Journal of Hospital Infection 90 (2015) 240e247

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Controlling urinary tract infections associated with

intermittent bladder catheterization in geriatric
hospitals
R. Girard a, *, S. Gaujard b, V. Pergay a, P. Pornon a, G. Martin Gaujard b,
C. Vieux a, L. Bourguignon c on behalf of the Urinary Tract Infection
Control Group
a
Unite dhygiene et epidemiologie, Hopitaux de Geriatrie des Hospices Civils de Lyon, Pierre Benite, France
b
Pole dactivite medicale de Geriatrie, Hospices Civils de Lyon, Pierre Benite, France
c
Pharmacie, Hopitaux de Geriatrie des Hospices Civils de Lyon, Pierre Benite, France

A R T I C L E I N F O S U M M A R Y

Article history: Background: Controlling urinary tract infections (UTIs) associated with intermittent
Received 22 October 2014 catheterization in geriatric patients.
Accepted 9 February 2015 Aim: After a local epidemiological study identified high rates of UTI, a multi-disciplinary
Available online 5 March 2015 working group implemented and evaluated corrective measures.
Methods: In 2009, a one-month prospective study measured the incidence of UTI,
Keywords: controlled for risk factors and exposure, in six geriatric hospitals. In 2010, a self-
Urinary tract infection administered questionnaire on practices was administered to physicians and nurses work-
Geriatric ing in these geriatric units. In 2011, the working group developed a multi-modal programme
Epidemiology to: improve understanding of micturition, measurement of bladder volume and indications
Catheter for catheter drainage; limit available medical devices; and improve prescription and
traceability procedures. Detailed training was provided to all personnel on all sites. The
epidemiological study was repeated in 2012 to assess the impact of the programme.
Findings: Over 1500 patients were included in the 2009 study. The incidence of acquired
infection was 4.8%. The infection rate was higher in patients with intermittent catheters
than in patients with indwelling catheters (29.7 vs 9.9 UTI per 100 patients, P 0.1013)
which contradicts the literature. In 2010, the 269 responses to the questionnaire showed
that staff did not consider catheterization to place patients at risk of infection, staff had
poor knowledge of the recommended indications and techniques, and the equipment
varied widely between units. Following implementation of the programme, the study was
repeated in 2012 with over 1500 patients. The frequency of UTI in patients with inter-
mittent catheters fell to rates in the published literature.
Conclusion: Multi-modal programmes are an effective means to control UTI.
2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Address: Unite dHygiene et Epidemiologie, Batiment 3B, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495
Pierre Benite, Cedex, France. Tel.: 33 04 78 86 12 73; fax: 33 04 78 86 41 22.
E-mail address: raphaele.girard@chu-lyon.fr (R. Girard).

