Infectious Diseases in Clinical Practice:
University of Maryland, Baltimore, MD.
Address correspondence and reprint requests to Manjari Joshi, MD, University of Maryland, 22S Greene Street, Baltimore, MD 21201. E-mail: Manjari03@aol.com.
In this issue of the journal, Al Raiy et al1 review a very common problem in intensive care unit (ICU) patients. Al Raiy et al1 retrospectively reviewed 90 ICU patients with positive urine cultures (≥105 colony-forming units/mL). Their results demonstrated that clinicians often treat urinary tract infection (UTI) in the ICU based on urine culture result only in the absence of symptoms and in the presence of infections in other sites. They record that therapy with antibiotics was associated with higher incidence of diarrhea. With increased antimicrobial use, they raise the potential issues of higher cost and increased antimicrobial resistance. Al Raiy et al1 correctly conclude that "UTI treatment guidelines for ICU patients are urgently needed."
Incidence of bacteriuria in patients with indwelling catheters is 3% to 10% every day. Of these, 10% to 25% develop UTI.2 Richards et al3 conducted the National Nosocomial Infections Surveillance System in ICU patients, reporting that UTI was the most common infection in critically ill patients. Another study demonstrated that the catheter-associated UTI (CAUTI) is associated with excess deaths, increased length of stay, and higher costs.4 Despite the importance of CAUTI, very few studies have focused on them.5 To this date, the criteria for diagnosis of CAUTI have not been established. Because of lack of guidelines for diagnosis, the incidence of CAUTI is not well defined. Furthermore, several treatment issues and few preventive criteria also need to be established. In fact, there seems to be more questions than answers associated with this infection (Table 1).
Therefore, how should a clinician approach an ICU patient with possible UTI? Clearly, with an open mind and with a degree of skepticism! Because of lack of clear diagnostic criteria, while diagnosing a CAUTI, it is imperative to simultaneously evaluate for other sites of infections. By carefully reviewing clinical data, urinalysis (pyuria, leukocyte estrase, nitrate), urine cultures, and underlying risk factors, the decision should be made to treat or not to treat. In a patient who is not critically ill, the decision to treat needs to be based on a number of factors and not merely on urine cultures alone. A scoring system similar to what has been proposed for hospital-acquired pneumonia can be useful in this setting. If the decision to treat is made, short and focused antimicrobial therapy should be used. If the decision is made not to treat, careful follow-up of patient's clinical picture, repeat urine studies, and catheter removal as soon as possible can prevent unnecessary use of antibiotics. Unfortunately, in this day and age, due to lack of diagnostic clarity, a critically ill patient with no other obvious site of infection will be treated for a UTI based on positive urine analysis or urine cultures alone.
Antibiotic stewardship in this day and age is an important responsibility we all carry. Clinicians can use antibiotics judiciously and go into the next decade with a lower burden of resistant organisms, or we can use the miracle drugs inappropriately and jeopardize our future. The responsibility is not just ours, but also of the decision makers who need to provide better guidelines for diagnosis, treatment, and prevention of this disorder. It is unfortunate that a common infection with such a tremendous degree of impact has such minimal clarity.
1. Al Raiy B, Jahamy H, Fakih MG, et al. Clinicians' approach to positive urine culture in the intensive care units. Infect Dis Clin Pract
2. Haley RW, Hooten TM, Culver DH, et al. Nosocomial infections in US hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med
3. Richards MJ, Edwards JR, Culver DH, et al. Nosocomial infections in combined medical-surgical care units in the United States. Infect Control Hosp Epidemiol
4. Centers for Disease Control. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR Morb Mortal Wkly Rep
5. Laupland KB, Bagshaw SM, Gregson DB, et al. ICU acquired UTI in regional critical care system. Crit Care