108 32.8% [5,6] CAUTIs 600 2,800 [7] CAUTIs 13.1 [3] 2008 10 (The Centers for Medicare and Medicaid Services) CAUTIs CAUTIs [7] 65~70% CAUTIs CAUTIs [

107 1 2 1 1,2 1 1 2 (catheter-associated urinary tract infections, CAUTIs) CAUTIs CAUTIs CAUTIs CAUTIs 2016:26:107-117 ( u r i n a r y t r a c t infections, UTIs) 40% ( 70%) 95% [1,2] 20% [3,4] 2007 139,000 (catheter-associated urinary tract infections, CAUTIs) [3] CAUTIs 105 1 5 105 4 29 386 07-3422121#2003 DOI: 10.6526/ICJ.2016.302 105 6

108 32.8% [5,6] CAUTIs 600 2,800 [7] CAUTIs 13.1 [3] 2008 10 (The Centers for Medicare and Medicaid Services) CAUTIs CAUTIs [7] 65~70% CAUTIs CAUTIs [8] 6.6 ~17.2 ( ) 9.8 CAUTIs 5.3 (1995~2003 ) 3.4 (2006~2008 ) 1.4~1.7 [9,10] 2002~2008 CAUTIs 3.76 [11] 2013 CAUTIs 4.2 2.79 [12] CAUTIs ( ) [13] ( ) (cross-transmission) 15% [14] [15] (National Healthcare Safely Network, NHSN) 2009 2010 CAUTIs (Escherichia coli) 26.8% (Klebsiella spp.) 11.2% (Pseudomonas spp.) 11.3% (Candida spp.) 18% (Enterococcus spp.) 10% (Pseudomonas spp.) 9% E. coli fluoroquinolone 29.1% 33.5% extended-spectrum beta-lactamases CAUTIs Klebsiella pneumoniae/ oxytoca 26.9% E. coli 12.3% (extended-spectrum

109 cephalosporins) CAUTIs Klebsiella spp. 12.5% carbapenems [16] (Enterococcus spp.) 1975 1984 (reservoir) (vancomycin-resistant Enterococcus, VRE) [16,17] CAUTIs [17] CAUTIs [15] CAUTIs 77% 95% 10% [2] SMART (Study for Monitoring Antimicrobial Trends) 2009 2010 8 E. coli (47.2%), K. pneumoniae (14.3%), P. aeruginosa (8.8%), Proteus mirabilis (8.0%) E. coli K. pneumoniae ESBL 15% 17% [18] 2013 Candida, E. coli, P. aeruginosa, K. pneumoniae Enterococcus ESBL carbapenem-resistant Enterobacteriaceae (CRE) ( ) [12] CAUTIs LTACHs a NHSN b SMART c TNIS d 2009~2010 2009~2010 2009~2010 2013 % ( ) [17] % ( ) [16] % ( ) [18] ( ) [12] Escherichia coli 14 (3) 26.8 (1) 47.2 (1) NA (2) Candida spp. 10(5) 12.7 (3) NA NA (1) Enterococcus spp. 14(3) 15.1 (2) NA NA Pseudomonas aeruginosa 19(1) 11.3(4) 8.8 (3) NA (3) Klebsiella (pneumoniae/oxytoca) 17(2) 11.2(5) 14.3 (2) NA (4) a. LTACHs : Long Term Acute Care Hospitals ( ) b. NHSN: National Healthcare Safely Network ( ) c. SMART: Study for Monitoring Antimicrobial Resistance Trends ( ) d. TNIS: Taiwan Nosocomial Infections Surveillance ( ) 105 6

