RESEARCH ARTICLE

Current status of indwelling urinary catheter

utilization and catheter-associated urinary
tract infection throughout hospital wards in
Korea: A multicenter prospective
observational study
Bongyoung Kim1, Hyunjoo Pai2, Won Suk Choi3, Yeonjae Kim4, Ki Tae Kweon5, Hyun
a1111111111
Ah Kim6, Seong Yeol Ryu6, Seong-heon Wie7, Jieun Kim2*
a1111111111
a1111111111 1 Department of Internal Medicine, Eulji University College of Medicine, Daejeon, Korea, 2 Department of
a1111111111 Internal Medicine, Hanyang University College of Medicine, Seoul, Korea, 3 Department of Internal Medicine,
a1111111111 Korea University College of Medicine, Ansan, Korea, 4 Department of Infectious Disease, National Medical
Center, Seoul, Korea, 5 Department of Infectious Disease, Patima Hospital, Daegu, Korea, 6 Department of
Internal Medicine, Gyemyeong University College of Medicine, Daegu, Korea, 7 Department of Internal
Medicine, St. Vincent Hospital, Suwon, Korea

* quidam76@hanyang.ac.kr
OPEN ACCESS

Citation: Kim B, Pai H, Choi WS, Kim Y, Kweon KT,

Kim HA, et al. (2017) Current status of indwelling Abstract
urinary catheter utilization and catheter-associated
urinary tract infection throughout hospital wards in To evaluate the frequency and appropriateness of indwelling urinary catheters (IUC) use
Korea: A multicenter prospective observational
and the incidence of catheter-associated urinary tract infections (CA-UTI), and explore the
study. PLoS ONE 12(10): e0185369. https://doi.
org/10.1371/journal.pone.0185369 risk factors for CA-UTI in hospitals as a whole, we conducted a study. This study was
divided into two parts; a point-prevalence study on Dec 12th 2012 and a prospective cohort
Editor: Steven J. Drews, University of Calgary,
CANADA study from Dec 13th 2012 to Jan 9th 2013 were performed in six hospitals in Korea. All hospi-
talized patients with newly-placed IUCs were enrolled and monitored weekly for 28 days
Received: February 21, 2017
after IUC placement. In the point-prevalence study, the IUCs were present in median 14.9/
Accepted: September 12, 2017
100 hospitalized patients (1Q 14, 3Q 16) across the six hospitals. In the prospective cohort
Published: October 9, 2017 study, the median IUC-days per patient was 5 (1Q 3, 3Q 10) and the median CA-UTI preva-
Copyright: © 2017 Kim et al. This is an open lence per 1,000 catheter days was 1.9 (1Q 0.7, 3Q 3.8) with significant inter-hospital varia-
access article distributed under the terms of the tion. The proportion of patients with inappropriate IUC maintenance increased with number
Creative Commons Attribution License, which
of IUC-days (8.5% on day 7, 9.4% on day 14, 16.3% on day 21, and 23.1% on day 28). Uri-
permits unrestricted use, distribution, and
reproduction in any medium, provided the original nary output monitoring (23/36, 63.9%) was the most common indication for inappropriate
author and source are credited. use after 1 week of ICU placement. In multivariate analysis, IUC-days was significantly
Data Availability Statement: All relevant data are associated with the development of CA-UTI (odds ratio 1.122, 95% confidence interval
within the paper and its Supporting Information 1.074–1.173, P< 0.001). IUC-days and CA-UTI rates vary between hospitals. IUC-days is a
files.
risk factor for CA-UTI, and is correlated with inappropriate use.
Funding: This work was supported by the research
fund of Hanyang University (HY-2013). The
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
the manuscript.

Competing interests: The authors have declared

that no competing interests exist.

