Hospital-Acquired Urinary Tract Infection

Jacob A. Lohr, MD, Leigh G. Donowitz, MD, and John E. Sadler Ill

From the Department of Pediatrics, University of Virginia Children’s Medical Center,

Charlottesville

ABSTRACT. From 16,534 admissions, 60 patients, 4 days development of bacteniunia in these patients is usu-
to 15 years of age, with one or more hospital-acquired
ally associated with a benign course and may ne-
urinary tract infections were identified during a 5-year
solve with removal of the catheter, with or without
period by a prospective surveillance system. The patient
charts were subsequently reviewed to characterize the antimicrobial therapy.9” On the other hand, corn-
population at risk for such infections and to describe the plications may include bactenernia in 3% of pa-
course and consequences of these infections. Infections tients,”2”3 with an associated mortality rate of
in individual patients ranged from one to >50. The hos- 12.5% to 50%.’’
pital-acquired urinary tract infection rate for the study
Nosocomial urinary tract infections in pediatric
period was 14.2 infections per 1,000 admissions. In the
patients in whom all urinary tract infections were well patients have not been characterized. The purpose
documented, the following characteristics were defined: of this study is to characterize the population at
(1) 92% (97 of 105) of the infections occurred in cathe- risk for such infections and to described, within the
terized patients; (2) almost half (49 of 105) of the infec- limitations of a retrospective chart review, the
tions occurred in patients exposed to only intermittent
course and consequences of these infections.
catheterization; (3) 28% (29 of 105) of the infections were
asymptomatic; (4) fever was the most frequent finding in
the symptomatic patients and occurred in 66% (60 of METHODS
105); (5) pyuria was found in only 51% (35 of 69) of the
urinalyses performed at diagnosis; (6) 85% (89 of 105) of Patient Source and Period of Study
the infections were single-organism infections; (7) 82%
(101 of 123) of the causative organisms were Escherichia The University of Virginia Children’s Medical
coli, Pseudomonas sp, coagulase-negative staphylococci, Center serves the city of Charlottesville and the
Enterococcus spp, Klebsiella spp, or Enterobacter sp. The
surrounding county with a population of approxi-
urinary tract infections in the 60 patients were not com-
plicated by bacteremia, and no direct relationship be- maiely 100,000, as well as the western half of Vir-
tween the infections and the minimal mortality in our ginia. The study included patients admitted
to the
patients could be established. Pediatrics 1989;83:193-199; newborn intensive care unit, intensive
pediatric
nosocomial infection, urinary tract infection, urinary tract care unit, preschool-aged ward, school-aged ward,
catheterization, bacteremia.
and burn unit during the period Jan 1, 1981,
through Dec 31, 1985.

Surveillance Procedures and Definitions

The urinary tract is the most frequently involved
site of primary infection in patients with hospital- During the study period, prospective surveillance
acquired infections, accounting for approximately of nosocomial infections was performed weekly in
40% of all nosocomial infections.’ In adult patients wand services and twice weekly in critical care areas
the foremost risk factor for acquisition of a noso- by trained infection control practitioners using
cornial urinary tract infection is catheterization or standard methods and definitions of infection.18”9
instrumentation of the genitouninary tnact.2 The Routine urine cultures were not performed as part
of the surveillance. We used University of Virginia
Hospital surveillance methodology: a catheterized
Received for publication June 1, 1987; accepted Feb 17, 1988. or uncathetenized symptomatic on asymptomatic
Reprint requests to (J.A.L.) Department of Pediatrics, Box 386,
patient with a nosocomial urinary tract infection
University of Virginia Children’s Medical Center, Charlottes-
ville, VA 22908.
was initially identified by a catheter on suprapubic
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the urine culture yielding greater than i0 colony-form-
American Academy of Pediatrics. ing units pen milliliter of urine. Asymptomatic in-

