World J Urol (2012) 30:5967 DOI 10.

1007/s00345-011-0757-1

TOPIC PAPER

Epidemiology, treatment and prevention of healthcare-associated urinary tract infections

F. M. E. Wagenlehner Mete Cek Kurt G. Naber Hiroshi Kiyota Truls E. Bjerklund-Johansen

Received: 17 April 2011 / Accepted: 23 August 2011 / Published online: 7 September 2011 Springer-Verlag 2011

Abstract Objectives Healthcare-associated urinary tract infections (HAUTIs) are the most frequent healthcare-associated infections in general hospitals. They are almost exclusively complicated UTIs, although complicating factors are very heterogenous. HAUTIs are mainly catheter associated. Most of them are asymptomatic and do not need antimicrobial therapy. However, cross-contamination and crossinfection may contribute to distribution of resistant uropathogens. The bacterial spectrum of HAUTI is broad, and antibiotic resistance is common. Methods The authors reviewed the literature from 2000 to 2010 to determine the epidemiology, prevention and best treatment strategies for HAUTI. The recommendations

F. M. E. Wagenlehner Department of Urology, University Giessen, Giessen, Germany F. M. E. Wagenlehner (&) Clinic of Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Rudolf-Buchheim-Str. 7, 35385 Giessen, Germany e-mail: Wagenlehner@AOL.com M. Cek Department of Urology, Trakya University, Edirne, Turkey K. G. Naber Technical University, Munich, Germany H. Kiyota Department of Urology, Jikei University Afliated Aoto Hospital, Tokyo, Japan T. E. Bjerklund-Johansen Urology Department, Aarhus University Hospital, Skejby, Aarhus University, Aarhus, Denmark

were summarized by determining the level of evidence and grading each recommendation. Results The treatment for HAUTI encompasses treatment for complicating factors as well as antimicrobial chemotherapy. At least in serious UTI, adequate initial antibiotic therapy results in lower mortality. Therefore, the initial antibiotic regimen must provide sufcient antibiotic coverage. This can only be achieved if the local or regional bacterial spectrum and antibiotic resistance patterns of uropathogens are followed continuously. Provisional microbiological ndings, such as reports on Gram-stain or certain biochemical results, can lead to early stratication of pathogens and allow a more tailored empiric antibiotic therapy. Antibiotic therapy of HAUTI has to consider therapeutic success in the individual patient and prevention of emergence of antibiotic-resistant mutants. For both aspects, adequate drug selection and dosing are paramount. Discussion Antibiotic treatment for HAUTI should follow prudent antibiotic use to prevent emergence of antibiotic resistance. Keywords Healthcare-associated UTI Nosocomial UTI Antibiotic treatment for UTI Emergence of antibiotic-resistant uropathogens

Summary of recommendations 1. All urinary tract infections (UTI) acquired in an outpatient or in an institutional care setting should be considered as healthcare-associated UTI (HAUTI) (GoR B). 2. Healthcare-associated asymptomatic bacteriuria should not be treated with antimicrobials, except before traumatizing interventions of the urinary tract and in pregnant women (GoR A).

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9. 10.

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In HAUTI, a wide spectrum of frequently also multiresistant uropathogenic bacteria has to be considered (GoR B). For rational empiric therapy, the local susceptibility pattern of the uropathogens must be continuously followed and considered (GoR A). A urine specimen and in case of urosepsis also a blood specimen for culture must be obtained before initiation of any antibiotic therapy (GoR A). Antibiotic treatment should be initiated after the results of the susceptibility testing are available, whenever possible (GoR B). If empiric antibiotic treatment is warranted, it should be tailored after the results of the susceptibility testing are available (GoR B). Antibiotics with best performance in biolm infection should be selected, and the dosage should be sufciently high when treating HAUTI (GoR B). Prevention of catheter-associated UTI is the gold standard for prevention of HAUTI (GoR A). For prevention of HAUTI in short-term catheterization, the following recommendations are to be considered: (i) staff education about catheter management; (ii) catheterization only when indicated and prompt removal of indwelling catheters; (iii) handwashing; (iv) catheter insertion with aseptic technique and sterile equipment; and (v) maintenance of a closed urinary drainage system (GoR A). For prevention of HAUTI in long-term catheterization, the following recommendations should be considered: (i) hydration; (ii) appropriate catheter exchange; and (iii) no antimicrobial prophylaxis for catheter-associated bacteriuria (GoR B). For avoidance of long-term bladder catheterization, the following methods should be considered: in case of incomplete emptying of the bladder: (i) medications for complete emptying the urinary bladder, such as cholinergic drugs and/or alpha-1 adrenergic inhibitors; (ii) operative deobstruction for benign prostatic hyperplasia (BPH); and (iii) clean intermittent catheterization (GoR B). in case of incontinence: (i) medications for incontinence and (ii) operative treatment for incontinence (GoR B).

