infection control and hospital epidemiology december 2007, vol. 28, no. 12

Does Catheter-Associated Urinary Tract Infection Increase Mortality in Critically Ill Patients?
Christophe Clec’h, MD; Carole Schwebel, MD; Adrien Franc¸ais, MSc; Dany Toledano, MD; Jean-Philippe Fosse, MD;
Maı¨te´ Garrouste-Orgeas, MD; Elie Azoulay, MD, PhD; Christophe Adrie, MD, PhD; Samir Jamali, MD;
Adrien Descorps-Declere, MD; Didier Nakache, PhD; Jean-Franc¸ois Timsit, MD, PhD;
Yves Cohen, MD; on behalf of the OutcomeRea Study Group
objective. To produce an accurate estimate of the association between catheter-associated urinary tract infection (UTI) and intensive
care unit (ICU) and hospital mortality, controlling for major confounding factors.
design. Nested case-control study in a multicenter cohort (the OutcomeRea database).
setting. Twelve French medical or surgical ICUs.
methods. All patients admitted between January 1997 and August 2005 who required the insertion of an indwelling urinary catheter.
Patients who developed catheter-associated UTI (ie, case patients) were matched to control patients on the basis of the following criteria:
sex, age (_ 10 years), SAPS (Simplified Acute Physiology Score) II score (_ 10 points), duration of urinary tract catheterization, and
presence or absence of diabetes mellitus. The association of catheter-associated UTI with ICU and hospital mortality was assessed by use
of conditional logistic regression.
results. Of the 3,281 patients who had an indwelling urinary catheter, 298 (9%) developed at least 1 episode of catheter-associated
UTI. The incidence density of catheter-associated UTI was 12.9 infections per 1,000 catheterization-days. Crude ICU mortality rates were
higher among patients with catheter-associated UTI, compared with those without catheter-associated UTI (32% vs 25%, Pp.02); the
same was true for crude hospital mortality rates (43% vs 30%, P ! .01). After matching and adjustment, catheter-associated UTI was no
longer associated with increased mortality (ICU mortality: odds ratio [OR], 0.846 [95% confidence interval {CI}, 0.659-1.086]; Pp.19
and hospital mortality: OR, 0.949 [95% CI, 0.763-1.181]; Pp.64).
conclusion. After carefully controlling for confounding factors, catheter-associated UTI was not found to be associated with excess
mortality among our population of critically ill patients in either the ICU or the hospital.
references
1. Eriksen HM, Iversen BG, Aavitsland P. Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003. J Hosp Infect 2005; 60:40-45.
2. Lizioli A, Privitera G, Alliata E, et al. Prevalence of nosocomial infections in Italy: result from the Lombardy survey in 2000. J Hosp Infect 2003;54:141-148.
3. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infectionsin combined medical-surgical intensive care units in the United States.Infect Control Hosp Epidemiol 2000; 21:510-515.
4. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International
Advisory Committee. JAMA 1995; 274:639-644.
5. Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med 1982; 307:637-642.
6. Rosenthal VD, Guzman S, Orellano PW. Nosocomial infections in medical- surgical intensive care units in Argentina: attributable mortality and length of stay. Am J Infect Control 2003; 31:291-295.

Dyad 6 guomanman and chenya

Prognosis

Complications
Recurrent Cystitis
Some women suffer from recurrent urinary tract infections:
20% of women who have had one urinary tract infection (UTI) will have one recurrence
30% of those women will have more than one recurrence
The recurrent infection usually stems from a different strain or type of bacteria from the original urinary tract infection (UTI)

During Pregnancy
If a pregnant woman develops a urinary tract infection (UTI) it often travels to the kidney causing pyelonephritis, due to hormonal changes and fluctuations and increased pressure on the bladder

In Babies
If left untreated the infection can harm the fetus
Newborn babies may get a systemic infection called Sepsis
After Menopause

Infection can occur when vaginal tissues start to break down due to a decrease in estrogen levels

Response: UTI- FOLLOW-UP GUIDELINES AND MORTALITY
By: Dyad2: Gil Legarda / Joanalyn Balino

Perinatal Risk for Mortality and Mental Retardation Associated with Maternal Urinary Tract Infection
By: Suzanne McDermott PhD, Virginie Daguise MSPH, Heather Mann MSPH, Lisa Szwejbka MSPH, William Callaghan MD, MPH.

