Final Report of the work done on Major Research Project Granted by University Grant Commission, New Delhi [F.No.-43-472/2014 (SR), w.e.f. 01/07/2015] Studies on Bacterial Colonization and Prevention of Biofilms in Urinary Catheters SUBMITTED BY Dr. NIRAJ GHANWATE Principal Investigator and Assistant Professor Department Of Microbiology Sant Gadge Baba Amravati University Amravati, 444602 Acknowledgement The investigators gratefully acknowledge the University Grants Commission, New Delhi, for sanctioning this major research project and providing financial assistance. Investigators also record their sincere thanks to the Vice Chancellor of Sant Gadge Baba Amravati University, Dr. Murlidhar Chandekar for providing the infrastructural facilities and all the amenities for the conduct of the study. We also express our sincere thanks to the Registrar Dr. Ajay Deshmukh for his timely help and support. We are grateful to the Heads of the departments of Microbiology and Biotechnology for their co-operation rendered in the conduct of the study. The researchers express their sincere thanks to all the administrative staff of the university and the students involved in the project. Principle Investigator Co-investigator Dr. Niraj Ghanwate Dr. P V Thakare Asst. Professor Associate Professor. Dept of Microbiology Dept of Biotechnology S G B Amravati University S G B Amravati University Amravati. Amravati Table of Contents Sr. No. Contents Page no. 1 Introduction and 1-17 Aims and Objectives 2 Review of Literature 18-20 3 Material and Methods 21-45 4 Results and Discussion 46-183 5 Conclusions 184-187 6 Bibliography 189-205 UGC-MRP Studies on Bacterial Colonization and Prevention Of Biofilm in Urinary F.No. 43- Catheters 472/2014(SR) 1. Introduction 1.1. Nosocomial Infections 'Nosocomial' is referred as any disease acquired by the patient under medical care (Krishna-Prakash, 2014). It was described as "healthcare-associated infections" the infections caused by the prolonged hospital stay, a major risk factor for serious health issues leading to death (Bursaferro, Arnoldo, Cattani, Fabbro, Cookson, & Gallagher, 2015) and about 75% of the burden of these infections is present in developing countries (Obiero, Seale, & Berkley, 2015). Asymptomatic patients may be considered infected if these pathogens are found in the body fluids or at a sterile body site, such as blood or cerebrospinal fluid (Murray, Rosenthal, & Pfaller, Medical Microbiology, 2005). Infections that are acquired by hospital staff, visitors or other healthcare personnel may also be considered as nosocomial (Lolekha, Ratanaubol, & Manu, 1981). Hospital-acquired infections appeared before the origination of hospitals and became a health problem during the miraculous antibiotic era. Due to these infections, not only the costs but also the use of antibiotics increased with an extended hospitalization. This resulted in elevated morbidity and mortality. Studies conducted in different parts of the world show that in North America and Europe 5– 10% of all hospitalizations result in nosocomial infections, while Latin America, Sub- Saharan Africa, and Asia show more than 40% hospitalizations with nosocomial infections (World Health Organization Prevention of hospital-acquired infections: a practical guide., 2015). Any organisms can cause Nosocomial infections but some pathogens are particularly responsible for hospital-acquired infections. Different 13 types with 50 infection sites of nosocomial infections have been classified based on biological and clinical criteria by National Healthcare Safety Network with Center for Disease Control for surveillance. The most commonly included in the site are urinary tract infections, surgical and soft tissue infections, gastroenteritis, meningitis and respiratory infections (Raka, Zoutman, Mulliqi, Krasniqi, Dedushaj, & Raka, 2006) . A change regarding nosocomial infection sites can be easily detected with time due to the elevated use of cancer chemotherapy, advancement in organ transplantation, immunotherapy and invasive techniques for diagnostic and therapeutic purposes. The perfect example of this can be seen in the case of pneumonia as the prevalence of nosocomial pneumonia increased from 17% to 30% during five years (Duque, Ferreira, Cezario, & Filho, 2007). Nosocomial infections 1 UGC-MRP Studies on Bacterial Colonization and Prevention Of Biofilm in Urinary F.No. 43- Catheters 472/2014(SR) mostly affect immunocompromised patients because of age and underlying diseases, or medical or surgical treatments. Because of aging of our population and increasingly aggressive medical and therapeutic interventions, including implanted foreign bodies, xenotransplantations and organ transplantations have created a cohort of, particularly vulnerable persons. Resulting, the highest infection rate in intensive care unit patients (Fridkin, Wekbel, & Weinstein, 1997). 