The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care
The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care
Susan E Hazelett 0
Margaret Tsai 0
Michele Gareri garerim@summa- 0
Kyle Allen 0
0 Address: 41 Arch St., room 212, Summa Health System , Akron, Ohio, 44304 , USA
Background: The use of indwelling urinary catheters (IUCs) is thought to be the most significant risk factor for developing nosocomial urinary tract infections (UTIs). However, it is unclear how many elderly patients have preexisting bacteriuria prior to IUC placement. The purpose of this study was to determine 1) the frequency and appropriateness of IUC use in the Emergency Department (ED) in elderly patients admitted to our acute care hospital, 2) the percentage of elderly patients with an IUC who were discharged from the hospital with a diagnosis of UTI, 3) the percentage of patients with IUCs who were diagnosed and treated for UTI in the ED or who had admission bacteriuria 105 organisms/ml indicating preexisting UTI, and 4) the percentage of patients with no indication of UTI on admission who had inappropriately placed IUCs and subsequently were diagnosed with a UTI. Methods: Retrospective chart review. Chi square used to test significance of differences in proportions. Results: Seventy three percent of patients who received an IUC in the ED were elderly (65 years old). During the study period, 277 elderly patients received an IUC prior to admission. Of these, 77 (28%) were diagnosed with UTI during their hospitalization. Fifty three (69%) of those diagnosed with a UTI by discharge either had the UTI diagnosed in the ED or had bacteriuria 105 organisms/ ml prior to IUC placement. Of the 24 elderly patients who developed a catheter-associated UTI (i.e., 9% of the elderly population who received an IUC), 11 of the IUCs were placed inappropriately. Thus, 4% of elderly patients with no indication of UTI on admission who received an inappropriate IUC in the ED had a primary or secondary diagnosis of UTI by discharge. The overall rate of nosocomial UTI due to an inappropriately placed IUC was the same in males and females. Conclusion: This study indicates that the strong association between IUC use and UTI may be partly explained by the high prevalence of preexisting UTI prior to IUC placement. Further prospective studies are needed to clarify the true risk vs benefit ratio for IUC use in acutely ill elderly patients.
Approximately 4 million people each year receive an
indwelling urinary catheter (IUC)  and 520% of
hospitalized patients who receive an IUC will be diagnosed with a
urinary tract infection (UTI) [1,2]. IUC use is thought to
be the most significant risk factor for developing
nosocomial UTIs, especially in acutely ill elderly patients [3-6].
Indeed, the leading category of nosocomial infections are
UTIs , and 80% of these are associated with IUCs .
UTIs are associated with increased morbidity, mortality,
length of stay, and costs [4,8-11]. Even with
improvements in nursing care of the catherized patient and
experimental redesign of catheters themselves, UTI remains a
problem in the catherized patient [1,10,12-15]. It is
important, therefore, to carefully weigh the risks vs
benefits in patients for whom an IUC is being considered and
to minimize the inappropriate use of IUCs.
The association between UTIs and IUCs in acutely ill
patients is well documented. However, this association
does not establish cause and effect and most studies that
establish the association between IUC and UTI do not
examine whether the UTI preceeded IUC placement. One
study by Gardam et al  showed that 2 of 24 (8.3%)
consecutive patients with IUCs in the Emergency Department
(ED) had a UTI prior to catheter insertion, and 5 of the 24
(20.8%) developed a catheter-associated UTI during their
hospital stay. Three of these 5 UTIs were associated with
inappropriate IUC placement. However, this study was
small, urine cultures were not obtained consistently, and
it included patients of all ages.
The presence of a preexisting UTI may be more likely in
elderly patients admitted to the hospital [1,8]. Previous
studies have found that asymptomatic bacteriuria affects
up to 50% of noninstitutionalized geriatric women and
30% of geriatric men . Johansson et al  found that
38% of elderly patients with hip fractures had positive
urine cultures on admission to the hospital. In addition,
O'Donnell et al  point out that 2050% of nursing
home residents have asymptomatic bacteriuria, and this
rises to 100% in patients with IUCs. Several factors
predispose the elderly to UTIs including functional
abnormalities (e.g., enlarged prostate gland, obstructions), chronic
diseases (e.g., diabetes, cerebrovascular disease, and
neurodegenerative diseases such as Parkinson's and multiple
sclerosis), and certain medications.
