BASIC CONCEPTS OF INFECTION CONTROL

Urinary Tract Infections

International Federation of
Infection Control

IFIC:2008

Urine is Normally Sterile

z

Urine is an ultrafiltrate of blood and is

normally sterile
z

small numbers of perineal/ vaginal/bowel

organisms in the distal urethra
constantly washed out by urination

Bacteriuria = bacteria in the urine

IFIC:2008

Diagnosis of UTI
z

Classic signs and symptoms are

z

Changes in urination
z
z
z

z
z

Dysuria (pain)
Frequency (increased frequency)
Nocturia (at night)

Bladder tenderness (cystitis)

Sometimes fever, increased peripheral
leucocytosis

However, these are unreliable for diagnosis

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Urinary Tract Sites Commonly

Associated with Infection

IFIC:2008

Significant Bacteriuria
z

Large amount of bacteria (>105/mL) in

bladder urine is evidence of true UTI

Smaller or insignificant amount of bacteria

may be due to contamination of the urine
specimen during collection, as urine passes
through urethra, or from the perineum or
genitalia

IFIC:2008

Quantitative Bacteriology
z

Microbiology labs count the number of

bacteria in a urine specimen as colonyforming units (cfu)

Significant bacteriuria, or 100,000 cfu/mL

urine in 2 carefully-collected mid-stream
urines (MSU), gives a >95% likelihood of
true UTI

IFIC:2008

Microbiological Support
z

The diagnosis of UTI in hospitals

depends on the microbiological support
available

In patients with indwelling catheters,

infections are frequently polymicrobial
z

The presence of multiple organisms does

not necessarily indicate contamination

IFIC:2008

Where Microbiological Support is

Poor or Unavailable
z

Clinical symptoms (fever, supra-pubic tenderness,

frequency, dysuria) may be useful (if not definitive)
in diagnosis, especially in non-catheterised patients

The presence of pyuria on microscopy or dip stick

(leukocyte esterase) is highly suggestive of UTI

A dip stick positive nitrite and leukocyte esterase

reactions is usually diagnostic

Organisms seen on microscopy of unspun urine

also is diagnostic if facilities are available
IFIC:2008

Careful Collection of Urine

z

Specimen contamination can be reduced by

z

Cleaning external urethral area before collection

Collecting MSUs: urethral organisms are washed

out in the first part of the stream

Processing specimen promptly, or refrigerating, to

prevent overgrowth of contaminants

Quantitative microbiology and potential

contamination or overgrowth are illustrated in
the following figures
IFIC:2008

True UTI with Significant

Bacteriuria
Bacteria in
bladder urine
multiply to
high numbers
before
collection

- -

- -

Infection
Infection

Natural
incubation
between
micturitions

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

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

>105 cfu/mL
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Urethral organisms contaminate specimens

with small numbers of bacteria

- -

- -

Incubation

Contamination

---

102 -103 cfu/mL

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Small numbers of contaminants increase

(overgrowth) if not processed promptly or
refrigerated

>105 cfu/mL
-- -- - - - - - - -- - -- - - - - - - - -- -- --- -

- -

- -

n
io
t
ba
u
c
In

102-103 cfu/mL
IFIC:2008

Overgrowth

UTIs Are Common

z

Usually caused by aerobic bacteria from

the large bowel/perineum ascending the
urethra and entering the bladder
z

It is more common in women than men

because of the short female urethra

IFIC:2008

UTIs Cause Both Community

and Hospital Infections
z

Commonly community-acquired infection

(CAI) and endogenous (i.e., originating from
the patients own normal flora)

However, UTI is also a common hospitalacquired infection (HAI)

z

Associated with surgical instrumentation and,

especially, bladder catheterisation

Hence CA-UTI and HA-UTI

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Simple and Complicated UTI

z

Simple
z

When urinary tract normal

Complicated
z

When underlying abnormality

z
z
z
z
z
z

Catheterisation
Congenital
Tumour
Neurological disorder
Prostatic hypertrophy
Stones, etc.

IFIC:2008

Simple UTI
z

In healthy young women

z

Community-acquired
z
z

With no obvious abnormality of UTI

With single antibiotic-sensitive organism
Typically E. coli

Easy to treat
z

Even without antibiotics

IFIC:2008

Complicated UTI
z

Underlying abnormality present

z

Must be treated for cure

Often >1 organism involved

Often hospital-acquired

Often caused by antibiotic resistant

opportunists such as Klebsiella,
Pseudomonas spp.