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 Indwelling urinary catheter use and CA-UTI

Introduction
Catheter-associated urinary tract infection (CA-UTI) is the most common nosocomial infec-
tion, accounting for up to 10–70% of all nosocomial infections especially in intensive care unit
(ICU) setting [1–3]. Approximately 3–7% of catheterized patients acquire a new infectious
organism per day, and the prevalence of bacteriuria approaches 100% by 30 days after catheter-
ization [4]. Symptomatic CA-UTI develops in 24% of patients with bacteriuria, and bacteremia
from CA-UTI develops in 3.6% of patients [5]. These complications of indwelling urinary
catheters (IUC) are associated with considerable morbidity, prolonged hospitalization, and
increased health care expenditure [6]. In one study, CA-UTI patients incurred a mean of $589
(median $356) of extra costs per patient for diagnostic tests and medication [7]. Hence, strate-
gies to prevent CA-UTI have been emphasized in many countries and hospitals.
The current guideline for prevention of CA-UTI recommends to minimize duration for
catheterization and maintain sterile technique for insertion and keep closed drainage system
[8]. Accordingly, each physician should insert catheters only for appropriate indications and
leave in place only as long as needed [9]. Implement records of indication for insertion, date of
catheter insertion, and daily presence of a catheter maintenance also prevent CA-UTI. Fur-
thermore, a systematic review found that the CA-UTI rate was reduced by 52% with use of a
reminder or stop order which prompt IUC removal [10].
Estimating the current status of IUC utilization and the burden of CA-UTI is indispensable
for developing and evaluating strategies for its prevention and control of CA-UTI. Identifying
risk factors is also important for identifying priority group for intervention. Most studies of
CA-UTI have focused on the intensive care unit (ICU) population. In Korea, data on CA-UTI
acquired in ICUs has been collected through the Korean National healthcare-associated Infec-
tions Surveillance System (KONIS) since 2006 [2]. However, there have been few studies of
IUC use, CA-UTI rates and risk factors for CA-UTI in the general wards of Korean hospitals.
This study aimed to assess the frequency and appropriateness of IUC use and the incidence
of CA-UTI, and to explore risk factors associated with CA-UTI among patients with IUCs
throughout the wards of hospitals.

Materials and methods

Study design and setting
Six hospitals with 543–791 beds participated in the study. They were: Hanyang University
Seoul Hospital (758 beds), Korea University Ansan Hospital (543 beds), Daegu Patima Hospi-
tal (657 beds), Keimyung University Dongsan Hospital (783 beds), St. Vincent’s Hospital (791
beds), and Hanyang University Guri Hospital (578 beds).

Point-prevalence study
On December 12th, 2012, researchers in each hospital collected information on the total num-
ber of hospitalized patients, the number of patients with IUCs and the number with CA-UTI
in all the wards of each hospital. There was no missing data for point-prevalence study.

Prospective cohort study

Patient population. Between December 13th, 2012 and January 9th, 2013, all hospitalized
patients with newly- placed IUCs were enrolled. Patients were excluded if they: (1) were under
18 years old, (2) died, were discharged, or were transferred to other medical institutions within
48 hours of IUC placement, and (3) received the IUC within 48 hours of the removal of a pre-
vious UC.

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 Indwelling urinary catheter use and CA-UTI

Data collection. The following information was collected at enrollment: demographic fea-
tures (age and gender), use of other instruments (central venous catheter, nasogastric tube,
endotracheal tube, or ventilator), operation history location (brain, spine, knee, stomach, or
colon) within the previous month, and underlying co-morbidities included hypertension,
ischemic heart disease, congestive heart disease, asthma, chronic obstructive pulmonary dis-
ease, hemodialysis, liver cirrhosis, cerebrovascular accident, malignancy, diabetes with/without
complications, and status of chronic kidney disease (mild/moderate/severe).
Thereafter follow-up monitoring was conducted weekly for day 28 (days 7, 14, 21, and 28
from the day of IUC placement). We assessed whether the IUCs were placed and maintained
appropriately, and checked for the development of CA-UTI. If patients were discharged or
transferred to other hospital with maintained IUCs, we regarded as dropped out of observa-
tion. Remained patients with IUCs were categorized with maintained or removed IUCs group.
The date of IUC removal was collected in order to calculate IUC-days.
The purpose of IUC placement was recorded by healthcare personnel on the day of inser-
tion and every follow-up monitoring day; multiple answers were allowed. Appropriate indica-
tions for IUC placement were: to relieve acute urinary retention, to measure urinary output
accurately in critically-ill patient, to manage perioperative conditions, to assist in healing of
open sacral or perineal wounds in incontinent patient, to improve comfort in end-of-life care,
and to support prolonged immobilization [8]. The adequacy of catheter maintenance was eval-
uated by an infectious diseases (ID) specialist: use was considered "inappropriate" when the ID
specialist considered it was not justified by any of the above criteria.
When CA-UTI was diagnosed during follow-up, we collected information about the causa-
tive organism. If there were more than two episodes of CA-UTI in a single patient, only the
first episode was included.

