Best Practices for Preventing Catheter-Associated Urinary Tract Infections

This document focuses on the prevention of catheter-associated urinary tract infections (CAUTI) in acute care hospitals.

The strategies highlighted may or may not be applicable to other healthcare spaces, such as outpatient settings or post-acute or long-term care facilities. Additionally, there may be differences in healthcare environments within the hospital that may affect the feasibility of specific recommendations.

1. Urinary tract infections (UTIs) are one of the most common healthcare-associated infections. In 2003, between 70% and 80% of UTIs were attributable to the presence of an indwelling urethral catheter. In a 2019 analysis, over 5 years, CAUTIs decreased in proportion to non-device-associated UTIs, but still accounted for an average of 44% of these infections per year among hospitalized patients.

2. Urinary catheters remain one of the most used medical devices by adults in emergency departments and hospitals around the world. Often, these devices are placed and maintained in use without adequate clinical indication justifying the risk compared to the benefit. Additionally, 12% to 16% of hospitalized adult patients will have an indwelling urethral catheter at some point during admission. Of the patients who have a urinary catheter placed in the hospital, up to half are placed in patients who may not have an appropriate indication.

3. The daily risk of developing bacteriuria ranges from 3% to 7% when an indwelling urethral catheter remains in place.

4. The high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.

5. Infection is only one of several adverse outcomes of urinary catheter use. Noninfectious complications include nonbacterial urethral inflammation, urethral stricture, mechanical trauma, and impaired mobility.

6. Previous research has shown that intensive care unit (ICU) CAUTI rates reported to NHSN ranged from 1.2 to 4.5 per 1,000 urinary catheter days in adult ICUs and from 1.4 to 3.0 per 1,000 urinary catheter days in adult ICUs. 1 per 1,000 urinary catheter days in pediatric ICUs. An 8% reduction was observed nationally in the incidence of CAUTI reported between 2018 and 2019, with the largest decrease observed in ICUs.

7. Bacteremia secondary to CAUTI is uncommon, as demonstrated in a review of 444 episodes of catheter-associated bacteriuria in 308 patients with CAUTI, in which only 3 patients (0.7%) developed bacteremia of urinary origin.

8. CAUTI has been associated with increased mortality and length of hospital stay, but the association with mortality may be a consequence of confounding caused by unmeasured clinical variables.

Inappropriate use of urine cultures may increase CAUTI rates. Inadequate treatment of asymptomatic catheter-associated bacteriuria may promote antimicrobial resistance and Clostridium difficile infection in acute care settings.

Risk factors for CAUTI

1. The duration of catheterization is the most important risk factor for developing infection. Consequently, reducing unnecessary catheter placement and minimizing catheterization duration are the main strategies for prevention.

2. Additional risk factors include female sex, older age, and not maintaining a closed drainage system. In pediatrics, specific clinical scenarios are often thought to require an open drainage system, including those with recent complex surgical repair or reconstruction of congenital anomalies of the urogenital system.

3. Risk factors for developing healthcare-related bloodstream infections include neutropenia, kidney disease, and male sex.

The clinical diagnosis of CAUTI is often a diagnosis of exclusion , making it difficult to have a standardized definition. Currently, all available definitions have substantial limitations. The optimal definition of CAUTI used for surveillance and quality improvement is one that only captures actual cases of symptomatic infection that would benefit from antimicrobial treatment.

The recommendations are classified as essential practices that should be adopted by all acute care hospitals or as additional approaches that may be considered for use in locations and/or populations within hospitals when CAUTIs are not controlled by essential practices.

Essential practices include recommendations in which the potential to impact the risk of CAUTI clearly outweighs the potential for undesirable effects.

Additional approaches include recommendations where the intervention is likely to reduce risk but there is concern about undesirable outcomes, the quality of evidence is low, or evidence supports the impact of the intervention in selected settings (e.g., during outbreaks) or for selected patient populations.

Hospitals can prioritize their efforts by initially focusing on implementing essential practices.

If surveillance or other risk assessments suggest that there are continued opportunities for improvement, hospitals should consider adopting some or all of the additional approaches. These interventions may be implemented in specific locations or patient populations or may be implemented hospital-wide, depending on outcomes data, risk assessment, and/or local requirements.