McDermott S. et al studied about the perinatal risk for morality and mental retardation associated with maternal urinary tract infection this research was done in a retrospective cohort design to explore the risk for fetal death and mental retardation or developmental delay associated with exposure to maternal UTI during pregnancy. There were about 53,043 pregnancies also they included 7522 repeat pregnancies. The setting of these study was held in South Carolina Department of Health and Human Services. All data gathered were recorded in the medical record and coded per month and year. Clinical diagnosis was supported by laboratory tests and findings and recorded by the attending physicians. On mental retardation the diagnosis was based on the standardized scores on the Stanford-Binet Intelligence Scale form. The data were analyzed by the used of chi-square tests, survival analysis procedures with use of SAS software and logistic regression modelling. The measures of outcomes were fetal death and mental retardation or developmental delay in the live-born children. There were some limitations identified in this study like issues significant to exposure variable and in the case definition for mental retardation or developmental delay differed for the two data sets.

This research shows an increased relative risk for mental retardation or developmental delay in the third trimester of pregnancy. A 2.23 or 95 percent fetal death associated with maternal Urinary tract infection in the third trimester relative hazard. The mother and child characteristics showed an equal proportion of black and white participants from low economic environments. A fetal death rate of one point nine percent and urinary tract infection of 15.6 percent.

Based on our review of this article an additional longitudinal studies are needed to assess and evaluate the association of the time of infection with presenting symptoms and the organism also anima models are helpful to understand the mechanisms of the mechanism of injury to the fetal brain. However the findings support an association between third trimester maternal UTI and fetal death and mental retardation.


Reference:
McDermott S. PhD et al (2001). Perinatal Risk for Mortality and Mental Retardation Associated with Maternal Urinary Tract Infection. Journal of Family Practice Vol. 50 pages 433-437

Dyad 6 guomanman and chenya

Urinary tract infection (UTI) is a common bacterial infection in children. Studies in Western countries suggested that it accounted for 5% of febrile illnesses in young children.1 It is especially common in infants, female and the White race.2 Imaging studies following UTI revealed a high incidence of abnormalities in the renal tract, with vesicoureteric reflux (VUR) in 30-50%1 and obstructive uropathies in 1-4%.3 Evidence of renal parenchymal damage was present in 1.6-15% as seen on intravenous urography3 and 59% as seen on 99mTechnetium-dimercaptosuccinic acids (DMSA) scans.4 The risk of renal scarring was positively associated with the severity of VUR and number of recurrent febrile UTI. The relationship of such radiographic findings to long term sequalae such as hypertension and chronic renal failure have been challenged. Nevertheless four of the 52 patients with VUR reported by Smellie et al developed end stage renal failure after 10 years.5 A review of the literature also found that end stage renal disease developed in 3-10% of patients with extensive scarring.1 Ethnic difference has also been reported in the incidence of UTI and VUR.6

Despite controversies in its management, it is important to recognise UTI in young children and be familiar with its clinical significance. In the local Chinese population, case series of childhood UTI were reported in the mid-1980's.7,8 In the present study we aimed to review the epidemiology, clinical findings, imaging studies and outcome of a more recent cohort of UTI patients and highlight any secular changes by comparing with previous reports, or any significant differences from the Western populations.
Results

Ninety-four patients were studied, including 73 boys (78%) and 21 girls (22%). The mean age of presentation was 9.5 months (median 3 months, range one day to 7.9 years). Eight patients (8.5%) were neonates (M:F = 7:1). Seventy-two (76.6%) were between 1-12 months old (M:F = 57:15), and 14 were older children (M:F = 9:5).

Fever (>=38.0°C) was the major symptom in 87.5% of the neonates (<1 month) and in 94.4% of infants. Other symptoms in these age groups were also non-specific. In older children, only 50% had fever, but 70% presented with dysuria. One neonate (12%) and 6 infants (8%) presented as febrile seizure. One patient had Escherichia coli septicemia secondary to UTI.
1. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics 1999;103:e54.

