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A
Preliminary Study of Catheter Associated Bacteriuria
Rohan Chaudhari*, Anjali Deshpande**, Subhash A Angadi***, Geeta
V Koppikar**** |
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| Knowledge of the incidence and the sensitivity
pattern of the bacteria causing catheter associated urinary tract
infection (CAUTI) will help to treat patient with the most correct
regimen even in case empirical treatment is resorted to. Knowing
the spectrum of organisms also paves the path for designing a
catheter by designing the material more unfavourable to bacterial
colonization. In this study involving thirty two catheterised
patients the incidence of CAUTI was found to be forty four per
cent. The predominant bacteria being Klebsiella species. All
the ogranisms were mostly resistant to the commonly used antibiotics.
Amikacin was found to be more effective amongst the antibiotics
tested. |
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| INTRODUCTION |
| Upto twenty five of patients who undergo short
term indwelling bladder catheterization in acute tertiary care
hospitals acquired CAUTI.3,4 Attempts have been made to identify
risk factors for infection in order to guide surveillance,
to provide insight into the mechanisms by which infection occurs
and to suggest method for preventing these infections. Our
aim was to study the incidence of CAUTI and the spectrum of
bacteria causing it and the antibiogram of these bacteria. |
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| Material and Methods |
| The study was carried out in the department of Microbiology
at Topiwala National Medical College and BYL Nair Charitable
Hospital, Mumbai from June to August 2002. |
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| Inclusion criteria |
| a) |
Age equal to or greater than
18 years.
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| b) |
Those who were catheterized for more
than 24 hours. |
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| Exclusion criteria |
| a) |
Patients with prior symptoms
of UTI.
The study includes 32 patients out of which
24 were men and 8 were women who were catheterized
with a
Foley’s catheter. After removal of catheter
with aseptic precautions, the tip of the catheters
were cut using a sterile blade and transported to
the laboratory immediately in a sterile test tube
for bacterial culture. The tip was flushed with nutrient
broth and incubated aerobically overnight at 37oC.
A
loopful of incubated broth was taken and inoculated
on blood agar and MacConkey’s agar plates,
which were incubated overnight at 37oC aerobically.
The colonies were identified the next day.
Morning
after removal of the catheter a mid stream urine
sample was collected within 24 hours after
removal of catheter under
aseptic precautions. The urine samples were processed for culture
and sensitivity testing within two hours after collection. A
wet mount preparation was done to record the count of RBCs, pus
cells, bacterial cells.
Urine was then cultured semiquantitatively
using standard loop method on MacConkeys and blood
agar
media. The colony count was noted on next day after
overnight incubation of the plates at 37oC aerobically.
Standard bacteriologic methods were used to identify
the organisms.
The new appearance of bacteriuria greater
than 103 CFUs/ml was considered to represent nosocomial CAUTI.3,6
Antibiotic
susceptibility testing was done by standard disk
diffusion by Kirby Bauers disk diffusion technique.
Antibiotics and disk strength used for antibiotic
sensitivity as mentioned bellow:
For Gram Negative
and Gram Positive Bacteria - Amoxyclav (30 mcg), Cefotaxime (30
mcg), Cotrimoxazole (25
mcg), Nalidixic acid (13 mcg), Norfloxacin (10 mcg)
Amikacin (30 mcg).
Pseudomonas species. Isolates -
Ticarcillin (75 mcg), Ceftazidime (30 mcg), Tobramycin
(10 mcg),
Amikacin (30 mcg), Ciprofloxacin (5 mcg), Cefoperazone
(75 mcg).
Standard reference strains were used as
controls with each set of disk diffusion test.9
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| Results |
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| Table 1 : Catheter culture and antibiotic
sensitivity |
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Organism cultured
|
Frequency |
Antibiotics |
Frequency |
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| Klebsiella species |
12
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Sensitive to
Amikacin |
5 |
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|
Resistant to all |
7 |
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|
|
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| Pseudomonas spp. |
2 |
Sensitive to
Cefoperazone |
1 |
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|
Resistant to all |
1 |
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|
|
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| E. coli |
3 |
Sensitive to
Amikacin |
1 |
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|
Resistant to all |
2 |
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|
|
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| Staphylococcus aureus |
7 |
Sensitive to
Amikacin and
Cotrimoxazole |
1 |
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|
Resistant to all |
1 |
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|
|
|
Staphylococcus faecalis
|
2 |
Sensitive to Amikacin |
1 |
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|
Resistant to all |
1 |
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|
|
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| No growth |
6 |
— |
6 |
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|
|
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|
|
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| Total |
32 |
— |
32 |
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| Table 2 : Urine culture and antibiotic sensitivity |
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Organism cultured
|
Frequency |
Antibiotics |
Frequency |
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| Klebsiella species |
6
|
Sensitive to
Amikacin |
1 |
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|
Sensitive to Amoxyclav, Cefotaxime, Norfloxacin, Nalidixic
acid |
1 |
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Resistant to all |
4 |
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|
|
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| Pseudomonas spp. |
3 |
Resistant to all |
3 |
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|
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| E. coli |
3 |
Sensitive to
Cefotaxime, Amikacin |
1 |
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|
Resistant to all |
2 |
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|
|
|
Enterococcus
faecalis
|
1 |
Resistant to all |
1 |
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| Acinetobacter
baumanini |
1 |
Sensitive to Amikacin |
1 |
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|
|
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| No growth |
18 |
— |
18 |
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|
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|
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|
|
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| Total |
32 |
— |
32 |
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| Discussion |
Urinary tract infection is a common cause
of morbidity and sometimes mortality in the hospitals, though
its treatment is often simple and effective. Newer catheters
are coated with silver alloys and hydrogel with precious
metal salts and made with materials (silastic catheters)
that resist bacterial biofilms.7,8
Catheterization is a potential
predisposing factor of CAUTI. Source of the infection may
be from the contaminated
catheter, faulty handling and microorganism from distal
urethra.
