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Preventing Catheter-Associated Urinary Tract Infections in the Intensive Care Unit

      Keywords

      Key points

      • Catheter-associated urinary tract infection (CAUTI) is common and costly and causes substantial patient morbidity, especially in the ICU setting.
      • CAUTI is often caused by hospital-based pathogens with a propensity toward antimicrobial resistance.
      • Duration of urinary catheterization is the predominant risk for CAUTI; preventive measures directed at limiting placement and early removal of urinary catheters significantly improve CAUTI rates.
      • Intervention bundles, collaboratives, and hospital leadership are powerful tools for implementing preventive measures for healthcare-associated infections, including CAUTI.

      Introduction: magnitude of the problem

      Healthcare-associated urinary tract infections (UTIs) account for up to 40% of infections in hospitals and 23% of infections in the intensive care unit (ICU).
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Nicolle L.E.
      Urinary catheter-associated infections.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      The vast majority of UTIs are related to indwelling urinary catheters; approximately 70% of UTIs (and 95% of UTIs occurring in ICUs) develop in patients with urinary catheters.
      • Burton D.C.
      • Edwards J.R.
      • Srinivasan A.
      • et al.
      Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007.
      The Centers for Disease Control and Prevention (CDC) estimated that in 2007, 139,000 CAUTIs occurred in US hospitals.
      CAUTI has significant clinical and economic consequences. Catheter-associated bacteriuria may be associated with excess mortality, even after controlling for underlying factors such as severity of illness and comorbidities; hospital-onset bloodstream infection resulting from a urinary source has a case fatality of 32.8%.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      • Chang R.
      • Greene M.T.
      • Chenoweth C.E.
      • et al.
      Epidemiology of hospital-acquired urinary-tract-related bloodstream infection at a university hospital.
      In addition, each episode of CAUTI is estimated to cost at least $600 while urinary-tract-related bloodstream infection costs at least $2,800.
      • Saint S.
      • Meddings J.A.
      • Calfee D.
      • et al.
      Catheter-associated urinary tract infection and the Medicare rule changes.
      Consequently, CAUTIs result in as much as $131 million excess direct medical costs nationwide annually.
      • Burton D.C.
      • Edwards J.R.
      • Srinivasan A.
      • et al.
      Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007.
      The financial implication for hospitals is underscored by the fact that since October 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the extra costs of managing a patient with hospital-acquired CAUTI.
      • Saint S.
      • Meddings J.A.
      • Calfee D.
      • et al.
      Catheter-associated urinary tract infection and the Medicare rule changes.
      Appropriately, prevention has become a priority for most hospitals, as 65% to 70% of CAUTIs are estimated to be preventable.
      • Umsheid C.A.
      • Mitchell M.D.
      • Doshi J.A.
      • et al.
      Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.
      This article reviews the pathogenesis and epidemiology of CAUTI, with a focus on preventive measures for CAUTI among the critically ill.

      Pathogenesis

      Urinary catheters interfere with the normal innate defense mechanisms that prevent attachment and migration of pathogens into the bladder; these mechanisms include length of the urethra and micturition.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      Biofilms, composed of clusters of microorganisms and extracellular matrix (primarily polysaccharide materials), form on both the internal lumen and external surfaces of urinary catheters.
      • Saint S.
      • Chenoweth C.E.
      Biofilms and catheter-associated urinary tract infections.
      • Donlan R.M.
      Biofilms and device-associated infections.
      Typically, the biofilm is composed of one type of microorganism, although polymicrobial biofilms are possible. Organisms in the biofilm grow slower than those in urine, and yet microorganisms in the biofilm may ascend the catheter in 1 to 3 days.
      Microorganisms, such as Proteus sp, have the ability to hydrolyze urea in the biofilm and increase urinary pH. As a result, minerals may precipitate, causing mineral encrustations along the catheter or renal calculi. Biofilms are also important because they provide a protective environment from immune cells. Antimicrobials penetrate into biofilms poorly, and microorganisms grow more slowly in biofilms, decreasing the effects of many antimicrobials.
      • Saint S.
      • Chenoweth C.E.
      Biofilms and catheter-associated urinary tract infections.
      • Donlan R.M.
      Biofilms and device-associated infections.
      Most microorganisms causing CAUTI enter the bladder by ascending the urethra from the perineum. Usually (66% of the time), organisms migrate in the biofilm on the external surface of the catheter. These organisms are primarily endogenous organisms colonizing the patient's intestinal tract and perineum.
      • Tambyah P.A.
      • Halvorson K.T.
      • Maki D.G.
      A prospective study of pathogenesis of catheter-associated urinary tract infections.
      A smaller proportion of infections (34%) are acquired from intraluminal contamination of the collection system from exogenous sources, resulting from cross-transmission of organisms from the hands of healthcare personnel.
      • Saint S.
      • Chenoweth C.E.
      Biofilms and catheter-associated urinary tract infections.
      • Tambyah P.A.
      • Halvorson K.T.
      • Maki D.G.
      A prospective study of pathogenesis of catheter-associated urinary tract infections.
      Rarely, organisms such as Staphylococcus aureus cause upper UTI from hematogenous spread.
      In most instances, CAUTI is caused by microorganisms from the patient's own gastrointestinal tract; however, approximately 15% of episodes of health-care-associated bacteriuria occur in clusters because of intrahospital transmission from one patient to another.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Saint S.
      • Chenoweth C.E.
      Biofilms and catheter-associated urinary tract infections.
      Most of these hospital-based outbreaks have been associated with improper hand hygiene of healthcare personnel.

