Thesis Nurs. 1995 B854r c.2 Briggs, Peggy. The risk of surgery in developing a catheter 1995. The Risk of Surgery in Developing a Catheter Associated Urinary Tract Infection: Comparison Study of Hospitalized Surgical and Nonsurgical Patients by PEGGY BRIGGS, RN, BSN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: yVC/lAS Chairperson, Thesis Committee Edinboro University of Pennsylvania Dare z). Date Committee/ Member -$Z105 colonies per milliliter of urine) in patient who has been in the hospital at least 24 hours. (Givens, 1980) 1 2 Nearly all nosocomial urinary tract infections occur in patients with indwelling urinary catheters (approximately 80 percent) or after other types of transient urologic instrumentation (nearly 20 percent). Specific host factors associated with an increased risk °f infection during or after instrumentation include female gender, older age, and an increasing degree of underlying illness. The risk of developing nosocomial bacteriuria in women exceeds the risk in men by approximately twofold in each decade of life, but men more often manifest secondary bacteremia. For both men and women, the risk of catheter-associated bacteriuria increases with age (Hooten, 1981; Stamm, Martin, and Bennett, 1977). In addition, 95 percent of deaths and 83 percent of bacteremia episodes occur in patients older that 50 years (Stamm, Martin, and Bennett, 1977). In addition to host factors (which, for the most part, cannot be altered), the risk of urinary tract infection relates directly to the type and duration of urologic instrumentation. After a single in-and-out catheterization, between 1 and 20 percent of patients acquire bacteriuria (Stamm, 1975; Turck, Goffee, and Petersdorf, 1962); lower rates occur in healthy 3 outpatients and higher rates in older hospitalized. Indwelling urethral catheters draining into an open collecting vessel result in bacteriuria in 100 percent of patients within 4 days (Kass, 1956). With the sterile closed collecting systems used in most hospitals today, bacteriuria occurs on the average in 10 to 25 percent of catheterized patients (Finkelberg and Kunin, 1969; Kunin, 1985; Thorton, and Andriole, 1970). The per-day risk of developing bacteriuria appears comparable through-out catheterization (3 to 6 percent), but the cumulative risk increases with duration of catheterization (Garilbaldi, 1980; Garilbaldi, Mooney, Epstien, and Britt., 1982). Thus approximately 50 percent of hospitalized patients catheterized longer than 7 to 10 days develop bacteriuria. (Garilbaldi, 1980; Kunin,1985) Patients undergoing surgery are at a special risk for UTI because of the decrease in immune response associated with surgical trauma.(Nielsen, 1989) At least 3% of surgical patients develop UTI during hospitalization. They threaten not only the patient's life and compromise the success of the operation, but they also prolong hospital stay and increase medical 4 expenses. (Crummy, 1985) According to a study by Givens and Wenzel, nosocomial urinary tract infection increased postoperative hospital stay by an average of 2.4 days and increased hospital costs by $550 per patient. Surgical patients account for 65-80 percent of nosocomial urinary tract infections of which 60 percent are foley related. The data from this study suggests that some of the Foley related UTI's in surgical patients might have been prevented by earlier catheter removal, since the mean duration of the foley catheterization postoperatively was 5.4 days(+3.2) and the infection occurred on a mean of 4.2 days (+2.0) postoperatively. (Givens, 1980) Statement of the Purpose The purpose of this study was to compare the risk of developing a catheter related urinary tract infection in a surgical patient to the risk of developing a catheter related urinary tract infection in a non-surgical patient. 5 Statement of the Problem The research question for this study was: ’’What is the risk of developing a catheter related urinary tract infection during a hospital stay for a surgical patient and catheter related urinary tract infection in a nonsurgical patient?” Null Hypothesis The Null Hypothesis for this study was: There is no difference between the risk of developing a catheter related urinary tract infection in a hospitalized surgical patient and a hospitalized non surgical patient. Definition of Terms For the purpose of this study, the following terms were defined: BACTEREMIA: the presence of bacteria in the blood Bacteria in the urine BACTERIURIA: CDC: The official voice of the United States Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Atlanta, Georgia 30333. NOSOCOMIAL: Hospital acquired NOSOCOMIAL URINARY TRACT INFECTION: is defined as one that is not present or incubating when the patient is admitted to the hospital and that can be documented by positive urine