present or incubating prior to the initiation of a healthcare encounter [1, 2]. The term healthcare-associated infection incorporates the term nosocomial or hospital acquired, which refers to infections that occur as a result of hospital care, but also any infection occurring in an institutional (long-term facilities, nursing home) or outpatient care setting. Healthcare-associated urinary tract infections (HAUTIs) are the most frequent healthcare-associated infections and account for more than 40% of all healthcareassociated infections in a general hospital [3, 4] (LoE 2b). They are mainly catheter associated [35] (LoE 2b). Bacteriuria should be distinguished from urinary tract infection and develops in up to 25% of patients who require a urinary catheter for seven days or more, with a daily risk of 5% [5] (LoE 3). Most of the catheter-associated bacteriuria are asymptomatic [6] (LoE 3) and therefore do not need antibiotic therapy. However, the pathogens are fully exposed to the healthcare setting (nosocomial) environment, including the selective pressure of antibiotic or antiseptic substances. Unfortunately, many studies do not differentiate between symptomatic UTI and asymptomatic bacteriuria. HAUTI comprises perhaps the largest institutional reservoir of antibiotic-resistant pathogens [5] (LoE 3). The aim of this review is to determine the epidemiology, prevention and best treatment strategies for HAUTI and provide evidence graded recommendations.

Methods This manuscript was published in part originally in: Naber KG, Schaeffer AJ, Heyns CF, Matsumoto T, Shoskes DA, Bjerklund Johansen TE (eds) Urogenital Infections. European Association of UrologyInternational Consultation on Urological Diseases, 1st edition 2010, Arnhem, The Netherlands, ISBN:978-90-79754-41-0 [7]. The review is based on a systematic literature search for the years 20002010 in PubMed. Two searches were performed using Boolean logic structure: (1) surveillance AND susceptibility AND nosocomial urinary tract infection (for search, the term nosocomial was used instead of healthcare associated) and (2) randomized clinical trials AND nosocomial urinary tract infection AND antibiotic therapy. The rst search revealed 55 publications. There were several local or national surveillance studies, but only three multinational studies were found and used for this review. The second search revealed 15 publications. No prospective controlled, randomized therapeutic study was found, in which only patients with nosocomial UTI were treated or such patients were substratied. Only one study investigated the effect of antibiotic prophylaxis at urinary catheter removal, which was included into this review, and one study investigated the effect of an antibiotic-coated

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Introduction A healthcare-associated infection is dened as a localized or systemic condition that results from an adverse reaction to the presence of an infectious agent or its toxin and was not

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urinary catheter on prophylaxis of nosocomial UTI, which was included into this review. These publications were augmented with publications known by the authors. The studies were rated according to their level of evidence, and the strength of the recommendations was graded according to the standards of the International Consultation on Urological Diseases [8, 9].