      Epidemiology of catheter-associated urinary tract infections

      CAUTIs make up approximately 40% of all hospital-acquired infections, but they account for a smaller proportion of healthcare-associated infections in the ICU setting. With interventions occurring across the country, rates of CAUTI in ICUs declined significantly between 1990 and 2007.
      • Burton D.C.
      • Edwards J.R.
      • Srinivasan A.
      • et al.
      Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007.
      Rates of CAUTIs reported through the National Healthcare Safety Network (NHSN) in 2010 ranged from 4.7 infections per 1000 catheter-days in burn ICUs to 1.3 infections per 1000 catheter-days in medical/surgical ICUs.
      • Dudeck M.A.
      • Horan T.C.
      • Peterson K.D.
      • et al.
      National Healthcare Safety Network (NHSN) Report, data summary for 2010, device-associated module.
      CAUTIs in pediatric ICUs occur at a rate of 2.2 to 3.9 UTIs per 1000 catheter-days. General care wards have rates of CAUTI equivalent to or higher than in the ICU setting, ranging from 0.2 to 3.2 per 1000 catheter-days; the highest rates occur in rehabilitation units.
      • Dudeck M.A.
      • Horan T.C.
      • Peterson K.D.
      • et al.
      National Healthcare Safety Network (NHSN) Report, data summary for 2010, device-associated module.
      • Weber D.A.
      • Sickbert-Bennett E.E.
      • Gould C.V.
      • et al.
      Incidence of catheter-associated urinary tract infections in a healthcare system.

      Microbial Cause

      Enterobacteriaceae are the most common pathogens associated with CAUTI, but in the ICU setting, Candida sp (18%), Enterococcus sp (10%), and Pseudomonas aeruginosa (9%) become more prevalent.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Burton D.C.
      • Edwards J.R.
      • Srinivasan A.
      • et al.
      Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007.
      In addition, antimicrobial resistance in CAUTI isolates from patients in ICU has risen in recent decades. In data reported from the CDC's NHSN in 2006 to 2007, 24.8% of all Escherichia coli isolates from patients with CAUTIs were resistant to fluoroquinolones.
      • Hidron A.I.
      • Edwards J.R.
      • Patel J.
      • et al.
      NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007.
      Many members of Enterobacteriaceae produced extended-spectrum β-lactamases; 21.2% of Klebsiella pneumoniae and 5.5% of E. coli isolates from patients with CAUTIs were resistant to ceftriaxone or ceftazidime. Even more concerning is that during this same time, 10.1% of all K. pneumoniae isolates from patients with CAUTIs were resistant to carbapenems.
      • Hidron A.I.
      • Edwards J.R.
      • Patel J.
      • et al.
      NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007.