cultures(>105 colonies per ml. urine) in 6 a patient who has been in the hospital at least 24 hours. In general, most infections occur >72 hours after the patient is admitted to the hospital. UTI - Urinary Tract Infection Assumptions It was assumed that two patients of the same sex, whether medical or surgical, having a urinary catheter in the same length of time, would have the same risk for developing a urinary tract infection. Limitations Uncontrolled variables to this study were the sterility in which the catheter was placed, the patients pre-existing conditions and hospital complications. This study was also limited by its small sample size CHAPTER II Review of Related Literature Catheter-associated urinary tract infections account for 40% of all nosocomial infections, making the urinary tract the most frequent site of hospital acquired infections. In numbers this translates to 400,000 patients admitted to the hospital annually develop urinary tract infections, almost 75 percent of which are related to urologic instrumentation, usually an indwelling bladder catheter, (Bielski, 1980) These infections are thought to give rise to as many as 60,000 cases of nosocomial bacteremias annually and to comprise a vast reservoir of antibiotic resistant hospital pathogens. (Star, 1982) Urinary tract infection is considered hospital- acquired on the basis of cultures, urinalysis or clinical impression made on or after hospital day three. A nosocomial urinary tract infection is defined as one that is not present or incubating when the patient is admitted to the hospital and that can be documented by positive cultures (105 colonies per milliliter of urine in a patient who has been in the hospital at least 24 hours). (Givens, 1980) 7 8 A single catheterization incurs a 1-2 percent risk of significant bacteriuria and infection in general. The risk may increase to 10-20 percent in pregnant women, elderly patients, diabetic patients or in those with a structural or neurologic abnormality causing urinary retention. Using an indwelling catheter without a closed system literally guarantees that in 90 to 95 of individuals, significant bacteriuria will develop in 3 to 4 days. The risk can be reduced markedly by maintaining a completely closed sterile urinary drainage system. About 10 percent of hospitalized patients have indwelling catheters and 8-10 percent of these patients have significant bacteriurias. As a result, approximately 296,000 to 370,000 patients each year are at serious risk for development of other problems. (Bielski, 1989) Problems that arise from UTIs can prolong hospital stay, cause permanent damage and even death. Complications arising in the use of urinary catheters are bacteriuria, pyelonephritis, and bacteremia/gramnegative sepsis. The development of bacteremia or bloodstream infection is the most serious life­ threatening complication of a hospital-acquired urinary tract infection (Krieger, 1983) The rate of gramnegative rod bacteremia as a result of UTI is twice that of gram-negative bacteremia secondary to other 9 sources, it is estimated that 30,000 deaths per year occur as a result of catheter related sepsis due to gram-negative bacilli. (Reese, 1980) A 23-month study was done by Krieger, Kaiser, and Wenzel on bloodstream infections with urinary tract infections among 40,718 consecutive admissions. Nosocomial bloodstream infections occurred in 565 patients, 32 of whom had bacteremias originating from UTI's for an attack rate of 2.7 per 100 patients with nosocomial bacteriuria. Patients with UTIs due to Serratia marcescens were most likely to develop secondary bacteremias (rate 16 per 100) compared to patients with nosocomial UTIs due to other organisms. Risk factor analysis indicated that men with UTIs were more likely to develop secondary bacteremias than were women. (Krieger, 1983) Nosocomial infections are a serious complication of surgery. Patients undergoing surgery are at a special risk for UTI because of the decrease in immune response associated surgical trauma. (Nielsen, 1989) At least 3% of surgical patient's develop UTI's during hospitalization. They threaten not only the patient's life and compromise the success of the operation, but they also prolong hospital stay and increase medical expenses. (Crumm, 1985) According to a study by Givens and Wenzel, nosocomial urinary tract infections 10 increased postoperative hospital stay by an average of 2.4 days and increased hospital costs by $550 per patient. Surgical patients account for 65-80 percent of nosocomial urinary tract infections of which 60 percent are catheter related. The data from this study suggests that some of the catheter related UTI's in surgical patients might have been prevented by earlier catheter removal, since the mean duration of the catheterization postoperatively