Definitions related to IUC and CA-UTI

Urinary catheterization was defined as insertion of a Foley catheter through the urethra. The
urinary catheter utilization ratio was defined as the number of urinary catheter days divided
by the number of patient days. Point-prevalence was defined as the frequency of all current
events on December 12th, 2012 [11]. In terms of duration of IUC placement, we counted 28
days of IUC use as 28 days.
CA-UTI was defined as follows among all patients with IUCs, including those whose uri-
nary catheters were removed within 48 hours: presence of at least one of the following signs or
symptoms that could not be explained by other causes (fever 38.0˚C, urgency, frequency,
dysuria, suprapubic tenderness, and costovertebral angle pain or tenderness) together with a
positive urine culture ( 105 CFUs/ml) with  2 bacterial species or at least one positive out-
come in the dipstick test, pyuria, and gram stain. Patients with a positive urine culture on the
day of IUC placement were excluded.

Statistical analysis
Categorical variables were analyzed by the Chi-square test or Fisher’s exact test. Continuous
variables were analyzed by independent t-tests or the Mann-Whitney U-test. A logistic regres-
sion analysis was performed to evaluate the effect of independent variables on risk. A P-value
of <0.05 in a two-tailed test was considered to be statistically significant. To assess inter-hospi-
tal differences in urinary catheter days, we used the Kruskal-Wallis test with the Bonferroni
correction, and considered a P-value of <0.0083 significant. All analyses were performed
using SPSS Statistics version 21.0 (IBM Corporation, Armonk, NY).

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 Indwelling urinary catheter use and CA-UTI

Ethics statement
The study protocol was approved by the institutional review boards of Hanyang University
Guri Hospital (IRB number: 2012-11-085), and the requirement for written informed consent
from patients was waived.

Results
The point-prevalence study
IUCs were present in 14.9% (576/3,870) of hospitalized patients [median 14.9/100 patients,
(1Q 14, 3Q 16)] on the day of examination. The point-prevalence of CA-UTI was 0.39 (1Q
0.23, 3Q 1.14) per 100 admissions or 2.39 (1Q 1.51, 3Q 8.35) per 100 patients with IUCs
(Table 1).

The prospective cohort study

Patient characteristics. A total of 1,298 patients were screened during the 4-week study.
Fifty patients were excluded for the following reasons: under 18 years of age (14 patients), and
discharged within 48 hours of IUC placement (36 patients). In the end 1,248 patients were
enrolled in the study.
The median age of the patients was 64 years (1Q 50, 3Q 74), and 57.4% were female. The
median observation period was 13 days (1Q 7, 3Q 22) and the median duration of IUC use
was 5 days (1Q 3, 3Q 10).
Table 2 shows inter-hospital differences in IUC use and CA-UTI incidence. There were
9,591 total catheter days and a median of 1,607 catheter days (1Q 1,391, 3Q 1,840). Catheter
days per patient differed significantly between hospitals (Kruskal-Wallis test; P<0.001).
Patients in hospitals A and C had significantly more catheter days than those in the other hos-
pitals (P-value < 0.0083; P-value for multiple comparison between A and B <0.001, between A
and D 0.028, between A and E <0.001, between A and F 0.005, between B and C <0.001,
between B and D >0.99, between B and E >0.99 between B and F >0.99, between C and D
0.014, between C and E <0.001, between C and F 0.002, between D and E 0.876, between D
and F >0.99, and between E and F 0.726.
Placement, maintenance, and removal of IUCs. After 1 week of IUC placement, 511
patients (511/1,248, 40.9%) had had their IUC removed and 313 patients (313/1,248, 25.1%)
had dropped out of observation. Of the remaining 424 patients (424/1,248, 34.0%), 36 (36/424,
8.5%) had no adequate indication for use of an IUC. After 2 weeks, 126 patients (126/424,
29.7%) had had their IUC removed, 117 (117/424, 27.6%) had dropped out, and 181 (181/424,
42.7%) remained, with 9.4% inappropriate use. After 3 weeks, 30 patients (30/181, 16.6%) had
had their IUC removed, 47 (47/181, 26.0%) had dropped out, and 104 (104/181, 57.5%)
remained, with 16.3% of inappropriate use. After 4 weeks, 16 patients (16/104, 15.4%) had had
their IUC removed, 23 (23/104, 22.1%) had dropped out, and 65 (65/104, 62.5%) remained,
with 23.1% of inappropriate use (Fig 1).
Indications for IUC use recorded by healthcare personnel. The most common indica-
tion for initial IUC use was perioperative care (594, 47.6%), followed by close monitoring of
urinary output (590, 47.3%) and relief of urinary retention (196, 13.1%) (Table 3). Over the
period that IUCs were monitored, the proportion of urinary catheters used for perioperative
care decreased (10.8%, day 7; 5.5%, day 14; 2.9%, day 21; 4.6%, day 28) and the proportion
used for close monitoring of urinary output increased (64.2%, day7; 70.2%, day 14; 72.1%, day
21; 76.9%, day 28).