      Risk Factors

      Duration of catheterization is the dominant risk factor for CAUTI; up to 95% of UTIs in the ICU are associated with an indwelling urinary catheter.
      • Burton D.C.
      • Edwards J.R.
      • Srinivasan A.
      • et al.
      Trends in catheter-associated urinary tract infections in adult intensive care units-United States, 1990-2007.
      Bacteriuria, the precursor to CAUTI, develops quickly at an average daily rate of 3% to 10% per day of catheterization. Almost 26% of patients with a catheter in place for 2 to 10 days develop bacteriuria, and virtually all patients catheterized for 1 month develop bacteriuria. Hence, catheterization for greater than 1 month is generally the definition for long-term catheterization.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      Box 1 outlines the major risk factors for CAUTI. Females have a higher risk of bacteriuria than males, and heavy bacterial colonization of the perineum increases this risk. Other patient factors identified in one or more studies include rapidly fatal underlying illness, age greater than 50 years, nonsurgical disease, hospitalization in an orthopedic or urological service, catheter insertion after the sixth day of hospitalization, catheter inserted outside the operating room, diabetes mellitus, and serum creatinine level greater than 2 mg/dL at the time of catheterization. Nonadherence to aseptic catheter care recommendations have been associated with increased risk of bacteriuria, whereas systemic antimicrobial agents have a protective effect on bacteriuria (relative risk = 2.0–3.9).
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      Risk factors associated with catheter-associated urinary tract infection

        Nonmodifiable, patient-level risk factors

      • Female sex
      • Severe underlying illness
      • Nonsurgical disease
      • Age greater than 50 years
      • Diabetes mellitus
      • Serum creatinine level greater than 2 mg/dL

        Modifiable risk factors

      • Duration of catheterization
      • Adherence to aseptic catheter care
      • Catheter insertion after the sixth day of hospitalization
      • Catheter insertion outside the operating room
      Risk factors for UTI-associated bacteremia are less clearly understood than for catheter-associated bacteriuria because catheter-associated bacteremia occurs in less than 4% of infections. Risk factors for bloodstream infections from a urinary source from early studies included infections due to Serratia marcescens, male sex, immunosuppressant therapy, history of malignancy, cigarette use in the past 5 years, and number of hospital-days before bacteriuria.
      • Krieger J.N.
      • Kaiser D.L.
      • Wenzel R.P.
      Urinary tract etiology of bloodstream infections in hospitalized patients.
      • Saint S.
      • Kaufman S.R.
      • Rogers M.A.
      • et al.
      Risk factors for nosocomial urinary tract-related bacteremia: a case-control study.
      In a more recent study, independent risk factors for bloodstream infection included neutropenia, renal disease, and male sex.
      • Greene M.T.
      • Chang R.
      • Kuhn L.
      • et al.
      Predictors of hospital-acquired urinary tract-related bloodstream infection.
      These predictors for hospital-onset urinary-tract-related bloodstream infection should aid in implementing appropriate preventive practices in patients at highest risk.
      • Greene M.T.
      • Chang R.
      • Kuhn L.
      • et al.
      Predictors of hospital-acquired urinary tract-related bloodstream infection.

      Surveillance for catheter-associated urinary tract infections

      Clinical diagnosis of CAUTI remains challenging, as neither pyuria nor bacteriuria is a reliable indicator of symptomatic UTI in the setting of catheterization.
      • Musher D.M.
      • Thorsteinsson S.B.
      • Airola II, V.M.
      Quantitative urinalysis: diagnosing urinary tract infection in men.
      • Tambyah P.A.
      • Maki D.G.
      The relationship between pyuria and infection in patients with indwelling urinary catheters: a prospective study of 761 patients.
      Bacteriuria in a catheterized patient is usually defined as growth of 102 or more colony forming units per milliliter of a predominant microorganism.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      The term, bacteriuria, is often used interchangeably with UTI in the published literature, as many early studies used bacteriuria to define catheter-associated infection. However, the distinction is clinically important because asymptomatic catheter-associated bacteriuria rarely results in adverse outcomes and generally does not require treatment.
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      Diagnosis of UTI in patients with long-term urinary catheters is particularly problematic because bacteriuria is universally present unless antimicrobial therapy is given. Fever or other systemic symptoms may be the only clinical indication of UTI, especially in patients who have spinal cord injuries.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      Clinical recognition of UTI remains important because a large proportion of antimicrobials in hospitalized patients is prescribed for treatment of UTI, most often asymptomatic bacteruria.
      • Gandhi T.
      • Flanders S.A.
      • Markovitz E.
      • et al.
      Importance of urinary tract infection to antibiotic use among hospitalized patients.
      • Cope M.
      • Cevallos M.E.
      • Cadle R.M.
      • et al.
      Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.
      An essential element of any preventive program is to measure the prevalence of the condition and provide feedback of the results of interventions to the clinical care providers. The NHSN surveillance definition for healthcare-associated UTI allows for standardization and interhospital comparison of infection rates.

      Centers of Disease Control and Prevention. NHSN manual: patient safety component protocols. Available at: http://www.cdc.gov/nhsn/TOC_PSCManual.html. Accessed July 23, 2012.