was 5.4 days (+3,2) + the infection occurred on a mean of 4.2 days (+2.0) postoperatively. (Givens, 1980) The patient's state of health is of primary importance as this directly relates to the individual's ability to combat infection. The incidence of bacteriuria with a bladder catheter depends on the host and the method and duration of catheterization. Research shows that the incidence of urinary tract infection is higher in females, especially the elderly female and highest in the critically ill. (West, 1983) It is easy to understand the high incidence in the critically ill patient. These patients are often immunocompromised, catheter placement is usually for a long period of time, maintenance of good personal hygiene is often difficult, medications often interfere with normal body defenses and these patients are at a high-risk for becoming colonized with hospital flora. 11 Factors that make women more prone than men to urinary infections are the location of the urethral meatus and the length of the urethral canal, The ’’normal" location of the meatus in women is 1-2 cm anterior to the vaginal opening, but in random sample done by Linden roughly 30 percent of women, the meatus was located in the vaginal introitus. In another 18 percent, it was situated less than 5 mm anteriorly, In such locations, the meatus is obviously bathed by vaginal secretions and is also more readily contaminated by fecal bacteria in those with poor hygiene or fecal incontinence.(Linden, 1981) In premenopausal women, the normally acid (ph 4.5) vaginal exudate harbors relatively harmless and largely anaerobic organisms that do not readily invade the urinary tract. In postmenopausal women, however, these organisms are frequently replaced by fecal organisms which then colonize or even infect the atrophic vaginal epithelium. Weakening of the pelvic floor muscles and atrophy of the urethral mucosa produce a shorten urethral canal that further impairs the natural defenses against bacterial invasion and leads to stress incontinence. If fluid intake is decreased, the urethra is flushed free of frequency with which the decreased increasing the potential organisms is further urinary tract. (Linden, 1981) of an infection of the 12 Overdistention of the bladder increases residual urine due to obstruction or due to incomplete or infrequent voiding causing ischemia, which predisposes tissues to bacterial invasion and increases susceptibility to infection. (Bielski, 1980) Introduction of a urethral bladder catheter creates an open, convenient pathway for organisms to ascend through the urinary tract, and interferes with the normal voiding mechanisms which acts as a defense to eliminate organisms that have found their way to the bladder. The catheter may also cause irritation or trauma to urethral and bladder tissue, thereby decreasing resistance and predisposing the tissues to bacterial invasion. (Bielski, 1980) A system becomes contaminated often by the introduction of bacteria by personnel handling the system and by patients contaminating the system. The means by which ’’personnel ” contaminate the system include: of the periurethral area prior to 1) inadequate prep especially common in patients insertion. This is inadequate cleansing of who have fecal soiling or distal urethra (Reese, 1980) the perineum and inserting the catheter 2) improper technique when during insertion 3) trauma to the urethra 13 4) pressure necrosis of the meatus due to insertion of too large a catheter 5) contamination of n or the catheter-tubing junction 6) contamination of the collection bag with bacteria which have migrated to the bladder. Contamination of the collection bag has been dramatically reduced by the creation of a ’’closed drainage” system. (West, 1983) At least three pathways have been described by which bacteria can enter the bladder during ’’indwelling catheterization". Microorganisms that inhabit the distal urethra may be introduced into the bladder during or shortly after insertion of a urinary catheter. Bacteria other than urethral flora generally gain access to the catheterized urinary tract at one of three sites: (1) the urethral meatus (2) the distal catheter-proximal drainage tube junction, and (3) the collecting vessel or bag. It has been showed that bacteria applied to the periurethral skin can be recovered from bladder via the urine after 24 or 72 hours. It is postulated that these bacteria enter the between the catheter bladder through a thin fluid space Another pathway is and urethral mucosa. (Stamm, 1975) that surrounds the catheter from the sheath of exudate entry point is through the in the urethra. The third air bubbles that catheter lumen itself, either by 14 travel upwards in drainage tube or by bacteria motility. (Crummy, 1985) Autoinfection is another manner by which patients