Urinary Tract Infections make up 31% of hospital-acquired infections, making them the most prevalent nosocomial infection in American intensive care units.1 Urinary tract infections (UTIs) lead to over two billion dollars in annual healthcare costs for doctor visits, with approximately 500 million dollars allocated specifically for treating hospital-acquired (nosocomial) infections. UTIs affect around 3% of hospitalized patients and represent 40% of the estimated 2 million nosocomial infections occurring in the United States each year. The prevalence of UTIs in Indian population varies from 21.8% to 31.3%.The frequency of UTIs in Indian women ranges from 3.14% to 19.87%, highlighting the condition's substantial impact, Complicated UTI that may occur in patients with indwelling catheter is called Catheter associated urinary tract infection or CAUTI and US Centers for Disease Control and Prevention (CDC) has defined criteria for CAUTI as :Patient having indwelling catheter for more than 2 days (with ‘day one’ being the day of catheter insertion)One sign or symptom including fever, suprapubic tenderness, costovertebral angle tenderness, urinary frequency or urgency or dysuria.2

Urine culture having more than 105 CFU/mL of one bacterial species. Catheter-associated urinary tract infections (CAUTIs) are the most common nosocomial infection, with one million cases reported each year in the United States.3 7 In different intensive care units across the world the number of catheter-related UTIs per 1,000 catheter days vary from 9% to 18%.3,8–11 Apart from ICU approximately 75% of hospital-acquired UTIs are associated with a urinary catheter. 15–25% of hospitalized patients use urinary catheters.4 Estimates of the annual costs of preventable CAUTI range from $115 million to $1.82 billion.5 the mortality rate for UTIs in catheterized intensive care unit patients is tripled. In India the incidence of CAUTI found to be 49.1%.    By taking different measures 69% of CAUTI incidents can be prevented. Unlike typical UTIs, patients who have a catheter-associated urinary tract infection (CAUTI) may complain of suprapubic pain or the urge to urinate, but they may not exhibit other symptoms of a UTI, such as dysuria or increased frequency of micturation6. Nonspecific symptoms including fever, anorexia, malaise, flank pain, altered mental status, and sepsis signs might occur in patients. Bacteria may enter the bladder through the catheter lumen, from the catheter's outside, or during catheter insertion. A biofilm forms on the uroepithelium and surrounding the catheter's exterior7. This biofilm allows bacteria to enter and shields them from host defenses, antibiotics, and the mechanical passage of urine, making bacterial removal challenging. There is a 5% probability of getting severe bacteriuria each day the catheter is indwelling, even with meticulously aseptic catheter placement and maintenance. 16 Up to 24% of people with bacteriuria go on to experience symptoms of a UTI. The length of catheterization, female sex, diabetes mellitus, opening a closed system, and inadequate aseptic procedures are risk factors for UTIs. Fungal urinary tract infections can potentially be exacerbated by indwelling bladder catheters. Overall, limited research has focused on understanding the risk factors associated with catheter-associated urinary tract infections (CAUTIs)8, such as the duration of catheterization, existing co-morbidities, and the microbiological profile of the infection. Although global studies have reported evolving trends in UTI etiology, data specific to CAUTI in the Indian context remains scarce.

AIM

Study of catheter associated urinary tract infections in ICU patients at a tertiary care centre.

This prospective, observational study was conducted at the Department of General Medicine, Mahatma Gandhi Medical College & Hospital, Jaipur, between April 2023 and September 2024. A total of 200 patients were selected for the study using simple random sampling, based on an anticipated prevalence of 14%. The study included patients aged 18 years or older who were catheterized following admission to the Intensive Care Unit (ICU). Patients were excluded if they had a pre-existing urinary tract infection (UTI), had a Foley’s catheter already in situ at the time of admission, had their catheter removed within 7 days, or if their baseline urine routine and microscopy examination revealed significant pyuria.

Table 1. Distribution of study population according to Age (N=200)

In this study most of the study population i.e., 67 (33.5%) belonged to age group 41-50 years and rest 31 (15.5%), 44 (22.0%), 23(11.5%), 17 (8.5%) and 18 (9.0%) belonged to age group 21-30, 31-40, 51-60, 61-70 and 71-80 years respectively. The mean age of the study subject was 45.72 + 14.22 years.

Table 2. Distribution of study subject according to Serum Creatinine Level (N=200)

In this study 179 (89.5%) study subjects have normal serum creatinine and rest 21 (10.5%) had high serum creatinine. The mean serum creatinine of the study subject was 0.98+0.46 mg/dl .