      The NHSN symptomatic CAUTI rate (UTI per 1000 urinary catheter-days) is the most widely accepted measure of infection surveillance and is endorsed by the CDC, Infectious Diseases Society of America, Society for Healthcare Epidemiologists of America (IDSA-SHEA) compendium, and Association for Professionals in Infection Control and Epidemiology (APIC).
      • Rebmann T.
      • Greene L.R.
      Preventing catheter-associated urinary tract infections: an executive summary of the Association for Professionals in Infection Control and Epidemiol.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      However, a population-based measure, in which 10,000 patient-days is used as the denominator, may be a better measure to assess quality improvement interventions at individual hospitals.
      • Fakih M.G.
      • Greene T.M.
      • Kennedy E.H.
      • et al.
      Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated infection.
      Surveillance for CAUTI was not a priority for most hospitals earlier, perhaps due to lack of resources required to perform full hospital surveillance and the low priority given to CAUTI, as compared with other healthcare-associated infections.
      • Saint S.
      • Kowalski C.P.
      • Forman J.
      • et al.
      A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals.
      • Saint S.
      • Kowalski C.P.
      • Kaufman S.R.
      • et al.
      Preventing hospital-acquired urinary tract infection in the United States: a national study.
      Since CMS has included CAUTI as one of the hospital-acquired complications that will not be reimbursed, hospitals have renewed interest in CAUTI.
      • Saint S.
      • Meddings J.A.
      • Calfee D.
      • et al.
      Catheter-associated urinary tract infection and the Medicare rule changes.
      • Meddings J.
      • Saint S.
      • McMahon L.F.
      Hospital-acquired catheter-associated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy.
      In addition, beginning in 2012, CMS has required, as a condition of participation, that hospitals submit ICU-level CAUTI rates to NHSN. Other process or proxy measures, such as rates of asymptomatic bacteriuria, percentage of patients with indwelling catheters, percentage of catheterization with accepted indications, and duration of catheter use, have been used in studies and collaboratives with good success.
      • Fakih M.G.
      • Watson S.R.
      • Greene T.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.

      Prevention of catheter-associated urinary tract infections

      Several guidelines exist regarding prevention of CAUTI.
      • Rebmann T.
      • Greene L.R.
      Preventing catheter-associated urinary tract infections: an executive summary of the Association for Professionals in Infection Control and Epidemiol.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      General strategies are formulated for prevention of all healthcare-associated infections, whereas targeted strategies are focused at risk factors specific for CAUTI (Box 2).
      Key strategies for prevention of catheter-associated urinary tract infection
      Avoid insertion of indwelling urinary catheters
      • Placement only for appropriate indications (Box 3)
      • Institutional protocols for placement, including perioperative setting.
      Early removal of indwelling catheters
      • Checklist or daily plan
      • Nurse-based interventions
      • Electronic reminders
      Alternatives to indwelling catheterization
      • Intermittent catheterization
      • Condom catheter
      • Portable bladder ultrasound scanner
      Proper techniques for insertion and maintenance of catheters
      • Sterile insertion
      • Closed drainage system
      • Avoidance of routine bladder irrigation
      Consider antimicrobial catheters in some settings
      Appropriate indications for the placement of indwelling urinary catheters
      • Acute anatomic or functional urinary retention or obstruction
      • Urinary incontinence in the setting of open perineal or sacral wounds
      • Perioperative use for selected surgical procedures
        • Surgical procedures of anticipated long duration
        • Urologic procedures
        • Intraoperatively for patients with urinary incontinence
        • Need for intraoperative urinary monitoring or expected large volume of intravenous infusions
      • Accurate monitoring of urine output
      • Improving comfort for end-of-life care or patient preference

