대한요로생식기감염학회지 : 제 4 권제 2 호 2009년 10월 Korean J UTII Vol. 4, No. 2, October 2009 종설 카테터관련요로감염의치료와예방 가톨릭대학교의과대학비뇨기과학교실 임승혁 하유신 손동완 이승주 한창희 이충범 조용현 [Abstract] Treatment and Prevention of Catheter-Associated Urinary Tract Infections Seung Hyuk im, U-Syn Ha, Dong Wan Sohn, Seung-Ju Lee, Chang Hee Han, Choong Bum Lee, ong-hyun Cho From the Department of Urology, College of Medicine, The Catholic University of Korea, Seoul, Korea Urinary tract infections (UTIs) represent the second most often observed infectious diseases in community, following the respiratory tract infections. Approximately 40% of nosocomial infections originate in the urinary tract; about 80% of urinary tract infections is related to urinary catheterization. The duration of catheterization is the most important risk factor for development of UTIs and additional risk factors include female sex, diabetes mellitus, renal function impairment, lack of antimicrobial therapy, and not maintaining a closed drainage system. There are many methods for preventing catheter-associated urinary tract infections (CAUTI); (i) an indwelling catheter should be introduced under antiseptic conditions; (ii) urethral trauma should be minimized by the use of adequate lubricant and the smallest possible catheter; (iii) the catheter system should remain closed; and (iv) the duration of catheterization should be minimal. Antimicrobial urinary catheters can prevent or delay the onset of CAUTI, but the effect on morbidity is not known. Antibiotic treatment is recommended only in symptomatic infection (bacteremia, pyelonephritis, epididymitis, prostatitis), but systemic antimicrobial treatment of asymptomatic CAUTI is only recommended in the following circumstances; (i) patients undergoing urological surgery or implantation of prosthesis; (ii) treatment may be part of a plan to control nosocomial infection due to a particularly virulent organism prevailing in a treatment unit; (iii) patients who have a high risk of serious infectious complications; and (iv) infections caused by strains causing a high incidence of bacteremia. (Korean J UTII 2009;4:159-169) Key Words: Urinary catheterization, Urinary tract infection 교신저자 : 조용현, 가톨릭대학교의과대학비뇨기과학교실서울시영등포구여의도동 62 번지우 150-713 Tel: 02-3779-1024, Fax: 02-761-1626, E-mail: cyh0831@catholic.ac.kr 159