The current study attempts to replicate the findings of
Gardam et al  with a larger sample. In addition, this study
focuses exclusively on elderly patients (i.e., those 65
The purpose of this study was to 1) examine the frequency
and appropriateness of IUC use in the ED in elderly
patients admitted to our acute care hospital, 2) to
determine the percentage of elderly patients with an IUC who
were discharged from the hospital with a primary or
secondary diagnosis of UTI, 3) to determine the percentage
of patients with IUCs who were diagnosed and treated for
UTI in the ED or who had admission bacteriuria 105
organisms/ml indicative of preexisting UTI, and 4) to
determine the percentage of elderly patients with no
indication of UTI on admission who had inappropriately
placed IUCs and subsequently were diagnosed with a UTI.
This study used retrospective chart review of all patients
admitted to our acute care hospital from the ED with an
IUC from March 131, 2004. Per hospital policy, all
catheters were placed using sterile technique. Data collected
included the patient's age, diagnoses, results of urine
cultures, and the reason for IUC use. The significance of
differences in proportions was determined using Chi square.
Permission to conduct this study was obtained from our
institution's Institutional Review Board (IRB).
For the purposes of this study, the presence of a UTI on
admission was defined as 1) an admission urine culture
with 105 organisms/ml or 2) the diagnosis and treatment
of UTI by the ED physician. Urine cultures positive only
for urogenital flora were considered negative for UTI for
Catheter appropriateness was determined using the
criteria of Nickel . IUCs were considered appropriate for
surgery, accurate measurement of intake and output,
urinary retention, urinary incontinence posing a risk to the
patient, urinary obstruction, altered blood pressure or
blood volume status requiring accurate urine
measurement, urine measurement in an uncooperative patient,
bladder irrigation for a urinary tract hemorrhage, and
palliative care for the terminally ill. This information was
obtained by chart review by Registered Nurses.
Reason for IUC placement in the elderly
Between March 1st and March 31st 2004, 1633 patients
were admitted to our acute care hospital from the ED. Of
these patients, a total of 379 patients received an IUC
(figure 1). Of these, 277 (73%) were patients 65 years old.
Significantly more elderly patients received and IUC than
those < 65 years old (30%vs 12%, respectively, p < .0001).
Overall, 139 (51%) of the elderly had IUCs appropriately
placed and 138 (49%) had inappropriately placed IUCs.
Table 1 shows the primary reason patients received an
IUC as determined by chart review. It also shows the
number of patients with an IUC for each reason who had
a UTI at admission, who had a UTI diagnosed by
dis1633 patients treated in the ED and admitted to the hospital
379 (23%) patients received an IUC
277 (73%) of patients receiving an IUC were >65 years old
77 (28%) had UTI as 1 or
2 diagnosis at discharge
200 had no UTI diagnosis
53 (69%) diagnosed
24 (31%) had no diagnosis
93 (46%) were 107 (54%)were
with UTI in the ED
of UTI in the ED
inappropriate appropriate inappropriate appropriate
FAisgsuocrieat1ion between IUC use and UTI in an acutely ill elderly population
Association between IUC use and UTI in an acutely ill elderly population.
Percentage of catherized patients who developed a
Seventy seven (28%) of the 277 elderly patients who
received an IUC had UTI as a primary or secondary
diagnosis at discharge. These patients ranged in age from 65 to
101 years old and 32 (42%) were from a nursing home.
Only 57 of the 77 (74%) had urine cultures performed, 40
of which were positive and 17 were negative. Four of the
77 were being treated for a UTI prior to arrival in the ED,
3 had urosepsis, 34 displayed clinical signs/symptoms of
UTI, and 36 had asymptomatic UTIs. Significantly more
patients with an IUC had a UTI diagnosed by discharge
than those with no IUC (28% vs 10%, respectively, p <
.0001). Of the 77, 53 (69%) were diagnosed and treated
for UTI in the ED or had urine cultures showing 105
organisms/ml, leaving 24 elderly patients without a UTI
on admission who received an IUC and subsequently
developed a UTI. In other words, 9% of the elderly
population who received an IUC developed a nosocomial UTI.
Association between nosocomial UTIs and inappropriately
Of the 24 elderly patients who developed a nosocomial
UTI, 11 of the IUCs were determined to have been placed
inappropriately (Table 2). Thus, 46% of the nosocomial
UTIs were due to inappropriately placed IUCs. Overall 11
of the 277 (4%) patients 65 years old who received an
IUC developed a nosocomial UTI associated with an
inappropriately placed IUC.