http://dx.doi.org/10.1016/j.jhin.2015.02.008
0195-6701/ 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247
Introduction
The Geriatric Interclin group was created to better coor-
dinate the prevention of infections in six geriatric hospitals of
the Hospices Civils de Lyon.
Prior epidemiological studies, conducted in other geriatric
facilities, have shown that urinary tract infections (UTIs) are
the most common nosocomial infections.1e4 In the absence of
local data on patient characteristics and the frequency of
exposure to at-risk care, it was impossible to identify priorities
in terms of prevention, or to assess the effectiveness of past
campaigns concerning indwelling catheters.
In 2009, the Geriatric Interclin group conducted an epide-
miological study measuring the incidence of UTI, controlled for
well-established risk factors5,6 and at-risk exposures.7 The
main result of the study was an abnormally high level of
nosocomial UTI associated with intermittent bladder cathe-
terization. The level of UTI associated with indwelling cathe-
ters was similar to the published literature. A multi-disciplinary
working group [Urinary Tract Infection Control Group (UTIC
Group)] was created to define prevention priorities and to
improve control actions, with the ultimate goal of reducing the
rate of UTI. The UTIC Group consisted of an infection control
team (physician and nurses), a clinical team (physicians and
nurses), urodynamics experts, a pharmacist and a quality
specialist.
The UTIC Group conducted practice evaluations and an
extensive educational campaign, and repeated the epidemio-
logical study in 2012 in order to verify the effectiveness of the
programme. An overview of the entire programme is presented
in Figure 1.
Population and methods
Population
Geriatric units at six geographical locations were included in
this study. These consisted of three geriatric hospitals with
acute care, subacute care/rehabilitation and long-stay units;
and three geriatric units in general hospitals. The total number
of beds was approximately 1200.
Epidemiological studies
Similar studies were conducted at the beginning and end of
the programme (2009 and 2012). This was a prospective cohort
study, and all the geriatric units in the six hospitals partici-
pated. In 2009, all hospitalized patients, regardless of whether
or not they were suffering from an infection, present in or
admitted to a participating unit from 1st June 2009 to 28th June
2009 were included. They were followed until discharge or
until 30th June 2009. In 2012, the corresponding dates were
from 1st June 2012 to 28th June 2012, and until discharge or
until 30th June 2012, respectively.
The study focused on clinical UTI, excluding asymptomatic
bacteriuria. The case definition of UTI used was that proposed
by the Ministry of Health in 2007 (http://www.sante-sports.
gouv.fr/IMG/pdf/rapport_vcourte.pdf), adapted from the
definition of the US Centers for Disease Control and Preven-
tion,8 and described in the guidelines as follows:
241
e at least one of the following signs: fever (>38 C) or chills,
urgency, urinary or suprapubic pain, burning urination,
incontinence or recent increase of dysuria or urinary fre-
quency, worsening of dependency or mental condition,
purulent urine in the absence of other causes; and
e positive leukocyturia (104 leukocytes/mL) and urine cul-
ture (103 micro-organisms/mL without urinary catheter-
ization and 105 micro-organisms/mL with urinary
catheterization) with no more than two micro-organisms.
UTIs were considered to be nosocomial if they developed at
least 48 h after hospitalization for external patients, and
regardless of the time frame for patients transferred during the
study from another geriatric unit taking part in the study.
The endpoints were nosocomial UTI, cumulative incidence
rate per 100 patients followed during the study period, and
incidence rate per 1000 patient-days attended during the study
period.
The data collected on exposure were defined based on the
literature:7,9,10 type of stay (short and medium stay vs long
stay) and dates, type of urinary catheterization (indwelling,
intermittent or suprapubic) and dates, presence of neph-
rostomy, and use of condoms and nappies. Intermittent cath-
eterization was only taken into account if it was used before
the onset of infection (occasional catheterization for micro-
biological testing was excluded).
The data collected on risk factors were: level of functional
dependency measured with a simplified activities of daily living
(ADL) score11 (from 0 for independent patients to 6 for fully
dependent patients), dementia, diabetes (treated with insu-
lin/hypoglycaemic drugs or stabilized using hygienic dietary
measures), urinary incontinence, urinary retention, bladder
dysfunction, post-voiding residual >300 mL, UTI antecedents
(last six months) and immunodeficiency (leukopenia, cancer or
immunosuppressive treatment). All the available risk factors
established in the literature were included.12e14 The data
collected in the case of a UTI were: date; micro-organisms
identified and antibiotic sensitivity; treatment approval or
adjustment according to antibiotic sensitivity; and antibiotics
prescribed (initial and adjusted treatments with type of anti-
biotic and duration).
The study was advertised on posters in the different geri-
atric units, according to the rules of good practice, and was
presented at unit meetings. In compliance with French regu-
lations, this type of non-interventional study does not require
ethical committee approval if the data are anonymous and if
the hospital has been registered previously by a specific
research committee.
For each patient included, a form was completed by the
practitioners and nurses, both on admission and during their
stay. The forms were collected in each unit in a book that
included the guidelines. Compliance was verified by the
infection control team.
Data capture and analysis were undertaken by the infection
control team using EpiInfo Version 3.1 (Centers for Disease
Control and Prevention, Atlanta, GA, USA) and Statistical
Package for the Social Sciences Version 17 (IBM Corp., Armonk,
NY, USA). Univariate analyses of UTI were performed to
compare the risk factors of patients and exposure. The
following tests were used for comparisons: Mantel-Haenszel c2
test for discontinuous variables (or Yates modified c2 for small
numbers), Z-test for incidence, and analysis of variance for
242 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247