160 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 서론요로감염은병원감염의약 40% 정도를차지하여병원감염의원인중가장흔하며, 1 이중 80% 는도뇨관삽관에기인한다. 2 입원환자의약 12 16% 에서도뇨관삽관을요하는것으로알려져있으며, 3 도뇨관이삽관되어있는환자에서요로감염의위험은매일 3 7% 정도로증가한다. 대부분의카테터관련요로감염은환자자신의대장내세균총 (colonic flora) 에서유래하며, 4 감염경로는주로집뇨주머니 (drainage bag) 의균오염후도뇨관내로균이침투하여발생하는것으로알려져있다. 5 카테터관련요로감염의위험인자로가장중요한것은도뇨관유치기간이다. 6 도뇨관 1회삽관시요로감염발생율은 1 5% 정도로알려져있으며, 7 여성환자및요폐를보이는환자, 당뇨환자등에서감염위험이높다. 7일이내의기간동안도뇨관유치시약 10 30% 에서요로감염이발생하며, 일반적으로가능한빨리도뇨관을제거하는것이요로감염예방에도움이된다고는하나, 아직최적의도뇨관제거시기에대한의견의일치는없는실정이다. 28일이상도뇨관유치시대부분의환자에서하나이상의균주가동정되며, 주로 E. coli가흔하다. 장기간도뇨관유치시대부분의환자에서요로감염을나타내나증상이있는경우는 10% 이하이므로, 도뇨관이유치되어있고발열을동반하는환자에서요로감염이외의다른발열원인을반드시밝혀야한다. 도뇨관유치기간외의요로감염위험인자로는집뇨주머니, 도뇨관및외요도주위의균집락, 당뇨, 여성, 고령, 신기능저하, 도뇨관의부적절한관리, 폐쇄도뇨법 (close drainage system) 을유지하지않는경우등이있다. 1981년에 US Centers for Disease Control and Prevention (CDC) 에서카테터관련요로감염의예방지침을처음으로제시한이후현재도개정되고있으며, 2001년과 2007년에 UK National Health Service (NHS) 에서예방지침을제시하여오늘에이르고있다. 일반적인카테터관련요로감염예방법으로도뇨관의무균적삽관, 삽관시적절한윤활액사용을통한요도손상의최소화, 폐쇄도뇨법유 지, 도뇨관유치기간의최소화등이제시되고있으며, 항생물질도포카테터는요로감염발생을늦추는효과는있으나요로감염이환에대한효과는아직알려져있지않다. 카테터관련요로감염의치료는일반적으로증상이있는경우에한하며, 7 일이상도뇨관이유치되어있는경우도뇨관교체혹은제거를고려한다. 카테터관련요로감염의예방및치료에대하여여러가이드라인이제시되었고또한개정되어왔다. 저자들은 Tenke 등 8 이제시한가이드라인에기초하고, CDC 및 NHS의기준등을참고하여카테터관련요로감염의예방및치료에대한최신경향에대해서술하고자한다. 본론 1. 병인론요도카테터에의해요로감염에대한방광의정상적인방어기전이억제되거나회피될수있다. 요도카테터를삽입한직후균이요로에침입할수있고, 9 이러한경우는회음부나원위부요도를부적절하게소독한후삽관하였을때흔히발생한다. 20% 이상의환자에서요도카테터삽관직후균집락을나타낼수있다. 10 도뇨관이유치되어있는남성에서주된균침투경로는도뇨관내강이며, 이는외인성감염에의한것으로추측된다. 이는도뇨관내강을통한상행감염 (32 48시간) 은도뇨관외부경로에의한것보다 (72 168시간) 그속도가빠르고, 11 집뇨주머니의배출구꼭지부분이소변을비울때오염되어이로인해집뇨주머니내에균감염후배뇨관및도뇨관내강을따라이동하여방광내감염을유발하게되거나집뇨주머니교체시도뇨관과배뇨관을떼어낼때연결부위의오염으로인하여요로감염이유발되는것으로설명가능하다. 도뇨관외부경로에의한요로감염은카테터와요도점막사이에형성된균막 (biofilm) 에의해촉진된균침투및증식에의해발생하며, 세균뇨발생률은여성에서 (70 80%) 남성에비해 (20 30%) 높게나타난다. 12 균막은미생물및미생물의세포
임승혁외 : 카테터관련요로감염의치료와예방 161 외생성물이축적되어고체표면에구조화된군락을형성하는상태로정의되며, 어느부위에서든지발생가능하다. 균막은표면조직혹은생체물질과접합되어있는연결막 (linking film), 기저막 (basal layer), 부유미생물 (planktonic organism) 이유리되는내강에인접한표면막 (surface film) 의세층으로이루어져있다. 균막내의미생물은요류에의한기계적세척이나숙주방어기전및항생제로부터보호되며, 일반적인검사로는잘검출되지않는다. 13 2. 도뇨관유치방법에따른요로감염위험도 1) 1회도뇨 1회도뇨시요로감염발생률은 1 5% 정도이다. 14 여성, 요폐를보이는환자, 분만전후도뇨관유치, 당뇨환자, 고령의환자에서요로감염의위험이증가한다. 15 2) 단기도뇨관유치보통 7일이내로도뇨관을유치하는경우로정의된다. 수술전후, 요로폐색, 급성질환의경우에서배뇨량측정을위한단기도뇨관유치의적응증이된다. 입원환자의 15 25% 정도에서 2 4일정도도뇨관유치가필요하며, 16 그중 10 30% 에서세균뇨가발생한다. 단기도뇨관유치시발생하는세균뇨중대부분이무증상이고단일균주에의해발생하며, 복수균주에의한세균뇨발생률은 15% 정도이다. 17 흔히발견되는균은 Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus epidermidis, Enterococcus 및 Candida 이다. 단기도뇨관유치시요로감염예방을위한적절한도뇨관제거시기및방법에대한의견의일치는아직없으며, 보통도뇨관을가능한빨리제거하는경우요로감염발생이줄어든다는것만알려져있다. 3) 장기도뇨관유치도뇨관유치기간이 28일이상인경우 장기 ' 혹은 만성 ' 으로정의한다. 장기간도뇨관이유치된환자에서적어도하나이상 ( 보통 2가지이상 ) 의 균주에의한세균뇨가일반적으로발생하고, 18,19 복수균주에의한요로감염발생율이 95% 에이르는것으로보고되어있으며, 20 가장흔한균주는 E. coli이다. 