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 Indwelling urinary catheter use and CA-UTI

Table 1. Point-prevalence of indwelling urinary catheter, catheter utilization ratio and urinary tract infections.
Hospital Total patients Patients with IUCs CA-UTI Point prevalence
IUC utilization ratio* CA-UTI
per 100 admission per 100 patients with IUCs
A 862 129 2 0.15 0.23 1.55
B 553 71 8 0.13 1.45 11.27
C 680 95 7 0.14 1.03 7.37
D 473 73 1 0.15 0.21 1.37
E 613 87 2 0.14 0.33 2.3
F 689 121 3 0.18 0.44 2.48
Total 3,870 576 23
Median (1Q, 3Q) 647 (533, 732) 91 (73, 123) 3 (2, 7) 0.15 (0.14, 0.16) 0.39 (0.23, 1.14) 2.39 (1.51, 8.35)

IUC, indwelling urinary catheter; CA-UTI, catheter-associated urinary tract infections

* Patients with IUCs/total patient

https://doi.org/10.1371/journal.pone.0185369.t001

Adequacy of IUC maintenance. The greater the number of IUC-days, the higher was the
proportion of patients using IUCs without appropriate indications (8.5% (36/424), day 7; 9.4%
(17/181), day 14; 16.3% (17/104), day 21; 23.1% (15/65), day 28. For the 36 inappropriate IUCs
used after 1 week of IUC placement, urinary output monitoring (23/36, 63.9%) was most com-
mon indication, followed by acute urinary retention (6/36, 16.7%) (Table 3). The proportion
of IUCs maintained for urinary output monitoring as inappropriate indication increased over
the period of monitoring (76.5%, day 14; 82.4%, day 21; 86.7%, day 28).
Inter-hospital differences in median IUC-days according to operation types. To mini-
mize the inevitable biasing of IUC-days according to operation type, we performed a sub-anal-
ysis of IUC-days by common operations. Brain operations were performed in 68 patients and
the median IUC-days was 7 (1Q 4, 3Q 17.8). There were no inter-hospital differences in IUC-
days associated with brain operations (P = 0.053 by Kruskal-Wallis test). Spine operations
were performed on 63 patients and the median IUC-days was 4 (1Q 2, 3Q 7) with no signifi-
cant inter-hospital differences (P = 0.296). Knee operations were performed in 40 patients and