First epidemiological study

Diagnosis
Urinary tract infections are more common with
intermittent vs indwelling bladder catheterization

Hypothesis 2
Hypothesis 1 Hypothesis 3
Protocol non-
Devices not Practices not
compliant with
adapted adapted
guidelines

Questionnaire
Observation Reviewing
study

Confirms Does not confirm Confirms

hypothesis hypothesis hypothesis

Multi-modal programme

Second epidemiological study

Diagnosis
Urinary tract infections are not more common with
intermittent vs indwelling bladder catheterization

Figure 1. Global schema of the urinary tract infection prevention programme.

continuous variables. Multi-variate analysis using a Cox model
was performed on nosocomial UTI, considering exposure
duration and risk factors that were found to be significant on
univariate analysis. Given the large number of tests, P < 0.01
was taken to indicate significance.
Devices and practice evaluation
This study focused on intermittent bladder catheterization,
which was associated with a higher risk of UTI in the 2009 study.
Three main objectives were identified: (1) to check that local
protocols complied with the guidelines; (2) to describe usual
practices and knowledge; and (3) to list all available materials.
In order to meet the first objective, the literature and
guidelines were reviewed. For the second objective, a survey
using a self-administered questionnaire was sent personally to
every physician and nurse working in the participating geriatric
units. For the final objective, a questionnaire was completed
by the hospital pharmacy. The references used to check pro-
tocol compliance and to describe the stages of intermittent
bladder catheterization were defined from a common protocol,
written according to French recommendations (http://www.
sf2h.net/publications-SF2H/SF2H_surveiller-et-prevenir-les-
IAS-2010.pdf) and European guidelines.15
Three different forms of collection were prepared and
tested: one physician sheet, one nurse sheet and one
pharmacist sheet. They were delivered by the infection
control team.
Data were entered into EpiInfo 2002 and a descriptive
analysis was performed. Mantel Haenszel c2 test (or c2 test
 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247 243

Table I
Presence of confounding factors and exposures to at-risk procedures: prevalence (% patients included)
Risk factors 2009 (1510 patients) 2012 (1547 patients) Pa
Patients included Prevalence Patients included Prevalence
Diabetes 268 17.7 292 18.9 0.420
High dependency (activities of daily living score >4) 771 51.1 690 44.6 <0.001
Dementia 826 54.7 808 52.2 0.170
Incontinence 866 57.4 892 57.7 0.862
Retentionb 157 10.4 122 7.9 0.681
Neurologic bladderb 51 3.3
Immunosuppression 146 9.7 153 9.9 0.836
Post-void residual 84 5.6 91 5.9 0.710
Infection during previous six monthsc 419 27.7 203 13.1 e
Indwelling catheterization 181 11.9 182 11.8 0.849
Intermittent bladder catheterizationd 40 2.6 32 2.1 0.275
Nappy use 853 56.5 981 63.4 <0.001
No exposure 428 28.3 336 21.7 <0.001
a
Mantel Haenzel c2 test between 2009 and 2012 data.
b
Comparison includes, for 2012, patient with retention or neurologic bladder (154 patients, 10.0%).
c
2012 definition was stricter, limited to infections during last six months, so no statistical comparison was made.
d
Possibly after indwelling catheters.

with Yates correction when theoretical numbers were <5) was were organized at the same time as training, in liaison with the
used for comparisons between professions. hospital pharmacies.

