New strategies to prevent catheter-associated urinary tract infections

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Abstract

Catheter-associated urinary tract infection (CAUTI) is the most common health-care-associated infection worldwide. Although not all cases of bacteriuria result in clinical infection, several hundred thousand episodes of CAUTI occur each year in the USA alone. The milieu in which the catheter is placed is highly conducive to bacterial colonization, biofilm formation on the catheter surface, and inevitable catheter-associated bacteriuria. A multitude of novel methods of CAUTI prevention have been described, including established approaches that are routinely recommended, such as the use of a secured, closed, silicone urinary catheter drainage system that mimics normal voiding, and newer strategies focusing on biocompatible catheter materials that cause minimal host inflammatory response and retard biofilm formation. Much recent research has focused on modification of the catheter surface by either coating or impregnation with antimicrobials or antiseptics. However, clinical trials that analyse cost-effectiveness and rates of antimicrobial resistance are awaited. More recently, innovative use of iontophoresis, vibroacoustic stimulation, bacterial interference and bacteriophage cocktails has been reported.

Key Points

  • Catheter-associated urinary tract infection (CAUTI) is the most common health-care-associated infection in the USA and worldwide

  • There is significant heterogeneity and overlap in the definitions of CAUTI, catheter-associated asymptomatic bacteriuria and catheter-associated bacteriuria

  • Prevention of CAUTI is predominantly based on reviewing the criteria for appropriate placement and early removal of catheters

  • The design of the indwelling urinary catheter remains largely unchanged since its inception

  • New strategies to prevent CAUTI must be based on a comprehensive understanding of the pathogenesis and key factors that influence the development of the infection

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Figure 1: Urinary bladder with an indwelling urinary catheter.

References

  1. 1

    National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am. J. Infect. Control 32, 470–485 (2004).

  2. 2

    Haley, R. W. et al. Nosocomial infections in U. S. hospitals, 1975–1976: estimated frequency by selected characteristics of patients. Am. J. Med. 70, 947–959 (1981).

  3. 3

    Tambyah, P. A. Catheter-associated urinary tract infections: diagnosis and prophylaxis. Int. J. Antimicrob. Agents 24 (Suppl. 1), S44–S48 (2004).

  4. 4

    Platt, R., Polk, B. F., Murdock, B. & Rosner, B. Mortality associated with nosocomial urinary-tract infection. N. Engl. J. Med. 307, 637–642 (1982).

  5. 5

    Weinstein, J. W. et al. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect. Control Hosp. Epidemiol. 20, 543–548 (1999).

  6. 6

    Warren, J. W. Catheter-associated urinary tract infections. Infect. Dis. Clin. North Am. 11, 609–622 (1997).

  7. 7

    Hooton, T. M. et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin. Infect. Dis. 50, 625–663 (2010).

  8. 8

    Warren, J. W., Tenney, J. H., Hoopes, J. M., Muncie, H. L. & Anthony, W. C. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J. Infect. Dis. 146, 719–723 (1982).

  9. 9

    Rebmann, T. & Greene, L. R. Preventing catheter-associated urinary tract infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide. Am. J. Infect. Control 38, 644–646 (2010).

  10. 10

    Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G. & Pegues, D. A. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect. Control Hosp. Epidemiol. 31, 319–326 (2010).

  11. 11

    Umscheid, C. A. et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect. Control Hosp. Epidemiol. 32, 101–114 (2011).

  12. 12

    O'Grady, F. & Cattell, W. R. Kinetics of urinary tract infection. II. The bladder. Br. J. Urol. 38, 156–162 (1966).

  13. 13

    Kunin, C. M. Can we build a better urinary catheter? N. Engl. J. Med. 319, 365–366 (1988).

  14. 14

    Garcia, M. M. et al. Traditional Foley drainage systems—do they drain the bladder? J. Urol. 177, 203–207; discussion 207 (2007).

  15. 15

    Stamm, W. E. Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am. J. Med. 91, 65S–71S (1991).

  16. 16

    Tambyah, P. A., Halvorson, K. T. & Maki, D. G. A prospective study of pathogenesis of catheter-associated urinary tract infections. Mayo Clin. Proc. 74, 131–136 (1999).