도뇨관을통해수집된소변에서검출되는균주의 1/4 정도는치골상부도뇨를통해수집된소변에서동시에검출되지않는데, 이는카테터관련요로감염에서어떤균들은요도카테터에서만집락을이루기때문인것으로생각된다. 21 장기도뇨관유치시세균뇨를보이는경우요로생식기감염의합병증이 10배정도증가하나, 22 증상을보이는경우는 10% 이내로드물기때문에, 발열을보이는경우요로감염이외의다른원인을반드시감별하여야한다. 일시적인무증상세균뇨는최초도뇨관삽입시혹은장기간도뇨관유치환자에서도뇨관을교체할때흔히발생한다. 최초도뇨관삽입시균혈증의위험도는기존의요로감염 (7%) 이나무균뇨 (8.2%) 에서비슷한정도로나타난다. 23 열성요로감염이나균혈증의발생률이상대적으로낮은이유는카테터관련요로감염에서의균집락이주로낮은병원성을나타내는균주에의해발생하기때문으로생각한다. 카테터관련요로감염의사망률에대한기여정도는아직불확실하다. 몇몇연구에서는높은사망률과는관계가없는것으로나타났으며, National Nosocomial Infetions Surveilance (NNIS) 의자료및여러다른연구에서는고령이더라도낮은사망률을보이는것으로나타났다. 24,25 카테터관련요로감염의사망률은 9% 에서 13% 로다양하게보고되고있다. 고령이외의다른위험인자로동반질환의심한정도, 부적절한항생제치료, 원격감염및인식되지않은비뇨기이상의존재등이있다. 도뇨관이유치되어있는환자에서경요도전립선절제술과같은경요도적수술을시행할경우사망률이약 2배정도로증가한다. 장기도뇨관유치시카테터폐쇄에의한하부요로폐색및요로결석, 부고환염, 전립선염, 음낭농양등이발생할수있다. 28일이상도뇨관이유치되어있는환자의 50% 이상에서반복적인가피형성에따른도뇨관폐쇄가나타난다. 간헐적인요폐에의해방광요관역류가발생하고상행감염이조장되는데, 감염을일으키는균주로요소분해세균중하나인
162 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 P. mirabilis가종종검출되며이에따른감염석발생위험이높아진다. 26,27 10년이상도뇨관이유치되어있는환자에서방광암의위험이증가하므 로, 28,29 방광암에대한선별검사를반드시시행하여야한다. Table 1. Advantages and disadvantages of various catheter modalities for bladder drainage Advantages Transurethral indwelling catheter - only few contraindications, e.g. urethral stricture, urethral trauma - instillation by trained nurse - catheters with several luminal sizes - special catheters for flushing the bladder - special catheters for permanent bladder irrigation - catheter insertion usually not very traumatic using optimal technique Disadvantages - local infection (urethritis) - urethral trauma, stricture and paraurethral abscess - prostatitis, epididymitis, pyelonephritis, urosepsis - high rate of nosocomial UTI - residual urine measurement not possible - more troublesome for the patient - higher amount of nursing workload Suprapubic catheter - no urethral interference (no urethritis, prostatitis, epididymitis) - no urethral stricture - lower rate of nosocomial urinary tract infection - spontaneous micturition and residual urine measurement - transurethral diagnostic procedures, e.g. cystoscopy, urethrography - less troublesome for the patient - lower amount of nursing workload - installation by physician - relative contraindications: bladder shrinkage, suprapubic scars, meteorism, pregnancy, obesity - absolute contraindications: bladder volume <200 ml bladder tumor, bladder displacement, e.g. by intraabdominal tumor anticoagulation therapy, hemorrhagic tendency, gross hematuria skin diseases in the puncture area Intermittent catheterization - less local periurethral infection, febrile episodes, stones and deterioration of renal