Description of the intervention

The aims of the programme were to update and disseminate
guidelines for medical prescriptions, practices and equipment
required for intermittent bladder catheterization, and to
harmonize the available materials and organization of training
sessions. Decisions were based on a wide-ranging review of the
literature, and the programme included the following points:
e limiting indications: defining specific retention situations,
collection of catheter urine samples only if unable to
obtain a mid-stream sample;
e improving diagnosis of urinary retention by increasing and
improving the use of devices for measuring bladder
volume;
e limitation of equipment: either bladder drainage kits (pre-
lubricated catheter pre-connected to sealed bag) or sterile
pre-lubricated catheters and sterile bags. All other equip-
ment was removed from the units. Pre-lubricated catheters
were chosen in order to limit pain, risk of urethral stricture
and UTI;16,17 and
e training and awareness-raising meetings for all caregivers
concerning aseptic technique (as for indwelling catheters)
and new clinical guidelines.
These meetings were held in all geriatric units, in short
sessions, with a different training team (physician, nurse,
infection control team member) in each hospital. The sessions
were held at various times of day and night, so that all pro-
fessionals could attend, between February and May 2011. A
shared training tool (slides, new materials and documents) was
used. The information was given to each new staff member
(physician or nurse) on arrival, and presented at institutional
meetings to managers, medical staff, forums etc. The removal
of obsolete equipment and the introduction of new materials
Results
Epidemiological data
For the purposes of brevity, the results of the two studies
are presented together, regardless of the time course. In June
2009, 1510 files were completed: 890 for short- and medium-
stay patients and 620 for long-stay patients. One thousand
and thirty women (68.2%) and 480 men (31.8%) were included in
the 2009 study. Their mean age was 85.2 years (standard de-
viation 7.4), with no significant difference between males and
females.
The mean duration of follow up was 13.5 days for short- and
medium-stay patients and 28.0 days for long-stay patients. At
baseline, the duration of stay prior to inclusion ranged from
0 days to 10 years, with a median follow-up of 19 days, and 35%
of patients were enrolled in the study on the day of admission.
In June 2012, 1547 files were completed: 1118 for short- and
medium-stay patients, and 429 for long-stay patients. The
difference in distribution compared with 2009 can be explained
by the separation of acute care and subacute care/rehabili-
tation in different hospitals and reduction of long-stay beds.
One thousand and fifty women (67.9%) and 497 men (32.1%)
were included in the 2012 study. Their mean age was 85.5 years
(standard deviation 7.0), with no significant difference be-
tween males and females.
The mean duration of follow-up was 10.5 days for short- or
medium-stay patients and 28.6 days for long-stay patients. At
baseline, the duration of stay prior to inclusion ranged from
0 days to 10 years, and 39.8% of patients were enrolled in the
study on the day of admission.
Concerning the prevalence of risk factors, the patients
included in 2012 did not differ significantly from the patients
included in 2009 (see Table I). The major difference was in the
244 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247

Table II
Cumulative incidence of nosocomial urinary tract infection (UTI) by exposure (% patients included)
Exposure 2009 2012 Pa
Number of patients UTI Number of patients UTI
included included
N Incidence N Incidence
Indwelling catheter 181 18 9.9 182 27 14.8 0.157
Intermittent bladder 37 11 29.7 17 3 17.6 0.405
catheterization aloneb
Nappy use 853 35 4.1 859 23 2.7 0.102
No exposure 428 5 1.2 477 9 1.9 0.381
All patients 1510 72 4.8 1547 63 4.1 0.349
a
Mantel Haenzel c2 test between years, or Yates modified c2 test for small numbers.
b
No other exposures during the follow-up period.