Essential practices to prevent CAUTI: recommended for all acute care hospitals

1. Conduct a CAUTI risk assessment and implement an organization-wide program to identify and remove catheters that are no longer needed using one or more methods documented as effective.

2. Provide adequate infrastructure to prevent CAUTI.

3. Provide and implement evidence-based protocols to address multiple steps of the urinary catheter life cycle: catheter suitability (step 0), insertion technique (step 1), maintenance care (step 2), and immediate removal (step 3 ) when it is no longer appropriate.

4. Ensure that only trained healthcare professionals insert urinary catheters and that competence is assessed periodically.

5. Ensure that supplies necessary for aseptic catheter insertion technique are available and conveniently located.

6. Implement a system to document the following in the patient record: physician order for catheter placement, directions for catheter insertion, date and time, name of person who inserted catheter, nursing documentation of placement , daily presence of a catheter and maintenance care tasks, and date and time of removal.

7. Ensure that sufficiently trained healthcare and technology resources are available to support monitoring of catheter use and outcomes.

8. Perform surveillance for CAUTI if indicated based on the facility’s risk assessment or regulatory requirements.

9. Standardize urine cultures by adapting an institutional protocol for appropriate indications for urine cultures in patients with and without an indwelling catheter.

Education and training

1. Educate healthcare personnel involved in the insertion, care and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters and catheter procedures.

2. Assess the competence of health professionals in the use, care and maintenance of catheters.

3. Educate healthcare personnel about the importance of urine culture management and provide indications for urine cultures.

4. Provide training on proper urine collection. Samples should be collected and arrive at the microbiology laboratory as soon as possible, preferably within one hour. If a delay in transport to the laboratory is expected, specimens should be refrigerated (no more than 24 hours) or collected in urine transport tubes with preservatives.

5. Train clinicians to consider other methods of bladder management (e.g., intermittent catheterization or male or female external collection devices) when appropriate before placing an indwelling urethral catheter.

Insertion of indwelling catheters

1. Insert urinary catheters only when necessary for patient care and leave them in place only as long as there are indications.

2. Consider other methods of bladder management, such as intermittent catheterization or male or female external collection devices, when appropriate.

3. Use proper technique for catheter insertion.

4. Consider working in pairs to help position the patient and monitor for possible contamination during positioning.

5. Practice hand hygiene (per CDC or World Health Organization guidelines) immediately before catheter insertion and before and after any manipulation of the catheter site or apparatus.

6. Insert catheters following aseptic technique and using sterile equipment.

7. Use sterile gloves, cloths and sponges, a sterile antiseptic solution to clean the urethral meatus, and a sterile single-use lubricating gel packet for insertion.

8. Use a catheter with the smallest possible diameter compatible with adequate drainage to minimize urethral trauma, but consider other catheter types and sizes when warranted for patients with anticipated difficult catheterization to reduce the likelihood that a patient will experience multiple attempts. of catheterization, sometimes traumatic.

Management of indwelling catheters

1. Properly secure indwelling catheters after insertion to prevent urethral movement and traction.

2.  Maintain a sterile and continuously closed drainage system.

3. Replace the catheter and collection system using aseptic technique when interruptions in aseptic technique, disconnections, or leaks occur.

4. To examine fresh urine, collect a small sample by aspirating urine from the needle-free sampling port with a sterile syringe or cannula adapter after cleaning the port with disinfectant.

5. Facilitate timely transportation of urine samples to the laboratory. If timely transportation is not feasible, consider refrigerating urine specimens or using specimen collection cups with preservatives. Obtain large volumes of urine for special testing (e.g., 24-hour urine) aseptically from the drainage bag.

6. Keep urine flow unobstructed.

7. Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is an unresolved issue, although emerging literature supports the use of chlorhexidine before catheter insertion. Alcohol-based products should be avoided given the concern that alcohol causes drying of mucosal tissues.

Additional Approaches to Prevent CAUTI

Use of these additional approaches is recommended in locations and/or in-hospital populations with unacceptably high CAUTI rates or standardized infection rates (SIRs) despite implementation of essential CAUTI prevention strategies. listed above.