110 Chenoweth CE, et al. [39] 50 2 mg/dl CAUTIs CAUTIs [1,2] UTI CAUTIs 2 mg/dl [2] CAUTIs ( ) [20,21] ( ) [22] 48 3 7

111 [20,22] ( ) (biofilm) [23] ( ) CAUTIs SMART 2009~2010 amikacin imipenem, piperacillin/tazobactam quinolone 70% [18] 2010~2011 - E. coli amikacin 96~97%, ceftazidime 46-77%, ciprofloxacin 65~66%, levofloxacin 64~67% Klebsiella pneumoniae amikacin 85~92%, ceftazidime 68~72%, ciprofloxacin 68~74%, e r t a p e n e m 9 0 ~ 9 7 %, i m i p e n e m : 91~96% Pseudomonas aeruginosa p i p e r a c i l l i n 8 2 ~ 8 3 %, piperacillin/tazobactam 84~86%, ceftazidime 83~87%, ciprofloxacin 73~79%, levofloxacin 69~77%, imipenem 83~87% [19] amikacin pieracillin/tazobactam AMK PTZ CAZ FEM CIP LEV ETP IPM 1762 91.7 84.9 66.0 65.3 51.4 54.4 86.9 86.6 Escherichia coli 995 96.1 93.4 68.7 62.2 43.2 44.1 99.3 99.9 Klebsiella spp. 243 93.4 77.8 66.3 67.5 66.7 74.1 95.9 96.7 Pseudomonas aeruginosa 126 76.2 65.8 57.1 59.5 55.6 55.6 --- 61.1 AMK: amikacin ; PTZ: piperacillin/tazobactam; CAZ: ceftazidime; FEM: cefepime; CIP: ciprofloxacin; LEV: levofloxacin; ETP: ertapenem; IPM: imipenem Lu PL, et al. [18] 105 6

112 imipenem ( ) ( ) 7 10 14 CAUTIs levofloxacin ciprofloxacin [20,24,25] CAUTIs ( ) ( ) ( ) ( ) [20,26] ( ) 1. 2. 3. ( ) 4. 5. [20,26] [27] 28% [28] (condom catheters):

113 [29,30] [31,32] (urinary catheter reminder systems) 37% 52% [33] [34] [35] ( ) 1. ( c o n d o m catheters) [20] 2. [20] ( ) CAUTIs (antiseptic) [20] [20] [20] (use of antiinfective catheters) (antiseptic or antimicrobial impregnated urinary catheters) CAUTI [20] (primary end point) [36] ( 14 ) primary end point (silver alloy-coated) nitrofural- 105 6

114 impregnated catheters CAUTIs [37] CAUTIs CAUTIs Bladder Bundle ( ) CAUTIs 25% [38] CAUTIs CAUTIs CAUTIs CAUTIs 1. Chenoweth C, Saint S: Preventing catheterassociated urinary tract infections in the intensive care unit. Crit Care Clin 2013;29:19-32. 2. Nicolle LE: Urinary catheter-associated infections. Infect Dis Clin North Am 2012;26:13-27. 3. Burton DC, Edwards JR, Srinivasan A, et al: Trends in catheter-associated urinary tract infections in adult intensive care units-united States, 1990-2007. Infect Control Hosp Epidemiol 2011;32:748-56. 4. Weber DJ, Sickbert-Bennett EE, Gould CV, et al: Incidence of catheter-associated and noncatheter-associated urinary tract infections in a healthcare system. Infect Control Hosp Epidemiol 2011;32:822-3. 5. Chang R, Greene MT, Chenoweth CE, et al: Epidemiology of hospital-acquired urinary tractrelated bloodstream infection at a university hospital. Infect Control Hosp Epidemiol 2011;32:1127-9. 6. Shuman EK, Chenoweth CE: Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit. Crit Care Med 2010;38(8 Suppl):S373-9. 7. Saint S, Meddings JA, Calfee D, et al: Catheterassociated urinary tract infection and the Medicare rule changes. Ann Intern Med 2009;150:877-84. 8. Umscheid CA, Mitchell MD, Doshi JA, et al: Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101-14. 9. Allegranzi B, Bagheri Nejad S, Combescure C, et al: Burden of endemic health-care-associated infection in developing countries: systematic