  17. 17

    Donlan, R. M. & Costerton, J. W. Biofilms: survival mechanisms of clinically relevant microorganisms. Clin. Microbiol. Rev. 15, 167–193 (2002).

  18. 18

    Ong, C. L. et al. Identification of type 3 fimbriae in uropathogenic Escherichia coli reveals a role in biofilm formation. J. Bacteriol. 190, 1054–1063 (2008).

  19. 19

    Davies, D. G. et al. The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 280, 295–298 (1998).

  20. 20

    Costerton, J. W., Lewandowski, Z., Caldwell, D. E., Korber, D. R. & Lappin-Scott, H. M. Microbial biofilms. Ann. Rev. Microbiol. 49, 711–745 (1995).

  21. 21

    Stickler, D., Morris, N., Moreno, M. C. & Sabbuba, N. Studies on the formation of crystalline bacterial biofilms on urethral catheters. Eur. J. Clin. Microbiol. Infect. Dis. 17, 649–652 (1998).

  22. 22

    Jain, P., Parada, J. P., David, A. & Smith, L. G. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch. Intern. Med. 155, 1425–1429 (1995).

  23. 23

    Munasinghe, R. L., Yazdani, H., Siddique, M. & Hafeez, W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect. Control Hosp. Epidemiol. 22, 647–649 (2001).

  24. 24

    Griffiths, R. & Fernandez, R. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst. Rev. CD004011 (2007).

  25. 25

    Loeb, M. et al. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J. Gen. Intern. Med. 23, 816–820 (2008).

  26. 26

    Saint, S., Kaufman, S. R., Thompson, M., Rogers, M. A. & Chenoweth, C. E. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm. J. Qual. Patient Saf. 31, 455–462 (2005).

  27. 27

    Topal, J. et al. Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am. J. Med. Qual. 20, 121–126 (2005).

  28. 28

    Gokula, R. M., Smith, M. A. & Hickner, J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. Am. J. Infect. Control 35, 589–593 (2007).

  29. 29

    Lukasse, M., Cederkvist, H. R. & Rosseland, L. A. Reliability of an automatic ultrasound system for detecting postpartum urinary retention after vaginal birth. Acta Obstet. Gynecol. Scand. 86, 1251–1255 (2007).

  30. 30

    Slappendel, R. & Weber, E. W. Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopaedic surgery and its effect on urinary tract infections. Eur. J. Anaesthesiol. 16, 503–506 (1999).

  31. 31

    Fedorkow, D. M., Dore, S. & Cotton, A. The use of an ultrasound bladder scanning device in women undergoing urogynaecologic surgery. J. Obstet. Gynaecol. Can. 27, 945–948 (2005).

  32. 32

    Boyce, J. M. & Pittet, D. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect. Control Hosp. Epidemiol. 23, S3–S40 (2002).

  33. 33

    Carapeti, E. A., Andrews, S. M. & Bentley, P. G. Randomised study of sterile versus non-sterile urethral catheterisation. Ann. R. Coll. Surg. Engl. 78, 59–60 (1996).

  34. 34

    Platt, R., Polk, B. F., Murdock, B. & Rosner, B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1, 893–897 (1983).

  35. 35

    Classen, D. C., Larsen, R. A., Burke, J. P. & Stevens, L. E. Prevention of catheter-associated bacteriuria: clinical trial of methods to block three known pathways of infection. Am. J. Infect. Control 19, 136–142 (1991).

  36. 36

    Maki, D. G. & Tambyah, P. A. Engineering out the risk for infection with urinary catheters. Emerg. Infect. Dis. 7, 342–347 (2001).

  37. 37

    Darouiche, R. O. et al. Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial. Am. J. Infect. Control 34, 555–560 (2006).

  38. 38

    Burke, J. P. et al. Prevention of catheter-associated urinary tract infections. Efficacy of daily meatal care regimens. Am. J. Med. 70, 655–658 (1981).

  39. 39

    Dudley, M. N. & Barriere, S. L. Antimicrobial irrigations in the prevention and treatment of catheter-related urinary tract infections. Am. J. Hosp. Pharm. 38, 59–65 (1981).