1. Develop a protocol to standardize the diagnosis and treatment of postoperative urinary retention, including nurse-directed use of intermittent catheterization and the use of bladder scanners when appropriate as alternatives to indwelling urethral catheterization.

2. Establish a system to analyze and report data on catheter use and adverse events from catheter use.

3. Establish a system to define, analyze and report data on non-catheter-associated UTIs, particularly UTIs associated with devices used as alternatives to indwelling urethral catheters. Noncatheter-associated UTIs are defined as UTIs that occur in hospitalized patients without an indwelling urethral catheter.

Approaches that should not be considered a routine part of CAUTI prevention

1. Routine use of catheters impregnated with antimicrobials or antiseptics.

2. Break a closed system.

3. Detection of asymptomatic bacteriuria in catheterized patients, except in the few patient populations for which it is expected to have more benefit than harm.

to. Treatment of asymptomatic bacteriuria is not an effective strategy for preventing CAUTI in other patient groups, as it increases the risk of antibiotic-associated complications more than any potential benefit for preventing symptomatic CAUTI. The conditions that predispose the patient to

Colonization of the bladder (anatomical, immunological) is not resolved with antibiotics, so bacteriuria recurs.

4. Catheter irrigation as a strategy to prevent infection.

5.  Routine use of systemic antimicrobials as prophylaxis.

6. Routine change of catheters to avoid infections.

7. Alcohol-based products on the genital mucosa.

Unresolved issues and future areas of study

1. Use of antiseptic solution versus sterile saline solution for cleaning the meatus and perineum before catheter insertion.

2. Use of urinary antiseptics (eg, methenamine) to prevent urinary tract infections.

3. Spatial separation of patients with urinary catheters in place to prevent transmission of pathogens that could colonize urinary drainage systems.

4. Standard of care for routine replacement of urinary catheters in place for more than 30 days for infection prevention.

5. Best practices to optimize and adapt the implementation of CAUTI prevention and urine culture management from the adult intensive care setting to the pediatric intensive care setting.

Internal reports

These performance measures are intended to support the hospital’s internal quality improvement efforts and do not necessarily address external reporting requirements.

Process measures

1. Percentage of inappropriate catheters according to insertion documentation.

2. Percentage of compliance with daily documentation of continued need for an indwelling urethral catheter

3. Point prevalence of indwelling urethral catheters for a specific unit

Outcome measures

1. CAUTI rates, stratified by risk factors (eg, ward, clinical service line).

2. Standardized infection rate (SIR). The SIR is a summary risk-adjusted measure that allows comparison with the national benchmark and can be used to track the incidence of CAUTI over time.

3.  Cumulative attributable difference (CAD). CAD is used in CDC’s Prevention Targeted Assessment Strategy to direct prevention efforts to hospitals or units with the highest excess.

CAUTI prevention requires focusing on both technical and socioadaptive (or behavioral) components. In recent years, regional and national CAUTI prevention initiatives have been implemented in acute care hospitals. Several of these initiatives have been successful but not in all patient care settings or settings.

Engage

Quality improvement projects aimed at improving compliance with ITUAC guidelines have used various techniques to engage hospital staff to raise awareness of the problem and increase acceptance.

1. Develop a multidisciplinary team.

2. Engage local advocates to promote the program.

3. Use peer-to-peer networks.

4. Involve the patient and his family.

Educate

Hospital staff education may include face-to-face sessions or educational materials available in print or electronic format. Educational sessions can describe the evidence behind program guidelines and goals and can focus on specific aspects of prevention.

Execute

The process for making quality improvement changes employs new protocols and algorithms. Interventions can be grouped into “packages” or “checklists” of practices to be implemented simultaneously. The electronic health record can be leveraged to drive practice change. Given the emphasis on quality improvement in physician training programs, the participation of resident physicians and other students in CAUTI prevention efforts may be useful in teaching hospitals.

Assess

The success of an ITUAC quality improvement program can be measured by process, outcome, and balance measures. Most programs have found that providing feedback to the hospital or unit increases awareness.