Risk factors Several characteristics related to the healthcare provider, the patient and the procedures are known to increase the risk of HAUTI. The most important risk factors for HAUTI are an indwelling catheter and the duration of catheterization [19]. Other signicant risk factors are (1) UTI during the previous 12 months; (2) urinary tract obstruction; (3) urinary stones; (4) previous antibiotic usage within the last 3 months; and (5) hospitalization within the last 6 months due to any reason [19]. The study also showed that for patients having more than three risk factors, there was a signicantly increased risk of having a Candida sp., Klebsiella sp. or Pseudomonas sp. as a causative pathogen, when compared to those patients with three or less risk factors. Another recent study also found strong evidence between HAUTI and prolonged length of stay (OR 5.28), urinary catheter (OR 5.16) [20], unresolved spinal injury (OR 4.07), fracture/dislocation on admission (OR 3.34), transfer to/from another hospital (OR 2.9), underlying neurologic disease (OR 2.59), some assistance required prior to admission (OR 2.58), previous stroke (OR 1.94) and male sex was protective (OR 0.44) [20]. Information on the effectiveness of risk-reducing strategies in those risk groups is now warranted. Studies suggested also the severity score of hospitalized patients as an important risk factor for the development of HAUTI [11, 21]. On the other hand, immunosuppressant therapy within 14 days, history of malignancy, cigarette smoking in the past and male sex are shown to be risk factors for healthcare-associated urinary tract-related bacteremia [22].

Epidemiology The incidence of healthcare-associated infections has stayed more or less stable over the last two decades. However, certain aspects of patient care have changed during this period. As minimally invasive techniques develop and patient care improves, patients are being treated either on an outpatient basis or they stay in hospitals for shorter periods. Particularly in urology, there is a wide range of operations, which allow the patient to be discharged within 48 h of operations. This has two important implications on the incidence of healthcareassociated infections: (1) More elderly patients with comorbidities are hospitalized [10, 11] and (2) shorter hospital stays make it difcult to assess the true frequency of healthcare-associated infections. The incubation periods of certain infections (e.g., surgical site infections) are sometimes longer than the hospital stay of patients. It is thus more preferable to calculate the incidence of healthcare-associated infections on the basis of patient days, rather than actual number of admissions [12]. The denominator can also be the number of patients at risk, or days of indwelling catheterization [13]. The rate of nosocomial infections per 1,000 patients days in the USA was calculated to be 9.8 in 1995 [12, 13]. More recent estimates (for 2009) exhibit a much more detailed analysis and are therefore not comparable to previous overall estimates [14]. On the other hand, the incidence of nosocomial urinary infections in European countries was found to be 3.55 episodes/1,000 patient days and the prevalence was estimated to be 10.65/1,000 [15]. The prevalence of HAUTI in urological departments was 11% in the combined analysis of the Pan European Prevalence (PEP) study and the Pan Euro-Asian Prevalence (PEAP) study [16]. The largest group was asymptomatic bacteriuria (29%) followed by cystitis (26%), pyelonephritis (21%) and urosepsis (12%). The prevalence of HAUTIs was found to be 14.7% in the Global Prevalence Study on Infections in Urology (GPIU) 2008 also showing a rising percentage of urosepsis from 9.3% in 2006 to 21.8% in 2008, while the prevalence of HAUTI stayed more or less stable around 14% in the same period [17]. This suggests that prophylactic measures in various urology clinics may not be appropriate [18].

Bacterial spectrum Whereas community-acquired UTI are often uncomplicated, almost all HAUTIs are complicated infections with structural or functional abnormalities within the urinary tract, such as indwelling catheters or some kind of urinary obstruction. The bacterial etiology of UTI differs markedly between uncomplicated and complicated UTIs, which is mainly due to the fact that bacteria causing uncomplicated UTI are highly selected clones with an array of virulence factors, which are not required to such an extent in bacteria causing complicated UTI [23]. Bacterial spectrum in complicated HAUTI The bacterial spectrum of complicated HAUTIs comprises a wide range of Gram-negative and Gram-positive species. The bacterial spectrum can vary geographically, over the time and between distinct specialities at the same institution [24] (LoE 3).

