0022-5347 /84/1323-0494$02.

00/0
THE JOURNAL OF UROLOGY Vol. 132, September
Copyright© 1984 by The Williams & Wilkins Co. Printed in U.S.A.

HOSPITAL-ACQUIRED BACTEREMIC URINARY TRACT INFECTION:

EPIDEMIOLOGY AND OUTCOME
CHARLES S. BRYAN AND KENNETH L. REYNOLDS
From the Department of Medicine, University of South Carolina School of Medicine and Richland Memorial Hospital, Columbia, South Carolina

ABSTRACT
Analysis of 221 episodes of hospital-acquired bacteremic urinary tract infection in 4 hospitals of
1 metropolitan area from 1977 to 1981 revealed an over-all mortality rate of 30.8 per cent. The
mortality rate attributed specifically to bacteremic urinary tract infection was 12.7 per cent. Of the
28 patients whose deaths were attributed directly to hospital-acquired bacteremic urinary tract
infection 19 were on medical services and all had focal or diffuse central nervous system disease,
malignancy, alcoholic liver disease or cirrhosis, advanced arteriosclerosis with renal failure and/or
diabetes mellitus with obliterative peripheral vascular disease. Extrapolation of these data suggests
that 3,520 deaths in the United States each year are directly caused by hospital-acquired bacteremic
urinary tract infection but that these deaths may be limited virtually to high risk patients with poor
prognoses from underlying diseases.