  40. 40

    Warren, J. W., Platt, R., Thomas, R. J., Rosner, B. & Kass, E. H. Antibiotic irrigation and catheter-associated urinary-tract infections. N. Engl. J. Med. 299, 570–573 (1978).

  41. 41

    Davies, A. J., Desai, H. N., Turton, S. & Dyas, A. Does instillation of chlorhexidine into the bladder of catheterized geriatric patients help reduce bacteriuria? J. Hosp. Infect. 9, 72–75 (1987).

  42. 42

    Ball, A. J. et al. Bladder irrigation with chlorhexidine for the prevention of urinary infection after transurethral operations: a prospective controlled study. J. Urol. 138, 491–494 (1987).

  43. 43

    Richter, S., Kotliroff, O. & Nissenkorn, I. Single preoperative bladder instillation of povidone-iodine for the prevention of postprostatectomy bacteriuria and wound infection. Infect. Control Hosp. Epidemiol. 12, 579–582 (1991).

  44. 44

    Elliott, T. S., Reid, L., Rao, G. G., Rigby, R. C. & Woodhouse, K. Bladder irrigation or irritation? Br. J. Urol. 64, 391–394 (1989).

  45. 45

    Mattelaer, J. J. & Billiet, I. Catheters and sounds: the history of bladder catheterisation. Paraplegia 33, 429–433 (1995).

  46. 46

    Stickler, D., Young, R., Jones, G., Sabbuba, N. & Morris, N. Why are Foley catheters so vulnerable to encrustation and blockage by crystalline bacterial biofilm? Urol. Res. 31, 306–311 (2003).

  47. 47

    Ruutu, M., Alfthan, O., Talja, M. & Andersson, L. C. Cytotoxicity of latex urinary catheters. Br. J. Urol. 57, 82–87 (1985).

  48. 48

    Edwards, L. E., Lock, R., Powell, C. & Jones, P. Post-catheterisation urethral strictures. A clinical and experimental study. Br. J. Urol. 55, 53–56 (1983).

  49. 49

    Goble, N. M., Clarke, T. & Hammonds, J. C. Histological changes in the urinary bladder secondary to urethral catheterisation. Br. J. Urol. 63, 354–357 (1989).

  50. 50

    Denstedt, J. D., Wollin, T. A. & Reid, G. Biomaterials used in urology: current issues of biocompatibility, infection, and encrustation. J. Endourol. 12, 493–500 (1998).

  51. 51

    Morris, N. S., Stickler, D. J. & Winters, C. Which indwelling urethral catheters resist encrustation by Proteus mirabilis biofilms? Br. J. Urol. 80, 58–63 (1997).

  52. 52

    Sun, Y. et al. Decreased urethral mucosal damage and delayed bacterial colonization during short-term urethral catheterization using a novel trefoil urethral catheter profile in rabbits. J. Urol. 186, 1497–1501 (2011).

  53. 53

    Morris, N. S. & Stickler, D. J. Encrustation of indwelling urethral catheters by Proteus mirabilis biofilms growing in human urine. J. Hosp. Infect. 39, 227–234 (1998).

  54. 54

    Beiko, D. T. et al. Urinary tract biomaterials. J. Urol. 171, 2438–2444 (2004).

  55. 55

    Bull, E., Chilton, C. P., Gould, C. A. & Sutton, T. M. Single-blind, randomised, parallel group study of the Bard Biocath catheter and a silicone elastomer coated catheter. Br. J. Urol. 68, 394–399 (1991).

  56. 56

    Sabbuba, N., Hughes, G. & Stickler, D. J. The migration of Proteus mirabilis and other urinary tract pathogens over Foley catheters. BJU Int. 89, 55–60 (2002).

  57. 57

    Tunney, M. M. & Gorman, S. P. Evaluation of a poly(vinyl pyrollidone)-coated biomaterial for urological use. Biomaterials 23, 4601–4608 (2002).

  58. 58

    Park, J. H., Cho, Y. W., Kwon, I. C., Jeong, S. Y. & Bae, Y. H. Assessment of PEO/PTMO multiblock copolymer/segmented polyurethane blends as coating materials for urinary catheters: in vitro bacterial adhesion and encrustation behavior. Biomaterials 23, 3991–4000 (2002).