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Bacterial spectrum of HAUTI in North America (SENTRY study) The SENTRY antimicrobial surveillance program, initiated in 1997, has chronologically examined urinary pathogens collected from hospitalized patients from different hospital departments across North America and thus provides insight into pathogen frequency and resistance rates [25] (LoE 3). A surveillance study based on 1998 data encompassed 31 North American institutions, which examined 1,510 urinary isolates from hospitalized patients from different departments [26] (Table 1). Bacterial spectrum of HAUTI in Europe (ESGNI-003 study) A European multicenter one-day prevalence study on HAUTI of patients from different hospital departments tested 607 uropathogens from 228 hospitals throughout Europe [27] (LoE 2b). Patients from different departments throughout the hospital were evaluated (Table 1). Bacterial spectrum of HAUTI in urological patients in Europe (PEP-study) A European multicenter one-day prevalence study on HAUTI in urology tested 320 uropathogens from 232 urological departments throughout Europe [19] (LoE 3) (Table 1).

(National Committee for Clinical Laboratory Standards) criteria [26] (LoE 3). Strains were sent from the local microbiology laboratories. Global resistance rates (combined resistance of E. coli, Klebsiella spp., P. aeruginosa and Enterococci) in North America for Ampicillin, Amoxicillin/clavulanate, Trimethoprim/Sulfamethoxazole and Ciprooxacin were 59, 31, 43 and 29%, respectively. Global resistance rates in Latin America for Ampicillin, Amoxicillin/clavulanate, Trimethoprim/Sulfamethoxazole and Ciprooxacin were 62, 36, 38 and 32%, respectively. Global resistance rates in Europe for Ampicillin, Amoxicillin/clavulanate, Trimethoprim/Sulfamethoxazole and Ciprooxacin were 62, 36, 38 and 32%, respectively (Table 1). Antibiotic resistance in HAUTI in Europe (ESGNI-003 study) The European Study Group on Nosocomial Infections (29 countries) also evaluated antimicrobial susceptibility against hospital-acquired urinary isolates [27] (LoE 2b). Sensitivity assays were not performed in a central laboratory, and local results of susceptibility testing were taken at face value. During 1999, 607 organisms from 522 patients with HAUTI were tested. For E. coli, resistance rates were comparable to those observed from the North American SENTRY experience (Table 1): TMP/SMX (28%), ampicillin (55%), ciprooxacin (9%) and gentamicin (6%). However, it is worth noting that non-European Union countries tended to have higher rates of E. coli resistance than European Union countries. In particular, amikacin, ceftazidime and cefepime were the most active agents ([90% susceptible), imipenem and tobramycin were moderately active ([85% susceptible) and ciprooxacin and gentamicin were the least active (*75% susceptible). In contrast, P. aeruginosa isolates from non-European Union countries (e.g., Estonia, Serbia) showed resistance rates of over 50% for uoroquinolones and non-amikacin aminoglycosides. The authors speculated that this high rate of resistance to pseudomonal strains might be explained by the lack of strict antimicrobial policies in hospitals within non-European Union countries. Antibiotic resistance in HAUTI in urological patients in Europe (PEP-study) The PEP-study also evaluated resistance rates of uropathogens causing HAUTI in urological patients [19] (LoE 3). However, there was no reference laboratory, and different standards were employed for testing of the strains (178 hospitals employed NCCLS criteria, 34 DIN (Deutsches r Normung) criteria, and 20 other criteria) and not Institut fu

Antibiotic resistance Since antibiotics have been introduced into clinical medicine, antibiotic-resistant bacteria have evolved. The epidemiology of antibiotic-resistant bacteria, however, varies from region to region, from speciality to speciality, from infection type to infection type and from time to time. Antibiotic resistance in complicated HAUTI Healthcare-associated uropathogens are frequently subject to antibiotic pressure and cross-infection [28] (LoE 2b). The inuence of these parameters can vary between regions and specialities [24] (LoE 3). Different species of uropathogens show distinct abilities to develop antibiotic resistance. Antibiotic resistance in HAUTI in North America, Latin America and Europe (SENTRY study) In the SENTRY study, which was a laboratory-based study, a central reference laboratory was employed using NCCLS

