Incidence and variation of microbiological profile of catheter-associated urinary tract infection in precise comorbidities associated with tribal sickle cell anemic patients of medical intensive care unit in a tribal tertiary care center

Monalisa Subudhi; PA T. Jagatheeswary; Susanta Kumar Sahu; Sudhanshu Kumar Das; KB Subudhi; Rashmi Ranjan Rout

doi:10.4103/joah.joah_184_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 12 | Issue : 3 | Page : 140-146

Incidence and variation of microbiological profile of catheter-associated urinary tract infection in precise comorbidities associated with tribal sickle cell anemic patients of medical intensive care unit in a tribal tertiary care center

Monalisa Subudhi¹, PA T. Jagatheeswary², Susanta Kumar Sahu³, Sudhanshu Kumar Das⁴, KB Subudhi⁵, Rashmi Ranjan Rout³
¹ Departments of Microbiology, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India
² Department of Microbiology, Saveetha Institute of Medical and Technical Science, Chennai, Tamil Nadu, India
³ Department of Microbiology, SLN Medical College, Koraput, Odisha, India
⁴ Pediatrics, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India
⁵ O and G, Gayatri Vidya Parishad Institute of Health Care and Medical Technology, Visakhapatnam, Andhra Pradesh, India

Date of Submission	28-Sep-2020
Date of Decision	16-Jan-2021
Date of Acceptance	06-Mar-2021
Date of Web Publication	21-Oct-2021

Correspondence Address:
Monalisa Subudhi
Department of Microbiology, Gayatri Vidya Parishad Institute of Health Care & Medical Technology, Visakhapatnam, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/joah.joah_184_20

Abstract

INTRODUCTION: Sickle cell anemia is a genetic hereditary disorder, with multifactorial cause for increase susceptibility, to bacterial infection leading to more intensive care unit (ICU) admission, morbidity, and mortality. When it is superadded by morbidities such as Type 2 diabetes mellitus (DM), chronic kidney disease (CKD), and chronic heart disease (CHD), chances of morbidity and mortality will increase multiple times in the ICU.
AIM: The aim of this study was to find out the incidence, variation, and load in the microbiological profile of catheter-associated urinary tract infection (CAUTI), depending on the comorbidities associated with these sickle cell anemic tribal patients in the medical ICU (MICU) of a tribal tertiary care center.
MATERIALS AND METHODS: This prospective study was conducted in MICU of a tribal tertiary care center from March 2019 to February 2020. It included diagnosed sickle cell anemic tribal patients with microbiologically confirmed cases of CAUTI following urinary catheterization for more than 48 h in the MICU. Demographic and clinical data of these patients were collected. Detailed investigations of the patients with antimicrobial susceptibility and resistance pattern of isolates were collected.
RESULTS: In our study, the DAI rate in tribal sickle cell anemic patients was 8.7 per 1000 device days with an incidence of 7.8%. CAUTI was more common in female sex (86.7%), low socioeconomic status (80%), duration of urinary catheter up to first 7 days (66.7%), and age group above 40–60 years (33.3%). The most commonly associated microorganism was Staphylococcus aureus (46.6%) followed by Escherichia coli (13.3%) and Pseudomonas aeruginosa (13.3%). Associated comorbidities were Type 2 DM (20%), cerebrovascular accident (CVA) (20%), ST-segment elevation myocardial infarction (STEMI) (13.3%), CKD (13.3%), and CHD (6.6%). S. aureus 7 (46.6%) and Klebsiella pneumoniae 1 (6.6%) were found in Type 2 DM, Streptococcus pneumoniae 1 (50%) in STEMI, E. coli 2 (13.3%) in CKD and CVA, P. aeruginosa in 1 (6.6%) case each with CVA and septic shock, and Acinetobacter baumannii in 1 (6.6%) case with epilepsy. Resistant antibiotic was ceftriaxone 28.4% to S. aureus and 100% to E. coli.
CONCLUSION: Our analysis precisely of this tribal population brings several important and unique findings, which will aid in the development of some new or update guidelines for the prevention of CAUTI to reduce morbidity and mortality in the MICU of a tribal tertiary care center.