patients level of dependence, which was generally lower in
2012 (patients with ADL score >4 44.6% vs 51.1%, P < 0.001).
UTI at study inclusion was more common in 2009 than in
2012 [143 cases (9.5%) vs 95 cases (6.1%), P < 0.001].
Concerning exposure, the patients included in the 2012
study did not differ significantly from the patients included in
the 2009 study (see Table I). The major difference was in the
use of nappies, which was more common in 2012 (63.4% vs
56.5, P  0.001). The limited number of patients with neph-
rostomy (eight in 2009 and seven in 2012) and patients with
suprapubic catheters (zero in 2009 and nine in 2012) should
also be noted.
The change in the cumulative incidence of nosocomial UTI
between 2009 and 2012 was small and not significant overall or
when broken down according to the type of exposure (see
Table II). In 2009, the incidence of UTI associated with inter-
mittent catheterization was much higher than that associated
with indwelling catheterization (29.7% vs 9.9%, P 0.002), but
this difference disappeared in 2012 (17.6% vs 14.8%, P 0.964).
The same was observed for the incidence of UTI according to
exposure (see Table III). Concerning the difference between
intermittent and indwelling catheterization, the difference in
terms of UTI observed in 2009 (13.38& vs 7.21&, P 0.050)
was not seen in 2012 (12.30& vs 8.81&, P 0.291).
As all risk factors included in the study were significantly
associated with UTI, all these factors, as well as the type of
exposure, were included in a Cox model, taking into account
the duration of follow-up in 2009 and 2012. The significant
increase in the risk of UTI related to intermittent catheteri-
zation found in 2009 was not seen in 2012 (see Table IV).
Description of UTI
In 2009, the type of UTI was not recorded. In 2012, cystitis
was the most common type of UTI (28 cases, 44.4% of cases of
UTI and 1.8% of all patients). Other UTIs were pyelonephritis
(13 cases, 20.6% of cases of UTI and 1.8% of all patients),
prostatitis (three cases, 4.8% of cases of UTI and 0.2% of all
patients), and specific UTIs on indwelling catheters (19 cases,
30.2% of cases of UTI and 1.2% of all patients). The micro-
organisms detected did not differ between 2009 and 2012
(see Table V). Escherichia coli remained the most common
pathogen, and the frequency of antibiotic resistance remained
low. In 2012, of the 36 E. coli, two were resistant to cefotaxime
and sensitive to imipemen, and one secreted extended-
spectrum beta-lactamase. Among the six Klebsiella spp., one
was resistant to cefotaxime and sensitive to imipemen, and one
secreted extended-spectrum beta-lactamase. Among the three
Morganella spp., no resistance was found.
Result of field studies
Protocol conformity
The protocol for intermittent catheterization complied with
the guidelines with a high level of asepsis, and use of closed
drainage and sterile pre-lubricated catheters and sterile bags.

Table III
Incidence of nosocomial urinary tract infection (UTI) by exposure (& patient days included)
Exposure 2009 2012 Pa
Follow-up inpatient days UTI Follow-up inpatient days UTI
N Incidence N Incidence
Indwelling catheter 2495 18 7.21 3064 27 8.81 0.255
Intermittent bladder 822 11 13.38 244 3 12.30 0.448
catheterization aloneb
Nappy use 18,375 35 1.90 17,661 23 1.30 0.077
No exposure 6726 5 0.74 7159 9 1.26 0.170
All patientsc 29,358 72 2.45 28,305 63 2.23 0.287
a
Z-test between years.
b
No other exposures during the follow-up period.
c
The sum of all patient data are not the sum of each exposure; suprapubic catheter data are not presented.
 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247 245