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World J Urol (2012) 30:5967 Table 1 Antimicrobial spectrum of healthcare-associated uropathogens (C2%) from distinct surveillance studies Name of study Regions of the world Year of surveillance Type of surveillance Origin of samples Number of pathogens Species % E. coli Klebsiella spp. Pseudomonas spp. Proteus spp. Enterobacter spp. Citrobacter spp. Enterococcus spp. Staphylococcus spp. Candida spp. Resistance rates of antibiotics % Ampicillin Ampicillin ? BLI TMP/SMZ Ciprooxacin Gentamicin Ceftazidime Amikacin Piperacillin/tazobactam Imipenem Vancomycin n.r. Not reported
a b c d e

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SENTRY [33] North America 2000 Longitudinal Microbiology laboratories n = 1,466 43 12 7 6 3 4 16 6 n.r.

SENTRY [33] Latin America 2000 Longitudinal Microbiology laboratories n = 531 60 12 6 7 4 2 4 3 n.r.

SENTRY [33] Europe 2000 Longitudinal Microbiology laboratories n = 783 46 9 9 10 4 2 13 3 n.r.

ESGNI-003 [27] Europe 2000 Cross-section Different departments in the hospital n = 607 36 8 7 8 4 2 16 4 9

PEP-study [19] Europe 2003 Cross-section Urology departments n = 320 35 10 13 7 3 n.r. 9 4 4

59e 31 43e 29e n.r. n.r. n.r. n.r. n.r. n.r.

e

62e 36 38e 32e n.r. n.r. n.r. n.r. n.r. n.r.

e

65e 36 48e 29e n.r. n.r. n.r. n.r. n.r. n.r.

e

66a 29a 32a 17b 18 13c 19c n.r. 14c 1

d

51 30 45 34 34 17 14 15 7 n.r.

Gram-negative bacteria excluding P. aeruginosa Gram-negative bacteria P. aeruginosa Enteroccoci E. coli, Klebsiella spp., P. aeruginosa, Enterococci

all hospitals have tested all antibiotics. Global resistance rates for the total bacterial spectrum were as follows (Table 1): Ampicillin 51%, ampicillin ? beta-lactamase inhibitor 30%, piperacillin 21%, piperacillin/tazobactam 15%, cefazolin 44%, cefuroxime 25%, ceftazidime 17%, cefepime 21%, imipenem 7%, gentamicin 34%, amikacin 14%, ciprooxacin 34% and TMP/SMZ 45%. In all these studies, increasing resistance rates were found for some species like E. coli, but not for all uropathogens. However, resistance rates may vary substantially between regions. Additionally, the results of those studies were published almost 10 years ago, and more recent published data on HAUTI are missing. Therefore, timely, local, hospital-based surveillance of the bacterial

spectrum and antibiotic sensitivity is paramount for a rational empiric therapy.

Treatment for HAUTI As mentioned earlier, HAUTI is mainly catheter associated. HAUTI has to be distinguished from asymptomatic bacteriuria, which does not need antibiotic therapy according to the current guidelines, except before an traumatizing intervention of the urinary tract and in pregnant women [29, 30] (LoE 1a). However, by cross-contamination and crossinfection healthcare-associated asymptomatic bacteriuria may also contribute signicantly to the distribution of

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resistant uropathogens throughout the institution (nursing home and hospital) [28] (LoE 2b) and also throughout the community in case of an outpatient care setting. Therefore, healthcare-associated asymptomatic bacteriuria may be an important factor for the spread of resistant uropathogens and should therefore be included into a systematic (not routine) surveillance. But in general, antibiotic therapy should only be considered for symptomatic HAUTI. In some situations, however, the distinction between healthcare-associated asymptomatic bacteriuria and symptomatic HAUTI may be difcult, e.g., intensive care medicine, patients with spinal cord injury, physically and mentally handicapped (geriatric) patients or children in young age. Careful consideration of all clinical parameters is necessary in those instances before antibiotic therapy is initiated. On the other hand, if systemic signs or symptoms such as fever or chills appear the urinary tract should be thoroughly investigated. General aspects of antibiotic therapy of UTI In the antimicrobial treatment of uncomplicated UTIs, the rapid elimination of the pathogen is most important. In complicated HAUTIs, the primary goal of antibiotic therapy is to limit the infection and prevent the emergence of resistant mutants. Drusano and Craig determined four parameters for the rational dosing of an antibiotic in a population [31]: 1. 2. 3. 4. the minimal inhibitory concentration (MIC) of the clinical isolates. the pharmacokinetic (pk) prole. the pharmacodynamic (pd) prole. the protein binding of the applied antibiotic.