Although an estimated 500,000 hospital-acquired urinary RESULTS

tract infections occur in the United States each year, the extent
of morbidity and excess mortality from these infections remains
controversial. On the one hand, it has been estimated that 1 to
3 per cent of these infections result in bacteremia, with a case
fatality ratio >30 per cent, 1 and it also has been suggested that
these infections may contribute to death by undefined mecha-
nisms.2 On the other hand, prospective studies in individual
hospitals suggest a low incidence of serious complications from
these infectionsa and also indicate that the relatively few pa-
tients who die of these infections may have extensive underly-
ing disease. 4 We studied the mortality and some determinants
of outcome of all documented hospital-acquired urinary tract
infections in 4 major hospitals of 1 metropolitan area from
1977 to 1981.
MATERIALS AND METHODS
The patient population, methods of study and definitions
have been described in the preceding paper. 5 Bacteremia was
considered to be hospital-acquired if the first positive blood
cultures were obtained on or after hospital day 3. Urinary tract
infection was considered to be hospital-acquired on the basis
of cultures, urinalyses and/or clinical impressions made on or
after hospital day 3. Because in some instances bacteremic
urinary tract infection would be considered hospital-acquired
by these definitions, although the urine might have been in-
fected at the time of hospitalization, we tabulated data sepa-
rately for those cases in which infection was considered to be
hospital-acquired according to epidemiologically oriented defi-
nitions but in which the underlying infection was probably
present at the time of admission to the hospital.
As noted in the preceding paper 5 this study was based on
systematic analysis of all documented episodes of bacteremia.
At the 2 teaching hospitals in this study routine surveillance of
hospital-acquired infections did not include attempts to identify
all nonbacteremic infections. Therefore, no attempt was made
to determine the percentage of hospital-acquired urinary tract
infections that resulted in bacteremia at those hospitals. At the
2 nonteaching community hospitals in this study ongoing sur-
veillance included attempts to identify all hospital-acquired
infections. Thus, data from these latter hospitals enabled esti-
mates to be made of the percentage of hospital-acquired urinary
tract infections that resulted in bacteremia.
Accepted for publication April 27, 1984.
494
From 1977 to 1981 we observed 1,520 episodes of hospital-
acquired bacteremia. Of these episodes 221 were attributed to
hospital-acquired urinary tract infection by the definitions
used. The over-all rate of hospital-acquired bacteremic urinary
tract infection was 7.3 episodes per 10,000 patients. The rate
varied among the 4 hospitals from 2.9 and 4.5 episodes per
10,000 patients, respectively, at the 2 nonteaching community
hospitals to 8.0 episodes per 10,000 patients at the teaching
municipal hospital and 21.8 episodes per 10,000 patients at the
teaching Veterans Administration hospital.
These 221 episodes occurred in 141 male and 68 female
patients. The same microorganisms were isolated from cultures
of blood and urine in 83.3 per cent of these episodes. Of the
patients 9 experienced polymicrobial bacteremia, 3 had 2 clin-
ically discrete occurrences of bacteremic urinary tract infection
and 1 had 3 clinically discrete occurrences.
Evidence that a retention urinary catheter had been present
before the onset ofbacteremia was obtained by review of patient
records in 71 per cent of these 221 episodes. At 1 of the non-
teaching community hospitals 686 episodes of hospital-acquired
urinary tract infection were identified, of which 31 resulted in
bacteremia, and at the other nonteaching community hospital
554 episodes of hospital-acquired urinary tract infection were
identified, of which 17 resulted in bacteremia. Thus, 3.9 per
cent of documented hospital-acquired urinary tract infections
at these 2 hospitals were complicated by bacteremia.
Of the 221 episodes of bacteremia 8.2 per cent were docu-
mented by blood cultures obtained on hospital day 3, 27.7 per
cent on day 7, 49.5 per cent on day 14, 62.3 per cent on day 21,
71.8 per cent on day 28 and 89.1 per cent on day 56.
Over-all mortality rate for patients experiencing hospital-
acquired bacteremic urinary tract infection was 30.8 per cent.
The mortality rate attributed directly to bacteremic urinary
tract infection was 12. 7 per cent. Of the 68 deaths 40. 7 per cent
occurred within 1 week of the first positive blood cultures (fig.
1). Mortality was related directly to the severity of underlying
disease (table 1). Although older patients experienced greater
mortality compared to younger patients, the differences were
not significant due to the relatively small numbers of patients
in the younger age groups (fig. 2). Similarly, the greater mor-
tality rate attributed directly to bacteremia among male com-
pared to female patients (14.0 versus 9.9 per cent) was not
significant. However, the mortality rate from all causes during
 HOSPTTAL-ACQUIRED BAC'T:t:?:HEiv_nc CRI1~A.RY TRACT Il\IFECTIOf'J 495
emic twct infection was 17.3 per cent on medical
I to 8.1 per cent on the other hospital services
e,v1,11~"ucu
deaths were attributed directly to bacteremic
urinary tract infection on urology services.
,--. 80 Each of the 28 patients whose deaths were attributed directly
f- to hospital-acquired bacteremic urinary tract infection had
z focal or diffuse central nervous system disease (17), malignancy
w
u (11), alcoholism (5), liver disease (3), arteriosclerotic cardio-
a: 60 vascular disease with chronic renal failure (2) and/or diabetes
UJ
CL
....,. mellitus with obliterative peripheral vascular disease (2) (table
2).
>-
f- 40
Review of the clinical records of the 28 patients whose deaths
_j
were attributed directly to hospital-acquired bacteremic urinary
<t: tract infection revealed no instances in which obstructive uro-
l- pathy was recognized clearly during life but was not relieved.
o:: However, postmortem examinations revealed abnormalities
0 20
2: that might have been corrected by surgery in 3 patients. Patient
4 (table 2) had calculi in the bladder and in both ureters,
patient 10 had a perinephric abscess and patient 13 had unilat-
eral ureterolithiasis. Postmortem examinations of 4 additional
2 4 6 8 10 12 14 16 18 21 patients revealed pyelonephritis in 3.
Clinically apparent shock was present during 37 of the 221
DAYS AFTER FIRST POSITIVE CULTURE episodes of hospital-acquired bacteremic urinary tract infection
Cumulative mortality for patients who died during hospital-
FIG. 1. and was associated with a 35.1 per cent mortality rate attributed
ization after experiencing hospital-acquired bacteremic urinary tract
infection, according to number of days between first positive blood to bacteremia and a 48.6 per cent mortality rate attributed to
cultures and day of death. all causes. Hypotension (systolic blood pressure <100 mmo Hg)
without clinically apparent shock was present in an additional
43 episodes and was associated with a 16.2 per cent mortality
MALES attributed to bacteremia and a 46.5 per cent mortality attrib-
40 [
35 uted to all causes. An operation had been done before 40 of
these episodes occurred. Of these episodes only 4 resulted in
30 -
D SURVIVED death attributed to bacteremia and only 9 were associated with
(f) 25
DEATHS DUE TO
death due to any cause during hospitalization. No mortality
w Ifill
0
20
BACTEREMIA was attributed directly to the 18 episodes preceded by urological
0
(f) surgery.
a:
UJ
15 Choice of initial antimicrobial therapy was not clearly related
u.. to outcome (table 3). Statistically significant differences among
0
r:r: the initial therapy groups could not be demonstrated among
5
LI.I
CD
patients in the various categories of underlying disease severity
~
::,
0 (rapidly fatal, ultimately fatal or nonfatal), including those who
z experienced shock. However, choice of antimicrobial therapy
subsequent to the day on which the first positive blood cultures
20 ~ FEMALES were obtained clearly affected mortality. The mortality rate