1.2. Urinary tract infections Urinary infections are the most common nosocomial infection and 80% of infections are associated with the use of an indwelling bladder catheter (Mayon-White, 1988). The bacteria responsible for infection area rise from the gut flora, either normal or acquired in the hospital. CAUTI are associated with increased morbidity and mortality and are collectively the most common cause of secondary bloodstream infections. Risk factors for developing a CAUTI include prolonged catheterization, female gender, older age and diabetes (Chenoweth, Gould, & Saint, 2014). Urinary tract infections are caused by both Gram-negative and Gram-positive bacteria, as well as by certain fungi. The most common uropathogen for both uncomplicated and complicated urinary tract infection is uropathogenic Escherichia coli. For the agents involved in uncomplicated UTIs, UPEC is followed in prevalence by Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis, group B Streptococcus, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus and Candida spp. (Nielubowicz & Mobley, 2010) (Kline, Schwartz, Lewis, Hultgren, & Lewis, 2011) (Foxman, Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden., 2014). For complicated UTIs, the order of prevalence for causative agents, following UPEC as most common, is Enterococcus spp., Klebsiella pneumoniae, Candida spp., Staphylococcus aureus, P. mirabilis, Pseudomonas. aeruginosa (Fisher, Kavanagh, Sobel, Kauffman, & Newman, 2011) (Chen, Ko, & Hsueh, 2013). Uropathogens use different mechanisms for survival in response to stresses in the bladder such as starvation and immune responses. By forming biofilm and undergoing morphological changes, uropathogens can persist and cause recurrent infections (Horvath, 2011) (Danese, Pratt, Dove, & Kolter, 2000) (Kostakioti, Hadjifrangiskou, & Hultgren, 2013). 2 UGC-MRP Studies on Bacterial Colonization and Prevention Of Biofilm in Urinary F.No. 43- Catheters 472/2014(SR) 1.3. Urinary catheter When the patients are immunocompromised or bedridden the urinary catheter is used for the easy urine drainage in hospitals. This urinary catheter is a Foley catheter a thin, sterile tube that medical personnel insert into a patient's bladder to drain urine. This catheter can be left in place for many days and is also known as an indwelling catheter. Medical personnel insert a Foley catheter into the patient's urethra and thread it into the bladder. An inflatable balloon filled with sterile water at one end of the catheter holds the catheter in place in the patient's bladder. The urine in the patient's bladder drains through the thin, sterile tube of the Foley catheter into a disposable bag that is emptied when full. The procedure to insert a catheter is called catheterization. Figure 1.1. Foley urinary catheters with labeled different section Figure 1.2. Foleys urinary catheters 3 UGC-MRP Studies on Bacterial Colonization and Prevention Of Biofilm in Urinary F.No. 43- Catheters 472/2014(SR) Figure 1.3. Foley urinary Catheters with inflated balloon Even with their immense benefits, there have been several complications that have been reported as a result of using catheters. Indwelling catheters have been noted to cause urinary tract infections. Symptoms of urinary tract infections include fever, bloody urine, headache, strong smelling urine, chills and burning in the genital area. Other complications include kidney damage, bladder stones, kidney infections and allergic reactions. When using a catheter, it is important to clean it regularly to avoid the risk of contracting a urinary tract infection. Complications due to frequent use of urinary catheters include infection, bladder spasms, catheter encrustations, and retained catheters. This is more so with long-term catheter usage. Even with sophisticated and improved nursing care, these issues still cause much debility and inconvenience to the patient. Catheter encrustations are frequently encountered and can be challenging to the attending urologist managing them. These can be classified as either intraluminal or extraluminal. The encrustations on the outside surface of the catheter can break away into the bladder, forming a bladder calculi and infections on catheter removal. A catheter and the encrustations are paramount in preventing further complications to the patient. Encrustation can impair deflation of the balloon and, therefore, make it impossible to remove the catheter. 4 UGC-MRP Studies on Bacterial Colonization and Prevention Of Biofilm in Urinary F.No. 43- Catheters 472/2014(SR) 1.3.1. History