failure - clean catheterization - elevated urethral trauma - urethral stricture - false passage - urethritis, epididymitis, prostatitis - cooperative and skilled patient - difficult process in men Condom catheter - lower incidence of bacteriuria - no urethral interference (no urethritis, prostatitis, epididymitis) - no urethral stricture - less painful procedure Urethral stent/prosthesis - lower incidence of bacteriuria - less troublesome for the patient - less urethral stricture - cooperative and skilled patient - obesity - short penis - skin maceration and ulceration - difficulty in proper placement, changing or removal - high migration rate - high level of scar formation - secondary stricture - calcification
임승혁외 : 카테터관련요로감염의치료와예방 163 3. 도뇨관유치이외의방법으로도뇨시장, 단점 (Table 1) 1) 간헐적도뇨간헐적도뇨법은신경인성방광기능이상을보이는환아, 조절되지않는반사성배뇨근수축을보이는여성, 배뇨근수축이미약하거나없는환자, 수술에부적당한건강상태에서방광출구폐쇄를보이는남자환자의네가지경우에서안전하고효과적인치료법이된다. 됴뇨관삽입시마다 1 3% 정도의세균뇨획득위험성이있으므로간헐적도뇨시행후 3주말경에는대부분의환자에서세균뇨를나타 낸다. 30,31 도뇨관유치환자에비해국소요도주위감염, 열성질환, 요로결석및신기능황폐를보이는경우는적으나이에대한확실한비교연구결과는아직없다. 간헐적도뇨의합병증으로는출혈, 요도감염및협착, 부고환염, 방광결석, 수신증등이있다. 간헐적도뇨와도뇨관의지속적유치를비교한몇몇연구에따르면, 지속적도뇨관유치에비해간헐적도뇨를시행한경우에서세균뇨발생률이낮았으며, 증상이있는요로감염의발생률은유의한차이를보이지않았다. 32 술후간헐적도뇨를시행하는것은단기도뇨관유치에비해세균뇨의위험을감소시킨다는증거가거의없어추천되지않으며, 예방적항생제및항생물질의방광내투 Table 2. Summary of recommendations from published guidelines for prevention of infections associated with short-term indwelling urethral catheters Recommendation CDC (1981) NHS Epic 1 Project (2001) NHS Epic 2 Project (2007) Ensure documentation of catheter insertion Ensure that trained personnel insert catheter Train patients and family Practice hand hygiene Evaluate necessity of catheterization Evaluate alternative methods Review ongoing need regularly Select catheter material Use smallest-gauge catheter possible Use aseptic technique/sterile equipment Use barrier precautions for insertion Perform antiseptic cleaning of meatus Use closed drainage system Obtain urine samples aseptically Replace system if a break in asepsis occurs Do not change catheter routinely Perform routine hygiene for meatal care Avoid irrigation Cohort patients Ensure compliance with training Ensure compliance with control measures Ensure compliance with catheter removal Monitor rates of CAUTI and bacteremia U N U N CAUTI, catheter-associated urinary tract infection; CDC, US Centers for Disease Control and Prevention; N, no (not recommended);, not discussed; NHS, UK National Health Service; U, unresolved (choice left to clinical experience and patient factors);, yes (recommended).