develop urinary tract infections. This may occur as the result of the patient's manipulation of the system, his or her treatments and his or her environment. We are all familiar with the agitated or confused patient who is always pulling on his catheter. place and infection can result. This is common First, we know that bacteria can ascend via the mucous sheath present around the outside of the catheter. An important host mechanism to block this process is local secretion of immunoglobulins. Second, medications have an impact on altering normal body flora. For example, mouth flora is changed—as is intestinal flora—within 48-72 hours of drug administration. Third, the environment is a factor. Foods served to patients contain hospital flora (organisms uncommon to the individual's home environment.) Additional studies have shown that approximately 30% of hospital personnel tested had hands colonized with antibiotic-resistant organisms. This, in combination with improper handwashing practices explains why catheters are a major source of cross infection. (West, 1983) Confused and uncooperative patients are at risk for UTIs with the use of condom catheters. High rates 15 Of UTIs (up to 50%) were seen with condom catheter use in the uncooperative patient who frequently manipulated the drainage system. Patients were predisposed to UTIs in this setting because of trauma to the distal urethra and/or the build-up of pressure in a twisted outflow tube. Introduction of fecal flora into the urinary bladder will increase the risk of developing a UTI. Consistent catheter care will lower the risk of introduction of fecal material into the urinary bladder. Proper catheter care should include: 1) regular cleansing of the catheter-meatus junction, particularly after bowel movements; 2) attachment of the drainage tube and catheter to the patient's leg to prevent pushing of the catheter into the bladder to relieve tension on the trigone caused by the catheter balloon. (Gross, 1976) Daily meatal care for prevention of catheter- associated bacteriuria has received much controversy. The efficacy of daily cleansing of the urethral meatus­ catheter junction in preventing bacteriuria during closed urinary drainage was evaluated in a study by Burke, Garibaldi, Britt, Jacobson, and Conti (1981). In randomized controlled trials of two widely recommended regimens for meatal care, 32 (16%) of 200 patients given twice daily applications of a povidone-iodine 16 solution and ointment acquired bacteriuria, as compared with 24 (12.4) of 194 patients not given this treatment. In 28 (12.2%) of 229 patients given one daily meatal cleansing with a nonantiseptic solution of green soap and water acquired bacteriuria as compared with 18 (8.1%) of 223 patients not given special meatal care. There was no evidence in either trial of a beneficial effect of meatal care. Moreover, each of four different statistical methods indicated that the rates of bacteriuria were higher in the treated groups than in the untreated groups. In subsets of female patients at high risk in both studies, significantly higher rates of bacteriuria were noted in the treated groups than in the untreated groups. In addition, gastro-intestinal colonization with organisms acquired during hospitalization has been associated with subsequent urinary tract infection in catheterized patients. The Enterobacteriaceae continue to be the most common causes of catheter associated bacteriuria in the acute hospital setting, particularly Escheri chia_ coli and Proteus mirabilias. Patients who have received antibiotics are at risk for infections with resistant bacteria such as enterococci, Pseudomonas aeruginosa, Serratia marcescens, and Enterobacter species. (Wenzel, 1993) Other pathogens that can cause infection in the patient who has 17 undergone urinary instrumentation are Serratia marcescens, Acinetobacter, and Candida albicans. Diabetic patients, patients on corticosteriods, or patients on immunosuppressive therapy are particularly vulnerable to colonization or infection with resistant bacteria, yeast or unusual organisms. (Bielski, 1980) The likelihood of infection increases with the duration of catheterization. Closed sterile drainage does not prevent bacteriuria in most of the patients catheterized for longer than 2 weeks. Therefore, the first goal in caring for a catheterized patient should be to have the catheter removed as soon as possible. The second goal should be to maintain a sterile closed drainage system. (Killion, 1982) CHAPTER III Methodology Sample and Setting This study was designed to compare the risk of developing a catheter-associated urinary tract infection in the hospitalized surgical patient to the risk of developing a catheter-associated urinary tract infection in the a hospitalized non-surgical patient, at a