      General Strategies for Prevention

      Strict adherence to hand hygiene is recommended for the prevention of all health-care-associated infections, including UTI.
      • Boyce J.M.
      • Pittet D.
      Guideline for hand hygiene in health-care settings. recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America.
      Most outbreaks of urinary pathogens have been linked to inadequate employee hand hygiene. The urinary tract of hospitalized patients, especially those in an ICU setting, represents a significant reservoir for multidrug-resistant organisms (MDRO). Indwelling devices, including urinary catheters, increase the risk of colonization with MDRO, and therefore, limiting their use is an important strategy for prevention of MDRO.
      Reduction in use of broad-spectrum antimicrobials, as part of an overall antimicrobial stewardship program, is an important strategy to prevent development of antimicrobial resistance related to urinary catheters.
      • Dellit T.H.
      • Owens R.C.
      • McGowan Jr., J.E.
      • et al.
      Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.
      Repeated antimicrobial treatment of bacteriuria during long-term catheterization is a significant risk for colonization with MDRO, yet some of this use may be inappropriate.
      • Gandhi T.
      • Flanders S.A.
      • Markovitz E.
      • et al.
      Importance of urinary tract infection to antibiotic use among hospitalized patients.
      • Cope M.
      • Cevallos M.E.
      • Cadle R.M.
      • et al.
      Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.
      A recent study revealed that a 1-hour educational session reduced the inappropriate use of antibiotic therapy for inpatients with urine cultures positive for MDRO.
      • Pavese P.
      • Saurel N.
      • Labarere J.
      • et al.
      Does an educational session with an infectious diseases physician reduce the use of inappropriate antibiotic therapy for inpatients with positive urine culture results? A controlled before-and-after study.
      In addition, audit and feedback to care providers has potential to decrease overdiagnosis of CAUTI and associated inappropriate antibiotic use.
      • Trautner B.W.
      • Kelly P.A.
      • Petersen N.
      • et al.
      A hospital-site controlled intervention using audit and feedback to implement guidelines concerning inappropriate treatment of catheter-associated asymptomatic bacteriuria.

      Specific Strategies for Prevention

      Several guidelines have been developed or updated recently for the prevention of CAUTI.
      • Rebmann T.
      • Greene L.R.
      Preventing catheter-associated urinary tract infections: an executive summary of the Association for Professionals in Infection Control and Epidemiol.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      Nevertheless, a 2005 nationwide survey identified that more than one-half of hospitals did not have a system for monitoring urinary catheters, three-quarters did not monitor duration of catheterization, and one-third did not conduct any surveillance for UTIs.
      • Saint S.
      • Kowalski C.P.
      • Kaufman S.R.
      • et al.
      Preventing hospital-acquired urinary tract infection in the United States: a national study.
      Surprisingly, even after enactment of the CMS nonpayment rule, in 2009, only 1 CAUTI prevention practice, use of bladder ultrasonography, was used in more than 50% of hospitals.
      • Krein S.L.
      • Kowalski C.P.
      • Hofer T.P.
      • et al.
      Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009.
      Even when focusing on ICUs, where the risk of CAUTI is highest, only a small proportion of ICUs have policies supporting bladder ultrasonography (26%), catheter removal reminders (12%), or nurse-initiated catheter discontinuation.
      • Conway L.
      • Pogorzelska M.
      • Larson E.
      • et al.
      Adoption of policies to prevent catheter-associated urinary tract infections in United States intensive care units.
      The collaborative approach to implementation of prevention measures, as detailed later, has begun to systematic changes in adoption of prevention practices.
      • Meddings J.
      • Saint S.
      • McMahon L.F.
      Hospital-acquired catheter-associated urinary tract infection: documentation and coding issues may reduce financial impact of Medicare’s new payment policy.
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.

