Postgrad Med J: first published as 10.1136/pgmj.54.636.668 on 1 October 1978. Downloaded from Postgraduate Medical Journal (October 1978) 54, 668-671 Bacteraemia after manipulation of the urinary tract. The importance of pre-existing urinary tract disease and compromised host defences RICHARD QUINTILIANI JOSEPH KLIMEK M.D. M.D. BURKE A. CUNHA EUFRONIO G. MADERAZO M.D. M.D. Division ofInfectious Diseases, Section ofHospital Epidemiology, Department ofMedicine and Medical Research Division, Hartford Hospital, Hartford, Connecticut 06115, U.S.A. Summary This surveillance system includes not only a tabu- The factors related to the occurrence of bacteraemia lation of all patients who have acquired a following urinary tract manipulation were studied in a bacteraemia, bacteriuria, wound infection or large community hospital. During a 3-year period, pulmonary infection, but also records the responsible forty-six of 326 episodes of hospital-acquired pathogen and the type of medical or surgical service bacteraemia were associated with urinary tract where the infection occurred. The criteria used for manipulation. All thirty of forty-six cases felt to be the determination of hospital-associated infections definitely related to urinary tract manipulation (other are those recommended by the Hospital InfectionsProtected by copyright. obvious sources of bacteraemia being absent) had Section of the Center for Disease Control, Atlanta, pre-existing urinary tract disease, especially of an Georgia (Bennett et al., 1971). obstructive type; only one in this group died from The charts of all patients with hospital-acquired sepsis. The remaining sixteen patients had other bacteraemias over a 3-year period (October 1970- possible sources of bacteraemia besides urinary tract October 1973) were reviewed for relevant clinical manipulation and had disorders associated with defects and epidemiological data to determine the number of in host defences; twelve (75%/) in this group died patients in whom the source for this infection was from overwhelming sepsis. Thus, if bacteraemia related to infection in the urinary tract. Figures in occurs in a patient having had urinary tract mani- the tables refer to the strains of organism recovered pulation but without any underlying urinary tract from a patient with a hospital-associated infection abnormality or impairment in host defences, its source due to this organism (i.e. one per patient per site). should be searched for in other areas of the body. If an organism was recovered from more than one site in the same patient, and if this organism was felt Introduction to be the cause of the hospital-associated infectionshttp://pmj.bmj.com/ Traditionally, most hospital epidemiology at those sites, it would count as more than one case. programmes have emphasized the distribution of Thus, one bacterium at two different sites in the infections but have paid considerably less attention same patient producing infection at each of these to the determinants. It is becoming increasingly clear sites would be considered as two cases. that the most important determinant in the acquisi- The bacteraemia was considered to be definitely tion of an infection in hospital is not the environ- related to instrumentation of the urinary tract only ment, but rather the adequacy of the host defence if the patient had no other obvious source for mechanisms of the patient. bacteraemia other than the urinary tract, and on September 25, 2021 by guest. This communication deals with the factors in cultures of urine and blood grew the same organism. patients in hospital that tend to make urinary tract A patient was felt to have significant bacteriuria if instrumentation a potentially lethal procedure, as a single midstream or catheter specimen of urine indicated by the development of bacteraemia. contained greater than 100 000 organisms/ml. Bladder instrumentation included any invasive Method procedure involving the urinary tract such as Since 1970 at Hartford (Connecticut) Hospital, an cystoscopy, single straight and indwelling bladder institution of about 950 beds, epidemiological data catherization, or recent operation on the urinary have been obtained on all patients who have tract. Since 1970, sterile, closed, indwelling bladder developed a hospital-associated infection, through catheter systems have been used, except in occasional the availability of two full-time nurse epidemio- circumstances where three-way catheters with logists and a computerized surveillance system. continuous antibiotic rinses have been employed. 