:;f= ~ ~ ~oonDllu
attributed to bacteremia was 8.1 per cent for patients who
received appropriate subsequent antimicrobial therapy com-

TABLE 1. Mortality according to severity of underlying disease,

< 1 1-10 11-20 21-30 31-40 41-50 s·1-so 61-70 71-BO >BO
infecting microorganism and hospital service
AGE GROUPS
No. Bacteremic No.All
FIG. 2. and sex distributions of patients with hospital-acquired Deaths(%) Deaths(%)
bacteremic tract infection and associated mortality.
Severity of underlying disease (No. epi-
sodes):
Rapidly fatal (14) 4 (28.6) 11 (78.6)
hospitalization was greater among male compared to female Ultimately fatal (91) 14 (15.4) 37 (40.7)
patients versus 16.9 per cent, p <0.005), Nonfatal (116) 10 (8.6) 20 (17.2)
There were 21 instances in which bacteremia was considered Microorganism (No. episodes):
E.coli (100) 11 (11.0) 27 (27.0)
to be hospital-acquired according to epidemiologically oriented Klebsiella-Enterobacter-Serratia (41) 4 (9.8) 13 (31.7)
definitions but in which the underlying infection was probably Proteus mirabilis (28) 7 (25.0) 13 (46.4)
present at the time of admission to the hospital. No deaths Other Enterobacteriaceae (8) 2 (25o0) 2 (25.0)
attributed directly to bacteremia resulted from these 21 epi- Pseudomonas aeruginosa (21) 2 (9.5) 4 (19.0)
Other gram-neg. (4) 2 (50.0) 3 (75.0)
sodes, although 2 patients died during hospitalization. Gram-pos. (19) 0 (0.0) 6 (31.6)
Mortality was not related to the infecting microorganism Hospital service (No. episodes):
(table 1). No deaths were attributed to the 19 episodes due to Medical (110) 19 (17.3) 41 (37.3)
gram-positive microorganisms, which included 14 episodes of General surgery (42) 6 (14.3) 12 (28.6)
Urology (28) 0 (0.0) 5 (17.9)
enterococcal bacteremia and 1 of Staphylococcus aureus bacte- Neurology and neurosurgery (16) 3 (18.8) 7 (43.8)
remia. Orthopedic surgery (9) 0 (0.0) 1 (11.1)
Of the 28 deaths attributed directly to hospital-acquired Pediatrics (9) 0 (0.0) 2 (22.2)
bacteremic urinary tract infection 19 occurred on medical serv- Obstetrics and gynecology (6) 0 (0.0) 0 (0.0)
Other services (1) 0 (0.0) 0 (0.0)
ices (table 1). The mortality rate attributed directly to bacter-
496 BRYAN AND REYNOLDS

