Urinary Tract Infections

„ Leading cause of morbidity and health

care expenditures in persons of all ages.

„ An estimated 50 % of women report

having had a UTI at some point in their
lives.

„ 8.3 million office visits and more than 1

million hospitalizations, for an overall
annual cost > $1 billion.
 Virulence Host factors

Infection No infection

UTIs may occur either because of

the pathogenicity of the organism,
the susceptibility of the host or a
combination of both factors
Peter Ulleryd, Sahlgrenska University Hospital, Göteborg, Sweden
Virulence factors of the gram-negative uropathogens E. coli and P. mirabilis
 Host defenses
Antibacterial properties of urine Anti-adherence mechanisms
• Osmolality (extremes of • Bacterial interference
Urinary Catheterization
high or low osmolalities (naturally endogenous
inhibit bacterial growth) bacteria in the urethra,
• High urea concentration vagina, and periurethral
region)
• High organic acid alters these • Urinary oligosaccharides
concentration
• pH (have the potential to
detach epithelial-bound E.
defensive mechanisms coli
• Tamm-Horsfall protein
Miscellaneous (uromucoid): coating of E.
coli by this protein might
• Mucopolysaccharide lining of the bladder prevent attachment
• Urinary immunoglobulins
• Spontaneous exfoliation of uroepithelial cells with bacterial
detachment
• Mechanical flushing of micturition
 Catheter-Associated UTI
„ Risk of bacteriuria is ~ 5%/day (long
term catheter bacteriuria is inevitable).
„ 40% of nosocomial infections
„ Most common source of gram-negative
bacteremia.
„ Etiology: E.coli, Proteus, Enterococcus,
Pseudomona, Enterobacter, Serratia,
Candida
 Duration of cahteterization
Daily Prevalence of Acquired Bacteriuria in Patients
Receiving Bladder Drainage by Indwelling Urethral Catheters

Garibaldi et al. Factors predisposing to bacteriuria during indwelling

uretheral catheterization. N Engl J Med 1974;291:215.
Risk Factors Associated with the Development of CAUTI

Increasing duration of catheterization

Not receiving system antibiotic therapy
Female sex
Diabetes mellitus
Older age
Rapidly fatal underlying diseases
Nonsurgical diseases
Faulty aseptic management of the indwelling catheter
Bacterial colonization of drainage bag
Azotemia (serum creatinine concentration > 2 mg/dl
Catheter not connected to a urine meter
Periurethral colonization with uropathogens
Asymptomatic Bacteriuria
• The best way to avoid having patients
develop IUC-related UTIs is to avoid initial
catheter insertion or to minimize the
duration of catheter use.

• UTIs are the tenth most likely reason for a

Medicare patient to have an unplanned
readmission to the hospital

Lee EA Perm J 2011

CA-UTI reduction initiatives began in late
2007 by creation of a catheter
management and removal policy:
• nurse and care partner education
• check off on sterile technique
• insertion competency
• strict guidelines on catheter and perineal
skin care
• mandatory removal of the urinary catheter
at 5 days unless a counter-order was
written.
Community-Acquired UTI

E. coli

S.epidermidis &
gram neg enterics
Enterococcus
Proteus
S.saprophyticus
K.pneumoniae
 Nosocomial UTI
catheter associated
Short Term Long Term
E.coli
Enterobacter E.coli

Enterococcus Proteus

Candida

Proteus
S.aureus Providencia
Morganella
Pseudomonas
Pseudomonas
 By patient age

FQ resistance

By patient sex

With time
Smithson A EJCMID 2011
 Prevalence (%) of ESBL producing isolates by species in
Assistance Publique Hopitaux de Paris long-term-care facilities
(2001–2005).

Nicolas-Chanoine et al. CMI 2008

Risk factors for ESBL-producing Escherichia coli
and Klebsiella pneumoniae

Mendelson et al EJCMID 2005

Multivariate logistic regression analyses:

• Fluoroquinolone use days: OR 1.33 (1.04–

1.69) P=0.02

• History of UTI: OR 2.56 (1.37–4.78)

P=0.003
Multidrug-Resistant Organisms in LTCF

• MDRGN were isolated more frequently than MRSA

or VRE throughout the study period.

• More than 80% of MDRGN isolates were resistant

to ciprofloxacin, TMP/SMX, and
ampicillin/sulbactam.

• Resistance to three, four, or more antimicrobials

were identified among 122 (67.8%), 47 (26.1%), and
11 (6.1%) MDRGN isolates, respectively.

O’Fallon J Gerontol. 2009

 Acquisition of Multidrug-Resistant Gram-
Negative Bacteria within a LTCF Population

O’Fallon E et al ICHE 2010

• There were significantly higher antibiotic
costs, re-consultation costs and total costs
for patients whose infections were
resistant to at least one antibiotic.

IJAA 2009
Appropriateness by Site of Infection
50
Appropriate
Inappropriate
40
p=0.76
30

20

10

0
ry l e t t r
i nary at o ti na
i ssu r oa T rac t he
Ur ir es h l O
e sp o int oft T se/T nit a
R r S o Ge
st in/ r/N
Ga Sk Ea

Lautenbach, Arch Intern Med 2003;163:601

What factors or conditions are likely
to have determined UTI?
What measures should have been
put in place to prevent it?