0032-5473/78/1000-0668 $02.00 (© 1978 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.54.636.668 on 1 October 1978. Downloaded from Bacteraemia after manipulation of the urinary tract 669 TABLE 1. Major organisms associated with hospital-acquired bacteraemia, bacteriuria, and urinary tract (UT) instrumentation (October 1970-October 1973) - number of cases Bacteraemia definitely associated Organism Bacteriuria Bacteraemia with UT instrumentation Escherichia coli 1007 72 9 Proteus sp. 301 11 6 Klebsiella pneumoniae 243 29 4 Pseudomonas aeruginosa 296 31 1 Serratia marcescens 166 8 1 Enterococcus spp. 181 20 4 Enterobacter sp. 150 23 3 Citrobacter sp. 15 2 2 Other bacteria 242 130 0 Total 2601 326 30 During the period of this study, 'open' non-sterile definitely associated with the instrumentation of the bladder drainage tubes have been prohibited. During urinary tract unless there was some type of under- the 3-year period of the study there were 29 859 lying urinary tract disease. indwelling bladder catheters dispensed from the Table 3 records both the type of urinary tract Central Supply Department, and 27375 blood disease and the kind of instrumentation employed cultures were processed by the Microbiology in these bacteraemiic patients. It is apparent from this Laboratory. Serotyping of the organisms was not chart that the majority of patients not only had performed. obstructive uropathy - usually produced by prostatic disease or calculi - but also underwent more than Protected by copyright. Results one type of instrumentation. In fact, eighteen The incidence of bacteriuria induced by urinary patients had all three types of instrumentation, tract instrumentation and the number of cases of namely indwelling bladder catheterization, cysto- bacteraemia from all types of hospital-acquired scopy, and operation of the urinary tract. Of the infection are shown in Table 1. Over the period remaining twelve cases, two had both cystoscopy reviewed, there was an average of 867 patients per and indwelling bladder catheterization, and ten year with hospital-acquired bacteriuria or an patients had insertion of a bladder catheter alone. accumulative total of 2601 cases over the 3-year In this group of thirty patients, one patient died period; during the same time, there were 326 from septic shock; this case had obstructive uro- episodes of bacteraemia. However, in only thirty pathy secondary to cancer of the bladder. patients (8%y) was it felt to be definitely related to the The predominant organism recovered from the urinary tract instrumentation. blood in these 30 patients was Escherichia coli (9). It was followed in decreasing frequency by Proteus TABLE 2. Associated conditions in patients with bacter- sp. (6), Enterococcus (4), Klebsiella pneumoniae http://pmj.bmj.com/ aemia definitely related to urinary tract (UT) instrumentation (4), Enterobacter sp. (3), Citrobacter freundii Condition No. cases (2) and one case each of Pseudomonas aeruginosa and Serratia marcescens. Pre-existing UT disease alone 23 Pre-existing UT disease and diabetes 4 Discussion Pre-existing UT disease and cirrhosis 2 Instrumentation of the urinary track has always Pre-existing UT disease, diabetes mellitus, I cirrhosis been a subject ofconsiderable controversy. Although No pre-existing UT disease 0 this procedure has been known for some time to be on September 25, 2021 by guest. a greater risk in patients with pre-existing renal Total 30 disease or compromised host defences, quantitation of the actual danger is still unavailable in different Table 2 records the associated conditions in the types of patients in hospital. The present surveillance thirty patients in whom the bacteraemia was data help to fill some of this gap in knowledge definitely related to urinary tract instrumentation. regarding the relative hazard of urinary tract All these patients had pre-existing urinary tract instrumentation in a diverse group of patients in a disease. In seven patients with underlying urinary large community hospital. tract disease, there were additional associated The present study indicates that urinary tract illnesses that could further compromise host defences instrumentation is frequently associated with such as diabetes mellitus and Laennec's cirrhosis. bacteriuria in all types of patient but is not a Importantly, in no patient was the bacteraemia common cause of sustained bacteraemia, except for Postgrad Med J: first published as 10.1136/pgmj.54.636.668 on 1 October 1978. Downloaded from 670 R. Quintiliani et al. TABLE 3. Pre-existing urinary tract disease in patients with bacteraemia definitely related to instrumentation of the urinary tract Type of instrumentation No. of Indwelling bladder Operation Urinary tract disease patients catheter Cystoscopy urinary tract Calculus ureter 5 5 5 5 Obstructive uropathy 20 BPH 5 5 1 - Postoperative TUR for BPH 5 5 5 5 Bilateral pyelonephritis 3 3 - - Obstructive uropathy 2'CA bladder