolated from both the urine and the blood cultures in the absence of other likely sources of infection. Clinical manifestations of bacteremia may include fever, chills, confusion, hypotension, and leukocytosis. Five studies have assessed the risk of bacteremia in patients with bacteriuria.4, 54, 55,
DEATH CAUSED BY CATHETER-RELATED INFECTION
Catheter-related bacteriuria is associated with an increased risk of death. Whether this relationship is causal is a matter of some controversy. Some believe that patients in whom catheter-related infection develops are fundamentally different from those in whom this catheter-related complication does not develop and, thus, may have a higher risk of dying because of these intrinsic factors. Proponents of this view would argue that acquisition of bacteriuria is merely a marker of severe
ECONOMIC CONSEQUENCES OF CATHETER-RELATED INFECTION
The clinical consequences of catheter-related infection undoubtedly increase health care costs for affected patients. The extent of this economic burden is unclear for several reasons. First, most of the economic evaluations performed in this area have become dated,60, 61, 62 given that changes in health care delivery and financing have led to substantial decreases in length of stay for most hospitalized patients.63, 64, 65 Second, previous evaluations often relied on billing data from
CONCLUSIONS
Indwelling catheter use is widespread in acute care settings across the United States. Although often a necessary intervention, urinary catheters unfortunately are the leading cause of UTIs in hospitalized patients. This quantitative synthesis of the literature estimates both the incidence of bacteriuria and the clinical consequences of bacteriuria by using accepted methods of statistical pooling. In addition, this report attempts to ascertain the economic burdens associated with
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Supported in part by a grant from the Association for Professionals in Infection Control and Epidemiology, Inc (APIC), Research Foundation. Dr. Saint was a Robert Wood Johnson Clinical Scholar at the time much of this work was conducted.
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Reprint requests: Sanjay Saint, MD, MPH, Division of General Medicine, University of Michigan Department of Internal Medicine, 3116 Taubman Center, Box 0376, Ann Arbor, MI 48109-0376. E-mail: [email protected].
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