Table 3. Distribution showing development of UTI at 48hr and day 7 according to Age (N=200)

UTI incidence increased significantly with age at both 48 hours and 7 days, with older age groups showing higher rates of infection (p<0.05).

Table 4. Distribution showing development of UTI at 48hr and day 7 according to Gender (N=200)

At 7th day, UTI was significantly more common in females than males (p<0.05), whereas at 48 hours, UTI occurrence was low and similar across genders with no significant difference (p>0.05).

Table 5. Distribution showing development of UTI at 48hr according to Duration of Symptoms (N=200)

UTI was more likely to develop by the 7th day in patients with symptom duration over 10 days, showing a statistically significant association (p<0.05), while no significant difference was observed at 48 hours (p>0.05).

UTI was significantly more common in patients with high serum creatinine, impaired mental status, and non-ambulatory status at both 48 hours and 7 days (p<0.05 to p<0.001). These factors were strongly associated with increased UTI risk over time.

Table 18. Distribution showing development of UTI at 48hr and day 7 according to Co-morbidity (N=200)

At 48 hours, UTI was absent in subjects without co-morbidities, while it was more frequent among those with hypertension, CAD, diabetes, and especially CKD, though at low rates.

One of the most prevalent bacterial illness is Urinary tract infections (UTIs) affecting about 150 million people globally 1 Most common nosocomial infection is catheter-associated urinary tract infections (CAUTIs) 13 and global data shows that the number of catheter-related UTIs per 1,000 catheter days vary from 9% to 18%.7,16–19   In India the incidence of CAUTI found to be 49.1%. 25 with pediatric medical ICU having the highest rate of CAUTI (4.5 per 1000urinary catheter days) . 26

In this study most of the study population i.e 67 (33.5%) belonged to age group 41-50 yrs with mean age 45.72 + 14.22 yrs.In a similar study by Khullar et all8 (2022) who studied the profile of UTI in Catheterised Patients in the Critically Ill Population in a Tertiary Care Hospital of New Delhi the average age of the study subject out of 200 was 57.3 ± SD 17.92 years with range of 19 - 93 years which was on the higher side compared to our study.

In this study after development of UTI at 7 days the sample was send for culture for detection of bacterial species and it was found that most common bacterial isolate was Escherichia coli found in 67 (33.5%) study subject. Enterococcus species, Pseudomonas species, Enterobacter aerogenes, Klebsiella species and Acinetobacter species was detected in culture in 39 (19.5%), 35(17.5%), 22 (11.0%), 15(7.5%) and 13 (6.5%) of study population respectively. Rest culture sample did not develop any bacterial growth or was sterile in 9 (4.5%) study subject. Khullar et all8 (2022) also reported that in the culture E. coli was the most commonly grown isolate (13 out of 25; 52.00%). Enterococcus spp. were the second highest contributing organisms (20.00%) followed by Pseudomonas spp. (04 out of 25; 16.00%). Klebsiella pneumoniae was isolated from 03 cases (12.00%).

In our study among the age group 31-40, 61-70 and 71-80 yrs at 48 hr UTI was present at in  1 (2.3%), 1 (5.9%) and 2 (11.1%) subjects respectively. So at 48 hr UTI was present more in older subjects and this difference was statistically significant (p<0.05) At 7th day among the age group 31-40, 41-50,51-60, 61-70 and 71-80 yrs UTI was present in  2 (4.5%), 5 (7.5%), 1 (4.3%), 3 (17.6%) and 6 (33.3%) subjects respectively. So again at 7 day UTI was present more in older subjects and this difference was statistically significant (p<0.05)

In our study at  48 hr among the males UTI was present in 2 (1.7%) study subject and  in females UTI was present in 2 (2.4%) study subject and   this difference was not statistically significant (p>0.05). But on day 7 among the males UTI was present in 6 (5.2%) study subject and in females UTI was present in 11 (13.1%) study subject. So at 7th day UTI was present more in female compared to males gender and  this difference was statistically significant (p<0.05).Saleem et all 9 (2022) in their study found that the most common age group seen with CAUTI infection was 70–80 years (n = 21, 30%), followed by 60–70 years (n = 16, 23%), and 50–60 years (n = 12, 17%), with the least common age group being 30–40 years (n = 2, 3%). So as in our study higher age group was associated more with CAUTI. Significantly more male patients had CAUTI compared to female patients, with a ratio of 1.12. This finding was in contrast to our finding in which female were suffering more from CAUTI.