  59. 59

    Kazmierska, K. A., Thompson, R., Morris, N., Long, A. & Ciach, T. In vitro multicompartmental bladder model for assessing blockage of urinary catheters: effect of hydrogel coating on dynamics of Proteus mirabilis growth. Urology 76, 515.e15–e20 (2010).

  60. 60

    Hamill, T. M., Gilmore, B. F., Jones, D. S. & Gorman, S. P. Strategies for the development of the urinary catheter. Expert Rev. Med. Devices 4, 215–225 (2007).

  61. 61

    Matsumura, Y., Yoshikata, K., Kunisaki, S. & Tsuchido, T. Mode of bactericidal action of silver zeolite and its comparison with that of silver nitrate. Appl. Environ. Microbiol. 69, 4278–4281 (2003).

  62. 62

    Saint, S., Elmore, J. G., Sullivan, S. D., Emerson, S. S. & Koepsell, T. D. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am. J. Med. 105, 236–241 (1998).

  63. 63

    Schumm, K. & Lam, T. B. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst. Rev. CD004013 (2008).

  64. 64

    Srinivasan, A., Karchmer, T., Richards, A., Song, X. & Perl, T. M. A prospective trial of a novel, silicone-based, silver-coated foley catheter for the prevention of nosocomial urinary tract infections. Infect. Control Hosp. Epidemiol. 27, 38–43 (2006).

  65. 65

    Regev-Shoshani, G., Ko, M., Crowe, A. & Av-Gay, Y. Comparative efficacy of commercially available and emerging antimicrobial urinary catheters against bacteriuria caused by E. coli in vitro. Urology 78, 334–339 (2011).

  66. 66

    Lellouche, J., Kahana, E., Elias, S., Gedanken, A. & Banin, E. Antibiofilm activity of nanosized magnesium fluoride. Biomaterials 30, 5969–5978 (2009).

  67. 67

    Costerton, J. W., Ellis, B., Lam, K., Johnson, F. & Khoury, A. E. Mechanism of electrical enhancement of efficacy of antibiotics in killing biofilm bacteria. Antimicrob. Agents Chemother. 38, 2803–2809 (1994).

  68. 68

    Chakravarti, A. et al. An electrified catheter to resist encrustation by Proteus mirabilis biofilm. J. Urol. 174, 1129–1132 (2005).

  69. 69

    Davis, C. P., Shirtliff, M. E., Scimeca, J. M., Hoskins, S. L. & Warren, M. M. In vivo reduction of bacterial populations in the urinary tract of catheterized sheep by iontophoresis. J. Urol. 154, 1948–1953 (1995).

  70. 70

    Stewart, M. J., Parikh, S., Xiao, G., Tonge, P. J. & Kisker, C. Structural basis and mechanism of enoyl reductase inhibition by triclosan. J. Mol. Biol. 290, 859–865 (1999).

  71. 71

    Bibby, J. M. Feasibility of preventing encrustation of urinary catheters. Cells Mater. 2, 183–195 (1995).

  72. 72

    Williams, G. J. & Stickler, D. J. Effect of triclosan on the formation of crystalline biofilms by mixed communities of urinary tract pathogens on urinary catheters. J. Med. Microbiol 57, 1135–1140 (2008).

  73. 73

    Hachem, R. et al. Novel antiseptic urinary catheters for prevention of urinary tract infections: correlation of in vivo and in vitro test results. Antimicrob. Agents Chemother. 53, 5145–5149 (2009).

  74. 74

    Regev-Shoshani, G., Ko, M., Miller, C. & Av-Gay, Y. Slow release of nitric oxide from charged catheters and its effect on biofilm formation by Escherichia coli. Antimicrob. Agents Chemother. 54, 273–279 (2010).

  75. 75

    Park, J. H. et al. Norfloxacin-releasing urethral catheter for long-term catheterization. J. Biomater. Sci. Polym. Ed. 14, 951–962 (2003).

  76. 76

    Cho, Y. W. et al. Gentamicin-releasing urethral catheter for short-term catheterization. J. Biomater. Sci. Polym. Ed. 14, 963–972 (2003).