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Complications of UTI: Acute

Pyelonephritis
z

Ascending infection from bladder to

kidney, involving collecting
ducts/kidney tissue

May go on to bacteraemia

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Complications of UTI:
Bacteraemia
z

Bacteraemia = Bacteria in bloodstream

Common complication of UTI

z

Most common source of bacteraemia in

hospital patients
Most common cause of both UTI and
septicaemia is E coli

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Common Pathogens of UTI

z

Escherichia coli
z
z
z

Most common cause of UTI

Usually from patients' own bowel
50-60% now resistant to ampicillin

Staphylococcus saprophyticus
z
z
z

Coagulase negative staph (novobiocin-res)

Normal skin flora of perineum
Common in sexually active women

IFIC:2008

Organisms of CA-UTI
z

UTI is usually an endogenous infection

caused by organisms from the patient's
own bowel

In CAI, the most common organism is E.

coli, followed by Proteus species and
Enterococcus faecalis

Usually CAIs from antibiotic-sensitive

organisms are relatively easy to treat

IFIC:2008

21

Organisms of HA-UTI
z

Nosocomial UTIs are also usually

endogenous, but the organisms are
commonly more antibiotic resistant

Hospitalised patients become colonised

with more resistant organisms, due to
increased length of hospital stay,
exposure to antibiotics, and crossinfection

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22

Organisms of UTI (%)

Organism

Community Hospital

Esch coli
Proteus
Klebsiella
Entero/citro
Pseudomonas
Acinetobacter

80-90
5-8
1-2

45-55
10-12
15-20
2-5
10-15
<1

Coag -ve staph

Staph aureus
Enterococci

1-2

1-2
<1
10-12

<1

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Infection with Antibiotic

Resistant Bacteria
z

Antibiotic therapy may lead to infection with

more resistant organisms present in patients
bowel on admission
Multi-Drug resistant (MDR) organisms may be
acquired by transfer from other patients, most
commonly via contaminated staff hands
In hospital patients, these organisms colonize,
especially in moist areas such as the groin.
Transfer is skin to skin via staff hands. MDR
organisms may then go on to colonise the
bowel

IFIC:2008

Hospital-Acquired UTI (HA-UTI)

z

The majority of UTIs in hospitalised

patients are associated with the use of
urinary drainage devices
z

z
z

Urethral flora, which tends to migrate into

the bladder, normally is flushed out during
urination
With a catheter, this flushing mechanism is
circumvented
Perineal & urethral flora pass up into the
bladder in the fluid layer between the outside
of the catheter & the urethral mucosa

IFIC:2008

Urine as a Source of Infection

z

Infected urine is a potential source of staff

hand contamination
z

Careful disposal of urine and urine catheter

systems

Bottles and jugs cleaned and disinfected

Proper handwashing

IFIC:2008

Catheterised Patients
z

Where bladder catheterisation is common,

UTIs may be the most frequent HAI
Although most infections are mild, some
are severe, leading to pyelonephritis,
bacteraemia and/or death
Even less severe UTIs increase the length
of hospitalisation and hospital costs
Because HA-UTIs are common, they are
responsible for significant morbidity
and costs
IFIC:2008

Use of Urinary Catheters

z

Urinary catheters should be inserted

only with clear medical indications
z

Relief of acute obstruction or retention

that cannot be treated with non-traumatic
intermittent catheterisation

Measurement of urine production in

critically ill patients

Perioperative use in patients who must

have a completely empty bladder for
specific gynaecological or urological
procedures
IFIC:2008

Infection Associated with Urinary

Catheterization
z

Hospital acquired UTIs

30 - 40 %

Incidence in ICU

15 - 25 %

Incidence of bacteriuria in patients with

indwelling catheter :
z
z
z

Average daily risk :

2- 10 days :
30 days :

3 -10 %
26 %
100 %

IFIC:2008

Reducing HA-UTI
z

HA-UTIs can be prevented by

z

Reducing unnecessary and inappropriately

prolonged bladder catheterisation

The use of closed drainage systems

Standard aseptic techniques during catheter

insertion

Good catheter care

IFIC:2008

Closed Catheter Systems

z

Bladder colonisation is almost inevitable if

catheters are left in place for prolonged
periods
Bladder infection can be caused by
bacterial reflux from contaminated urine in
drainage bag
Closed drainage system significantly
reduces urine contamination and infection
Open systems should be avoided