The goal of preventing nosocomial CAUTI is predicted
in part on the assumption that the infection adversely
affect the patient to acquire them and they increases the
cost of the hospitalization.
In this study we found the
incidence of UTI to be 44%. This correlates well with the
results of Tullu MS, et al
and Platt R, et al.
The commonest organism isolated in this study in urine was Klebsiella
spp. (42.8%), followed bPseudomonas species and E. coli (21%). The catheter
colonization was predominated by Klebsiella species. (46%), S. aureus
(27%), Staphylococcus saprophyticus (8%), E. Coli (12%) and Pseudomonas
species (8%) respectively.
From Tables it can be seen that several of
the isolated organisms in urine and catheter were found to be resistant
to the commonly used antibiotics. Amikacin was the most
effective amongst the antibiotic tested.
CAUTI comprise
a huge reservoir of antibiotic resistant bacteria. Thus efforts to prevent
CAUTI by improved catheter
care and deployment of the technological advances designed
for prevention must be continue to receive high priority
in institutional infection control programme.7
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| Acknowledgement |
We are indebted to Dean Dr. (Mrs.) GV Koppikar
for permitting us to work on the project. We all thank Department
of Medicine for their kind cooperation throught the project.
This
project was a part of presentation made before Indian Institute
of Science under Kishore Vijyanik Protsahan Yojana.
|
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| References |
| 1. |
Burke JP, Garibaldi RA, Britt
MR, et al. Efficacy of Daily Meatal Care Regimens. Am
J Med 1981; 70 : 655-58. |
| 2. |
Butreau JW. Nosocomial urinary tract infection.
Progress on urologic 1997; 7 (4) : 674-82. |
| 3. |
Garibaldi RA, Burke JP, Dickman ML, et
al. Factors predisposing to bacterium during indwelling
urethral catheterization. NEJM 1974; 291 : 215-19. |
| 4. |
Platt R, Polk BF, Murdoc B, Rosner B.
Risk factors for nosocomial urinary tract infection.
Am J Epidemiol 1986; 124 : 977-85. |
| 5. |
Plowman R, Graves N, Esquivel J. An economic
model to assess the cost and benefits of the routine
use of silver alloy coated urinary catheters to reduce
the risk of urinary catheters to reduce the risk of urinary
tract infection in catheterized patients. J Hosp Inf
2001; 48 : 33-42. |
| 6. |
Tambayh PA, Maki DG. The relationship
between pyuria and infection in patients with indwelling
urinary catheters. Arch Intern Med 2000; 160 : 673-77. |
| 7. |
Thibon P, Coutour XL, Leroyer R, Fabry
J. Randomized multicenter trial of the effects of a catheter
coated with hydrogel and silver salts on the incidence
of hospital acquired urinary tract infections. J Hosp
Inf 2000; 45 : 117-24. |
| 8. |
Tullu MS, Deshmukh CT, Baveja SM. Bacterial
profile and antimicrobial susceptibility pattern in catheter
related nosocomial infections. J Post Grad Med 44 (1)
: 7-13. |
| 9. |
Mackie and Mc Cartney. Practical Medical
Microbiology 14th ed. 1996 Pub Churchill living stone. |
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Scars and Keloids
Several treatments are used, but the evidence
base is lacking
Many keloids are unresponsive to silicone gel sheeting
or steroids, and radiation therapy (1200-2000 gy
in five doses) has been used with success, although
the risks have made some clinicians avoid it altogether.
An intriguing approach to treat difficult scars and
keloids in small uncontrolled series is the use of
local chemotherapeutic agents, such as bleomycin
and 5-fluorouracil.
Thomas A Mustoe, BMJ, 2004, 328 : 1329-30
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