164 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 여역시추천되지않는다. 2) 치골상부도뇨환자만족도의관점에서볼때치골상부도뇨는도뇨관유치에비해몇가지의장점이있다. Cochrane 보고 33 에따르면세균뇨 ( 무증상세균뇨포함 ), 도뇨관교체, 도뇨관폐쇄및치료에견딜수있는정도에대해치골상부도뇨법이도뇨관유치에비해우월한효과가있는것으로나타났다. 다만단기유치의경우증상이있는요로감염이나다른합병증의예방효과가불충분하여일상적으로적용하지않도록한다. 3) 콘돔카테터콘돔카테터는방광출구폐색이있는남성에서유용하게쓰일수있으나, 환자가비협조적이거나정신착란을보이는경우혹은비만에따른짧은음경의경우적용하기어렵다. 피부짓무름이나궤양이발생할수있으므로, 2일간격으로교체하는것이감염위험도에관련이없다고하더라도콘돔카테터를매일교체하는것이추천된다. 34 콘돔카테터사용시장기도뇨관유치에비해낮은세균뇨발생률을보인다. 4) 요도스텐트및보형물삽입요도스텐트나보형물은신경인성방광기능이상, 요도협착예방및요폐의치료등을위해전립선요도부위에삽입된다. 복압성요실금의경우약 50% 에서만족스러운치료효과를보인다. 35 보통무증상세균뇨를보이며, 환자의 10 35% 에서발생한다. 36 다른도뇨방법에대한세균뇨및증상을보이는요로감염발생의유의한차이를비교한연구결과는아직없다. 4. 예방 1) 도뇨관관리 (Table 2) 도뇨관을무균적으로삽입하여야하고, 도뇨관삽입전후손을청결하게유지하여야하며, 1회용무균윤활제사용및요도손상최소화를위해가능 한내경이작은도뇨관을사용하도록한다. 소수의연구에서무균적삽입, 청결삽입및항균젤을사용한경우를비교하였을때세균뇨발생위험의차이가없음이보고된바있다. 37,38 도뇨관은반드시필요한경우에만유치하도록하는데, 수술전후에선택적으로사용하거나, 중환자에서의요량측정, 급성요폐의치료, 요실금이있는환자에서욕창치유촉진및환자가배뇨불편감을해소하기위해요청하는경우가그적응증이된다. 39,40 카테터관련요로감염예방에가장중요한두가지사항은, 폐쇄도뇨법을유지하는것과카테터유치기간을최소화하는것이다. 도뇨관삽입후도뇨관이움직이거나요도견인이되는것을방지하기위해하복부에도뇨관을고정해주어야하고, 도뇨관을세척해야하는경우이외에는도뇨관과배뇨관을분리하지말아야하며, 무균적도뇨가되지않는상황및도뇨관과집뇨주머니가분리되거나연결부에서소변이새는경우도뇨관의집뇨관연결부위를소독후집뇨주머니를교체한다. 검사를위한요채취는무균적으로이루어져야하는데, 채뇨량이적은경우채취부위를소독후무균주사기로소변을흡입하여채취하고, 채뇨량이많은경우집뇨주머니에서무균적으로채취한다. 도뇨관이꼬여서막히지않도록주의하여야하고, 규칙적으로집뇨주머니를비우도록하는데이때집뇨주머니의배출꼭지부위가오염되지않도록주의하여야한다. 집뇨주머니는중력방향으로방광보다항상낮게위치하도록한다. 도뇨관밸브 (catheter valve) 사용시집뇨주머니를사용한도뇨법에대한요로감염발생률의차이는없었다고하나, 41 균집락의위험을배제할수는없다. 카테터관련요로감염예방을위해적절한요량 (50 100mL/h 이상 ) 이유지되어야하며, 이를위해적절한수분을섭취하여야한다. 요도혹은요도구주위에항균제를도포하거나항균제도포카테터를사용하는것은균혈증예방에도움이되지않으며, 일상적인청결유지로충분하다. 적절한카테터교체주기에대한의견의일치는아직없고일상적으로도관을교체하지않는것이통설이나, 도뇨관이제기능을하지못하거나소변이새는경우교체주기를짧게해야하며, 일반적으