IFIC:2008

Condom Catheters
z

Use condom catheters for short-term

drainage in co-operative male patients

Frequent changes (e.g. daily) may avoid

complications
z

Remove at first sign of penile irritation or skin

breakdown

Avoid condom use for 24 hour periods

Use other methods at night (napkins or

absorbent pads)
IFIC:2008

Four Sites Where Bacteria May Reach

Bladder in Catheterized Patients

fromDamani NN,KeyesJK.InfectionControlManual,2004
IFIC:2008

1a. External Urethral Meatus &

Urethra

fromDamani NN,KeyesJK.InfectionControlManual,2004
IFIC:2008

1a. External Urethral Meatus &

Urethra
z

Insert catheter under strict aseptic

conditions

Use sterile catheter of the smallest size

and gender-specific catheter
z
z

female 10 -14
male 12-16

Pass catheter when bladder is full for

wash-out effect
IFIC:2008

1a. External Urethral Meatus &

Urethra
z

Before catheterization prepare urinary

meatus with an antiseptic
z
z

0.2% chlorhexidine aqueous solution

povidone iodine

Inject single-use sterile lubricant gel (e.g.,

1-2% lidocaine) into urethra and hold it for 3
minutes before inserting catheter

IFIC:2008

1b. Urethral Meatus-Catheter

Junction
z
z
z
z
z

Secure catheter to prevent movement in

urethra
Keep periurethral area clean and dry
Use soap and clean water during daily
hygiene of meatal area
Bladder washes and antibacterial
ointments are of no value
Clean area and change catheter after
faecal incontinence
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2. Junction Between Catheter &

Drainage Tube
z

Do not disconnect catheter

unless absolutely necessary

Use sampling port for urine

specimen collection

Disinfect outside of
sampling port by applying
alcohol-impregnated wipe

Allow port to dry completely

Aspirate urine with a sterile

needle and syringe
fromDamani NN,KeyesJK.InfectionControlManual,2004

IFIC:2008

3. Junction Between Drainage

Tube & Collection Bag
z

Keep bag below level

of bladder. If necessary
to raise collection bag
above bladder level for
a short period,
temporarily clamp
drainage tube
Empty bag every 8
hours or sooner if full
Do not hold bag upside
down when emptying

fromDamani NN,KeyesJK.InfectionControlManual,2004

IFIC:2008

4. Tap at Bottom of
Collection Bag
z
z

z
z
z
z

Collection bag must never touch

floor
Always wash or disinfect hands
(e.g., with 70% alcohol) before
and after opening tap
Use a separate disinfected jug to
collect urine from each bag.
Don't put disinfectant in urinary
bag
Don't take urinary specimen from
the bag ; use sampling port
Change urine drainage bag
every 5 to 7 days unless
otherwise indicated
fromDamani NN,KeyesJK.InfectionControlManual,2004
IFIC:2008

To Treat or Not to Treat!

z

Significant colony count

z

> 102-105 cfu/mL

WBC
z

Pyuria is less strongly correlated with UTI

in catheterized patients

IFIC:2008

To Treat or Not to Treat!

Bacteriuria

Symptoms

Treatment

No

No

Yes

Yes

Presence of fever,
urgency,
frequency,
dysuria, or
suprapubic tenderness

Antibiotics unable
to penetrate biofilm
to eradicate
microorganisms;
removal of catheter
may be necessary
if the catheter is in place
for > 1 week

IFIC:2008

Key Points
z

Avoid urinary catheterization if possible

z

Do not use urinary catheters for urinary incontinence

Regularly assess patients clinical need for

continuing urinary catheterization

Remove catheter as soon as clinically possible,

preferably within 5 days

Perform urinary catheterization with sterile

equipment
z

If not possible, use high-level disinfection with heat

IFIC:2008

Key Points
z

Maintain aseptic technique during

insertion and aftercare procedures
z

Disinfect hands before insertion and clean

the periurethral area thoroughly, preferably
with an antiseptic

Do not change catheters routinely as it

increases risk of bladder and urethral
trauma
z

Change catheter if associated with antibiotic

treatment or if there is an obstruction

IFIC:2008

Key Points
z

Maintain closed drainage system

z Avoid use of open systems
z Prevent back flow of urine
The bag should not be on the floor
z The bag should not rise above waist
height
z

IFIC:2008

Key Points
z

Do not perform bladder irrigation or

washout
Do not instill antiseptics or antimicrobial
agents
Empty the drainage bag once per nursing
session into a clean receptacle used only
on one patient
z

Do not use communal buckets

Disinfect hands before and after emptying

draining bags
IFIC:2008

References and Further Reading

z

European and Asian guidelines on management

and prevention of catheter-associated urinary
tract. International Journal of Antimicrobial
Agents 2008;31S: S68S78

UK Department of Health. Epic2 Guidelines.

Guidelines for preventing infections associated
with the use of short term urethral catheters. J
Hosp Infect 2007; 65S(Suppl.):S28S33

IFIC:2008

References and Further Reading

z

Department of Health. Epic Guidelines.

Guidelines for preventing infections associated
with the insertion and maintenance of short term
indwelling urethral catheters in acute care. J
Hosp Infect 2001;47 Suppl:S3946

Society for Healthcare Epidemiology of America.

Urinary tract infections in long-term care
facilities. Infect Control Hosp Epidemiol
2001;167:16775

Huang W-C, Wann S-R, Lin S-L, et al. Catheterassociated urinary tract infections in intensive
care units can be reduced by prompting
physicians to remove unnecessary catheters.
Infect Control Hosp Epidemiol 2004;25:974-8
IFIC:2008

 IFIC:2008