TABLE 2. Underlying diseases in patients with deaths attributed to significantly higher for these patients (16.0 versus 10.7 per cent
hospital-acquired bacteremic urinary tract infection for patients in whom only urinary tract infection was docu-
mented). However, the mortality rate from all causes was
Pt. -Age-Sex Underlying Diseases
No. significantly higher for patients with additional sites of infec-
1-28-M Alcoholic liver disease, acute meningitis, mastoiditis and tion (42.0 versus 24.3 per cent for patients in whom only urinary
hronchopneumonia, post-cardiorespiratory arrest with tract infection was documented, p <0.01).
hypoxic cerebral injury including brainstem injury There were 1,299 episodes of hospital-acquired bacteremia in
2-39-M Alcoholism, seizure disorder, cerebral cortical contusion
with clinical diagnosis of brain death supported by
this patient population, which were not attributed to urinary
electroencephalography tract infection. However, among these were 311 episodes in
3-47-M Alcoholic liver disease, hepatic encephalopathy, delirium which urinary tract infection was documented during hospital-
tremens, bacteremic pneumococcal pneumonia on ad- ization (table 4). The mortality rate attributed to bacteremia
mission to hospital
4-49-F Multiple sclerosis with mental confusion and paraplegia,
was not significantly higher for these 311 episodes (22.2 versus
decubitus ulcers, chronic retention urinary catheter 17. 7 per cent for the 988 episodes of bacteremia in patients
5-53-M Ca of lung with cerebral metastases, chronic obstructive without evidence of urinary tract infection). However, the
lung disease, arteriosclerotic cardiovascular disease mortality rate from all causes was significantly higher for
with heart failure
6-54-M Diabetes mellitus, arteriosclerotic peripheral vascular dis-
patients who experienced urinary tract infection compared to
ease, post-bilat. above the knee amputation, myocardial patients who did not experience urinary tract infection (51.8
infarction versus 37.6 per cent, p <0.001) (table 4).
7-56-M Acute myelogenous leukemia
8-60-M Glioblastoma multiforme with hemiparesis and seizure DISCUSSION
disorder
9-61-M Adenoca. of lung with cerebral metastases, pneumonia The extent of excess morbidity and mortality attributable to
10-62-F Chronic lymphocytic leukemia with superimposed malig- hospital-acquired urinary tract infection continues to be an
nant lymphoma, gangrene of extremities and intestines,
renal failure
unsettled issue. Platt and associates suggested that hospital-
11-66-F Ca of lung with widespread metastases, decubitus ulcers acquired urinary tract infection may cause excess mortality
12-66-M Cerebrovascular accident with hemiparesis, arterioscle- even in the absence of documented bacteremia and concluded
rotic cardiovascular disease with heart failure and gan- that a specific catheter care program reduced mortality. 2• 6
grenous lower extremity, alcoholism
13-66-M Cerebral thrombosis with quadriparesis and aphasia, dia-
However, Gross and Van Antwerpen 7 could not demonstrate
betes mellitus, hypertension excess mortality due to hospital-acquired urinary tract infection
14-67-M Arteriosclerotic cardiovascular disease with cholesterol in a case-control study, and Nicolle and associates 8 found that
emboli, renal failure requiring hemodialysis, acute res- therapy of bacteriuria did not prolong the survival of elderly
piratory failure
15-68-M Cerebrovascular accident with hemiparesis, seizure disor-
institutionalized men.
der, pneumonia, alcoholism We attempted to determine the incidence of hospital-ac-
16-68-M Ca of bladder, arteriosclerotic cardiovascular disease with quired bacteremic urinary tract infection and also the associ-
heart failure, arteriolar nephrosclerosis, rheumatoid ar- ated mortality in 4 hospitals of 1 metropolitan area. We at-
thritis
17-70-F Ca of gallbladder with metastases, heart failure, hyper-
tempted to distinguish between deaths due directly to bacte-
tension remia and deaths due to other causes. Although this distinction
18-70-F Cirrhosis, multiple small liver abscesses, chronic pancrea- can be difficult, failure to make such a distinction may have
titis, diabetes mellitus led to overestimates of the mortality actually caused by hospi-
19-71-M Recurrent cerebrovascular accidents, arteriosclerotic pe-
ripheral vascular disease with previous amputations of
tal-acquired bacteremias. 9
both lower extremities, diabetes mellitus The over-all incidence of hospital-acquired bacteremic uri-
20-71-M Chronic myelogenous leukemia in blastic crisis nary tract infection in this population (7.3 episodes per 10,000
21-72-M Histiocytic lymphoma, arteriosclerotic cardiovascular dis- patients) closely resembles that reported from the University
ease with previous myocardial infarction, previous cere-
brovascular accident
of Virginia Hospital during 1979 and 1980 (7.9 episodes per
22-75-M Multiple cerebral infarctions with pseudobulbar palsy and 10,000 patients). 10 However, the incidence varied considerably
dementia, hypertensive arteriosclerotic cardiovascular among the 4 hospitals included in our study. At 2 nonteaching
disease, chronic obstructive lung disease community hospitals we found that bacteremia complicated 3.9
23-77-M Chronic organic brain syndrome with diffuse cerebral
atrophy and dementia, malnutrition, anemia
per cent of all documented episodes of hospital-acquired bac-
24- 78-F Ca of cervix with extensive invasion of pelvis and renal teriuria. At the University of Virginia Hospital Krieger and
failure associates determined that bacteremia complicated 2. 7 per cent
25-80-M Coma of undetermined etiology, diabetes mellitus, pneu- of all recognized hospital-acquired urinary tract infections. 10
monia
26-84-M Chronic organic brain syndrome, respiratory failure at-
By the criteria used in our study it was determined that 41
tributed to active pulmonary tuberculosis and pneu- per cent of deaths among patients who experienced hospital-
monia of uncertain etiology, hip fracture acquired bacteremic urinary tract infection were directly attrib-
27 -86-M Ischemic heart disease, hip fracture, arteriolar nephro- utable to these infections. From these data and on the basis of
sclerosis
28-88-F Head injury with cerebral contusion and deep coma, myo-
35 million admissions to acute care hospital facilities in the
cardial infarction United States each year, 11 it could be estimated that approxi-
mately 25,600 hospital-acquired bacteremic urinary tract infec-