Table 2. Inter-hospital differences in indwelling urinary catheter use and evaluation and prevalence of catheter-associated urinary tract
infections.
Hospital IUC utilization Frequency of urine culture Prevalence of CA-UTI
Total patients IUC-days, IUC-days, per patient, Number of Number of cultures/ Number of CA- CA-UTI/1,000
(%) total median (1Q, 3Q) cultures (%) 1,000 IUC-days UTI (%) IUC-days
A 154 (12.3) 1,527 7 (5, 13) 66 (23.2) 43.2 1 (4.2) 0.7
B 248 (19.9) 1,686 4 (2, 8) 56 (19.6) 33.2 5 (20.8) 3
C 197 (15.8) 1,952 7 (4, 13) 72 (25.3) 36.9 12 (50.0) 6.1
D 156 (12.5) 1,152 5 (3, 9.5) 9 (3.2) 7.8 2 (8.3) 1.7
E 245 (19.6) 1,471 3 (2, 8) 46 (16.1) 31.3 2 (8.3) 1.4
F 248 (19.9) 1,803 4 (2, 9) 36 (12.6) 20 1 (4.2) 0.6
Total 1,248 (100) 9,591 285 (100) 23 (100)
Median (1Q, 221 (156, 1,607 (1,391, 5 (3, 10) 51 (29, 68) 32.3 (17.0, 38.5) 2 (1, 6.8) 1.6 (0.7, 3.8)
3Q) 248) 1,840)

IUC, indwelling urinary catheter; CA-UTI, catheter-associated urinary tract infections

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 Indwelling urinary catheter use and CA-UTI

Fig 1. A flow diagram showing status of indwelling urinary catheters. From the placement of urinary
catheter through day 28 of follow-up monitoring, maintenance and removal of indwelling urinary catheter was
traced weekly.
https://doi.org/10.1371/journal.pone.0185369.g001

Table 3. Indications for indwelling urinary catheter (IUC) use and adequacy of IUC maintenance during the period of weekly monitoring.
Indication IUC-day Days from IUC placement N (%)
median (1Q, the day of Day 7 Day 14 Day 21 Day 28
3Q) placement Total Inapp. Total Inapp. Total Inapp. Total Inapp.
use use use use use use use use
Acute urinary retention 8 (5,14.8) 196 (15.7) 111 6 (16.7) 43 (23.8) 1 (5.9) 23 2 (11.8) 12 0 (0.0)
(26.2) (22.1) (18.5)
Urinary output monitoring 7 (4,13) 590 (47.3) 272 23 (63.9) 127 13 (76.5) 75 14 (82.4) 50 13 (86.7)
(64.2) (70.2) (72.1) (76.9)
Open sacral or perineal 10 (5,24) 11 (0.9) 12 (2.8) 4 (11.1) 6 (3.3) 1 (5.9) 6 (5.8) 1 (5.9) 3 (4.6) 1 (6.7)
wound
Comfort for end of life 6 (3,12.8) 36 (2.9) 13 (3.1) 3 (8.3) 8 (4.4) 0 (0.0) 4 (3.8) 0 (0.0) 2 (3.1) 0 (0.0)
Perioperative care 3 (2,5.3) 594 (47.6) 46 (10.8) 0 (0.0) 10 (5.5) 1 (5.9) 3 (2.9) 0 (0.0) 3 (4.6) 1 (6.7)
Other 6 (4,10) 67 (5.4) 34 (8.0) 2 (5.6) 18 (9.9) 0 (0.0) 10 (9.6) 1 (5.9) 6 (9.2) 0 (0.0)
Total 5 (3, 10) 1248 424 36 181 17 104 17 65 15

Inapp., Inappropriate; IUC, indwelling urinary catheter

Multiple answers were allowed

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 Indwelling urinary catheter use and CA-UTI