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2 February 1 989 193
fections were detected by urine cultures ordered by study purposes, the patients were assigned to three
the patients’physicians. In some cases, these cul- groups: newborn intensive care unit patients, non-
tunes were ordered because of the presence of a newborn intensive care unit patients with limited
urinary catheter; in other cases, the charts did not (<6 months) hospitalization, and non-newborn in-
reflect a specific reason for these urine cultures. tensive care unit patients with chronic (6 months)
Infections were classified as hospital-acquired if hospitalization. The study groups are further char-
symptoms occurred 48 hours or more after admis- actenized in Table 1.
sion or if previously collected urine revealed no The six non-newborn intensive care unit patients
evidence of infection. Patients with recorded who were chronically hospitalized differed signifi-
asyrnptomatic infections were all required to have cantly from the non-newborn intensive care unit
had a negative urine culture prior to urinary tract patients with limited hospitalization in that each
infection documentation. Documentation in all pa- was hospitalized for more than 365 days during the
tients was defined as the date of the first positive study period. Four of these patients were quadni-
urine cultures. plegic and
one was paraplegic. One patient had
multiple congenital renal abnormalities and end-
Urinalysis stage renal disease, was undergoing chronic penito-
neal dialysis on hemodialysis, and underwent renal
Routine uninalyses were performed according to
transplantation of limited success during the study
standard laboratory procedures. Specimens were
period.
chemically analyzed using the Ames Clini-Tek. Mi-
It was not possible in our retrospective chart
croscopic analyses were performed on centrifuged
review to verify complete details concerning the
sediments using ICL Scientific’s KOVAR system.
hospital courses of the six patients because of their
WBCs were reported per high-power field.
extremely complicated hospital courses, missing
volumes of their hospital records, poor documen-
Microbiology
tation of type and duration of urinary catheter use,
Quantitative bacteriologic cultures were per- presence of persistent bacteniunia in some, and an-
formed according to standard laboratory proce- tibiotic treatment of multiple infections outside the
dunes.2#{176}Specimens were inoculated onto sheep urinary tract. All six patients did have multiple
blood and MacConkey’s agar culture plates with a catheterizations, including intermittent and in-
0.00i-mL calibrated loop. Culture plates were eval- dwelling procedures. No patient had fewer than 15
uated after 18 to 24 hours of incubation at 37#{176}C. infections, and one had at least 50 infections during
the study period. In the individual infections that
Chart Review were documented, a single organism was usually
isolated and only rarely were more than two orga-
The charts of qualifying patients were reviewed
nisms isolated. The species of organisms identified
retrospectively for the following information: ad-
did not differ from those identified in the other
mitting inpatient unit, number of hospitalizations,
groups.
number of individual infections, age, sex, race, pnin-
cipal diagnosis, urinary tract catheterization (type
Diagnoses
and duration prior to documentation), symptoms
and physical signs at documentation, urinalysis The principal diagnoses for the three groups are
findings, bacteria isolated from urine cultures ob- listed in Table 1. Neurologic disorders accounted
tamed at documentation, and outcome. for 31 of the 60 principal diagnoses. Of these 31
patients, most had CNS trauma,’4 meningomyelo-
Statistical Analysis celes with neurogenic bladders,9 or brain tumors in
the postcraniotomy period.5 Of the patients, 20%
Intragroup differences were analyzed using x2 had primary renal disease. In the five patients with
analysis of Student’s t test.
cardiac malformations, urinary tract infections had
developed following corrective cardiac surgery. Of
RESULTS the newborn intensive care unit patients, seven
were premature; however, all but two patients had
Patients
another major diagnosis thought to be more directly
We identified 60 patients with one or more hos- related to the subsequent development of urinary
pital-acquired urinary tract infections. The male to tract infection. Eight of the 12 newborn intensive
female ratio for the 60 patients was 0.9. The ratio care unit patients had documented radiographic
of white to black patients was 3:1, reflecting the and/or sonographic studies of their urinary tracts
racial composition of the patient population. For and five had significant findings including bladder

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 TABLE 1. Characteristics of Stu dy Groups
Characteristics Newborn Non-Newborn Intensive
Intensive Care Unit Patients
Care Unit . .