Keywords: Catheter-associated urinary tract infection, cerebrovascular accident, chronic heart disease, chronic kidney disease, coronary artery disease, diabetes mellitus, medical intensive care unit, National Healthcare Safety Network, sickle cell anemia, ST-segment elevation myocardial infarction

How to cite this article:
Subudhi M, T. Jagatheeswary P A, Sahu SK, Das SK, Subudhi K B, Rout RR. Incidence and variation of microbiological profile of catheter-associated urinary tract infection in precise comorbidities associated with tribal sickle cell anemic patients of medical intensive care unit in a tribal tertiary care center. J Appl Hematol 2021;12:140-6

How to cite this URL:
Subudhi M, T. Jagatheeswary P A, Sahu SK, Das SK, Subudhi K B, Rout RR. Incidence and variation of microbiological profile of catheter-associated urinary tract infection in precise comorbidities associated with tribal sickle cell anemic patients of medical intensive care unit in a tribal tertiary care center. J Appl Hematol [serial online] 2021 [cited 2023 Jun 4];12:140-6. Available from: https://www.jahjournal.org/text.asp?2021/12/3/140/328717

Introduction

Urinary tract infection (UTI) is an infection of the urinary system, involving kidney, ureter, bladder, or urethra.^[1] It is a common health-care-associated infection (HAI) accounting for 30%–50% of HAIs and comprising 8%–21% of all HAIs in intensive care units (ICUs).^[2],[3] The incidence of UTIs in patients with indwelling catheters in the hospital is approximately 15%.^[4] The definition of catheter-associated urinary tract infection (CA-UTI), as per the Centers for Disease Control and Prevention, indwelling catheter must be in place for >2 calendar days on the date of event, with at least one of the following clinical features such as fever (>38°C), frequency, urgency, suprapubic tenderness, dysuria, and a positive urine culture of a bacterium ≥10⁵ colony-forming unit (CFU)/ml.^[5]

Sickle cell anemia (SCA) is an inherited autosomal recessive genetic red blood cell disorder.^[6] It is characterized primarily by chronic anemia, periodic episodes of pain crisis, and with fatal complications such as pulmonary hypertension, stroke, organ dysfunction (kidney, liver, and spleen), osteomalacia, and leg ulcers.^{[7],[8],[9],[10]} The leading causes of death in SCA are infection, pain crisis, acute chest syndrome, and stroke.^[10] The common microorganisms involved are Staphylococcus and Escherichia coli.^[6]

Because of unawareness, lack of health consciousness, poor hygiene practice, and living style, tribal people are more prone to infection than people of urban and rural areas, leading to more ICU admission, morbidity, and mortality. Furthermore, SCA is a condition where the cause of increased susceptibility to bacterial infection is multifactorial including defect in compliment activation, functional asplenia, and micronutrient deficiencies.^[11] Again when it is superadded by morbidities such as Type 2 diabetes mellitus (DM), chronic kidney disease (CKD), and chronic heart disease (CHD), chances of morbidity and mortality will increase multiple times in the ICU. The common nosocomial infection in the medical intensive care unit (MICU) is CAUTI. It is a definite important precipitating factor for development of vaso-occlusive crisis in SCA. As our hospital is a tribal tertiary care center and the SCA cases are more, as compared to other genetic diseases found in this population, we decided to do a study on sickle cell anemic tribal patients. During our study, we found that there is a variation in pathogen and their profile depending on the comorbidities associated with these people.

Here, we tried to explore the incidence of CAUTI and variation and load in the microbiological profile of CAUTI, depending on the comorbidities associated with these sickle cell anemic tribal patients, during their MICU stay, so that preventive strategies should be planned such as antibiotic policy, protocol for using device, and health awareness in the MICU to prevent CAUTI, to give quality health care, and reduce morbidity and mortality in sickle cell anemic tribal patients, in the ICU of any hospital in a tribal area.

Materials and Methods

Study design

This prospective study of CAUTI in Tribal patients with SCA was conducted in the medicine ICU of a tribal tertiary care center from March 2019 to February 2020 with the approval of the institutional ethical committee.

Inclusion criteria

(1) MICU patients aged ≥18 years with diagnosed case of SCA; (2) all MICU patients with transurethral indwelling catheter for >48 h; (3) patients who are willing to give an admission urine sample following catheterization for culture and sensitivity to rule out preexisting UTI; (4) patients having symptoms with microbiological confirmation of CAUTI; (5) patients with comorbidities as Type 2 diabetes, CHD, CKD, ST-segment elevation myocardial infarction (STEMI), and cerebrovascular accident (CVA); and (6) those who are willing and signed the consent form of the study.

Exclusion criteria

(1) Patients with preexisting UTI, (2) presence of signs and symptoms of CAUTI within 2 calendar days of catheterization, (3) patients who used antibiotics more than 2 weeks before the time of the study, and (4) patients without comorbidities.

Study population

The study population was all adult aged ≥18 years tribal patients ,with diagnosed cases of SCA, admitted to MICU with different complaints,undergone catheterisation with an indwelling urinary Foley's catheter more than 48 h developed features of symptomatic UTI,were included in the study.