In this study most of the study subject i.e 76 (38%) presented with duration of symptoms of more than 15 days , 20 (10.0%) presented with symptoms less than 5 days, 57 (28.5%) presented with symptoms of 6 to 10 days and 47 (23.5%) presented with symptoms of 11 to 15 days. At 48 hr with duration symptoms 11-15 days UTI was present in 1 (2.1%) study subject and with duration symptoms more than15 days UTI was present in 3 (3.9%) study subject .So at 48hr the development of CAUTI was not related to duration of symptoms. (p>0.05) At 7th day with duration symptoms 11-15 days UTI was present in 6 (12.8%) study subject and  with duration symptoms more than15 days UTI was present in 11 (14.5%) study subjects. So CAUTI developed more in those study subject with more duration of symptoms and this difference was statistically significant. (p<0.05) Again as duration of catheterization increased from 2 days to 7 days the CAUTI increased from 4 (2.0%) to 17 (8.5%) patients. Saleem et all9 (2022) found that the majority of the patients with long-term indwelling urethral catheterization (IUC) had a significantly higher prevalence of CAUTI (37; 53%) than those with short-term IUC (13; 13%).

In this study 165 (82.5%) study subjects were in their normal mental status and rest 35 (17.5%) had impaired mental status. Total 140 (70%) study subjects were ambulatory and rest 60 (30%) were non ambulatory. At 48 hr UTI was absent in all 165 (100 %) study subjects with normal mental status  and among the subject with impaired mental status  UTI was present in 4 (11.4%) which depicted that at 48 hr  UTI was associated with impaired mental status and this difference was  statistically significant (p=0.001). At 7th day among the subject with normal mental status UTI was present in 4 (2.4%) and among the subject with impaired mental status UTI was present in 13 (37.1%) So UTI was again more associated with impaired mental status at 7th day and this difference was statistically significant (p<0.001).

In our study at 48 hr UTI was absent in all 140 (100 %) ambulatory subject study subjects and among the non ambulatory subject UTI was present in 4 (6.7%). So UTI was present more in non-ambulatory subject at 48 hr and this difference was statistically significant (p<0.05). Similarly at 7th day among the ambulatory subject UTI was present in 3 (2.1%) and among the non-ambulatory subject UTI was present in 14 (23.3%).So UTI was more in non-ambulatory patients at 7th day and this difference was statistically significant (p<0.001).Khullar et all8 (2022) in their study found that 16.84% patients with impaired level of consciousness developed CAUTI within 7 days of catheterisation as compared to 08.57% of alert patients. (P-value = 0.039) which signified that patients with impaired consciousness were 2.2 times more likely to develop CAUTI than alert patients with indwelling urethral catheter. This finding was similar to our findings. In which patients with impaired consciousness developed more CAUTI bot at 48 hr and at day 7 .

In this study, 74.5% of subjects had at least one co-morbidity, with hypertension (48.5%) being the most common, followed by diabetes (39.0%) and CKD (15.0%). At 48 hours and 7 days, UTI was absent in all subjects without co-morbidities, while its incidence was notably higher among those with CKD (10.0% at 48 hr, 30.0% at 7 days), CAD, hypertension, and diabetes. These findings indicate a strong association between CAUTI and the presence of co-morbid conditions, especially CKD. Bagchi et all10 (2015) also depicted the same finding that diabetes increases the chance of CAUTI

Catheter-associated urinary tract infection (CAUTI) is a significant healthcare issue influenced by various risk factors. Older age, female gender, and prolonged symptom duration were identified as key contributors to CAUTI development. The presence of co-morbid conditions such as chronic kidney disease (CKD), hypertension, coronary artery disease (CAD), and diabetes showed a stronger association with CAUTI. Additionally, patients with impaired mental status and those who were non-ambulatory exhibited a higher risk. Elevated serum creatinine levels and a history of prior catheterization further increased susceptibility. E. coli emerged as the most frequently isolated pathogen in culture. The findings underscore the need for restricted and judicious use of Foley’s catheter, with efforts to minimize its duration of use. Effective management of co-morbidities could significantly reduce the risk. Regular training for healthcare personnel, including doctors, on CAUTI prevention protocols is essential, and hospital administrations must prioritize CAUTI prevention as a key component of infection control programs.

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