2. Shaw KN, Gorelick M, McGowan KL, Yakscoe NM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998;102:e16.

3. Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. J Pediatr 1996;128:15-22.

4. Gordon I, Barkovics M, Pindoria S, Cole TJ, Woolf AS. Primary vesicoureteric reflux as a predictor of renal damage in children hospitalized with urinary tract infection: a systematic review and meta-analysis. J Am Soc Nephrol 2003;14:739-44.

5. Smellie JM, Barratt TM, Chantler C, et al. Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomised trial. Lancet 2001;357:1329-33.

6. Melhem RE, Harpen MD. Ethnic factors in the variability of primary vesico-ureteral reflux with age. Pediatr Radiol 1997;27:750-1.

7. Chow CB, Yau FT, Leung NK. Symptomatic urinary tract infection in Hong Kong children. JHK Med Assoc 1988;40:276-80.

8. So LY, Davies DP. Urinary tract infection in childhood: a study of 137 cases. HK J Paediatr 1988;5:17-24.

9. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003;348:195-202.

10. Craig JC, Knight JF, Sureshkumar P, Mantz E, Roy LP. Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr 1996;128:23-7.

11. To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352:1813-6.

12. Smellie JM, Hodson CJ, Edwards D, Normand IC. Clinical and radiological features of urinary infection in childhood. Br Med J 1964;5419:1222-6.

13. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics 1999;103(4 Pt 1):843-52.

14. Wong SN, Chiu W, Ho S, et al. Clinical Guideline on Management of Urinary Tract Infections in Children below 2 Years of Age (Part I): The Diagnosis and Initial Management. HK J Paediatr (new series) 2002;7:205-13.

15. Honkinen O, Lehtonen OP, Ruuskanen O, Huovinen P, Mertsola J. Cohort study of bacterial species causing urinary tract infection and urinary tract abnormalities in children. BMJ 1999;318:770-1.

16. Wong SN, Chiu W, Ho S, et al. Clinical guideline on management of urinary tract infections in children below 2 years of age (part II): investigations following a documented infection. HK J Paediatr (new series) 2003;8:47-54.

17. Mangiarotti P, Pizzini C, Fanos V. Antibiotic prophylaxis in children with relapsing urinary tract infections: review. J Chemother 2000;12:115-23.

18. Williams G, Lee A, Craig J. Antibiotics for the prevention of urinary tract infection in children: A systematic review of randomized controlled trials. J Pediatr 2001;138:868-74.

19. Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am 1987;1:713-29.

20. Elder JS, Peters CA, Arant BS Jr, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997;157:1846-51.

Dyad Three (3)
Byron Webb A. Romero
Von Deneb H. Vitto
Raymond C. Ursal

DYAD RESPONSE TO: FOLLOW-UP FOR UTI

It is practice parameter for children (aged 2 months to 2 years) with first-time febrile UTI to conduct a repeat urine culture if the control of fever is not achieved within 48 hours. The rationale behind this is that the suggested parameter assumes repeat urine culture will provide useful information that will change the course of clinical management. Of the 364 patients identified to have UTI, 79.9% or 291 patients underwent follow-up urine cultures, none of which was found to be positive according to the study conducted by Currie, Mitz, Raasch, and Greenbaum (2003). Fever lasted beyond 48 hours in 32% of the patients. This result, however, did not have an effect of changing the current clinical management.

In conclusion, the findings suggest that there is no evidence that repeat urine culture provides useful information that would change the current clinical management. Therefore, follow-up would in patients with fever beyond 48 hours does not need repeat urine culture. Fever that is beyond 48 hours is considered common and therefore it is not an appropriate criterion to justify either a repeat urine culture or even prolonging hospital stay.