Patients Limited Chronic

Hospitalization Hospitalization
No. of patients 12 42 6
No. of urinary tract infections
Per patient 1 1-10 >10
Forgroup 15 90 130
No. of admissions
Per patient 1 1-5 1-18
Forgroup 12 90 31
Age
Range 4 d-5 mo 5 wk-15 yr 6-15 yr
Mean 32.8 d 8.1 yr 10.0 yr
Median 14.0 d 10.0 yr 10.0 yr
Sex
Male 5 19 4
Female 7 23 2
Race
White 8 32 5
Black 4 10 1
Principal diagnoses
Neurologic 4 22 5
Renal 3 7 1
Cardiac 0 5 0
Hematologic 0 #{149}3 0
Thermal 0 3 0
Gastrointestinal 3 0 0
Prematurity 2 0 0
Orthopedic 0 1 0
Multiple major diagnoses 0 1 0

TABLE 2. Inpatient Unit-Specific Infection Rates5

Group Unit No. of No. of No. of No. of
Patients Infections Admissions Infections!
(n = 60) (n = -235) (N = 16,534) 1,000
Admissions
(n = ‘-14.2)
NICU patients NICU 12 15 1,910 7.9
Non-NICU patients
Limited hospitalization PICU 10 19 i,846t 10.3
PAW 8 12 6,511 1.8
SAW 21 55 6,126 9.0
BU 3 4 141 28.4
Long-term hospitalization PICU
PAW 6 ‘-130 --9.0
SAW
S Abbreviations: NICU, newborn intensive care unit; PICU, pediatric intensive care unit; PAW, preschool-aged ward
SAW, school-aged ward; BU, burn unit.
.t These figures include all non-NICU patients of limited and long-term hospitalizations.

abnormalities (two), renal dysplasia (two), or ob- rates in the inpatient units. In the remaining pa-
struction (one). tients, infection rates varied significantly according
to inpatient unit (x2 = 43.7, df = 4, P < .001). The
Inpatient Units rate in the wand for school-aged children was sig-
nificantly higher than the rate in the ward for
Inpatient unit-specific infection rates for the preschool-aged children (x2 30.5, df 1, P <
three groups are shown in Table 2. The non-new- .001). The rate in the ward for school-aged children
born intensive care unit patients with chronic hos- did not vary significantly from the rates in the
pitalization were excluded from the comparison of newborn intensive care unit and pediatric intensive

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care unit (P > .50). The rate in the burn unit was the mean durations for infections following indwell-
greater than the rate for all other units (x2 = 10.9, ing catheter use either alone (14.3 days; t = 0.67, P
df = 1, P < .001) but did not vary significantly from > .50) or in sequence with intermittent or condom
the rate in the pediatric intensive care unit (.10> catheter use (16.8 days; t = 0.24, P .50).
P > .05). The combined infection rate in the inten-
sive care units (newborn intensive cane unit, pedi-
Patient Symptoms
atnic intensive care unit, and burn unit) (9.7 infec-
tions per 1,000 admissions) was significantly Patients were asymptomatic with five (33%) of
greater than the combined rate in the general wards the 15 newborn intensive care unit infections and
(preschool-aged children and school-aged children) 24 (27%) of the 90 infections in non-newborn in-
(5.3 infections per 1,000 admissions) (x2 = 9.34, df tensive care unit patients with limited hospitaliza-
= i,P< .01). tion. Because surveillance urine cultures were not
routinely performed, additional asymptomatic in-
Catheter Use fections could have been missed. Fever was the only
Catheter use among the newborn intensive cane symptom in ten (67%) of the 15 newborn intensive
unit patients and the non-newborn intensive cane care unit infections and 42 (47%) of the 90 non-
unit patients with limited hospitalization is defined newborn intensive cane unit infections. The other
in Table 3. None of the patients was catheterized symptoms (dysunia, frequency, abdominal on flank
at the time of admission. Five infections in four pain, and incontinence) could not be assessed in
newborn intensive cane unit patients and three the newborn intensive cane unit patients, in some
infections in two non-newborn intensive cane unit of the younger non-newborn intensive care unit
patients occurred without catheter exposure. The patients, on in certain patients with CNS injuries
four newborn intensive care unit patients were all or surgery. Abdominal or flank pain was the only
premature infants. The two non-newborn intensive symptom noted by catheterized patients.
care unit patients had leukemia and were neutno-
penic when their infections were documented. Urinalysis
Seven (70%) of the ten infections in catheterized
newborn intensive care unit patients and 42 (48%) Urinalysis was performed on the same day of
of the 87 infections in catheterized non-newborn infection documentation for a majority of the infec-
intensive cane unit patients occurred following only tions in the newborn intensive care unit patients
intermittent catheterizations. In the non-newborn and in the non-newborn intensive cane unit patients
intensive cane unit patients, the mean duration of with limited hospitalization. More than five poly-
catheter use before infection documentation for morphonuclean leukocytes per high-power field
infections following only intermittent catheteniza- were seen in half of the 69 infected urine samples
tions 15.7 days) was not significantly different from subjected to analysis.

