COMPREHENSIVE ANALYSIS OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS: RISK FACTORS, MICROBIAL DYNAMICS, AND ANTIMICROBIAL CHALLENGES IN A TERTIARY CARE SETTING

Objective: Our objectives included investigating CAUTI incidence, exploring factors contributing to UTI risk, examining the correlation between bacteriuria and symptomatic CAUTI, and recording microbiological profiles and antibiotic sensitivities for insights into microbial dynamics and treatment strategies. Method: We aimed to assess patient and catheter-related factors influencing urinary tract infections (UTIs) in 105 catheterized patients. Results: Among the studied cohort, with an average age of 47.73 years, various catheter sizes were employed, and post-operative catheterization was the predominant indication. Microbial presence in urine samples was detected in 31.4% of cases, with a 21% prevalence of symptomatic UTIs. Diabetes mellitus showed a significant association with increased UTI occurrences (p=0.019). Notably, catheterization outside the operating theater (OT) and prolonged catheterization duration were significantly associated with increased infection rates (p=0.000 and p=0.003, respectively). Despite antibiotic treatment, Escherichia coli remained the most prevalent organism causing infection (17.1%), and antibiotic resistance trends were observed, highlighting the challenges of antimicrobial stewardship. Conclusion: The study emphasizes the importance of preventive measures, such as reducing catheterization duration and meticulous diabetes management, to mitigate the burden of CAUTIs. In conclusion, this study provides valuable insights into the prevalence, risk factors, and microbial dynamics of CAUTIs, urging a shift toward proactive prevention strategies and judicious antibiotic use to enhance patient outcomes and alleviate the strain on health-care resources.


INTRODUCTION
The utilization of indwelling urinary catheters is integral to various medical procedures [1].Catheter-associated urinary tract infection (CAUTI) stands as the most prevalent nosocomial infection globally, constituting approximately 30-40% of all institutionally acquired infections [2].Moreover, UTIs contribute to over 9.5% of infections reported by acute care hospitals [3].The Centers for Disease Control (CDC) define CAUTI as any urinary tract infection (UTI) occurring in a patient with an indwelling catheter in place at the time of or within 48 h before the onset of infection [1].CAUTI can manifest in various forms, ranging from asymptomatic bacteremic UTIs to symptomatic UTIs, potentially leading to genitourinary complications such as pyelonephritis, cystitis, prostatitis, epididymo-orchitis, and systemic complications such as vertebral osteomyelitis, septic arthritis, endocarditis, endophthalmitis, and meningitis.Notably, 3% of all catheterized patients develop bacteremia [4].According to the CDC, CAUTI increases morbidity and mortality by 2.8-fold, and the length of hospitalization is extended by 1-3 days [1].While antibiotics serve as the cornerstone for CAUTI treatment, the catheter's abiotic surface is prone to biofilm formation.In addition, antibiotic treatment can lead to collateral damage and alterations in the vaginal and gut microbiota [5].
The global concern over antibiotic resistance is evident in declarations made by the CDC in 2013, stating that the human race has entered a "post-antibiotic era," and the World Health Organization's warning in 2014 about the dire nature of the antibiotic resistance phenomenon [6,7].
In light of these challenges, this study was conducted to assess patient and catheter-related factors contributing to UTIs in catheterized patients.The aim is to mitigate the burden of hospital-acquired infections at Karnataka Institute of Medical Sciences (KIMS), Hubballi, a tertiary care hospital.

Aims and objectives
The objectives of the study are as follows: The gender distribution revealed that 67% of the participants were male, while 33% were female.Various catheter sizes, including 14 Fr, 16 Fr, 18 Fr, and 20 Fr, were utilized, with 14 Fr being the most frequently employed (48.57% in 51 cases).
Microbial presence in urine samples from catheterized patients was detected in 31.4% of cases.Specifically, 21% of the catheterized participants (22 out of 105) exhibited the coexistence of microorganisms in urine samples alongside symptoms such as fever, suprapubic, or loin pain.Consequently, the prevalence of symptomatic UTIs in catheterized patients within this study reached 21%.
These findings provide valuable insights into the demographic characteristics, catheter usage patterns, and prevalence of symptoms and microbial presence among catheterized individuals, contributing to our understanding of UTIs in this cohort.
The analysis of various factors related to UTI revealed significant associations.Specifically, the place of catheterization outside the operating theater (OT) exhibited a notably significant association (p=0.000)with increased infection rates.However, no significant associations were found between infection and other monitored variables, including output monitoring (p=0.084),acute urinary retention (p=0.558),urinary incontinence (p=0.592), and post-operative status (p=0.345).In addition, catheter size did not show a significant association with UTI (p=0.436).
The distribution of cases without detectable organisms in urine was higher in the 2-4 days catheterization group, comprising 62 cases, compared to the >4 days catheterization group, which had 10 cases.
Conversely, the presence of organisms in urine was more prevalent in the >4 days catheterization group, with 13 cases, compared to the 2-4 days catheterization group, which had 20 cases.This observed association indicates a significant relationship between the duration of catheterization and the presence of organisms in urine, including bacteriuria and CAUTIs (p=0.003).
Another Chi-square analysis was conducted to explore the association between the duration of catheterization and the presence or absence of fever.The results revealed no statistically significant association between these variables (p=0.345).
The presence of symptoms, such as fever, suprapubic or loin pain, and irritative LUTS, exhibited a statistically significant association (p=0.012)with the growth of organisms in the analysis of variables related to organisms in the sample.Specifically, cases where these symptoms were present showed a higher incidence of organism growth compared to cases where these symptoms were absent.
Out of the 105 patients, 11 individuals (10.47%) had microbial growth in their urine, with Escherichia coli being the most common organism.Interestingly, these patients did not exhibit symptoms such as fever, flank pain, or LUTS.Among the study subjects, the most prevalent organism causing infection was E. coli (17.1%, 18 cases), followed by Klebsiella (7.6%, 8 cases).
Among the antibiotics studied, piperacillin and tazobactam showed sensitivity in 20 cases (62.5%) and resistance in 12 cases (37.5%) against the microorganisms present in the urine samples.Similarly, amikacin exhibited sensitivity in 19 cases (59.4%) and resistance in 13 cases (40.6%).These findings suggest that piperacillin and tazobactam, as well as amikacin, displayed higher sensitivity compared to ciprofloxacin, which showed sensitivity in 10 cases (31.3%) and resistance in 22 cases (68.8%).Furthermore, nitrofurantoin exhibited sensitivity in 11 cases (34.4%) and resistance in 2 cases (6.3%) against the microorganisms found in the urine samples.