임승혁외 : 카테터관련요로감염의치료와예방 165 로장기도뇨관유치시도뇨관폐쇄발생전및폐쇄위험이있는경우에도뇨관을교체한다. 도뇨관폐쇄에걸리는시간이개인에따라다르므로, 통상한달에 1회정도교체하는것이통례이나도뇨관폐쇄가빨리발생하는환자에서는매주교체하거나주당 2회교체하는경우도있다. 카테터관련요로감염에대한예방적항생제투여는세균뇨감소효과가확실하지않아추천되지않는다. 가능하다면도뇨관유치보다는요로감염위험이적은간헐적도뇨, 콘돔카테터도뇨법등을사용하도록한다. 항생제가포함된용액에의한지속방광세척을예방목적으로는하지말아야하고, 도뇨관폐쇄가예견되는경우에한하여시행하도록한다. 혈종이나점액및다른원인에의한요폐개선을위해간헐적인방광세척을시행할수있다. 2) 항생물질이도포된도뇨관및도뇨관재료에따른예방효과요로감염의발생을지연시키고세균의흡착과번식을막기위해다양한도뇨관재료및항생물질도포도뇨관이개발되었다. 먼저도뇨관재료와요로감염발생의관계에대해살펴보면, 자연고무로제작된도뇨관에서국소숙주염증반응과조직괴사가라텍스나실리콘으로제작된도뇨관에비해매우높게나타났다. 42 라텍스도뇨관은가장저렴하나자극증상및알레르기반응이일어날수있다는단점이있고, 실리콘도뇨관은라텍스도뇨관에비해생체적합성이높기때문에장기도뇨관유치에적합한재료이다. 실리콘도뇨관은라텍스에비해도뇨관폐쇄가적게발생하며, 테플론 (Teflon) 이나실리콘으로도포된라텍스도뇨관이유치된환자에서도뇨관가피가잘형성되는경향이있다. 43,44 염산폴리비닐은단단한재료로서보통방광세척을위한세방향도뇨관의구성물질이된다. 그러나아직단기도뇨관유치환자에서어떤도뇨관이요로감염의위험을낮추는데에가장효과적인지에대한확증이없으므로, 임상적인적응증과가격, 효용성및개인의선호도에따라도뇨관을선택하여야할것이다. 다음으로항생물질도포카테터와요로감염발생의관계에대해살펴보면, 항생물질도포카테 터에는항균물질혹은항생제를도뇨관재료에주입하여제작된도뇨관및도뇨관표면에항생제가포함된중합체기질 (polymer matrix) 을도포하여소변내에일정하게항생제를유리하고세균의흡착을방지하려는목적으로제작된도뇨관이있는데, 항생물질도포카테터는유치기간이 1주이내인경우에만세균뇨감소에효과가있는것으로나타났고, 45-49 Cochrane 보고 44 에따르면항생물질도포카테터는세균뇨발생률감소에효과는있으나증상이있는요로감염발생을낮추지는못하였다. 산화은 (silver oxide) 도포카테터는단기도뇨관유치시세균뇨발생을지연시킬수있으며, 은합금도포카테터는도뇨관표면관련세균의세포막단백질을침전시키고균집락을방해하는것에대해산화은도포카테터보다효과적이다. 은이온은뮤레인 (murein, 당질과아미노산으로구성되어있는세균의형질막외측에위치한그물구조의물질로세포벽을형성 ) 에결합하여정균작용을나타내지만, 은이온농도가매우높은경우제균작용또한나타낼수있다. 50,51 Cochrane 보고 43 에따르면, 산화은도포카테터의경우단기도뇨관유치시세균뇨의유의한감소를보이지못한반면, 은합금도포카테터의경우같은조건에서무증상세균뇨및증상을보이는세균뇨모두의감소를보였으나, 유치기간이 1주이내인경우에만효과가있었다. 포스포릴콜린 (phosphorylcholine) 및헤파린도포카테터사용시에도가피형성및균막형성억제에효과가있었다는연구결과가있다. 52,53 그러나상기의여러방법은장기도뇨관유치시의요로감염예방에는도움이되지않으며, 중환자실에서단기도뇨관유치목적으로사용시에만효과가있는것으로보인다. 요약하자면, 항생물질도포카테터는카테터관련요로감염의발생을예방하거나발생을지연시킬수있으나요로감염이환률에대한효과는아직알려진바없다. 5. 치료 1) 무증상세균뇨의치료세균뇨가완전히제거되지않거나급속히재발할
166 대한요로생식기감염학회지 : 제 4 권제 2 호 2009 년 10 월 수있기때문에무증상세균뇨를일반적으로는치료하지않으나, 항생제치료시내성균및항생제부작용에대한정보를얻을수는있다. 카테터관련요로감염환자에서항생제치료시이환율과사망률이감소한다는증거가없으므로다음의경우에한하여무증상세균뇨에대한항생제치료를한다. (i) 비뇨기과적인수술혹은보형물삽입술을받은환자 (ii) 특정병원성세균에의한원내감염을제어하기위한계획에의한항생제투여 (iii) 심각한감염성합병증의위험이있는환자 (iv) 균혈증발생위험이높은균주에의한요로감염도뇨관을통한배뇨가잘이루어지는경우에무증상의도뇨관유치환자에서일상적인균배양검사를시행하는것이추천되지않는이유는일반적으로치료가필요없기때문이다. 무증상요로감염상태에서병원균이배양된경우, 그균이요로감염증상이나타났을때원인균이되는지의여부역시확실하지않다. 도뇨관을제거하였을때환자의 1/3 1/2 정도에서저절로요로감염균이없어지며, 이는 65세이상의여성혹은감염균이 S. epidermidis 인경우에서흔한현상이지만, 고령의여성에서카테터제거시에도세균뇨가남아있거나증상을동반한감염발생시항생제치료를시행하여야한다. 