community hospital in Northwestern Pennsylvania. Participants in this study met the following criteria: 1. had a hospital stay between January 1, 1994 and December 31, 1994 2. had a documented normal urinalysis (<10 white blood cells per high power field) or sterile culture before bladder catheterization 3. they did not have a neurogenic bladder 4. patients in the study group had a foley catheter in place longer than 24 hours and had a documented catheter associated urinary tract infection Study patients were identified through the microbiological report sheets and the infection control records. These patients charts were reviewed to assure they met the criteria. If the patient met the selection criteria, he or she was kept in the study. If the patient did not meet the criteria, he or she was rejected from the study. The patients were then divided 18 19 into surgical patients with a catheter-associated urinary tract infection or non-surgical patients with a catheter-associated urinary tract infection. Instrumentation The tool was a researcher-designed tool. (Appendix A) The tool was reviewed by two infectious disease physicians, (one of the physicians serves as the chairman of the Infection Committee of a Northwestern Hospital) an infection control coordinator of the same institution, and a clinical nurse specialist. Data collected for each patient and control included: 1) patient identification number, 2) name, 3) admitting diagnosis, 4) age, 5) gender 6) date admitted, date discharge, and total number of hospital days, 7) type of surgery (for surgical group only), 8) urinalysis results—before and after UTI diagnosis, 9) number of days from admission to insertion of catheter, 10) date urinary catheter inserted, 11) date urinary catheter removed, 12) total number of days with urinary catheter, 13) number of days from insertion of urinary catheter until urinary tract infection 14) bacterial species isolated in significant number 15) length of stay in the intensive care (if applicable), 16) significant medical history, 17) 20 Collection of Data After obtaining institutional approval, patients were identified through the microbiological forms and the infection control data base. The charts of these patients were reviewed by the researcher to determine if the patients met the criteria for the study. One hundred thirty five (135) patients charts were reviewed of which forty eight (48) patients met the criteria and were included in this study. Twenty-three (23) of these patients were included in the surgical group and twenty five (25) were included in the nonsurgical group. The patients that met the criteria were then divided into surgical and nonsurgical patients. The patients were then evaluated based on admitting diagnosis and were divided into one of eight categories. The surgical patients were evaluated based on surgical procedures and divided into seven categories. Other information that was collected and evaluated was gender, age, total length of hospital stay, length of hospital stay before catheterization, intensive care unit stay, length of time from insertion of urinary catheter and catheter days. 21 Analysis of Data Measured variables were statistically analyzed between the two groups under observation using the Mann Whitney Test. The Mann Whitney Test assesses the statistical significance between the medians of the two independent groups, the surgical group and the nonsurgical group. The Mann Whitney Test was used because it is applicable to sample data that is not normally distributed. Data that was analyzed using the Mann Whitney Test was age, total hospital stay, hospital stay before catheterization, ICU stay, hospital days until diagnosis of UTI, and catheter days. The level of significance was p<.05. Attributes such as gender and diagonsis were analyzed using the Chi Square Test. The level of significance p was <.05. Data that were analyzed using frequency count and percentages for patients accepted or rejected in the study, admitting diagnosis, surgical and nonsurgical diagnosis frequency and type of surgical procedures. CHAPTER iv Presentation and Analysis of Data presentation of Data The purpose of this study was to compare the risk of developing a urinary tract infection that resulted from an indwelling urinary catheter in a surgical patient to the risk of developing a urinary tract infection that resulted from an indwelling urinary catheter in a nonsurgical patient. Approval to collect data was obtained by following the research approval process established at a community hospital in Northwestern Pennsylvania. To obtain permission, the researcher presented a proposal to the Chairman of the Infection Committee who is also an infectious disease physician. The proposal then received discipline-specific peer review. The proposal was