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

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Date

Committee/ Member

-$Z Committee Member

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Abstract
Catheter-associated urinary tract infections

account for 35

45% of all nosocomial infections,

making the urinary tract the most frequent site of

hospital acquired infections.

A non-experimental study

was conducted to collect data identifying the risks of
developing a catheter associated nosocomial urinary

tract infection at a community hospital in Northwest
Pennsylvania. The sample size for this study consisted

of 48 patients, 25 in the surgery group and 23 in the
nonsurgery group.

A researcher design tool was the vehicle by which

the data was collected.

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
a infection control data base.

The charts of these

patients were reviewed and information was collected by
the researcher if the patients met the criteria.
Results of the study showed that surgery does not
increase a patients risk of developing a catheter
associated urinary tract infection in a acute care

setting.

Seven identified variables utilizing Chi

Square and Mann Whitney test supports that surgery is
not a risk for developing a catheter-associated urinary

tract infections.

Acknowledgements
This paper is dedicated to the memory of my mother

whose love and encouragement gave me the confidence to

obtain my goals and whose disease gave me the
motivation to research this subject.

I would like to express my appreciation to my

advisor and committee chairperson, Dr. Charlotte Paul,
for all her help, encouragement and continued guidance.
I would also like to thank my other committee members,

Dr. David Fulford and Ms. Ellen Pfadt for their time,

guidance and flexibility throughout this thesis
process.
A special thank you to Tim Cooney, Dr. Sandra

Fortna, Kay Grignol and Dr. Paul Newell for their help,
guidance and suggestions.
Thanks to my typist Dee for her flexibility and

enthusiasm which always makes any project easier.
A special thanks to my dear friend Aggie and my

sister Sally for all their love, support, and
encouragement.

Last, but not least, thank you to my beautiful
daughters Jaime and Julie whose constant reminders

"Aren't you done with that thesis yet" helped motivate
me to keep going.

My deepest thanks and love to my

husband Steve for believing and supporting me during

the time I needed it most.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS

ii

TABLE OF CONTENTS

iii

LIST OF TABLES

v

CHAPTER

I.

INTRODUCTION
Background of the problem

1

Statement of Purpose

4

Definition of Terms

5

Assumptions

6

Limitations

6

II.

REVIEW OF LITERATURE

III.

METHODOLOGY

IV.

1

7

18

Sample and Setting

18

Instrumentation

19

Collection of Data

20

Analysis of Data

21

PRESENTATION AND ANALYSIS OF DATA

22

Presentation of Data

22

Analysis of Data

22

iii

V.

CONCLUSION
Summary

32

Discussion

32

Conclusions

34

Recommendations

35

APPENDICES
Appendix A - Research Tool

36

Appendix B - Medical History, Hospital Complications,
Frequency of Organisms

37
38

REFERENCES

iv

List of Tables

Table Number

Title

PAGE

1

Patients Accepted and Rejected
By Date of Infection

23

2

Surgery and Nonsurgery Admitting
Diagnosis

25

3

Surgery and Nonsurgery Diagnosis
Frequency

25

4

Type of Surgical Procedures and
Frequency

26

5

Gender Frequency

28

6

Diagnosis Frequency

28

7

Age, Total Stay, Days to Catheter
Placement,ICU Stay, Days to Diagnosis,
Period of Catheterizaton

29

V

CHAPTER 1
INTRODUCTION

Background of the Problem

Catheter-associated urinary tract infections

account for 35-45% of all nosocomial infections, making

the urinary tract the most frequent site of hospital
acquired infections.(Bielski, 1980) Thus, approximately

2 per 100 patients admitted to acute-care hospitals in

the United States, or more than 0.8 million patients

annually, acquire nosocomial bacteriuria.

In the

National Nosocomial Infections Surveillance (NNIS)
System, urinary tract infections have consistently

accounted for 40 percent of all hospital-acquired
infections, with little change evident over the period

1970-1990 (Stamm, 1991)

Urinary tract infection is considered hospitalacquired 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 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
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