Sample collection

Under all aseptic condition, urine sample was collected with a sterile syringe from the sampling port of indwelling urinary catheter, and the catheter was also removed. The distal 5 cm of the aseptically removed catheter was cut and sent to the microbiology department for routine microscopic examination and culture sensitivity test. Infection surveillance and consent form with necessary details were filled up simultaneously. Urine culture showing equal or more than 10⁵ CFUs per ml with one or two microorganisms isolated was considered as a confirmation of UTI. Standard culture methods MacConkey's agar and cysteine-lactose-electrolyte-deficient agar were used to identify the microorganism. Susceptibility of antimicrobials was done by the disk diffusion method on isolates.

Data collection

The demographic and clinical data of patients as age, gender, socioeconomic status, area, admission date, indication and duration of catheterization, risk factors, length of ICU stay, previous antibiotic use, and severity of illness were collected. The comorbidities such as presence of Type 2 DM, hypertension, coronary artery disease (CAD), CHD, CKD, CVA, and septic shock due to cerebral malaria and meningitis were assessed. Empirically, antibiotics were started. Consent from enrolled patients was taken. Detailed investigations of the patients were taken. Culture and sensitivity and antimicrobial susceptibility and resistance pattern of isolates were collected.

Statistical analysis

Microsoft Excel was used for data entry and analyzed with SPSS software version 20.0. For quantitative variable, median and, for qualitative variable, frequency (percentage) were used to present the results.

Results

The study was conducted in a 20-bedded medicine ICU over a period of 1 year from April 2019 to March 2020 in a tribal tertiary care center. Total 190 patients were exposed to indwelling urinary catheter device for a total duration of 1712 device days and treated for an aggregated duration of 2772 days with different complaints in the MICU. The device utilization rate was 0. 61. Out of 190 catheterized patients, 46 (24.2%) were diagnosed microbiologically as CAUTI with an incidence of 24.2%, and the device-associated infection rate was 26.8/1000 days. Of these, 15 individuals were tribal CAUTI patients with SCA. The DAI rate in these 15 tribal sickle cell anemic patients was 8.7 per 1000 device days with an incidence of 7.8% [Table 1].

Table 1: Incidence of catheter-associated urinary tract infection in the study

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The study group was more common in the age group of >40–60 years in 5 cases (33.3%), followed by the age group of up to 20 years in 4 cases (26.7%). Female sex was more common in 13 cases (86.7%) as compared to male sex in 2 cases (13.3%). People of low socioeconomic status were most affected in 12 cases (80%) than people of medium socioeconomic status in 3 cases (20%) [Table 2].

Table 2: Distribution sickle cell anemia patients according to sex, age, area, and socioeconomic status

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In majority of cases, the duration of urinary catheter used in patients up to first 7 days was in 10 cases (66.7%), whereas in >7–14 days of catheter use, 3 (20%) cases were present [Table 3]. In 2 (13.3%) cases, catheters were used for more than 14 days [Table 3].

Table 3: Distribution of cases according to duration of urinary catheterization in tribal sickle cell anemic patients

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The tribal patients with SCA developed CAUTI due to single organism in 9 (60%) cases and due to mixed infection by two organisms in 6 (40%) cases [Table 4].

Table 4: Distribution of cases according to type of infection in tribal sickle cell anemic patients

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One study where we found the incidence of CAUTI was 29.3% in patients other than sickle cell patients. The more common risk factors were tribal people (71.7%), female (67.4%), low socioeconomic people (67.4%), catheter stays >7–14 days (47.8%), age of people >40–60 years (41.3%), and Type 2 diabetes (26.1%). Associated bacteremia was 58.7%. The most common microorganisms responsible were Staphylococcus aureus (30.4%), E. coli (26%), Candida albicans (19.6%), Klebsiella (10.9%), Streptococcus (8.7%), and Pseudomonas (4.4%). There were bacterial etiology in 80.4% of cases and Candida etiology in 19.6% of cases.

In our study, we not only identified single but also mixed infections due to more than one organism in tribal patients with SCA in our MICU. S. aureus 7 (46.6%) was the most common single organism infection found in tribal patients with SCA followed by E. coli in 2 (13.3%) and Pseudomonas aeruginosa in 2 (13.3%) and C. albicans in 1 (6.6%) case, whereas mixed infection with two organisms was associated with the pathogens C. albicans in 3 (50%), E. coli in 2 (33.3%), and Klebsiella pneumoniae in 1 (16.6%) case [Table 5].