Table IV The answers regarding the key stages of different practices

Significant factors for nosocomial urinary tract infection in multi- are reported in Table VI. Few differences were found between
variate analysis using Cox model the practices of the two groups. Physicians reported less
compliance with rinsing and wiping after genital cleaning,
Factor RR 95% CI of RR P
traceability of actions, and clamping to stop the drain in the
2009 event of a large volume of urine. Aqueous povidone iodine was
Intermittent bladder 5.143 2.665e9.924 <0.001 the main antiseptic used. Only 53 nurses reported their criteria
catheterization alone for selecting equipment. The main criterion cited was avail-
Post-void residual 2.252 1.028e4.933 0.042 ability (cited 43 times), followed by the prevention of infection
Indwelling bladder 1.911 0.992e3.681 0.053 by the closed system (cited five times), practicality (cited four
catheterization times) and patient comfort (cited twice). Two nurses reported
Level of dependencya 1.286 1.088e1.286 0.004 that the bladder drainage kit with integrated bag was awkward
Dementia 0.489 0.298e0.801 0.005 because the catheter and hose were too short.Eight physicians
Retention 0.416 0.173e0.999 0.050 indicated their selection criteria: the main criterion cited was
2012 handy or practical (cited four times), followed by patient
Indwelling bladder 6.055 3.527e9.219 <0.001 comfort (cited twice), prevention of infection by the closed
catheterization system (cited once) and availability (cited once).
Infection during the 3.376 1.856e5.435 <0.001 Knowledge of the protocol was poor, especially among
previous six months physicians [six physicians, (16.2%) vs 135 nurses (58.7%),
Intermittent bladder 1.254 0.458e3.733 0.659 P < 0.001]. The protocol was usually consulted to present to
catheterization alone students or new members of staff or, more rarely, in case of
Dementia 0.562 0.329e0.960 0.035 doubt regarding the technique.
Incontinence 0.501 0.295e0.849 0.010
RR, relative risk, CI, confidence interval. Available devices
a Most pharmacies did not provide advice regarding which
Measured with activities of daily living score [numeric data, from
0 (not dependent) to 6 (totally dependent)]. equipment to use, except for one hospital that recommended
the use of a lubricated catheter, and another hospital that
recommended the use of a bladder drainage kit. The devices
Practices and knowledge evaluation concerning and equipment available varied widely. For example, more
intermittent catheterization than 20 different types of catheter were found in one hospital.
In total, 269 professionals answered the questionnaire: 31
senior physicians, eight residents (32.3% of physicians) and 230
nurses (63.5%). They practised in short-, medium- and long-stay
Discussion
units. The most commonly mentioned indication was retention,
The implementation of a preventative programme adapted
cited by 25 physicians (51.2%), and post-void residual was cited
to the local situation has been associated with the control of
by 16 physicians (43.3%). Five physicians (13.5%) preferred
UTI associated with intermittent bladder catheterization. In
urine samples to be taken with a catheter.
2009, the incidence of UTI associated with intermittent
The questions on prescriptions were the same for both
bladder catheterization was higher than the incidence of UTI
nurses and physicians. The results showed that oral pre-
associated with indwelling catheterization, contradicting the
scriptions were made occasionally, although written pre-
literature.18e20 Following the study intervention, the incidence
scriptions were the rule: 109/263 professionals (41.4%)
of UTI has fallen in line with the published literature.
reported that they always made written prescriptions. The
The effectiveness of this control programme was probably
answers did not differ between physicians and nurses.
due to: (1) significant improvement in aseptic quality when
using intermittent catheterization, thanks to the clear mes-
Table V sages given during training in compliance with numerous
Micro-organisms causing urinary tract infections by year guidelines;15,21 (2) generalization of closed drainage and
lubricated catheters; and (3) increased availability of bladder
Micro-organism 2009 2012 scan evaluation equipment and better understanding of its
N % N % use.22
Citrobacter spp. 2 1.4 1 1.5
The results can be considered reliable as: (1) a large popu-
Escherichia coli 67 46.8 36 52.2
lation was included; (2) the population was similar between the
Enterococcus spp. 12 8.4 8 11.6
two periods; (3) the criteria were not modified except for the
Enterobacter aerogenes or cloacae 4 2.8 1 1.5
timeframe for preliminary UTI (only during the last six months
Klebsiella (pneumoniae or other) 5 3.5 6 8.7
in 2012); (4) the antibiotic resistance patterns were similar for
Proteus mirabilis 11 7.7 3 4.3
both periods; and (5) the medical team did not change between
Pseudomonas aeruginosa 9 6.3 4 5.8
the two periods.
Morganella spp. 4 2.8 3 4.3
The differences in terms of the level of dependency and the
Staphylococcus aureus 8 5.6 0 0
use of nappies could be explained by improved understanding
Other Gram-positive cocci 3 2.1 1 1.5
of the relationship between nosocomial UTI and these criteria,
Candida spp. 3 2.1 0 0
and more complete data collection.
Not available 15 10.5 6 8.6
The frequency of UTI in the present study should be
compared with data in the literature. The incidence of UTI in
246 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247