even be sufciently high enough to eradicate also the rst step resistant mutants [36] (LoE 3). At least in severe UTIs, adequate initial antibiotic therapy results in lower mortality compared with inadequate antibiotic treatment [37] (LoE 3). Susceptibility testing should be carried out in any case of HAUTI, and if possible, the results should be awaited before treatment. However, in severe infections, an initial empiric therapy must be instigated immediately after microbiological sampling. Susceptibility testing can serve in these cases to narrow the antibiotic coverage. Provisional microbiological ndings, such as reports on Gram-stain or certain biochemical results, such as oxidase, coagulase and catalase, can lead to early stratication of pathogens and allow a more tailored empiric antibiotic therapy [38] (LoE 3). Prudent use of antimicrobials may also help to reduce the selection of resistant pathogens to a minimum. Antibiotic selection for therapy of complicated HAUTI and urosepsis Antibiotics with an enlarged antibacterial spectrum are necessary for initial empiric treatment in severe cases [39] (LoE 4). The empiric parenteral treatment could start with a cephalosporin group 3a, a uoroquinolone with good renal excretion or with an aminopenicillin in combination with a beta-lactamase inhibitor. If clinical improvement fails after 23 days, treatment should be switched to a pseudomonas active acylaminopenicillin/beta-lactamase inhibitor, a group 3b cephalosporin or a group 1 carbapenem. Other reasons for treatment failure, such as persistent complicating factors, other infections or non-infectious sources, should also be taken into account and be re-evaluated. Local and regional variations in resistance must be also considered for empiric treatment. The use of parenteral antibiotics is determined by the general condition of the patient (e.g., nausea and vomiting) and the severity of the infection; oral antibiotics can be continued as soon as the clinical situation has improved. After the results of the susceptibility testing have arrived, the antibiotic treatment should be aligned accordingly. Treatment duration should continue for at least 35 days beyond defervescence, dependent on the removal of the complicating factor. However, this recommendation does not hold true for the treatment of pyelonephritis with abscess formation or chronic bacterial prostatitis, which should usually continue for several weeks.

The distribution of the MIC values of nosocomial clinical isolates is the greatest variable parameter, and the MICs vary geographically and by time [32, 33] (LoE 2b). The other three parameters are usually determined from Phase I to III studies. There is, however, a surprisingly high interindividual variation. Certain subgroups of patients, however, are not studied, and recommendations for antibiotic therapy must be extrapolated from the results of other related groups. An additional 5th parameter is extremely important for the treatment of HAUTI. In many cases of complicated UTIs, biolm infection is predominant, which leads to reduced susceptibility of the pathogens [34] (LoE 2b). Antimicrobial therapy in complicated UTIs may only kill the bacteria dissolved from the biolm (planktonic form) and thus inhibits the spread of the infectious process. An accompanying urological therapy must aim to remove the biolm. In any case, antibiotics with best performance in biolm infection should be selected and the dosage should generally be high when treating complicated HAUTIs [35]. The dosage should

Prevention of HAUTI The best treatment is prevention; this is also true for HAUTI. Since most HAUTIs are catheter associated,