reviewed by another infectious disease physician, an infection control coordinator and a clinical nurse specialist. Patients who developed a hospital acquired urinary tract infection during the time frame of January 1, 1994 through December 31, 1994 were identified for the study by the researcher through the infection control of these patients were reviewed data base. The charts by the researcher to determined if the patients met the 22 23 criteria for the study. One hundred thirty-five (135) patients' charts were reviewed of which forty-eight (48) patients met the criteria and were included in the study. Twenty-three (23) of these patients were included in the surgical group and twenty-five (25) were included in the nonsurgical group. TABLE I Patients Accepted and Rejected By Date of Infection Month Patients Reviewed Surgical Pts Non-surgical Patients Accepted Patients Rejected Jan. 11 3 2 6 Feb. 19 4 4 11 March 14 3 2 9 April 8 1 0 7 May 9 1 1 7 June 6 1 1 4 July 8 2 3 4 Aug. 14 6 0 7 21 1 6 14 Sept. 9 1 2 7 Oct. 8 0 1 7 Nov. 2 5 8 1 Dec. 135 25 23 Total 86 24 There were 86 patients that were identified through the infection control data base that developed a nosocomial urinary tract infection that did not meet the criteria for the study and were rejected. Thirty- nine (45%) patients that were rejected from the study did not have a urinalysis done on admission or prior to developing a urinary tract infection. Eighteen (20%) of the patients rejected were surgical patients. The most frequent type of surgical patient that was rejected for this study because- they did not have a urinalysis on admission or prior to developing a urinary tract infection was the cardiovascular surgical patient. There were eleven patients rejected from the study that had cardiovascular surgery. Eight of these patients rejected had open heart surgery. The patients that developed a nosocomial urinary tract infection were divided into surgical and nonsurgical patients. These patients were then evaluated based on admitting diagnosis. The patients were divided into eight (8) admitting diagnoses, The admitting diagnoses included cancer, cardiac, gastrointestinal, urinary/renal, neuro, orthopaedic, trauma, and respiratory. Table 2 compares the surgical and nonsurgical 25 groups based on admitting diagnosis, Table 3 compares the top three diagnosis of the surgical and nonsurgical groups. Table 2 Surgery and Nonsurgery Admitting Diagnosis Surgical Nonsurgical Cancer 3 2 Cardiac 11 5 Gastrointestinal 0 6 Genital/Urinary/Renal 3 2 Neuro 1 4 Orthopaedic 4 1 Trauma 1 1 Respiratory 2 2 Total 25 23 Table 3 Surgical and Nonsurgery. Diagnosis Frequency Highest Second Third Surgery Nonsurgery Cardiac Gastrointestinal (11/25, 44%) (6/23, 26%) Orthopaedic Cardiac (4/25, 16%) (5/23, 22%) Neuro Neuro (2/25, 8%) (4/23, 17%) 26 The surgical patients were evaluated based on surgical procedures. types. The surgical procedures were divided into seven Cardiovascular surgery was the most frequently occurring surgery in which a patient developed a nosocomial urinary tract infection. Coronary artery bypass was the most frequently occurring type of cardiovascular surgery in which a patient developed a nosocomial urinary tract infection. Table 4 includes the breakdown of the surgical procedures and their frequency. Table 4 Type of Surgical Procedures and Frequency Type of Surgery Number of Cases Frequency Distribution CARDIAC TOTAL *Pacemaker *Aorta-femoral Bypass *Coronary Artery Bypass 12 1 1 10 (12/25, 48%) (1/25, 4%) (1/25, 4%) (10/25, 40%) GASTROINTESTINAL TOTAL *Colectomy *Exploratory Laparotomy 5 2 3 (5/25, 20%) (2/25, 8%) (3/25, 12%) ORTHOPAEDICS TOTAL *Total Hip *0pen Reduction and Internal Fixation 4 3 1 (4/25, 16%) (3/25, 12%) (1/25, 4%) NEUROSURGERY TOTAL *Craniotomy *Laminectomy 2 1 1 (2/25, 8%) (1/25, 4%) (1/25, 4%) GENITAL URINARY TOTAL *Kidney Stents *Cystoscopy Urethral Dilatation 2 1 1 (2/25,8%) (1/25, 4%) (1/25, 4%) 27 The null hypothesis for this study was: There is no difference between the risk for developing a catheter related urinary tract infection in a hospitalized surgical patient and hospitalized nonsurgical patient. The number of days from insertion of the urinary catheter until diagnosis of urinary tract infection were compared between the surgical and nonsurgical group. Based on the Mann Whitney Test, there was no statistically significant differences found between the two groups at the .05 level of significance. Other factors that were evaluated to assess the risk factors for nosocomial catheter associated urinary tract infection in the surgical and nonsurgical groups were admitting diagnosis, gender, age, date admitted, date discharge,and total number of hospital days, type of surgery, number of days from admission to insertion of catheter, date of urinary catheter inserted, date urinary catheter removed, total number of hospital days with urinary catheter, and length of stay in intensive care unit. Table five and six shows the comparison of for these factors. Based surgery and nonsurgery groups there was no statistical on the Mann Whitney Test, , found between the surgical and nonsurgical significance groups at the.05 level of significance. 