pared to 30.3 per cent for the 33 patients who either received TABLE 3. Mortality according to antimicrobial therapy
inappropriate therapy or who were not treated (p <0.001). Of No. Bacteremic No. All
the 15 patients who never received antimicrobial therapy 7 died Deaths(%) Deaths(%)
of bacteremic urinary tract infection and 4 died of other causes Therapy on day when first pos. blood cultures were
(table 3). obtained (No. episodes):
Among the 221 episodes of hospital-acquired bacteremic uri- Appropriate (134) 17 (12.7) 40 (29.9)
nary tract infection were 81 in which at least 1 additional site Inappropriate (42) 6 (14.3) 13 (31.0)
None (45) 5 (11.1) 15 (33.3)
of infection was documented during hospitalization. In 14 of Therapy subsequent to day when first pos. blood cul-
these 81 episodes > 1 additional site of infection was docu- tures were obtained (No. episodes):
mented. These 81 episodes included 59 instances of pneumonia, Appropriate (185) 15 (8.1) 48 (25.9)
12 wound infections and 25 miscellaneous infections. The mor- Inappropriate (18) 3 (16.7) 6 (33.3)
None (15) 7 (46.7) 11 (73.3)
tality rate attributed directly to bacteremia was slightly but not
 aue ell to tract
preserd
Source to lAThich Tract Infection
Bacteremia was Episodes(%)
Attributed5
Pneumonia 89/151 (58.9) 30/49
Wound infection 47/116 (40.5) 26/46
Vascular access site infectio;1 10/31 (32 3) 9/20
Other documented infections 93/309 (30.1) 37/77 (48.1)
Source not apparent 132/381 (34.6) 59/119 (49.6)
Totals 371/988 (37.6) 161/311 (51.8)