Of the 200 elderly patients who received an IUC but were
not diagnosed with a UTI during their hospital stay, 93
(46%) of the IUCs were placed inappropriately, while 107
(54%) were appropriately placed.
A significantly greater proportion of elderly patients
receiving an IUC were female vs male (73% vs 27%
respectively, p < .0001) (figure 2). Both groups, however,
had similar rates of UTI as a primary or secondary
diagnosis at discharge (27% females, 29% males). Of those
diagnosed with UTI by discharge, both groups also had similar
Number of patients with
IUC for this reason
Number with IUC for this Number with IUC for this
reason who had UTI diagnosis reason who had UTI
by discharge diagnosis at admission
Fractured Hip 17
Intubated/IntensiveCareUnit/CriticalCareUnit admission 36
Rectal bleed 1
Surgical case 21
Unresponsive/Loss of conciousness 14
Short of breath 4
Unable to ambulate 9
Do Not Resucitate status 2
Preexisting catheter 3
Renal failure 2
Urinary retention 3
IntensiveCareUnit admission looked likely at admission 4
Blood in urine 3
Fall/syncope prior to arrival 11
Abdominal pain 7
Cardiac catherization 1
Gastrointestinal bleed 2
Incontinent prior to arrival 3
rates of nosocomial UTI (29% females, 36% males). In
females with nosocomial UTIs, IUC placement was
inappropriate 50% of the time while in males with
nosocomial UTIs, IUC placement was inappropriate only 25% of
the time. Overall, 4% of all elderly females and 3% of all
elderly males developed a nosocomial UTI after having an
IUC placed inappropriately.
IUCs are routinely cited as the primary cause of
nosocomial infections [3-6]. On the other hand, previous studies
have shown that decreasing IUC use is not associated with
a decrease in UTIs . The present study showed that
28% of elderly patients who received an IUC were
diagnosed with a UTI during their hospitalization. These data
support the strong association between IUC use and a
diagnosis of UTI that has been shown in previous studies.
However, closer examination of the clinical data reveals
that 53 (69%) of the patients who were diagnosed with
UTI had either clinical signs/symptoms of UTI that were
diagnosed and treated in the ED or they had an admission
bacteriuria 105 organisms/ml indicative of a preexisting
UTI. Thus, only 9%, rather than 28%, of elderly patients
who received an IUC developed a nosocomial UTI. Thus,
this study suggests that when preexisting UTIs are
eliminated from the data, the association between IUC use and
There is general agreement that the use of IUCs is
appropriate in specific clinical situations. None-the-less,
previous studies have shown that when using agreed upon
definitions of appropriateness for IUC use, only about
50% of IUCs are used appropriately [2,18]. Our results
support these previous findings by showing that in this
elderly population with IUCs who developed a
nosocomial UTI, only 54% of the IUCs were placed
appropriately. However, this means that only 11 of the 277 (4%)
patients 65 years old who received an IUC developed a
nosocomial UTI associated with an inappropriately
placed IUC. Thus, when IUC appropriateness is taken into
consideration, the proportion of preventable nosocomial
UTIs may also be smaller than previously thought.
In this study, female elderly patients were more
susceptible to inappropriate IUC use than their male counterparts.
Indeed, only two (25%) male patients who developed a
nosocomial UTI had an IUC placed inappropriately, while
8 (50%) females who developed a nosocomial UTI had an
inappropriately placed IUC. However, overall males and
females were essentially equal in their rate of nosocomial
UTI associated with an inappropriately placed IUC.
Appropriate (n = 13)
The main limitation of this study was the use of
retrospective chart review (with its inherent problems of missing
data) to determine the appropriateness of IUC placement.
As has been noted in previous studies, the reason for IUC
placement was rarely explicitly stated in the chart and
therefore had to be deduced from the available clinical
information. However, the lack of documentation
regarding the reason for IUC placement would only result in an
underestimation of IUCs that were appropriate using the
criteria established by Nickel . For example, Nickel's
criteria for appropriateness allows for catheter use for
urine measurement in uncooperative patients. In our
sample, the largest number of inappropriate IUCs was for
confused patients, some of whom were undoubtedly
uncooperative and therefore may have actually had an
appropriately placed IUC. To ensure the most reliable
interpretation of the reason for IUC placement from the
chart review, Registered Nurses, one of whom was an ED
nurse, were used as chart reviewers.