54 2) 증상이있는요로감염의치료증상이있는요로감염환자에서가장흔한임상증상은발열이며, 저체온, 빈맥 (>90/min), 빈호흡 (>20/min 및 / 또는 pco2<33mmhg), 백혈구증가증및백혈구감소증중적어도두가지이상의소견을보이는패혈증상태를나타내는경우도있다. 장기간도뇨관이유치되어있는환자에서거의항상균배양검사에서양성소견을보이므로, 요로생식기의특정한증상이없거나요배양검사양성균에의한균혈증을보이지않는환자에서열성증상혹은패혈증소견을보일때정확한진단을내리기가어렵다. 요로감염이발열의원인이될수있으나, 요폐나혈뇨, 늑골척추각압통등의특정증상이동반되 지않는경우다른진단을염두에두어야하며, 환자가임상적으로안정되어있으면서미열이있는경우즉각적인항생제치료를시작하기보다는일단경과관찰하도록한다. 요로감염에대한항생제치료는증상이있는경우 ( 균혈증, 신우신염, 부고환염, 전립선염 ) 에한하여시행하도록한다. 도뇨관이유치된환자에서열성증상을보일경우전신적항생제투여를시행하는데, 요로감염관련균혈증이나신우신염의가능성이높기때문이다. 세균이도뇨관표면의균막에격리되어있을확률이있으므로, 도뇨관이 7일이상유치되어있는환자에서증상이있는카테터관련세균뇨에대한치료전에도뇨관을교체하거나제거할필요가있다. 55-57 광범위항생제에의한경험적치료시작후요배양검사결과에따라적절한항생제를선택하기때문에, 항생제치료시작전에소변및혈액샘플을채취하여배양검사를하도록한다. 카테터관련요로감염의적절한치료기간에대해언급한연구결과는없으나, 보통원인균, 동반이환상태나환자의치료반응에따라투여기간은 5일에서 21일정도로다양하다. 58 장기간의항균치료는효과가없어서일반적으로추천되지않으며, 도뇨관유치시소변은영구적으로멸균상태가될수없는것으로알려져있다. 59 간혹요배양검사에서칸디다균이배양되는경우가있는데, 보통무증상이며치료없이호전되는경우가많다. 칸디다뇨증의경우전신적인항진균제투여및방광세척을위한국소투여모두에서적응증이되지않으며, 60,61 도뇨관혹은스텐트제거를고려한다. 배뇨증상이나전신감염증상과관련된칸디다뇨증의경우항진균제의전신적투여에대한적응증이된다. 62 6. 교차감염의예방원내의료인은도뇨관이유치된환자사이의교차감염위험을항상염두에두어야하며, 손세정및 1회용멸균장갑사용에대한프로토콜을숙지하여야한다. 요도주위세균총, 도뇨관및도뇨주머니표면, 오염된소변저장고및환자의피부를통하여의료인의손이오염되며이로인하여다른환
임승혁외 : 카테터관련요로감염의치료와예방 167 자에대한감염전파위험이발생한다. 절개상처를관리할때처럼멸균수로손세정후멸균장갑을사용하여도뇨관을관리하면감염전파위험이감소될수있다. 결론카테터관련요로감염은원내감염중가장흔히발생하며, 이에대한대처가소홀할경우감염된환자에서의합병증발생및사망위험도가증가함은물론다른환자에대한감염전파위험이높아지므로, 병원내의료인은적절한도뇨관관리법을숙지하여야할것이다. 불필요한도뇨관삽관및예방적항생제사용을지양하고, 가능한도뇨관이외의도뇨법을사용하며, 도뇨관을삽입해야하는경우유치기간을최소화하는동시에폐쇄도뇨법을사용하는등의노력으로카테터관련요로감염의위험을줄이는것이의사의직접적인역할이다. 또한, 간호사나그외의료보조인력에대한지침이되는환자의청결관리, 오염된소변의처리, 감염전파방지를위한손세정및멸균장갑사용등이포함된카테터관련요로감염예방에대한프로토콜작성에주도적으로참여하는것역시의사의중요한역할이된다. 최근개정된해외의여러가이드라인을참고하고국내의카테터관련요로감염실태를파악하여학회차원의가이드라인을제정하고지속적으로개정하는것이필요할것으로생각한다. REFERENCES 1. Gentamicin-releasing urethral catheter for short-term catheterization. Cho W, Park JH, Kim SH, Cho H, Choi JM, Shin HJ, et al. J Biomater Sci Polym Ed 2003;14:963-72 2. Saint S, Chenowith CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003;17:411-32 3. Weinstein JW, Mazon D, Pantelick E, Reagan- Cirincione P, Dembry LM, Hierholzer WJ. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999;20: 543-8 4. Garibaldi RA, Burke JP, Britt MR, Miller MA, Smith CB. Meatal colonization and catheter-associated bacteriuria. N Engl J Med 1980;303:316-8 5. Bukhari SS, Sanderson PJ, Richardson DM, Kaufman ME, Aucken HM, Cookson BD. Endemic cross-infection in an acute medical ward. J Hosp Infect 1993; 24:261-71 6. Riley DK, Classen DC, Stevens LE, Burke JP. A large, randomized clinical trial of silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection. Am J Med 1995;98:349-56 7. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents 2001;17:299-303 8. Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T, Tambyah PA, Naber KG. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Int J Antimicrob Agents 2008;31 (1 Suppl): S68-78 9. Ha US, Cho H. Catheter-associated urinary tract infections: new aspects of novel urinary catheters. Int J Antimicrob Agents. 2006;28:485-90 10. Platt R, Polk BF, Murdock B, Rosner B. Risk factors for nosocomial urinary tract infection. Am J Epidemiol 1986;124:977-85 11. Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;146:719-23 12.Stamm WE, Hooton TM, Johnson JR, Johnson C, Stapleton A, Roberts PL, et al. Urinary tract infections: from pathogenesis to treatment. J Infect Dis 1989;159:400-6 13. Choong S, Whitfield H. Biofilms and their role in infections in urology. BJU Int 2000;86:935-41 14. Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am 1999;26:821-8 15. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997;11:609-22 16. Haley RW, Hooton TM, Culver DH, Stanley RC, Emori TG, Hardison CD, et al. Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by
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