tions occur in the United States annually and that these infec- Morthland, V. I--!.: Nosocomial urinary tract infection: a prospec-
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3,520 deaths. Our data suggest that these deaths occur primarily 380, 1981.
4. Gross, P. A., Neu, H. C., Aswapokee, P., Van Antwerpen, C. and
among patients on medical services who have severe underlying
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Urethral catheterization was documented before 71 per cent 490, 1984.
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tract infection in our study. Undoubtedly, the surveillance mortality associated with nosocomial urinary tract infection.
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7. Gross, P. A. and Van Antwerpen, C.: Nosocomial infections and
However, these data are in general agreement with previous
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Infect. Dis., 148: 57, 1983.
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acquired rather than hospital-acquired. We are aware of no Finegoid, S. M.: Clinical aspects of bacteremia aftei" manipula-
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McGowan 17 N,r,rwcar1 that 63 per cent of all tract 13. Stamm, W. E., Martin, S. M. and Bennett, J. V.: ~rncterrnolo/,:;y
infections at Grady Memoriai an 11-week nosocomial infection due to Gram-negative aspects
ratherthanuvoµ,ca,-o,~~ vant to development and use of vaccines. J. Infect. Dis., suppl.,
136: 1977.
14. Hambraeus, A., Myrback, K.-E., "'-·-·"-·"··- B. and
· Prevaience of hospital-associated in five
ho~rn,t;,ig in November 1975. Scand. J. Infect. Dis., Hl:

15. """--"J"'''"· J, E., Jr., Parrott, P. L. and V. P.: Nosocomio.l

tion and bacteremia. Potential for prevention of procedure-related cases"
tract infection. The criteria used in this were -~,~,...,.,- J.A.Iv!.A., 237: 2727, 1977.
m;~11.,cu1, v rather than ~"··"'~v.'"' ,w,cwn-~,,, and could have caused
lR Jo R., Relle:r L, B. and Licht,2nstein,
1

blood cultures: a
overestimation or underestimation of the rate due
compl'ehensive of bacteremia and fun-
these infections. it should be en1e;ntlerect that in the gemia in adults. II. observations, with special refe:rence
and Keefer 18 found the rate to factors influencing p:rognosis. Rev, Infect. Dis", 54\ 1983.
among with Escherichia coli bacteremia from 17. McGowan, J. E. Jro: Antimicrobial resistance in hospital v•;sm,rn.urn
1

the urinary tract to be 20 per cent, and Scott 19 found the and its relation to antibiotic use. Rev. Infect. Dis., 5:
rate for bacteremias encountered in urological prac- 18. Felty, A. R. and Keefer, C. S.: Bacillus coli sepsis: a clinical study
tice to be only 18 cent. Since most of the mortality attrib- of 28 cases of blood stream infection by the colon bacillus.
utable to these lil our occurred in ,-.,~•a,~,.,vu 82: 1430, 1924.
who were ill from processes, we suggest that 19. Scott, W. ·Bloodstream infections in urology: a report of eighty-
two cases. J. Urol., 21: 527, 1929.
further lowering of mortality will be achieved with
difficulty.
EDITORIAL COMMENTS
This epidemiologically oriented study documents a 13 per cent
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