Reference:
Currie, M.L., Mitz, L., Raasch, C.S., & Greenbaum, L.A. (2003). Follow-up Urine Cultures and Fever in Children with Urinary Tract Infection. Archives of Pediatrics & Adolescent Medicine. 2003; 157:1127-1240. Retrieved July 7, 2009, from http://archpedi.ama-assn.org/cgi/content/full/157/12/1237?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=follow-up+urinary+tract+infection&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.

Quality of Life in Women With Urinary Tract Infections: Is Benign Disease a Misnomer?
Anne K. Ellis, MD, Sarita Verma, LLB, MD
Published: 11/01/2000

Almost 10%-20% of the women had experienced infection of the urinary tract during their lifespan. The knowledge about the risk factors, diagnostic procedure, and therapeutic management in connection with this condition is well-established. However, research studies with regards to the impact of urinary tract infection on patient’s quality of life during their symptomatic state were unprecedented. There are no previous researches were attempted to quantify the quality of lime among patients with urinary tract infections. This study is intended to perform an explanatory evaluation of quality of life indicators for female clients suffering from urinary tract infection. This study utilizes the RAND health surveys which comprises of 36-item questionnaire. The tool was utilized to 47 women diagnosed with urinary tract infections whom met the necessary inclusion criteria. Scores were compared between subject and control participant data utilizing the Mann-Whitney test for the nonparametric data. The Spearman correlation coefficient was used in order to determine the correlation between the quality of life and urinary tract infection severity and duration.

All the results of SF-36 quality of life were significantly decreased with the experimental group when compared to the controlled population. The theme formed includes patient general health perceptions, physical functioning, role limitation owing to physical health, and emotional health, vitality, emotional well-being, paint and social functioning. It can be concluded that patient suffering from the condition can significantly influence the quality of life among patients. Presence of urinary tract infections on women can lead to comparison whether if the case is acute, non-life threatening illness be as regarded as benign.

The quality of life among individuals, most especially patients, should be considered as a valid portion of patient’s holistic assessment. The sign and symptoms associated with the condition should be taken as seriously as part of a disease process. Since the result shows affectation in the quality of life of individuals which involves social function, vitality, and emotional well-being, physicians are encourage to provide preventive strategies later on after provision of management to urinary tract infection. The findings of this study will warrant further investigation into the impact on the quality of life.

Authors and Disclosures
Data taken from: J Am Board Fam Med. 2000;13(6) © 2000 American Board of Family Medicine
Anne K. Ellis, MD, Department of Medicine, Kingston General Hospital; Sarita Verma, LLB, MD, Department of Family Medicine, Queen's University, Kingston, Ontario, Canada.

DYAD 4
BALAJADIA, BOND
ZANO, ALEXIS

Female Stress Urinary Incontinence Clinical Guidelines Panel Summary Report on Surgical Management of Female Stress Urinary Incontinence

The American Urological Association convened the Female Stress Urinary Incontinence Clinical Guidelines Panel to analyze the literature regarding surgical procedures for treating stress urinary incontinence in the otherwise healthy female subject and to make practice recommendations based on the treatment outcomes data. The panel searched the MEDLINE data base for all articles through 1993 on surgical treatment of female stress urinary incontinence. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative surgical procedures.

The data indicate that after 48 months retropubic suspensions and slings appear to be more efficacious than transvaginal suspensions, and also more efficacious than anterior repairs. The literature suggests higher complication rates when synthetic materials are used for slings.

The panel or the authors of the study found sufficient acceptable long-term outcomes data (longer than 48 months) to conclude that surgical treatment of female stress urinary incontinence is effective, offering a long-term cure in a significant percentage of women. The evidence supports surgery as initial therapy and as a secondary form of therapy after failure of other treatments for stress urinary incontinence. Retropubic suspensions and slings are the most efficacious procedures for long-term success (based on cure/dry rates). However, in the panel's opinion retropubic suspensions and sling procedures are associated with slightly higher complication rates, including longer convalescence and postoperative voiding dysfunction.

Reference: Leach, G. et. al. Female Stress Urinary Incontinence Clinical Guidelines Panel Summary Report on Surgical Management of Female Stress Urinary Incontinence. The Journal of Urology. Volume 158, Issue 3, Pages 875-880. September 1997