Table VI
Intermittent catheterization practices
Steps and devices Physicians (N 37)* Nurses (N 230) Pa
Always N (%) Usually N (%) Sometimes, rarely Always N (%) Usually N (%) Sometimes, rarely
or never N (%) or never N (%)
Washing with soap 22 (59.5) 3 (8.1) 0 (0.0) 189 (82.2) 25 (10.9) 8 (3.4) 0.70
Rinsing 19 (51.4) 7 (18.9) 0 (0.0) 205 (89.9) 8 (3.5) 4 (1.8) <103
Wiping 17 (45.9) 4 (10.8) 4 (10.8) 183 (81.7) 16 (7.1) 14 (6.2) 0.04
Antisepsis 19 (51.4) 3 (8.1) 3 (8.1) 191 (83.0) 19 (8.3) 10 (4.3) 0.14
Hand disinfection 23 (62.2) 3 (8.1) 0 (0.0) 198 (86.1) 22 (9.6) 0 (0.0) 0.74
Sterile gloves 23 (62.2) 1 (2.7) 2 (5.4) 163 (70.9) 14 (6.1) 42 (18.3) 0.121
Sterile closed drainage 11 (29.7) 2 (5.4) 10 (27.0) 105 (45.7) 31 (13.5) 73 (31.7) 0.82
Lubricationb 12 (32.4) 7 (18.9) 5 (13.5) 99 (43.0) 36 (15.7) 61 (26.5) 0.96
Clamping if >500 cc 15 (40.5) 7 (18.9) 5 (13.5) 173 (75.2) 19 (8.3) 24 (10.3) 0.001
in bladder
Transmission 12 (32.4) 9 (24.3) 4 (10.8) 172 (74.8) 36 (15.7) 8 (3.5) <103
*Of the 39 physicians that responded to the study, 37 described their practices concerning catheterization, the other two described only pre-
scription practices.
a
Mantel Haenzel c2 test between nurses and physicians, or Yates modified c2 test for small numbers.
b
Pre-lubricated catheter or lubrication using sterile gel.