      Limitation of use of urinary catheters

      Indwelling urinary catheters are the primary risk factor for healthcare-associated UTIs, therefore, the most effective strategy for CAUTI prevention is limitation or avoidance of catheterization.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Nicolle L.E.
      Urinary catheter-associated infections.
      • Shuman K.
      • Chenoweth C.E.
      Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
      Catheter use rates vary by ICU type but range from 0.16 urinary catheter-days per patient-days in pediatric medical ICUs to 0.80 urinary catheter-days per patient-days in trauma ICUs.
      • Dudeck M.A.
      • Horan T.C.
      • Peterson K.D.
      • et al.
      National Healthcare Safety Network (NHSN) Report, data summary for 2010, device-associated module.
      Decreasing catheter usage may require interventions at several stages of lifecycle of a urinary catheter (Fig. 1).
      • Meddings J.
      • Saint S.
      Disrupting the life cycle of the urinary catheter.
      Figure thumbnail gr1
      Fig. 1Life cycle of a urinary catheter in the intensive care unit.
      (From Meddings J, Saint S. Disrupting the life cycle of the urinary catheter. Clin Infect Dis 2011;52:1291–3; with permission.)
      The first step toward decreasing catheter use is limiting placement of indwelling urinary catheters; catheters should be inserted only for appropriate indications (see Box 3). Despite these recommendations, studies indicate that urinary catheters are placed for inappropriate indications in 21% to 50% of catheterized patients.
      • Munasinghe R.L.
      • Yazdani H.
      • Siddique M.
      • et al.
      Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service.
      • Saint S.
      • Wiese J.
      • Amory J.K.
      • et al.
      Are physicians aware of which of their patients have indwelling catheters?.
      Healthcare institutions should develop written policies and criteria for indwelling urinary catheterization based on these widely accepted indications.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      Physician orders should be required for insertion of any urinary catheter, and institutions should implement a system for documenting placement of catheters.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      Interventions for limiting placement of urinary catheter targeted at hospital locations where initial placement usually occurs, such as emergency departments and operating rooms, have the most impact.
      • Fakih M.G.
      • Pena M.E.
      • Shemes S.
      • et al.
      Effect of establishing guidelines on appropriate urinary catheter placement.
      A multifaceted approach including several types of education, system redesign, rewards, and feedback managed by a dedicated nurse resulted in a marked decrease in daily prevalence of urinary catheter-days.
      • Knoll B.M.
      • Wright D.
      • Ellingson L.
      • et al.
      Reduction of inappropriate urinary catheter use at a Veterans Affairs hospital through a multifaceted quality improvement project.
      Once catheters are placed, strategies for early removal become essential. Urinary catheter management based on physicians' orders alone may be inadequate because physicians are frequently unaware that their patient has a urinary catheter. In one study, 28% of physicians were unaware that their patient had a catheter, with the lack of awareness increasing with the level of training.
      • Saint S.
      • Wiese J.
      • Amory J.K.
      • et al.
      Are physicians aware of which of their patients have indwelling catheters?.
      In addition, physician orders for catheter placement or documentation of presence of catheter occurs in less than 50% of catheters.
      • Conybeare A.
      • Pathak S.
      • Imam I.
      The quality of hospital records of urethral catheterisation.
      Nurse-driven interventions have demonstrated effectiveness in reducing duration of catheterization.
      • Fakih M.G.
      • Dueweke C.
      • Meisner S.
      • et al.
      Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.
      • Saint S.
      • Kaufman S.R.
      • Thompson M.
      • et al.
      A reminder reduces urinary catheterization in hospitalized patients.
      A nurse-based reminder to physicians to remove unnecessary urinary catheters in a Taiwanese hospital resulted in a reduction in CAUTI from 11.5 to 8.3 per 1000 catheter-days.
      • Huang W.C.
      • Wann S.R.
      • Lin S.L.
      • et al.
      Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters.
      Such interventions are easy to implement and may consist of either a written notice or a verbal contact with the physician regarding the presence of a urinary catheter and alternative options. The feasibility of this type of intervention was demonstrated in a statewide effort that resulted in significant decrease in catheter use and increase in appropriate indications of catheters.
      • Fakih M.G.
      • Watson S.R.
      • Greene T.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      However, computerized physician order entry systems may offer a more cost-effective and efficient system to reduce both placement of catheters and duration of catheterization. Cornia and colleagues
      • Cornia P.B.
      • Amory J.K.
      • Fraser S.
      • et al.
      Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients.
      found that a computerized reminder reduced the duration of catheterization by 3 days. A systematic review and meta-analysis reports that urinary catheter reminder systems and stop orders seem to reduce the mean duration of catheterization by 37% and CAUTI by 52%.
      • Meddings J.
      • Rogers M.A.M.
      • Macy M.
      • et al.
      Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
      As the rate of catheterization use decreases, some centers have noted a paradoxic increase in their rate of UTI per 1000 catheter-days.
      • Wright M.-O.
      • Kharasch M.
      • Beaumont J.L.
      • et al.
      Reporting catheter-associated urinary tract infections: denominator matters.
      In reality, the actual number of CAUTIs decreased, but because of a decline in the denominator (catheter-days), the rate increased. This observation has led some experts to recommend that the rate of UTI per 10,000 patient-days be used as a more appropriate outcome measure for quality improvement interventions surrounding urinary catheters.
      • Fakih M.G.
      • Greene T.M.
      • Kennedy E.H.
      • et al.
      Introducing a population-based outcome measure to evaluate the effect of interventions to reduce catheter-associated infection.

