Overview and Implications
Urinary Tract Infection (UTI)
UTIs can be divided into upper tract infections, which involve the kidneys (pyelonephritis), and lower tract infections, which involve the bladder (cystitis), urethra (urethritis), and prostate (prostatitis). Infection may spread from one site to the other. Although urethritis and prostatitis are infections that involve the urinary tract, the term UTI usually refers to pyelonephritis and cystitis (Imam, 2020a).
Most cases of cystitis and pyelonephritis are caused by bacteria. The most common nonbacterial pathogens are fungi (usually candidal species), and, less commonly, mycobacteria, viruses, and parasites. Nonbacterial pathogens usually affect patients who are immunocompromised; have diabetes, urinary tract obstruction, or structural abnormalities; or have had recent urinary tract instrumentation. Urethritis is usually caused by sexually transmitted infections (STI). Prostatitis is usually caused by bacteria and sometimes STIs (Imam, 2020a).
Infections in the elderly often have atypical clinical presentation and residents of LTC can also be cognitively impaired or have comorbidities like dementia and stroke that impede communication of symptoms (Happe et al., 2017). Up to 50 per cent of elderly Canadians in long-term care facilities have bacteria in their urine without symptoms of a urinary tract infection. This is referred to as asymptomatic bacteriuria representing a colonization state — not an infection. The inappropriate use of antibiotics for elderly patients with asymptomatic bacteriuria exposes them to considerable harm and promotes antimicrobial resistance, which ultimately affects the health of all Canadians (Blondel-Hill et al., 2018).
Urinary tract infections (UTIs) are the fifth most common type of healthcare-associated infection, with an estimated 62,700 UTIs in acute care hospitals (US) in 2015. UTIs additionally account for more than 9.5 per cent of infections reported by acute care hospitals. Virtually all healthcare associated UTIs are caused by instrumentation of the urinary tract. (Centers for Disease Control and Prevention, 2021).
Catheter-Associated Urinary Tract Infection (CAUTI)
A catheter-associated urinary tract infection (CAUTI) is a UTI in which the positive culture was taken when an indwelling urinary catheter had been in place for > 2 calendar days. Patients with indwelling bladder catheters are predisposed to bacteriuria and UTIs. Symptoms may be vague or may suggest sepsis. Diagnosis depends on the presence of symptoms (Imam, 2020b).
A urinary catheter provides a portal of entry into the urinary tract. The source of bacteria causing CAUTI is usually endogenous — typically via meatal, rectal, or vaginal colonization — but rarely may be exogenous, from equipment or contaminated hands of healthcare personnel (Association for Professionals in Infection Control and Epidemiology, 2014).
The most important risk factor for development of CAUTI is the duration of catheterization. Daily risk of acquisition of bacteriuria with urinary catheters is around seven per cent (Saint, 2000). Other factors predispose CAUTI including patient-related factors such as diabetes, fecal incontinence, incomplete emptying of the bladder, dehydration etc.; care provider related factors such as poor hand hygiene practices, poor insertion technique, etc.; and hospital, equipment, and/or environmental systems (APIC, 2014) and female sex (Imam, 2020b).
CAUTIs account for the majority of healthcare-associated UTIs and have been associated with increased morbidity, mortality, hospital cost, and length of stay (APIC, 2014). During hospitalization, from 12 to 16 per cent of patients may receive short-term indwelling urinary catheters. The average rate of CAUTI is higher in ICU patients than in non-ICU patients (APIC, 2014).
An estimated 17 to 69 per cent of CAUTIs may be preventable with implementation of evidence-based practices. Although there has been modest improvement in CAUTI rates, progress has been much slower than other device-associated infections (APIC, 2014).
Post-partum UTI may begin as asymptomatic bacteriuria during pregnancy and is sometimes associated with bladder catheterization to relieve urinary distention during or after labor (Imam 2020). Compared with intended vaginal delivery, intended caesarean delivery was significantly associated with a higher risk of postpartum urinary tract infection. The timing of the postpartum UTI diagnosis did not vary by mode of delivery because 75 per cent of the postpartum UTIs occurred within 15 days post partum, irrespective of mode of delivery (Gundersen et al., 2018). Physiological changes in the bladder occur during pregnancy and predispose women to develop post-partum urinary retention (PUR) during the first hours to days after birth which can lead to UTI (Leach, 2011).
UTIs Among Neonates
The characteristics of UTI in neonates differ from UTIs in infants and children. Its prevalence is much higher, male sex is affected predominantly non-Escherichia coli infections are more frequent, and there is a higher risk of urosepsis than in older age groups. UTI in neonates may be the first indicator of underlying abnormalities of kidneys and the urinary tract (Beetz, 2012). Some 35 to 50 per cent of term and preterm neonates with UTI have abnormal urinary tract ultrasounds (Bonadio & Maida, 2014; Goldman et al., 2000; Ismaili et al., 2011; Sastre et al., 2007).
The prevalence of UTIs among full-term neonates has been reported to be up to 1.1 per cent, increasing up to seven per cent among those with fever. Evidence indicates that up to approximately 15 per cent of febrile neonates have positive urine culture (Bonadio & Maida, 2014; Ismaili et al., 2011) and most UTI in neonates is related to pyelonephritis as compared to cystitis in older children. The presence of UTI is significantly higher in uncircumcised vs circumcised boys (Beetz, 2012).
Prevention of urinary tract infection by implementing recommended components of care.
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