Table 5: Distribution of pathogens in sickle cell anemic tribal patients

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The commonly associated morbidities in sickle cell anemic tribal patients were Type 2 DM in 3 (20%) cases, cardiovascular accident in 3 (20%) cases, STEMI in 2 (13.3%) cases, CKD in 2 (13.3%) cases, and septic shock due to meningitis and cerebral malaria in 2 (13.3%) cases [Table 6].

Table 6: Distribution of cases according to morbidities in sickle cell anemic patients

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In our study, S. aureus 7 (46.6%) were found in Type 2 DM, ST-elevated MI, CKD, CVA, sickle pain crisis, septic shock (malaria/meningitis), and CHD type of morbidities in these patients. Streptococcus pneumoniae in 1 (50%) case was detected only in ST-elevated MI. E. coli 2 (13.3%) were identified as infection of single organism in CKD and CVA and in 2 (33.3%) cases as mixed infection of two organisms in Type 2 DM and septic shock (malaria and meningitis). K. pneumoniae in 1 (6.6%) case were identified as single infection in Type 2 DM and 1 (16.6%) as mixed infection in septic shock (malaria and meningitis). P. aeruginosa was associated in 1 (6.6%) case each with CVA and septic shock (malaria and meningitis). Acinetobacter baumannii in 1 (6.6%) case as single infection was associated with epilepsy. One case of C. albicans was found as single infection in Type 2 DM and as mixed infection in 3 (50%) cases in CKD, sickle pain crisis, and epilepsy [Table 7].

Table 7: Distribution of pathogens according to morbidities in sickle cell anemia patients

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The resistant antimicrobial pattern to bacteria in CAUTI were ceftriaxone 2 (28.4%) to S. aureus, ceftriaxone and cefixime each 2 (100%) to E. coli, cefepime and cefixime each 1 (100%) to K. pneumoniae, cefixime, amoxicillin, and gentamicin each 1 (100%) to S. pneumoniae, cefepime and cefoperazone-sulbactam each 1 (50%) to P. aeruginosa, cefuroxime, amikacin, and imipenem became each 100% to A. baumannii]. Hence, the common resistant antimicrobials in Gram-positive cocci were gentamicin, cefixime, and amoxicillin. Vancomycin resistance developed in only one (14.2%) case of S. aureus. The Gram-negative bacillus isolates were resistant to cefepime, ceftriaxone, and cefixime where cefepime was common to all except in A. baumannii and ceftriaxone to P. aeruginosa [Table 8].

Table 8: Distribution of bacterial isolates according to their antimicrobial resistance pattern

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Discussion

The National Healthcare Safety Network (NHSN) reported that UTIs are the most common type of HAI. In hospitals, approximately 75% of acquired UTIs are associated with an indwelling urinary catheter. Transurethral urinary catheter is the important definite risk factor in causation of infection in many complications of SCA. In our study, the incidence of CAUTI in total was 24.2% and in tribal patients with SCA was 7.8%. This finding was less in comparison to Omer et al. study where it was 22.55%.^[12] In their study, they considered patients from both ward and ICU, so their incidence was high because of large sample size as compared to our study in MICU only.

The DAI rate in our study due to indwelling urinary catheters in total patients with CAUTI was 26.8/1000 and in tribal patients with SCA was 8.7/1000 catheter days. Our findings were more than 6.8 CA-UTI per 1000 device days in one study by Vonberg et al.^[13]

In our study, female sex was mostly involved in 86.7% of cases, almost similar to other studies.^[14] Patients of low socioeconomic status 12 (80%) were common than other groups. Cases with transurethral catheter of up to first 7 days were 10 (66.7%). It showed that how much these tribal patients with SCA were prone to infection. We propose the use of antimicrobial urinary catheters and/or new female external catheter technology to reduce infection.

In our study, we not only identified single but also mixed infections due to more than one organism in tribal patients associated with SCA in our MICU. The microbiological trend in our tribal sickle cell anemic patients are S. aureus 7 (53.8%) the most common pathogen followed by E. coli and P. aeruginosa, each in 2 (13.3%) cases as single infection. C. albicans 4 (25%) were the most common organism responsible for mixed infection.