      Perioperative management of urinary catheters

      Specific protocols for the management of postoperative urinary catheters are important for reducing urinary catheterization use. CMS has now included removal of urinary catheters within 24 hours of surgery as one of the Surgical Care Improvement Project (SCIP) measures that are reported by all hospitals.
      Approximately, 85% of patients admitted for major surgical procedures had perioperative indwelling catheters; patients with duration of catheterization greater than 2 days were significantly more likely to develop UTIs and were less likely to be discharged home.
      • Wald H.L.
      • Ma A.
      • Bratzler D.W.
      • et al.
      Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data.
      Older surgical patients were particularly at risk for prolonged catheterization; 23% of surgical patients older than 65 years were discharged to skilled nursing facilities with an indwelling catheter in place and were substantially more likely to have rehospitalization or death within 30 days.
      • Wald H.L.
      • Epstein A.M.
      • Radcliff T.A.
      • et al.
      Extended use of urinary catheters in older surgical patients: a patient safety problem?.
      In a large prospective trial of patients undergoing orthopedic procedures, a multifaceted protocol for perioperative catheter management resulted in a two-thirds reduction in the incidence of UTI. The protocol consisted of limiting catheterization to surgeries longer than 5 hours or to total hip and knee replacements, removal of urinary catheters on postoperative day 1 after total knee arthroplasty, and postoperative day 2 after total hip arthroplasty.
      • Stephan F.
      • Sax H.
      • Wachsmuth M.
      • et al.
      Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study.
      Evaluation of patients undergoing one of the SCIP surgeries revealed that postoperative urinary retention developed in 2.1% of patients.
      • Wu A.K.
      • Auerbach A.D.
      • Aaronson D.S.
      National incidence and outcomes of postoperative urinary retention in the surgical care improvement project.
      This group has significance because it is at risk of requiring recatheterization (see Fig. 1). Patients who developed postoperative retention were more likely to be older men, undergoing knee, hip, or colon surgery. It will be important to focus future studies on interventions to prevent urinary retention in this higher-risk group.

      Alternatives to indwelling urinary catheters

      Compared with indwelling urinary catheterization, intermittent urinary catheterization reduces the risk of bacteriuria and UTI. Patients with neurogenic bladder and long-term urinary catheters, in particular, may benefit from intermittent catheterization.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      A recent meta-analysis reported a reduced risk of asymptomatic and symptomatic bacteriuria with the use of intermittent catheterization in patients after hip or knee surgery compared with indwelling catheterization.
      • Niel-Weise B.S.
      • van den Broek P.J.
      Urinary catheter policies for short-term bladder drainage in adults.
      Combining the use of a portable bladder ultrasound scanner with intermittent catheterization may reduce the need for indwelling catheterization.
      • Lo E.
      • Nicolle L.
      • Classen D.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      • Stevens E.
      Bladder ultrasound: avoiding unnecessary catheterizations.
      Alternatively, condom catheters may be considered in place of indwelling catheters in appropriately selected male patients without urinary retention or bladder outlet obstruction. A randomized trial demonstrated a decrease in bacteriuria, symptomatic UTI, or death in patients with condom catheters, when compared with those with indwelling catheters; the benefit was primarily seen in men without dementia.
      • Saint S.
      • Kaufman S.R.
      • Rogers M.A.
      • et al.
      Condom versus indwelling urinary catheters: a randomized trial.
      Condom catheters may also be less painful than indwelling catheters in some men.
      • Saint S.
      • Kaufman S.R.
      • Rogers M.A.
      • et al.
      Condom versus indwelling urinary catheters: a randomized trial.
      • Saint S.
      • Lipsky B.A.
      • Baker P.D.
      • et al.
      Urinary catheters: what type do men and their nurses prefer?.

      Aseptic techniques for insertion and maintenance of urinary catheters

      If urinary catheterization is necessary, aseptic catheter insertion and maintenance is essential for prevention of CAUTI. Urinary catheters should be inserted by a trained healthcare professional using aseptic technique.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Pratt R.J.
      • Pellowe C.
      • Loveday H.P.
      • et al.
      Guidelines for preventing infections associated with the insertion and management of short term indwelling urethral catheters in acute care.
      Cleaning the meatus before catheter insertion is recommended, but ongoing daily meatal cleaning using an antiseptic has not shown clear benefit and may increase rates of bacteriuria compared with routine care with soap and water.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      Lubricant jelly should be used for insertion to reduce urethral trauma; the jelly should be sterile but antiseptic properties are not necessary.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      Closed urinary catheter collection systems reduce the risk of CAUTI and have been the standard of care in the United States for many years. Opening the closed system should be avoided; sampling urine may be performed aseptically from a port or from the drainage bag when large samples are required.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      • Pratt R.J.
      • Pellowe C.
      • Loveday H.P.
      • et al.
      Guidelines for preventing infections associated with the insertion and management of short term indwelling urethral catheters in acute care.
      Prophylactic instillation of antiseptic agents or irrigation of the bladder with antimicrobial or antiseptic agents has been shown to increase infection and is not recommended.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      Reduction in bacteriuria associated with exchange of catheters is only transient, therefore routine exchange of urinary catheters is not recommended, except for mechanical reasons.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Pratt R.J.
      • Pellowe C.
      • Loveday H.P.
      • et al.
      Guidelines for preventing infections associated with the insertion and management of short term indwelling urethral catheters in acute care.
      Exchange of long-term catheters at the time of treatment of symptomatic UTI, however, is likely beneficial.
      • Raz R.
      • Schiller D.
      • Nicolle L.E.
      Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection.