TABLE 3. Association Between Infections and Catheterizations

Newborn Non-Newborn Combined
Intensive Intensive Groups
Care Unit Care Unit (n = 54)
Patients Patients
(n = 12) With Limited
Hospitalization
(n = 42)
No. of infections 15 90 105
Infections in noncatheterized pa- 5 3 8
tients
Infections in catheterized patients 10 87 97
per catheter type
Indwelling 3 24 27
Indwelling and intermittent 0 17 17
Indwelling and condom 0 4 4
Intermittent 7 42 49
Duration of catheterization prior to
infection (d)
Range 4-150 1-40
Mean 25.9 16.3
Median ii 14

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Microbiology Enterococcus spp predominated. Fungi were path-
ogens only in the non-newborn intensive care unit
All positive cultures yielded greaten than iO col-
infections and accounted for four (4%) of the 104
ony-fonming units per milliliter of urine for each
isolates.
organism considered a pathogen. A single organism
was isolated in 89 (85%) of the 105 infections in
Associated Bacteremia
the newborn intensive cane unit patients and non-
chronic non-newborn intensive cane unit patients One patient, a non-newborn intensive care unit
(Table 4). Two organisms were isolated in 14 (13%) patient with limited hospitalization, had a urinary
and three organisms in two (2%) of the 105 infec- tract infection and concomitant bactenemia with
tions in the combined groups. The predominant the same organism, a coagulase-negative Staphylo-
organisms in the newborn intensive care unit infec- coccus, proven on the first day of the infection. A
tions were coagulase-negative staphylococci, Enter- central venous catheter was in place and coagulase-
obacter spp, Escherichia coli, and Enterococcus spp negative staphylococcal bacteremia had been doc-
(Table 5). In the non-newborn intensive care unit umented and treated 2 weeks prior to documenta-
infections, Escherichia coli, Pseudomonas spp, co- tion of a urinary tract infection; previous urine
agulase-negative staphylococci, Kiebsiella spp, and cultures had been negative.

TABLE 4. Microbiology
Newborn Non-Newborn Combined
Intensive Intensive Group
Care Unit Care Unit (n = 54)
Patients Patients
(n = 12) With Limited
Hospitalization
(n = 42)
Total No. of infections 15 90 105
Total No.(%) of organisms isolated 19 104 123 (100)
No. (%) of organisms isolated from in-
dividual infections
Single organism 11 78 89 (85)
Two organisms 4 10 14 (13)
Three organisms 0 2 2 (2)

TABLE 5. Microbiology5
Organism No. (%) of Times No. (%) of Times
Pathogen Isolated Pathogen Isolated
From Urine of From Urine of
Newborn Non-Newborn
Intensive Care Intensive Care
Unit Patients Unit Patients
(n = 19) With Limited
Hospitalization
(n = 104)
Escherichia coli 3 (15.8) 23 (22.1)
Pseudomonas spp 1 (5.3) 22 (21.2)
Kiebsiella spp 1 (5.3) 11 (10.6)
Enterobacter spp 4 (21.1) 4 (3.9)
Proteus spp 0 (0) 3 (2.9)
Serratia spp 1 (5.3) 1 (1.0)
Acinetobacter spp 0 (0) 2 (1.9)
Morganella spp 0 (0) 2 (1.9)
Citrobacter spp 0 (0) 1 (1.0)
Coagulase-negative staphylococci 6 (31.6) 13 (12.5)
Staphylococcus aureus 0 (0) 3 (2.9)
Enterococcus spp 3 (15.8) 10 (9.6)
Nonhemolytic streptococci 0 (0) 5 (4.8)
Candida spp 0 (0) 3 (2.9)
Other fungi 0 (0) 1 (1.0)

S NICU, newborn intensive care unit.

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Deaths asymptomatic. Fever was the most frequent abnor-
mality and was documented in 66% of the infec-
Two infants died: one newborn intensive care
tions.
unit patient, with documentation of a urinary tract
More than five polymorphonuclear leukocytes
infection three days earlier, and one non-newborn
per high power field were identified in only half of
intensive cane unit patient with limited hospitali-
the uninalyses performed on the day of documen-
zation, with infected urine at the time. Death was
tation of urinary tract infection. Few or absent
attributed to noninfectious cases in both patients.
polymorphonuclean cells do not rule out the pres-
ence of a nosocomial urinary tract infection.
DISCUSSION The incidence of coagulase-negative staphylo-
cocci (15%) in the combined groups was notable.
The 60 patients in our study had 235 urinary
This percentage exceeds the isolation rate for the
tract infections during a total of 133 admissions to
individual services in the hospitals included in the
the hospital (Table 1). The urinary tract infection
1984 National Nosocomial Infection Surveillance
rate for the study period (14.2 infections pen 1,000
report.’ The organism was listed as one of the five
admissions) is comparable to the 1984 National
most common isolates in only the obstetrics (4% of
Nosocomial Infection Surveillance’ system rates for
isolates) and newborn (10% of isolates) services. In
surgery (19.5 infections per 1,000 discharges), med-
our newborn intensive care unit infections, coagu-
icine (19.5 infections per 1,000 discharges), and
lase-negative staphylococci were the most frequent
gynecology (14.4 infections per 1,000 discharges)
isolates, accounting for 32% of the total.
and exceeds that for obstetrics (4.2 infections per
Fungi were isolated infrequently in our series, in
1,000 discharges). The newborn intensive care unit
contrast with the 9% and 11% isolation of Candida
patients in our study had a urinary tract infection
spp in the newborn and pediatric services, respec-
rate of 7.9 infections per 1,000 admissions, which
tively, documented in the 1984 National Nosoco-
far exceeds the rate of 1.0 infections per 1,000
mial Infection Surveillance report.’
discharges compiled by the National Nosocomial
Only one of our patients had a positive blood
Infection Surveillance system for newborns in large
culture with the same organism isolated from the
teaching hospitals. Direct comparison of these rates
urinary tract. This blood culture was obtained on
is not feasible, however, because the surveillance
the same day that the urinary tract infection was
system figures included well-baby nursery dis-
documented. A previous bactenemia with the same
charges.
organism had occurred, but previous urine cultures
As expected, the combined rate of infection in
were negative. Thus, it seems likely that the bac-
the intensive care units (newborn intensive cane
tenemia, rather than the urinary tract infection,
unit, pediatric intensive care unit, and burn unit)
was the primary event. Bacteremia was not a doc-
(9.7 infections pen 1,000 admissions) was signifi-
umented complication in any of our patients. This
cantly higher than the combined rate among pa-
finding is in contrast with adult studies in which
tients admitted to the general wards (preschool-
the attack rate for bacteremia was 3% for patients
aged and school-aged children) (5.3 infections per
with nosocomial bacteniunia.”2”3
1,000 admissions). Nosocomial infection rates in
No mortality could be directly attributed to the
general are higher for intensive cane units than for
urinary tract infections in our patients. One patient
general wards.2”22
had a urinary tract infection at death, but other
The at-risk population was almost exclusively
disorders were considered the cause of death. The
the group of patients subjected to urinary tract
second patient who died did not have a urinary
catheterization. A total of 92% of the infections
tract infection at death.
occurred in catheterized patients and 89% of the
infected patients were catheterized (Table 3).
CONCLUSIONS
Of the catheter-associated infections, 51% were
in patients exposed only to intermittent catheteni- (1) Hospital-acquired urinary tract infections in
zations. A previous study from the University of our pediatric patients occurred at a rate comparable
Virginia Medical Center defined a 9% risk for un- to that documented for adults. (2) The population
nary tract infections among pediatric patients who at risk was almost exclusively the group of patients
were catheterized.’9 Further study is needed to de- subjected to urinary tract catheterization; 92% of
fine specific risks for infection in pediatric patients the infections occurred in catheterized patients and
exposed to different types of catheterization. 89% of the infected patients were catheterized. (3)
Of the infections in the newborn intensive cane Infections were equally distributed between those
unit patients and non-newborn intensive care unit patients subjected to in and out catheterization only
patients with limited hospitalization, 28% were and those exposed to indwelling catheterization,

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 disposing to bacteriuria during indwelling urethral catheter-
either alone on in sequence with in and out on
ization. N Engl J Med 1974;291:215-219
condom catheterization. (4) More than one quarter 8. Burke JP: Status of methods to prevent urinary catheter-
of the infections were asymptomatic. (5) Lack of associated infections. Presented at a symposium at Harvard
Medical School in honor of Dr Maxwell Finland, Boston,
pyunia did not exclude the possibility of an infec-
March 13, 1982
tion. (6) The infections were caused by a single 9. Clarke BG, Joress S: Quantitative bacteriuria after use of
organism 85% of the time. The predominant onga- indwelling catheters: Incidence in genito-urinary surgery.
JAMA 1960;174:1593-1596
nisms were
Escherichia coli, Pseudomonas spp, co-
10. Cox CE, Hinman F Jr: The incidence of bacteriuria with
agulase-negative staphylococci, Enterococcus spp, indwelling catheters in normal bladders. JAMA 1961;
Kiebsiella spp, and Enterobacter spp. (7) The un- 178:919-921
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terization to persistent bacteria in gynecologic patients. Am
tenemia. (8) A direct relationship between the un- J Obstet Gynec 1963;86:998-1002
nary tract infections and the minimal mortality in 12. Krieger JN, Kaiser DL, Wenzel RP: Urinary tract etiology
of blood stream infections in hospitalized patients. J Infect
our patients could not be established.
Dis 1983;148:57-62
13. Garibaldi RA, Mooney BR, Epstein BJ, et al: An evaluation
of daily bacteriologic monitoring to identify preventable
ACKNOWLEDGMENTS episodes ofcatheter-associatedurinary tract infection. Infect
Control 1982;3:466-470
The authors thank Richard A. Garibaldi, MD, and 14. McCabe WR, Jackson GG: Gram-negative bacteremia: II.
Richard P. Wenzel, MD, for reviewing the manuscript. Clinical, laboratory and therapeutic observations. Arch In-
The prospective surveillance of the patients was done by tern Med 1962;110:856-864
15. Freid MA, Vosti KL: The importance of underlying disease
Mary Ann Searcy of the University of Virginia Epide-
in patients with gram-negative bacteremia. Arch Intern Med
miology Program.
1968;121:418-423
16. DuPont HL, Spink WW: Infections due to gram-negative
organisms: An analysis of 860 patients with bacteremia at
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 Hospital-Acquired Urinary Tract Infection
Jacob A. Lohr, Leigh G. Donowitz and John E. Sadler III
Pediatrics 1989;83;193

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 Hospital-Acquired Urinary Tract Infection
Jacob A. Lohr, Leigh G. Donowitz and John E. Sadler III
Pediatrics 1989;83;193

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