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optimal management of any indwelling catheter and prevention of catheter-associated UTI should be of highest priority in urology. Prevention of HAUTI in short-term indwelling catheterization According to CDC guidelines, prevention of catheterassociated UTI is the gold standard for prevention of HAUTI [40]. The following have to be considered: 1. 2. 3. 4. 5. 6. staff education about catheter management, catheterization only when indicated and prompt removal of indwelling catheters, Handwashing, catheter insertion with aseptic technique and sterile equipment, maintenance of a closed urinary drainage system, silver- or antibiotic-coated urinary catheter may reduce the risk of catheter-associated bacteriuria [41, 42] (LoE 1b), but whether this also holds true for episodes of symptomatic catheter-associated UTI, needs to be shown, and a short-term antibiotic prophylaxis at urinary catheter removal may prevent UTI after short-term indwelling catheterization [43] (LoE 1b), however may increase the total antibiotic selection pressure for the development of antibiotic resistance.

3.

No antimicrobial prophylaxisantimicrobial prophylaxis can delay the occurrence of catheter-associated bacteriuria. However, the incidence of drug-resistant bacteria increases in the presence of antimicrobial prophylaxis. Therefore, antimicrobial prophylaxis for prevention of catheter-associated bacteriuria should be avoided [5] (LoE 4).

Avoidance of long-term indwelling catheterization To prevent catheter-associated UTI, long-term indwelling catheterization should be avoided at the rst place. There are two frequent indications for long-term bladder catheterization: incomplete emptying of the bladder and non-obstructive incontinence.

7.

Prevention of HAUTI in long-term indwelling catheterization The CDC guidelines mentioned earlier have been developed only for the patients with short-term indwelling urethral catheterization. Catheter-associated bacteriuria is ultimately not avoidable in patients with long-term indwelling catheterization. Since most catheter-associated bacteriuria with long-term indwelling catheterization are asymptomatic [44] (LoE 3), prevention of symptomatic episodes is the aim to look for. The following practical points are recommended, but the level of evidence is low (LoE 4). 1. Hydrationthe increase in urine volume by hydration results in washout of bacteria from the urinary bladder and thus inhibiting bacterial growth in the urinary bladder. Hydration also prevents obstruction of the urethral catheter due to encrustation. Catheter exchangeroutine catheter exchange is usually performed every 46 weeks. However, the optimal frequency of catheter exchange depends on the individual patient, because the catheter encrustation sometimes happens in shorter periods. In these cases, catheter exchange should be performed more frequently.

In both indications attempts, such as (1) medications for complete emptying the urinary bladder, (2) operative techniques such as deobstruction in case of prostatic obstruction in males [45, 46], or pelvic oor reconstruction in case of pelvic oor disorders, such as cystocele formation, (3) clean intermittent catheterization; or (4) urethral stent for benign prostatic enlargement [47, 48] (LoE 3), [49, 50] (LoE 3) may be considered. There is little evidence whether clean intermittent catheterization prevents symptomatic UTIs [51] (LoE 4). The frequency of clean intermittent catheterization may be important for the prevention of UTIs.

Further research In the past most studies did not distinguish between healthcare-associated symptomatic UTI and asymptomatic bacteriuria. There is now agreement that healthcare-associated asymptomatic bacteriuria should not be treated with antimicrobials; therefore, routine screening for bacteriuria seems to be not indicated. However, its impact to induce infections when spread to other patients is not well understood. Prospective studies are needed to clarify, whether systematic surveillance of healthcare-associated asymptomatic bacteriuria is recommended and if so, at what time intervals.

2.

Conclusions HAUTIs are almost exclusively complicated UTI and mainly catheter associated. Healthcare-associated asymptomatic bacteriuria should not be treated with antimicrobials