The most frequent pathogens associated with CAUTI as per NHSN statistics 2006–2007, were E. coli (21.4%), Candida spp. (21.0%), Enterococcus spp. (14.9%), P. aeruginosa (10.0%), K. pneumoniae (7.7%), and Enterobacter spp. (4.1%).^[15] This microbiological trend of CAUTI was different in our study, where S. aureus 7 (46.6%) was commonly followed by E. coli 2 (13.3%), P. aeruginosa 2 (4.3%), C. albicans 1 (6.6%), K. pneumoniae 1 (6.6%), CONS 1 (6.6%), S. pneumoniae 1 (6.6%), and A. baumannii 1 (6.6%) in order of frequency, in tribal people with SCA. We did not identify any Enterococcus spp. or Enterobacter spp. in our study. A. baumannii, a Gram-negative isolate, was recovered in our study, which was not in NHSN statistics list. One study conducted in India by Pramodhini et al.,^[16] where they found 70% of isolates were E. coli, whereas, in our study, S. aureus was 50%.

The commonly associated morbidities in sickle cell anemic tribal patients were Type 2 DM in 3 (20%) cases, cardiovascular accident in 3 (20%) cases, STEMI in 2 (13.3%) cases, CKD in 2 (13.3%) cases, and septic shock due to meningitis and cerebral malaria in 2 (13.3%) cases.

In the present study, the pathogens identified in comorbidity Type 2 DM were S. aureus 1 (33.3%), K. pneumoniae 1 (33.3%), and C. albicans 1 (33.3%). Shah et al.,^[17] in their study, concluded that the most common uropathogen identified from the urine of DM patients was E. coli followed by K. pneumoniae. According to Pargavi et al.,^[18] E. coli (56%), K. pneumoniae (35%), and Proteus mirabilis (85%) were the most common uropathogens found in diabetic patients. In STEMI, the pathogens were S. aureus 1 (50%) and S. pneumoniae 1 (50%). Sims et al.^[19] conducted one study, where they found that UTI was three times more common in patients with acute coronary syndrome. In case of CKD, the microorganisms were S. aureus 1 (50%) and E. coli 1 (50%), whereas in some studies, E. coli was the most common pathogen for both outpatients and hospitalized patients,^[20],[21] and in one study, P. aeruginosa was found in association with chronic Foley catheter use or with complicated UTI.^[22] S. aureus was found in 1 case each in sickle pain crisis, septic shock (malaria/meningitis), and CHD type of morbidities. A. baumannii in 1 (6.6%) case as single infection was associated with epilepsy. In some studies, it was found that UTIs occur frequently after stroke (CVA) and are associated with poor neurological outcome^[23] and death or disability at 3 months.^[24],[25] The pathogens identified in our study were S. aureus 1 (50%) and E. coli 1 (50%) and P. aeruginosa 1 (50%).

Hsiao et al.,^[26] in their study, reported the percentages of septic shock in comorbidities as Type 2 DM (32.5%), hypertension, CHF (12.5%), CAD (13.8%), CKD (13.8%), liver cirrhosis (5%), CVA (30.0%), and indwelling urinary tract catheter (10%) in UTI.

Ceftriaxone was the most common (38.8%) initial drug given at the onset of treatment, followed by piperacillin-tazobactam (16.7%). The most common resistant antimicrobials were ceftriaxone 2 (28.4%) to S. aureus, ceftriaxone and cefixime each 2 (100%) to E. coli, cefepime and cefixime each 1 (100%) to K. pneumoniae, cefixime, amoxicillin, and gentamicin each 1 (100%) to S. pneumoniae, cefepime and cefoperazone-sulbactam each 1 (50%) to P. aeruginosa, cefuroxime, amikacin, and imipenem became each 100% to A. baumannii.

Preventive strategy

Because Foley catheters have an established link to UTI, some preventive strategies, even if not studied more on them, can be considered as antiseptic-coated catheters, antibiotic-impregnated catheters, condom catheters, and appropriate catheter use to reduce CAUTI in MICU.^{[27],[28],[29],[30]}

Limitation

Some limitations of our study were as follows: first, we started a common antibiotic empirically for all cases without any policy. Second, we had not tested the resistance pattern for C. albicans. Third, our study was done in ICU only.

Conclusion

Our analysis precisely of these superadded comorbidities associated with sickle cell anemic tribal population brings several important and unique findings, which will aid in the development of some new or update guidelines for the prevention of CAUTI in the MICU of a tribal tertiary care center. With the knowledge of antibiotic resistance pattern of these pathogens, new antibiotic policy will be developed to reduce empirically use of antibiotics and thereby reduce the length of ICU stay, morbidity, and mortality in these tribal sickle cell anemic patients in the MICU of a tribal tertiary care center.

Recommendation

More surveillance study on CAUTI over these tribal sickle cell anemic patients with large sample size over a long time period was recommended to reach a solid guideline with antibiotic policy in MICU of a tribal tertiary care center.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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