the study population in 2012 was 4.1% of patients and 2.23& of
patient-days, including 11.9% of patients with indwelling
catheters. Recent studies in geriatric units have found similar
cumulative incidences23 and similar incidence rates.24 These
comparisons are limited as few studies have investigated inci-
dence; prevalence is studied more often, and the data were
not analysed separately by type of catheter. The predominance
of E. coli amongst the pathogens has also been reported in
other studies.25,26
This work indicates that interventions to prevent UTI were
acceptable in the group of study hospitals, but the improve-
ments need to be sustained. Training of new staff (nurses and
physicians), good communication about cases of UTI, obser-
vation of practice and further epidemiological studies will be
prioritized.
Acknowledgements
The authors would like to thank the members of the UTIC
Group: E. Castel-Kremer, N. Michel-Laaengh, C. Moindrot, J.
Martignolles, B. Cracco, M-E. Gengler, L. Oltra, N. Bercegol and
C. Mauranne. The authors also wish to thank the Heads of Units:
M. Bonnefoy, B. Comte, P. Krolak-Salmon, B. Depagneux, G.
Albrand and E. Andre-Fouet.
Conflict of interest statement
None declared.
Funding sources
None.
References
1. Engelhart ST, Hanses-Derendorf L, Exner M, Kramer MH. Prospec-
tive surveillance for healthcare-associated infections in German
nursing home residents. J Hosp Infect 2005;60:46e50.
2. Ellidokuz H, Ucku R, Uysal U, Abacioglu H. Hospital-acquired in-
fections in elderly patients: results of a West Anatolian University
Hospital surveillance. Arch Gerontol Geriatr 2003;37:259e263.
3. French Prevalence Survey Study Group. Prevalence of nosocomial
infections in France: results of the nationwide survey in 1996.
French Prevalence Survey Study Group. J Hosp Infect
2000;46:186e193.
4. Golliot F, Astagneau P, Cassou B, Okra N, Rothan-Tondeur M,
Brucker G. Nosocomial infections in geriatric long-term-care and
rehabilitation facilities: exploration in the development of a risk
index for epidemiological surveillance. Infect Control Hosp Epi-
demiol 2001;22:746e753.
5. Haber N, Paute J, Gouot A, et al. [Incidence and clinical charac-
teristics of symptomatic urinary infections in a geriatric hospital].
Med Mal Infect 2007;37:664e672.
6. Kunin CM. Urinary-catheter-associated infections in the elderly.
Int J Antimicrob Agents 2006;28(Suppl. 1):S78eS81.
7. Jahn P, Preuss M, Kernig A, Seifert-Huhmer A, Langer G. Types of
indwelling urinary catheters for long-term bladder drainage in
adults. Cochrane Database Syst Rev 2007;3:CD004997.
8. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM.
Infectious Diseases Society of America guidelines for the diagnosis
and treatment of asymptomatic bacteriuria in adults. Clin Infect
Dis 2005;40:643e654.
9. Kunin CM. Genitourinary infections in the patient at risk: extrinsic
risk factors. Am J Med 1984;76:131e139.
10. Inelmen EM, Sergi G, Enzi G. When are indwelling urinary cathe-
ters appropriate in elderly patients? Geriatrics 2007;62:18e22.
11. Sato S, Demura S, Minami M, Kasuga K. Longitudinal assessment of
ADL ability of partially dependent elderly people: examining the
utility of the index and characteristics of longitudinal change in
ADL ability. J Physiol Anthropol Appl Human Sci 2002;21:179e187.
12. Ismail NH, Lieu PK, Lien CT, Ling ML. Bacteraemia in the elderly.
Ann Acad Med Singapore 1997;26:593e598.
13. Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD.
Predictors of urinary tract infection after menopause: a pro-
spective study. Am J Med 2004;117:903e911.
14. Omli R, Skotnes LH, Mykletun A, Bakke AM, Kuhry E. Residual urine
as a risk factor for lower urinary tract infection: a 1-year follow-up
study in nursing homes. J Am Geriatr Soc 2008;56:871e874.
15. Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T,
Tambyah PA, Naber KG. European and Asian guidelines on man-
agement and prevention of catheter-associated urinary tract in-
fections. Int J Antimicrob Agents 2008;31(Suppl. 1):S68eS78.
16. Giannantoni A, Di Stasi SM, Scivoletto G, Virgili G, Dolci S,
Porena M. Intermittent catheterization with a prelubricated
 R. Girard et al. / Journal of Hospital Infection 90 (2015) 240e247
catheter in spinal cord injured patients: a prospective randomized
crossover study. J Urol 2001;166:130e133.
17. Mauroy B, Soret R, Bonnal JL, Fantoni JC. [Comparison of 3 self
lubrificated urethral catheters: prospective study on 27 patients].
Ann Urol (Paris) 2001;35:223e228.
18. Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Inter-
mittent versus indwelling catheters for older patients with hip
fractures. J Clin Nurs 2002;11:651e656.
19. Tang MW, Kwok TC, Hui E, Woo J. Intermittent versus indwelling
urinary catheterization in older female patients. Maturitas
2006;53:274e281.
20. Duffy LM, Cleary J, Ahern S, et al. Clean intermittent catheteri-
zation: safe, cost-effective bladder management for male resi-
dents of VA nursing homes. J Am Geriatr Soc 1995;43:865e870.
21. Pratt RJ, Pellowe CM, Wilson JA, et al. epic2: National evidence-
based guidelines for preventing healthcare-associated infections
in NHS hospitals in England. J Hosp Infect 2007;65(Suppl.
1):S1eS64.
247
22. Borrie MJ, Campbell K, Arcese ZA, et al. Urinary retention in pa-
tients in a geriatric rehabilitation unit: prevalence, risk factors,
and validity of bladder scan evaluation. Rehabil Nurs
2001;26:187e191.
23. Kang CY, Chaudhry OO, Halabi WJ, et al. Risk factors for post-
operative urinary tract infection and urinary retention in patients
undergoing surgery for colorectal cancer. Am Surg
2012;78:1100e1104.
24. Lim CJ, McLellan SC, Cheng AC, et al. Surveillance of infection burden
in residential aged care facilities. Med J Aust 2012;196:327e331.
25. den Heijer CD, Beerepoot MA, Prins JM, Geerlings SE,
Stobberingh EE. Determinants of antimicrobial resistance in
Escherichia coli strains isolated from faeces and urine of women
with recurrent urinary tract infections. PLoS One 2012;7:e49909.
26. Fagan M, Maehlen M, Lindbaek M, Berild D. Antibiotic prescribing
in nursing homes in an area with low prevalence of antibiotic
resistance: compliance with national guidelines. Scand J Prim
Health Care 2011;30:10e15.