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World J Urol (2012) 30:5967 12. Weinstein RA (1998) Nosocomial infection update. Emerg Infect Dis 4(3):416420 13. National Nosocomial Infections Surveillance (NNIS) (2004) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32(8):470485 14. Cited 2011 02.06.2011. Available from: http://www.cdc.gov/ nhsn/PDFs/dataStat/2010NHSNReport.pdf 15. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J (2001) A European perspective on nosocomial urinary tract infections II. Report on incidence, clinical characteristics and outcome (ESGNI-004 study). European Study group on nosocomial infection. Clin Microbiol Infect 7(10):532542 16. Bjerklund Johansen TE, Cek M, Naber K, Stratchounski L, Svendsen MV, Tenke P (2007) Prevalence of hospital-acquired urinary tract infections in urology departments. Eur Urol 51(4):11001112 17. Tandogdu Z, Cek M, Tenke P, Naber K, Bjerklund Johansen TE (2010) Prevalence of nosocomial urinary tract infections: what has changed in years. In: European Urology Supplements. 25th Anniversary EAU congress 2010. European Association of Urology, Barcelona, p 171 18. Naber KG (2006) Urogenital infections: the pivotal role of the urologist. Eur Urol 50(4):657659 19. Johansen TE, Cek M, Naber KG, Stratchounski L, Svendsen MV, Tenke P (2006) Hospital acquired urinary tract infections in urology departments: pathogens, susceptibility and use of antibiotics. Data from the PEP and PEAP-studies. Int J Antimicrob Agents 28(Suppl 1):S91S107 20. Graves N, Tong E, Morton AP, Halton K, Curtis M, Lairson D et al (2007) Factors associated with health care-acquired urinary tract infection. Am J Infect Control 35(6):387392 21. Leone M, Albanese J, Garnier F, Sapin C, Barrau K, Bimar MC et al (2003) Risk factors of nosocomial catheter-associated urinary tract infection in a polyvalent intensive care unit. Intensive Care Med 29(7):10771080 22. Saint S, Kaufman SR, Rogers MA, Baker PD, Boyko EJ, Lipsky BA (2006) Risk factors for nosocomial urinary tract-related bacteremia: a case-control study. Am J Infect Control 34(7): 401407 23. Dobrindt U, Chowdary MG, Krumbholz G, Hacker J (2010) Genome dynamics and its impact on evolution of Escherichia coli. Med Microbiol Immunol 199(3):145154 A, Tambic T, Kuc is ec-Tepes N (1996) Prevalence and 24. Tambic antibiotic sensitivity pattern variations of bacterial isolates in different settings and different periods of time. Acta med Croatica 50:510 25. Jones RN, Kugler KC, Pfaller MA, Winokur PL (1999) Characteristics of pathogens causing urinary tract infections in hospitals in North America: results from the SENTRY Antimicrobial Surveillance Program, 1997. Diagn Microbiol Infect Dis 35(1):5563 26. Mathai D, Jones RN, Pfaller MA (2001) Epidemiology and frequency of resistance among pathogens causing urinary tract infections in 1,510 hospitalized patients: a report from the SENTRY Antimicrobial Surveillance Program (North America). Diagn Microbiol Infect Dis 40(3):129136 27. Bouza E, San Juan R, Munoz P, Voss A, Kluytmans J (2001) A European perspective on nosocomial urinary tract infections I. Report on the microbiology workload, etiology and antimicrobial susceptibility (ESGNI-003 study). European Study Group on Nosocomial Infections. Clin Microbiol Infect 7(10):523531 28. Wagenlehner FM, Krcmery S, Held C, Klare I, Witte W, Bauernfeind A et al (2002) Epidemiological analysis of the spread of pathogens from a urological ward using genotypic, phenotypic and clinical parameters. Int J Antimicrob Agents 19(6):583591

except before traumatizing interventions of the urinary tract and in pregnant women. Besides of an adequate antibiotic therapy, the complicating factors need to be treated effectively. For initial empiric therapy, the local susceptibility prole of common uropathogens such as E. coli must be known to choose the most appropriate antibiotic. In case of severe, bacteremic UTI, it has been shown that an inadequate initial antibiotic regimen has an elevated mortality. Before initiation of antibiotic therapy, a urine specimen for culture must be obtained to be able to adapt the antibiotic regimen to the susceptibility prole. Increasing antibiotic resistance requires a more prudent use of antimicrobial drugs also in the treatment of HAUTI.
Conict of interest of interest. The authors declare that they have no conict

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