the median IUC-days was 3.5 (1Q 3, 3Q 5) with significant inter-hospital differences
(P<0.001). There were significant differences in IUC-days between hospitals C and E, and hos-
pitals D and E, after the Bonferroni correction (P<0.001 and <0.001, respectively). Colorectal
surgery was performed in 29 patients and the median IUC-days was 3 (1Q 2, 3Q 6) with signif-
icant inter-hospital differences (P = 0.049). There were significant differences in catheter days
between hospital D and F, and hospital E and F, (P = 0.036 and 0.006, respectively). Only the
P-value for hospitals E and F was significantly different after the Bonferroni correction. Stom-
ach operations were performed in 26 patients and the median IUC-days was 3 (1Q 2.8, 3Q 6)
with significant inter-hospital differences (P = 0.027). There were significant differences in
catheter days between hospital B and D, and hospital D and E, (P = 0.006 and 0.029). Only the
P-value for hospitals B and D was significantly different after the Bonferroni correction.
CA-UTI. A total of 285 urine cultures were set up, and the median number of urine cul-
tures per 1,000 catheter days was 32.3 (1Q 17.0, 3Q 38.5). A total of 25 pathogens were identi-
fied by urine culture from 23 patients with CA-UTI. Enterococcus spp. was the leading
causative organism (8/25, 32%), followed by Escherichia coli (7/25, 28%) (Table 4). The median
prevalence of CA-UTI per 1,000 catheter days was 1.6 (1Q 0.7, 3Q 3.8).
The clinical characteristics of patients with CA-UTI are compared with those of patients
without CA-UTI in Table 5. The median age of the CA-UTI group was 69 (1Q 56, 3Q 74), and
that of the non-CA-UTI group was 64 (1Q 50, 3Q 74.8) (P = 0.194). Male gender was more
common in the CA-UTI group (62.5% vs. 42.4%, P = 0.049). Among underlying diseases,
hypertension was more frequent in the CA-UTI group (65.2% vs. 42.8%, P = 0.037), but there
were no significant differences for other parameters. As for the use of additional equipment, the
CA-UTI group used ventilators more frequently than the non-CA-UTI group (21.7% vs. 6.5%,
P = 0.008). There were no significant differences in the use of central venous catheters, nasogas-
tric tubes and endotracheal tubes. The non-CA-UTI group underwent more operations within
a month before enrollment than the CA-UTI group (52.3% vs. 30.4%, P = 0.044). Median IUC-
days was significantly longer in the CA-UTI group than the non-CA-UTI group [18 days (1Q 1,
3Q 28) vs. 5 days (1Q 3, 3Q 9), P< 0.001]. Inappropriate use of IUCs on days 7, 14, 21, and 28
was not correlated with the development of CA-UTI (P = 0.709, >0.99, 0.163, and >0.99,
respectively). In multivariate logistic regression analysis, only IUC-days was significantly associ-
ated with CA-UTI (Odd ratio 1.127, 95% confidence interval 1.077–1.180, P< 0.001).

Discussion
The purpose of this multicenter study was to examine the frequency and adequacy of IUC use,
to identify reasons for catheter maintenance, and to assess the extent and risk of hospital-
acquired CA-UTI associated with IUCs in hospital wards as a whole.

Table 4. Causative organisms of catheter-associated urinary tract infection.

Pathogens Number (%)
Acinetobacter spp. 2 (8)
Candida spp. 4 (16)
Enterococcus spp. 8 (32)
Escherichia coli 7 (28)
Proteus mirabilis 1 (4)
Pseudomonas spp. 2 (8)
Staphylococcus spp. 1 (4)
Total 25a (100)
a
Total number of identified organisms from 23 patients

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 Indwelling urinary catheter use and CA-UTI

Table 5. Clinical characteristics of catheter-associated urinary tract infection (CA-UTI) patients and non-CA-UTI patients.
Total CA-UTI Non-CA-UTI simple Odd ratio P-value multiple Odd ratio P-value
(n = 1248) (n = 23) (n = 1225)
Demographic data
Age, median (1Q, 3Q) 64 (50, 74) 69 (56, 74) 64 (50, 74.5) 1.019 (0.992, 1.047) 0.161 0.997 (0.965, 1.029) 0.839
Male sex (%) 532 (42.6) 14 (60.9) 520 (42.4) 0.474 (0.204, 1.104) 0.083 1.767 (0.728, 4.291) 0.208
Underlying disease (%)
Hypertension 539 (43.2) 15 (65.2) 524 (42.8) 2.508 (1.056, 5.960) 0.037 2.199 (0.842, 5.747) 0.108
Ischemic heart disease 56 (4.5) 1 (4.3) 55 (4.5) 0.967 (0.128, 7.305) 0.974
Congestive heart failure 47 (3.8) 1 (4.3) 46 (3.8) 1.165 (0.154, 8.831) 0.883
Asthma 21 (1.7) 1 (4.3) 20 (1.6) 2.739 (0.352, 21.319) 0.336
COPD 22 (1.8) 0 (0.0) 22 (1.8)
Hemodialysis 10 (0.8) 0 (0.0) 10 (0.8)
DM 287 (23.0) 6 (26.1) 281 (22.9) 1.186 (0.463, 3.036) 0.723
Utilization of other instruments (%)
Central venous catheter 232 (18.6) 3 (13.0) 227 (18.5) 0.659 (0.194, 2.238) 0.504
Nasogastric tube 188 (15.1) 6 (26.1) 182 (14.9) 2.023 (0.787, 5.198) 0.144
Endotracheal tube 236 (18.9) 7 (30.4) 229 (18.7) 1.903 (0.774, 4.679) 0.161
Ventilator 85 (6.8) 5 (21.7) 80 (6.5) 3.976 (1.439, 10.986) 0.008 1.791 (0.607, 5.289) 0.291
a
Operation history 648 (51.9) 7 (30.4) 641 (52.3) 0.399 (0.163, 0.976) 0.044 0.915 (0.346, 2.422) 0.858
IUC-days, median (1Q, 3Q) 5 (3, 10) 18 (11, 28) 5 (3, 9) 1.138 (1.090, 1.188) <0.001 1.127 (1.077, 1.180) <0.001