28 Gender was evaluated in the surgical and nonsurgical groups. Catheter associated nosocomial urinary tract infections occurred more frequently in females in both the surgical and nonsurgical groups. Based on the Chi Square Test, there was no statistical difference between the surgical and nonsurgical groups at the .05 level of significance. The literature supports that the female gender increases the risk of urinary tract infection during or after instrumentation.(Hooten, 1981, Stamm, Martin, and Bennett, 1977) TABLE 5 Gender Frequency Nonsurgery Surgery Gender male female (7/23, 30%) 6 (6/25, 24%) 7 19 (19/25,76%) 16 (16/23.70%) (X2=0.031, d.f. 1, p=0.86) TABLE 6 Diagnosis Frequency Diagnosis Frequency Cardiac (11/25,44%) Ortho (4/25,16%) Neuro (2/25,8%) GI (6/23,26%) Cardiac (5/23,22%) Neuro (4/23,17%) (X2=9.551, d.f.=8, p=0.29) 29 TABLE 7 Surgery Nonsurgery Average/Median Age 74.2/76 yrs. 66.7/73 yrs. Mann Whitney Test: Standarized U: Z=-1.064, p>0.25 Average/Median 30.8/23 days 22.3/18 days Stay (Total) Mann Whitney Test: Standardized U:Z=-1.085, p>0.25 Average/Median r5.7/1 ” " days 3.4/2 days Days to Catheter placement Mann Whitney Test: Standardized U:Z=-0.08, p>0.4 Average/Median 12.4/10 days 8.1/0 days ICU Stay Mann Whitney Test: Standardized U:Z=-1.762, p> 0.05 Average/Median 12.4/10 days 10.2/7 days Days to Diagnosis of UTI Mann Whitney Test: Standardized U:Z=-I.086, p>0.25 11.4/8 days Average/Median 13.2/10 days Period of Catheterization Mann Whitney Test: Standardized U:Z=-0.641, p>0.5 Age was evaluated in the surgical and nonsurgical groups. The average age for a patient developing a catheter associated nosocomial urinary tract infection in the surgical patient was 74.2. The median age in the surgical group was 76 years of age. The average for a patient in the nonsurgical group was 66.7 and the median age was 73. Older age increases the risk of catheter associated infection.(Hooten 1981, Stamm, Martin & Bennett, 1977) 30 The total length of hospital stay was evaluated between the surgical ;and nonsurgical groups. The average length of stay for the surgical patient was 30.8 days and the median was 23 days. The average length of stay for the nonsurgical patient was 22.3 days and the median was 18 days. The length of stay before catheterization was evaluated between the surgical and nonsurgical groups. The average length of stay for the surgical patient before catheterization was 5.7 days. The median length of stay for the surgical patient before catheterization was 1 day. The average length of stay before catheterization in the nonsurgical patient was 3.4 days. The median length of stay was 2 days. The average and median intensive care stay was evaluated in both groups. The average length of stay in the intensive care unit in the surgical patient was 12.4 days and the median length of stay was 4 days. The average length of stay in the intensive care unit in the nonsurgical patient was 8.1 days and the median length of stay was 0 days. The length of time from insertion of the Urinary a urinary tract infection catheter until diagnosis of the surgical patient the average was evaluated. In 12.4 days with the median being 10 length of time was 31 days. In the nonsurgical group the average length of time was 10.2 days with the median being 7 days. The catheter days were evaluated for both groups. In the surgical patient the average length of time the catheter was in place was 13.2 days with the median being 10 days. In the nonsurgical patient the average length of time the catheter was in place was 11.4 days with the median being 8 days. The result of this study show that there is no statistically significant differences between the surgical and nonsurgical patients' risk of getting an infection. Therefore the null hypothesis failed to be rejected at the .05 level of significance. Chapter V Conclusions Summary The purpose of this non-experimental study was actual data collection to compare the risks of developing a catheter associated nosocomial urinary tract infection in a surgical patient to the risk of developing a catheter associated urinary tract infection in a nonsurgical patient. The literature review emphasized the relationship of the indwelling urinary catheter and hospital acquired urinary tract infection. Actual data was collected on 48 patients at a community hospital in Northwestern, Pennsylvania during January 1, 1994, through December 31, 1994. Data collection