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Clinical and economic consequences of nosocomial catheter-related bacteriuria*,**,*

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Abstract

Indwelling catheters are strongly associated with the development of bacteriuria, which can lead to significant morbidity in hospitalized patients. This report, a review of the literature, evaluates the infectious outcomes of patients with indwelling catheters to determine the precise clinical and economic impact of catheter-related infection. Statistical pooling was used to estimate the incidence of bacteriuria in hospitalized patients with indwelling catheters. In addition, the proportion of patients with catheter-related bacteriuria in whom symptomatic urinary tract infection and bacteremia will develop was estimated through quantitative synthesis of previous reports. Costs were estimated by using microcosting techniques.

Of patients who have indwelling catheters for 2 to 10 days, bacteriuria is expected to develop in 26% (95% confidence interval [CI], 23% to 29%). Among patients with bacteriuria symptoms of urinary tract infection will develop in 24%, (95% CI, 16% to 32%), and bacteremia from a urinary tract source will develop in 3.6% (95% CI, 3.4% to 3.8%). Each episode of symptomatic urinary tract infection is expected to cost an additional $676, and catheter-related bacteremia is likely to cost at least $2836. Given the clinical and economic burden of urinary catheter-related infection, infection control professionals and hospital epidemiologists should use the latest infection control principles and technology to reduce this common complication. (AJIC Am J Infect Control 2000;28:68-75.)

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.

. General characteristics of 10 prospective studies used to estimate the cumulative incidence of bacteriuria in patients with indwelling catheters

SourceNumber 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.

    **

    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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