DISCUSSION
Indwelling urinary catheters have become a routine aspect of care for many urological patients.However, like any medical intervention, the

Microorganism (n) Antibiotic
Pipzo  [12][13][14].Factors such as prolonged catheterization, gender, diabetes, advancing age, and catheter care violations were found to increase the risk.Our study similarly found a statistically significant association (p=0.019) between the presence of diabetes mellitus and increased UTI occurrences.Diabetics consistently showed an elevated risk of CAUTI across various studies, potentially attributed to increased colonization of microorganisms in the perineum and urine, as well as altered host immunity, though further investigation is needed [15,16].
No significant associations were observed between UTI and gender (p=0.214),HTN (p=0.198),TB (p=0.967), or COPD (p=0.967) in our study.However, the place of catheterization outside the sterile confines of the operating room exhibited a notably significant association (p=0.000)with increased infection rates.Furthermore, the duration of catheterization emerged as a significant risk factor (p=0.003), indicating a relationship between prolonged catheterization and bacteriuria/ CAUTI.This aligns with findings from a comprehensive study by Maki and Tambyah, indicating that longer catheterization durations increase the likelihood of ascending infections (OR 5.2).
Catheter size did not show a significant association with UTI (p=0.436),consistent with literature findings.
The predominant organisms causing infection in our study were E. coli (18 cases, 17.1%) and Klebsiella (8 cases, 7.6%), mirroring findings in other studies.We sought to evaluate the sensitivity and resistance of uropathogens to commonly available antibiotics at KIMS, Hubballi.However, the results indicated resistance trends, with ciprofloxacin and nitrofurantoin showing limited sensitivity, potentially linked to the overarching issue of over-treatment of CAABU with antibiotics, use of over-the-counter drugs, and the universal occurrence of biofilm formation on catheter surfaces in the urinary tract.
Biofilms, structured communities of microorganisms within a selfdeveloped polymeric matrix adherent to a surface, contribute to bacteriuria becoming prevalent in long-term catheterization cases.Antimicrobial exposure in patients with indwelling urinary catheters often leads to antimicrobial-resistant bacteria isolation, with E. coli strains persisting due to the presence of Type 1 pili and the Tamm-Horsfall protein.Catheter care violations emerged as a significant risk factor in our study, consistent with findings from studies by Maki and Tambyah [17] and Tenke et al. [18].
In conclusion, the study sheds light on the prevalence and risk factors associated with CAUTI, emphasizing the importance of judicious antibiotic use and catheter care practices in managing UTIs among catheterized patients.

CONCLUSION
The presence of an indwelling catheter poses an elevated risk of infection to the urinary system, with the majority of patients developing CAUTI within seven days of catheterization.The increased and inappropriate use of antibiotics further heightens the risk of infections from antibiotic-resistant organisms.Instead of focusing on treating CAUTI after it occurs, the primary objective for every appropriately catheterized patient should be CAUTI prevention.This is particularly crucial in developing nations like ours, where understanding the significant risk factors contributing to CAUTI development can alleviate additional strain on the healthcare system.
The study's findings underscore key preventive measures, including reducing the duration of catheterization, vigilant management of diabetes, and adopting hygienic precautions during indwelling catheter insertion and maintenance, all contributing to CAUTI avoidance.
Consistent adherence to the CDC's definitions of CAUTI is imperative to ensure comparable results for future research.It is essential to assess numerous recommendations and research endeavors aimed at preventing UTIs associated with catheter use.Future studies should explore the role of antibiotic prophylaxis, the instillation of antibiotics and other agents in drainage bags, and the use of various perineal care agents.
Ultimately, the focus should be on identifying, disseminating, and implementing effective methods to prevent or reduce the occurrence of UTIs related to catheter use.This approach is critical for enhancing patient outcomes and minimizing the burden on health-care resources.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE
Ethical approval for conducting the study was obtained from the KIMS, Hubballi.Written informed consent was obtained from the patient for her participation in the study.

CONSENT FOR PUBLICATION
The patient's informed consent has been acquired for the publication of the case details, clinical images, and relevant medical information.
All efforts have been made to ensure patient confidentiality, and any identifying information has been appropriately anonymized.

Pharm Clin Res, Vol 17, Issue 3, 2024, 88-91 Jadhav et al.
Various studies, including those by Platt et al.Shapiro et al. and Johnson et al., have identified risk factors significantly associated with CAUTI