CA-UTI, catheter-associated urinary tract infections; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; IUC, indwelling urinary catheter
a
Within one month before the day of enrollment

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In a previous study by Lewis et al., the IUC utilization ratio was 0.83 in ICUs, 0.21 in non-
ICUs, and 0.24 overall [12]. The incidence rate of CA-UTI per 1,000 catheter days was 1.21
throughout hospitals. Even though the IUC utilization ratio was lower in non-ICUs than
ICUs, the incidence rates of CA-UTI were similar (1.31 and 1.33 per 1,000 catheter days in
non-ICUs and ICUs, respectively). In this study, the IUC utilization ratio in all hospital wards
was 0.15 and the value for ICUs given in the previous KONIS study by Lewis et al was 0.84 [2].
We performed a point-prevalence study to calculate the utilization ratio, and others have per-
formed prospective surveillance studies. Therefore direct comparison with previous studies
such as the KONIS may have limitations due to difference of study design. However, our study
yielded findings resembling those of the Lewis study, in which CA-UTI prevalence per 1,000
catheter days was 2.6 in hospitals overall and 1.2 in ICUs. In other words, non-ICU patients
use IUCs less than ICU patients, but CA-UTI occurs more frequently in non-ICU patients.
These findings point to a need to monitor the adequacy of IUC use throughout hospital wards
to lower the rate of CA-UTI.
Median IUC-days varied significantly among the participating hospitals in this study. The
incidence of CA-UTI also varied: it was approximately 10 times more frequent in hospital C
(6.1/1,000 catheter days) than in hospital F (0.6/1,000 catheter days). Even though we com-
pared IUC-days by type of operation to minimize bias from patients’ characteristics, signifi-
cant inter-hospital differences were noted. Thus, it is important to ensure the adequate use of
IUCs and to implement infection controls against CA-UTI throughout hospital wards.
Increased length of IUC stay is a well-known risk factor for CA-UTI [6, 13]. Apisarntha-
narak et al. demonstrated that patients who remained in IUCs inappropriately for prolonged
times had a higher probability of developing CA-UTI [14], which prolonged hospitalization
and increased costs. In the present study, the frequency of inappropriate use was 8.5% on day

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 Indwelling urinary catheter use and CA-UTI