115 review and meta-analysis. Lancet 2011;377:228-41. 10. Dudeck MA, Weiner LM, Allen-Bridson K, et al: National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control 2013;41:1148-66. 11. Chen YY, Chen LY, Lin SY, et al: Surveillance on secular trends of incidence and mortality for device-associated infection in the intensive care unit setting at a tertiary medical center in Taiwan, 2000-2008: a retrospective observational study. BMC Infect Dis 2012;12:209. 12. (TNIS) 2013 2014. 13. Tambyah PA, Halvorson KT, Maki DG: A prospective study of pathogenesis of catheterassociated urinary tract infections. Mayo Clin Proc 1999;74:131-6. 14. Saint S, Chenoweth CE: Biofilms and catheterassociated urinary tract infections. Infect Dis Clin North Am 2003;17:411-32. 15. D e m u t h P J, G e r d i n g D N, C r o s s l e y K : Staphylococcus aureus bacteriuria. Arch Intern Med 1979;139:78-80. 16. Sievert DM, Ricks P, Edwards JR, et al: Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hosp Epidemiol 2013;34:1-14. 17. Chitnis AS, Edwards JR, Ricks PM, et al: Deviceassociated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infect Control Hosp Epidemiol 2012;33:993-1000. 18. Lu PL, Liu YC, Toh HS, et al: Epidemiology and antimicrobial susceptibility profiles of Gramnegative bacteria causing urinary tract infections in the Asia-Pacific region: 2009-2010 results from the Study for Monitoring Antimicrobial Resistance Trends (SMART). Int J Antimicrob Agents 2012;40 Suppl:S37-43. 19. 2010~2011 2012;26:308-14. 20. Hooton TM, Bradley SF, Cardenas DD, et al: Diagnosis, prevention, and treatment of catheterassociated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63. 21. Tambyah PA, Maki DG: Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000;160:678-82. 22. Nicolle LE, Bradley S, Colgan R, et al: Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54. 23. Raz R, Schiller D, Nicolle LE: Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection. J Urol 2000;164:1254-8. 24. Dow G, Rao P, Harding G, et al: A prospective, randomized trial of 3 or 14 days of ciprofloxacin treatment for acute urinary tract infection in patients with spinal cord injury. Clin Infect Dis 2004;39:658-64. 25. Peterson J, Kaul S, Khashab M, et al: A doubleblind, randomized comparison of levofloxacin 750 mg once-daily for five days with ciprofloxacin 400/500 mg twice-daily for 10 days for the treatment of complicated urinary tract infections and acute pyelonephritis. Urology 2008;71:17-22. 26. Lo E, Nicolle LE, Coffin SE, et al: Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35 Suppl 2:S32-47. 27. Fakih MG, Pena ME, Shemes S, et al: Effect of establishing guidelines on appropriate urinary catheter placement. Acad Emerg Med 2010;17:337-40. 28. Saint S, Wiese J, Amory JK, et al: Are physicians aware of which of their patients have indwelling urinary catheters? Am J med 2000;109:476-80. 29. Parry MF, Grant B, Sestovic M: Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. Am J Med 2013;41:1178-81. 30. Quinn P: Chasing Zero: A nurse-driven process for catheter-associated urinary tract infection reduction in a community hospital. Nurs Econ 105 6

116 2015;33:320-5. 31. Nadelman RV, Nadelman DA, Montecalvo MA: A computer-based automated reminder increases the percentage of urinary catheters justified by an order and increases urinary catheter discontinuation orders. Am J Infect Control 2015;43:647-9. 32. Cornia PB, Amory JK, Fraser S, et al: Computerbased order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med 2003;114:404-7. 33. Meddings J, Rogers MA, Macy M, et al: Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 2010;51:550-60. 34. Stephan F, Sax H, Wachsmuth M, et al: Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis 2006;42:1544-51. 35. Palese A, Buchini S, Deroma L, et al: The effectiveness of the ultrasound bladder scanner in reducing urinary tract infections: a meta-analysis. J Clin Nurs 2010;19:2970-9. 36. Johnson JR, Kuskowski MA, Wilt TJ: Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med 2006;144:116-26. 37. Pickard R, Lam T, MacLennan G, et al: Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet 2012;380:1927-35. 38. Saint S, Greene MT, Kowalski CP, et al: Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA Intern Med 2013;173:874-9. 39. Chenoweth CE, Gould CV, Saint S: Diagnosis, management, and prevention of catheter-associated urinary tract infections. Infect Dis Clin North Am 2014;28:105-19.

117 Diagnosis, Management, and Prevention of Catheter-associated Urinary Tract Infections Jui-Kuang Chen 1, Ching-Hsien Li 2, Susan Shin-Jung Lee 1, Hung-Chin Tsai 1,2, and Yao-Shen Chen 1 1 Division of Infectious Diseases and 2 Department of Internal Medicine Infection Control Unit, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Catheter-associated urinary tract infections (CAUTIs), often caused by drugresistant organisms, are common healthcare associated infections. However, CAUTIs are often overdiagnosed because pyuria and bacteriuria are not credible indicators. Treatment of asymptomatic urinary tract infections is not necessary, except for prevention of the development of acute pyelonephritis or blood stream infections, when treating pregnant women, or during urinary tract invasive procedures. Empirical antibiotic choices for treatment of CAUTIs are dependent on the epidemiology and resistance patterns of microorganisms in the hospital. Antibiotic de-escalation and appropriate treatment duration are necessary to avoid development of new drug resistant strains of microorganisms. Reducing the number of indwelling catheters and shortening the indwelling time are the principles methods of prevention of CAUTIs. Recently, bundle care of urinary catheters was proven to effectively decrease CAUTI rate. Prevention is the best method to treat CAUTIs. Key words: Catheter-associated urinary tract infections, asymptomatic urinary tract infections, bundle care, antibiotics 105 6