  77. 77

    Kowalczuk, D., Ginalska, G. & Golus, J. Characterization of the developed antimicrobial urological catheters. Int. J. Pharm. 402, 175–183 (2010).

  78. 78

    Morris, N. S. & Stickler, D. J. The effect of urease inhibitors on the encrustation of urethral catheters. Urol. Res. 26, 275–279 (1998).

  79. 79

    Burton, E. et al. Antibiofilm activity of GlmU enzyme inhibitors against catheter-associated uropathogens. Antimicrob. Agents Chemother. 50, 1835–1840 (2006).

  80. 80

    Tamilvanan, S., Venkateshan, N. & Ludwig, A. The potential of lipid- and polymer-based drug delivery carriers for eradicating biofilm consortia on device-related nosocomial infections. J. Control Release 128, 2–22 (2008).

  81. 81

    Pugach, J. L. et al. Antibiotic hydrogel coated Foley catheters for prevention of urinary tract infection in a rabbit model. J. Urol. 162, 883–887 (1999).

  82. 82

    Stickler, D. J. Bacterial biofilms in patients with indwelling urinary catheters. Nat. Clin. Pract. Urol. 5, 598–608 (2008).

  83. 83

    Hull, R. A. et al. Virulence properties of Escherichia coli 83972, a prototype strain associated with asymptomatic bacteriuria. Infect. Immun. 67, 429–432 (1999).

  84. 84

    Darouiche, R. O. et al. Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder. Urology 78, 341–346 (2011).

  85. 85

    Trautner, B. W., Hull, R. A., Thornby, J. I. & Darouiche, R. O. Coating urinary catheters with an avirulent strain of Escherichia coli as a means to establish asymptomatic colonization. Infect. Control Hosp. Epidemiol. 28, 92–94 (2007).

  86. 86

    Lopez, A. I. et al. Biofunctionalization of silicone polymers using poly(amidoamine) dendrimers and a mannose derivative for prolonged interference against pathogen colonization. Biomaterials 32, 4336–4346 (2011).

  87. 87

    Trautner, B. W. et al. Nanoscale surface modification favors benign biofilm formation and impedes adherence by pathogens. Nanomedicine 8, 261–270 (2012).

  88. 88

    Carson, L., Gorman, S. P. & Gilmore, B. F. The use of lytic bacteriophages in the prevention and eradication of biofilms of Proteus mirabilis and Escherichia coli. FEMS Immunol. Med. Microbiol. 59, 447–455 (2010).

  89. 89

    Sulakvelidze, A., Alavidze, Z. & Morris, J. G. Jr. Bacteriophage therapy. Antimicrob. Agents Chemother. 45, 649–659 (2001).

  90. 90

    Fu, W. et al. Bacteriophage cocktail for the prevention of biofilm formation by Pseudomonas aeruginosa on catheters in an in vitro model system. Antimicrob. Agents Chemother. 54, 397–404 (2010).

  91. 91

    Lazar, V. Quorum sensing in biofilms—how to destroy the bacterial citadels or their cohesion/power? Anaerobe 17, 280–285 (2011).

  92. 92

    Manefield, M. et al. Evidence that halogenated furanones from Delisea pulchra inhibit acylated homoserine lactone (AHL)-mediated gene expression by displacing the AHL signal from its receptor protein. Microbiology 145 (Pt 2), 283–291 (1999).

  93. 93

    de Nys, R., Givskov, M., Kumar, N., Kjelleberg, S. & Steinberg, P. D. Furanones. Prog. Mol. Subcell. Biol. 42, 55–86 (2006).

  94. 94

    Dror, N., Mandel, M., Hazan, Z. & Lavie, G. Advances in microbial biofilm prevention on indwelling medical devices with emphasis on usage of acoustic energy. Sensors 9, 2538–2554 (2009).

  95. 95

    Hazan, Z. et al. Effective prevention of microbial biofilm formation on medical devices by low-energy surface acoustic waves. Antimicrob. Agents Chemother. 50, 4144–4152 (2006).

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D. M. Siddiq and R. O. Darouiche contributed equally to researching data for the article, discussion of content, writing and reviewing the manuscript before submission.

Correspondence to Danish M. Siddiq.

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