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Hospital Harm: UTI

Urinary Tract Infection (UTI) 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).

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Prevention of urinary tract infection by implementing recommended components of care.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

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).

Healthcare-Associated UTI

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

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).

Importance to Patients and Families

Steps that can reduce the risk of UTIs include drinking plenty of liquids, especially water and possibly cranberry juice, and wiping from front to back (Mayo Clinic, 2020). ​​Catheters should be removed as soon as they are no longer clinically indicated. This often makes patients more comfortable, reduces their exposure to infections, and shortens their time in hospital (IHI, 2012).

Patient Story​​

Don't get 'caught' in the CAUTI trap

One nurse's story: My father died of a heart attack at age 39, and our mother raised my siblings and me. We were all close to mom; however, as the oldest she and I had a special bond. At age 46 she had undergone a mitral valve replacement and her aortic valve was replaced about nine years later. She had survived a cardiac arrest and pulmonary artery rupture. When she was hospitalized with dehydration and acute kidney injury, we believed she would spend some time in the hospital and be discharged. Her kidney function improved with fluids, and her output was carefully monitored with a urinary catheter. She had a history of atrial fibrillation and her rate control medications were held. One day, her temperature soared to 102.8 F and her heart rate increased to 130 beats per minute. She developed sepsis, which placed further stress on her pulmonary and cardiovascular system. In June 2001 my mother died from complications related to a catheter associated urinary tract infection. She was 61 years old; I still miss her (Townsend et al, 2013).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of hospital associated UTI, clinical and system reviews should be conducted to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is being carried out (process measures), and whether any unintended consequences ensue (balancing measures).

In selecting your measures, consider the following:

Whenever possible, use measures you are already collecting for other programs.

Evaluate your choice of measures in terms of the usefulness of the results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Try to include both process and outcome measures in your measurement scheme.

You may use different measures or modify the measures to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Posting your measure results within your hospital is a great way to keep your teams motivated and aware of progress. Try to include measures that your team will find meaningful and exciting (IHI, 2011).

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: B13: Urinary Tract Infections

Concept: Urinary tract infections identified during a hospital stay.

Notes: In the neonatal age group, underestimation is probable, due to the identification of in-utero or birth process infections versus environment-acquired infections has been documented as a challenge.

Success Stories

Four BC Hospitals Recognized for Surgical Care Quality

Burnaby Hospital, Chilliwack General Hospital, Lions Gate Hospital and Surrey Memorial Hospital were recognized in November by the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) for exemplary results for patients in surgical care. [They] were recognized in the "all cases" category for outcomes in … urinary tract infection... Using validated, risk-adjusted data from NSQIP, sites are able to compare their data provincially, nationally, and internationally as well as identify specific areas on which to focus their improvement efforts. (BC Patient Safety & Quality Council, 2021).

References

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