Dr. Averch started off the discussion by defining the scope of the problem. The incidence of catheter associated urinary tract infections (CAUTIs) was 9.4 per 1000 catheterizations in 2001. This led to 13,000 attributable deaths/year, excess length of stay and increased costs. In 2008, the Center for Medicare & Medicaid Services made it a never event and no longer provided reimbursement for hospital acquired CAUTIs. Following this the CAUTI rate dropped to 5.3 cases in 2010. Risk factors for CAUTIs are female gender, emergency hospital admission, transfer patients and Medicare patients. Many organizations have their own CAUTI definition but the most commonly used one is the CDC definition. The goal for 2020 is a 25% reduction in CAUTIs from the 2015 level. Dr. Averch recommended not prescribing antibiotics if patients have asymptomatic bacteruria and to not place or maintain unnecessary catheters.
Dr. Griebling next discussed CAUTIs in the geriatric population. In nursing homes, Foley catheters are present in 13.9% short-term residents and in 7.3% long-term residents. The immune system changes with aging including altered levels of urinary cytokines, increased free radical formation and oxidative stress, decrease in cellular immunity and alterations in natural host-defense mechanisms. Older adults also have co-morbidities that put them at risk including diabetes mellitus and voiding dysfunction. The most common indication for catheters in the geriatric population is urinary retention. Older adults have atypical symptoms including delirium/confusion, anorexia or new onset of urinary incontinence. Dr. Grieblin reiterated that it is very important to distinguish asymptomatic bacteruria and to not treat these patients with antibiotics. The McGreer diagnostic criteria are most commonly used to define UTIs in long-term care facilities. Many quality initiatives are in place to help reduce the number of CAUTIs in nursing homes and there has been significant progress in reducing these episodes.
Dr. Ben Chew next discussed solutions to combat CAUTIs and specifically antimicrobial coatings for catheters. No biomaterial exists that can completely withstand the effects of the urinary environment. Initial work using Triclosan loaded ureteral stents showed a decrease in Proteus mirabilis in a rabbit model but the FDA never approved it and it did not have similar results in humans. This is hypothesized to be secondary to the urinary conditioning film that covers coatings and drug eluting surfaces. Currently, Dr. Chew is working with polymer coatings, which has shown an ability to repel conditioning films. Simple coating techniques may help reduce CAUTIs and he encouraged close collaboration with industry colleagues.
Dr. Schwartz concluded the session by mentioning that at UTSF when both urine analysis and urine cultures are ordered then the culture is only performed when white blood cells are found in the urine. These reflex culture techniques are recommended to help reduce the unnecessary treatment of asymptomatic bacteruria.
Presented by: Brian S. Schwartz, Tomas Lindor Griebling, Timothy Averch, and Ben Chew
Written by: Roshan Patel, Department of Urology, University of California-Irvine at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA