The prevention of hospital-acquired urinary tract infection.

The prevention of hospital-acquired infection has recently received increased prominence as infection rates have been propelled into the spotlight of mandated public reporting, together with expectations of " getting to zero " as the benchmark for infection incidence. These revolutionary initiatives were initially directed toward surgical site infection, ventilator-associated pneumonia, and bloodstream infection. The fourth leg of the tetrad of major hospital-acquired infections—uri-nary tract infection—has received relatively little attention. This neglect seems exceptional, because urinary infection is the single most common hospital-acquired infection [1]. Health care–acquired urinary infection is a substantial burden for patients and the health care system [1]. They constitute 40% of all hospital-acquired infections, and fully 80% of these infections are attributable to indwelling urethral catheter use. Twelve percent to 16% of hospital inpatients will have an indwelling catheter placed at some time during hospitalization. While the catheter remains in situ, 3%–7% of patients will acquire a urinary infection each day. Catheter-associated bacteriuria has harmful outcomes beyond infection, including catheter or stent obstruction caused by biofilm formation, which usually requires removal and rein-sertion of the device [2] and provision of an environmental reservoir for drug-resistant organisms, which may be transferred between patients, occasionally causing outbreaks [3–5]; and life-threatening complications, such as bacteremia and sepsis syndrome [6]. There are also adverse effects of urethral catheters unrelated to infection, such as trauma to the bladder and urethral mucosa, immobility and discomfort for patients, and reactions to catheter materials, including hypersensi-tivity reactions to latex or inflammatory responses leading to urethral strictures [7–9]. The national survey reported by Saint et al. [10] suggests that many American hospitals are not paying attention to the substantial problems attributable to in-dwelling urethral catheter use. The insertion of a urethral catheter is an invasive procedure with negative consequences for patient safety, yet less than one-half of hospitals responding to the survey monitored whether patients had a urinary catheter in place. Only one-quarter of facilities documented the duration of catheterization. The most important strategies for prevention of catheter-related urinary infection are to avoid insertion of a catheter and, if a catheter must be used, to limit the duration to as short a time as possible. It is remarkable that so few facilities measure this risk exposure. The survey also reports no consistent approach in the use of other potential preventive strategies, such as use of antimicrobial-coated catheters, catheter reminders, or bladder scanners. Although the majority of …