7, lower than in previous studies (21–54%) [14, 15]. The frequency of inappropriate use
increased with time to 23.1% at the end of the study period. We need to be aware that the
greater the number of IUC-days, the higher the rates of inappropriate use of IUCs.
Reasons of inappropriate IUC use have varied between studies. Elpern et al. demonstrated
that close monitoring for urinary output, no clear indication, and urinary incontinence were
major indication for inappropriate use [16]. Admission to the medical ICU, non-ambulatory
functional status, female gender, older age, and not having had surgery were independently
associated with inappropriate use [14, 17]. In many countries and hospitals, medical staff
including physicians are often unaware of the placement of IUCs in their patients [13, 15, 18].
This leads to prolonged installation of IUCs that are clinically unnecessary. These findings
indicate that a large proportion of inappropriate and prolonged IUC use is preventable by
careful monitoring. In this study, the most common reason for inappropriate IUC use was
close monitoring of urinary output. Even though the number of instances of inappropriate use
decreased with time (from 23 to 13), the proportion of instances installed for close monitoring
of urinary output increased (from 63.9% to 86.7%). We suggest that healthcare personnel
should be aware of IUCs that have been in place for more than a week to monitor urinary out-
put, so as to prevent inappropriate use. Furthermore, strategies to enhance each medical staff’s
adherence to guidelines of CA-UTI prevention are also necessary. Some studies showed prom-
ising strategies. Gokula et al. increased appropriate use of IUC from 37% to 51% in emergency
room by using combined educational intervention and an indication checklist [19]. Other
study showed that nurse-led multidisciplinary rounds were effective to reduce the unnecessary
IUC use [20]. In addition, reminder or stop order was also helpful to reduce CA-UTI inci-
dence [10].
There are several limitations to this study. First, we only included university hospitals. In
Korea, there are a total of 3,472 hospitals and 2.3% (82/3,472) comprises university hospitals.
Therefore, our results may not be generalizable to other types of hospital. Moreover, even
though the participating hospitals had similar numbers of beds, the patients’ characteristics
may have differed, which could have led to divergent results for urinary catheter management
as well as CA-UTI rates. Second, we did not collect data on whether patients were hospitalized
in ICUs or non-ICU wards. Therefore, we could not assess differences of CA-UTI incidence
between ICUs and non-ICUs. Finally, the adequacy of IUC use was decided by researchers in
the individual hospitals, and we cannot exclude the possibility of inter-researcher differences
in making this decision.
This study showed that the overall incidence CA-UTI in hospitals including non-ICU
wards was higher than in ICUs and the duration of IUC use, and CA-UTI rates, varied
between hospitals. The main risk factor for CA-UTI was prolonged IUC use, which correlated
with inappropriate use. All medical staff should be advised to be alert to inappropriate IUC use
in order to prevent CA-UTI. Introducing tools that can be easily applied to promote appropri-
ate management of IUCs and prevent and control CA-UTI in Korean hospitals would be a
good strategy to enhance medical staff’s awareness. Further researches are required in the
future.

Supporting information
S1 File. CA-UTI multicenter-dataset.sav. This file included raw data of this study except per-
sonal and potentially identifying participant data.
(SAV)

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 Indwelling urinary catheter use and CA-UTI

Author Contributions
Conceptualization: Bongyoung Kim, Jieun Kim.
Data curation: Bongyoung Kim, Won Suk Choi, Yeonjae Kim, Ki Tae Kweon, Hyun Ah Kim,
Seong Yeol Ryu, Seong-heon Wie, Jieun Kim.
Formal analysis: Bongyoung Kim.
Funding acquisition: Jieun Kim.
Investigation: Bongyoung Kim, Won Suk Choi, Yeonjae Kim, Ki Tae Kweon, Hyun Ah Kim,
Seong Yeol Ryu, Seong-heon Wie, Jieun Kim.
Methodology: Hyunjoo Pai, Won Suk Choi, Jieun Kim.
Project administration: Bongyoung Kim, Won Suk Choi, Yeonjae Kim, Ki Tae Kweon, Hyun
Ah Kim, Seong Yeol Ryu, Seong-heon Wie, Jieun Kim.
Resources: Won Suk Choi, Yeonjae Kim, Ki Tae Kweon, Hyun Ah Kim, Seong Yeol Ryu,
Seong-heon Wie, Jieun Kim.
Software: Bongyoung Kim, Jieun Kim.
Supervision: Hyunjoo Pai, Jieun Kim.
Validation: Won Suk Choi, Yeonjae Kim, Ki Tae Kweon, Hyun Ah Kim, Seong Yeol Ryu,
Seong-heon Wie, Jieun Kim.
Visualization: Bongyoung Kim, Jieun Kim.
Writing – original draft: Bongyoung Kim, Jieun Kim.
Writing – review & editing: Hyunjoo Pai, Jieun Kim.

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