Rarely did it appear that there was a single reason for IUC
placement. Indeed, it seemed in most cases that there were
several patient characteristics contributing to the decision
to use an IUC. For example, some patients were confused,
dehydrated, and syncopal prior to arrival in the ED. Some
had significant drops in their oxygen saturation levels
when they were moved around in the bed. Some were in
pain, immobile, and incontinent. While any one of these
reasons alone may not meet the criteria for an
appropriately placed IUC, we should consider the possibility that,
taken together, the combination of clinical factors may tip
the risk benefit scale. Perhaps appropriateness needs to be
redefined on an individual basis when there is a
constellation of factors that may contribute to IUC use.
Another limitation of this study is the fact that we did not
record the duration of IUC use in relation to nosocomial
UTI development. Numerous studies demonstrate that
the risk of UTI increases as the duration of catherization
increases [9,12,18-20]. Unfortunately, in this
retrospective study we were unable to look at this relationship due
to inconsistent documentation by nursing staff regarding
the timing of IUC discontinuation.
The use of antibiotics might confound the results seen
here. We did not examine correlations between antibiotic
use and UTI in patients with IUCs due to the unreliable
nature of pre-hospitalization medication histories. We
know, however, that some patients who were diagnosed
with UTI were being treated with antibiotics for various
reasons prior to ED admission, some were treated with
antibiotics in the ED, and some were treated with
antibiotics on the nursing unit. Furthermore, we have no
evidence to suggest that antibiotic use in our sample was
substantially different from that which would be seen in
any typical ED population. Thus, the effects of antibiotic
use on the generalizability of our findings may be
A final limitation of this study may be the criteria used for
a positive UTI (i.e., diagnosis and treatment of UTI by the
ED physician or 105organisms/ml in admission urine
culture). While some authors define UTI simply by colony
counts in urine cultures , others say that a positive
diagnosis depends on the presence of UTI
signs/symptoms and a positive urine culture . Some authors define
UTI as 103 organisms/ml  and state that >90% of
these patients are asymptomatic. As stated by Nicolle ,
"neither a positive urine culture nor clinical presentation
allows a diagnosis of symptomatic urinary infection to be
made with a high degree of certainty" in the elderly. As
with other studies, our definition is not optimal since UTI
may be over-diagnosed and treated by ED physicians.
Unfortunately, urine cultures are not routinely obtained
when UTI is diagnosed and treated in the ED, making
verification of the diagnosis difficult. However, there is also
evidence from this study that UTI may be
under-diagnosed in the ED as 18 patients had positive cultures but
were not diagnosed with UTI in the ED. We chose 105
organisms/ml or the presence of UTI symptoms
prompting treatment in the ED as indicators of UTI which is in
line with the Center for Disease Control and other
national guidelines defining UTI [24,25].
The results of this study indicate that IUC use following an
emergency admission may not pose as high a risk for
277 patients with IUCs >65 years old
202 females (73%)
75 males (27%)
55 (27%) diagnosed with
UTI by discharge
22 (29%) diagnosed with
UTI by discharge
39 (71%) diagnosed
14 (64%) diagnosed
with UTI in ED
with UTI in ED
FGiegnudreer 2differences in IUC outcomes
Gender differences in IUC outcomes.
nosocomial UTI as previously thought, nor are they as
highly associated with preventable UTIs. These findings
run contrary to conventional wisdom and to our own
expectations. Further research using better documentation
for the reason for IUC use and the duration of use is
warranted. Furthermore, despite these findings there is still a
sizeable percentage of patients who develop nosocomial
UTIs after the inappropriate placement of an IUC. Given
the morbidity and mortality associated with UTIs in
acutely ill elderly patients, it is still reasonable to make
every effort to limit the use of IUCs to only those patients
for whom an IUC is appropriate. Finally, the
indiscriminant use of IUCs in acute care hospitals should still be
avoided in the elderly due to the associated increased risk
of functional impairment, falls, and immobility. Further
research is needed to clarify the relationship between IUC
use and preventable UTIs so that clinicians can more
accurately assess the risks compared to the benefits of IUC use.
SH contributed to the study design, data collection, data
analysis, and manuscript preparation. MT contributed to
the study design, data collection, and manuscript
preparation. MG contributed to study design, data collection, and
manuscript preparation. KA conceived the study and
contributed to the study design and manuscript preparation.
All authors read and approved the final manuscript.
Funding for Susan E Hazelett, Margaret Tsai, Michele Gareri, Kyle Allen was
provided by the Health Services Research and Education Institute with
funds from the Summa Health System Foundation.
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