was accomplished with a researcher designed tool. Discussion The question answered in this study was "what is the risk of developing a catheter associated urinary surgical tract infection during a hospital stay for a patient and a nonsurgical patient?” The results of the data show that the in which a cardiovascular surgery was the surgery a nosocomial urinary patient most frequently developed 32 33 tract infection. Coronary artery bypass was the type of cardiovascular surgery in which a patient most frequently developed a nosocomial urinary tract infection. The most frequently occurring patient in the nonsurgical group that developed a catheter associated urinary tract infection was the patient with gastrointestinal disease. The most frequently occurring organism identified in this study causing catheter associated urinary tract infections in the surgical and nonsurgical groups was E. coli. (Appendix B) According to the literature, Enterobacteriacue continue to be the most common causes of catheter associated bacteriuria in the acute care setting, particularly E. Coli and Proteus mirabiliu_s. (Wenzel, 1993) Nosocomial urinary tract infections occurred more frequently in females in both the surgical and Research shows that nonsurgical groups in this study. infection is higher in the incidence of urinary tract females. (West, 1983) surgical and nonsurgical The catheter days of the There was no statistical groups were evaluated. the groups. According to Crumm significance between patients develop UTIs (1985), at least 3% of surgical during hospitalization. 34 Age, diagnosis, total hospital days, number of days from admission to insertion of catheter, and length of stay in the intensive care unit, were evaluated to see if any of these factors increased the risk for the surgical patient. There was no statistical significance between any of these factors. Conclusions This data led to the following conclusions: 1. The surgical patient is not at greater risk for developing a catheter associated urinary tract infection than the nonsurgical patient. 2. Certain surgical patients are at greater risk than other surgical patients for developing a catheter associated urinary tract infection. 3. The cardiovascular surgical patient is at greatest risk for developing a catheter-associated urinary tract infection was the coronary artery bypass patient. 4. E. coli is the bacteria that most frequently causes catheter—associated urinary tract infections in the surgical and nonsurgical patient. 35 5. Females are at greatest risk for developing a urinary tract infection in both the surgical and nonsurgical patient. Recommendations 1. Verbally report results of this study to the infection control committee and the cardiovascular service line. 2. Make abstract available in the community hospital's library. 3. Further assess the risk for catheter associated urinary tract infection in the coronary artery bypass patient by doing a case control study; 4. Monitor catheter-associated urinary tract infections through a yearly prevalence study. 5. Investigate reasons for omissions of presurgical urinalysis of patients. a future study that 6. Other factors to investigate in a nosocomial could have impact on the developement of antibiotic usage, fluid urinary tract infection are intake and output, kidney function and diet. APPENDICES 36 Appendix A J," DEVELOr'I'"3 A CATHETER ASSOCIATED ™E "Data Collection Sheet" SURGICAL NONSURGICAL GROUP 1. Pt. ID#. 2. Name 3. Admitting Diagnosis. 4. Age. 5. Sex 6. Date Admitted Total # of hosp. days. 7. Type of Surgery. 8. Urinalysis before UTI. after UTI_ 9. Number of days from admission to insertion of catheter ________________________ Date Discharges. 10. Date Foley Catheter Inserted. 11. Date Foley Catheter Removed-------------------- 12. Total number of days with Foley Cath----------- 13. Number of days from insertion of Foley until UTI Di agnos i s 14. Bacterial species isolated insignificant number 15. Length of stay in ICU------ 16. Significant medical history. 17. Hospital complications. 37 Appendix B MEDICAL HISTORY Surgery Nonsurgery (5/25) 20% 6(23) 26% Hypertension(4/25) 16% 8(23) 35% Obesity (2/25) 8% 3(23) 13% Hypothyroid (0/25) 0% 3(23) 13% Renal Hx 3(23) 13% Diabetic (5/25) 20% HOSPTIAL COMPLICATIONS Surgery Renal Failure (7/25) 28% Nonsurgery Renal (6/23) 26% FREQUENCY OF ORGANISMS Highest Second Third Surgery Nonsurgery E. Coli (6/25) 24% E. Coli (7/23) 305 Pseudomonas aeruginosa.. (5/25) 20 Enterococcus, Klebsiella pneumonia (3/25) 12^ Yeast (5/23) 22% Enterococcus (4/23) 17% 38 REFERENCES Bennett, j.v.,/^&Br " ~ achman, P-S., (Eds.) (1992). Hospital‘Infections V (3rd ed.). Boston, Little, Brown, and Company. Bielski M. (1980). Preventing infection in the catheterized patient. 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