      Use of anti-infective catheters

      Antiseptic-impregnated or antimicrobial-impregnated urinary catheters have been studied extensively as an adjunctive measure for preventing CAUTI.
      • Stensballe J.
      • Tvede M.
      • Looms D.
      • et al.
      Infection risk with nitrofurazone-impregnated urinary catheters in trauma patients: a randomized trial.
      • Schumm K.
      • Lam T.
      Types of urethral catheters for management of short-term voiding problems in hospitalised adults.
      • Johnson J.R.
      • Kuskowski M.A.
      • Wilt T.J.
      Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.
      Antimicrobial catheters are typically coated with nitrofurazone, minocycline, or rifampin, but other agents are being evaluated in newer catheters.
      In a large meta-analysis, silver alloy catheters were found to significantly reduce the incidence of asymptomatic bacteriuria in adult patients catheterized for less than 7 days, but the effect was diminished in those catheterized for greater than 7 days.
      • Schumm K.
      • Lam T.
      Types of urethral catheters for management of short-term voiding problems in hospitalised adults.
      Similarly, antibiotic-impregnated catheters were found to decrease the rate of asymptomatic bacteriuria in those catheterized for less than 7 days but demonstrated no benefit when the duration of catheterization was greater than 7 days.
      • Schumm K.
      • Lam T.
      Types of urethral catheters for management of short-term voiding problems in hospitalised adults.
      • Johnson J.R.
      • Kuskowski M.A.
      • Wilt T.J.
      Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.
      Few studies have evaluated antiseptic-coated and antibiotic-coated catheters in long-term urinary catheterization; thus, no conclusion can be drawn on use of anti-infective catheters in this setting.
      • Jahn P.
      • Preuss M.
      • Kernig A.
      • et al.
      Types of indwelling urinary catheters for long-term bladder drainage in adults.
      The use of anti-infective catheters may be considered when the rates of CAUTI remain persistently high despite adherence to other evidence-based practices or in patients deemed to be at high risk for CAUTI or its complications.
      Despite the fact that anti-infective urinary catheters seem to reduce bacteriuria in patients with short-term urinary catheterization, there is no convincing evidence that use of these catheters prevents CAUTI, UTI-related bloodstream infection, or mortality. Therefore, there is no recommendation for routine use of anti-infective urinary catheters to prevent CAUTI.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • et al.
      Healthcare Infection Control Practices Advisory Committee. (HICPAC). CDC Guideline for prevention of catheter-associated urinary tract infections 2009.
      A national mixed-methods study revealed that in 2009, 45% of nonfederal and 22% of Veteran Affairs hospitals used antimicrobial catheters; hospitals using anti-infective catheters often based their decisions on hospital-specific pilot studies.
      • Saint S.
      • Kowalski C.P.
      • Forman J.
      • et al.
      A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals.
      • Krein S.L.
      • Kowalski C.P.
      • Hofer T.P.
      • et al.
      Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009.
      Finally, systemic antimicrobial therapy reduces the risk of CAUTI.
      • Chenoweth C.E.
      • Saint S.
      Urinary tract infections.
      • Greene M.T.
      • Chang R.
      • Kuhn L.
      • et al.
      Predictors of hospital-acquired urinary tract-related bloodstream infection.
      However, because of issues of cost, potential adverse effects, and possible selection for MDRO, systemic antimicrobial therapy specifically for the purpose of preventing CAUTI is not recommended.
      • Dellit T.H.
      • Owens R.C.
      • McGowan Jr., J.E.
      • et al.
      Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.

      Implementation: the role of bundles and collaboratives

      Recently, “bundles” of interventions have been used with resounding success for prevention of several types of healthcare-associated infections. An example of a bundle applied to CAUTI prevention is the memory aide “ABCDE” outlined in Box 4.
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.
      This bundle for preventing CAUTI was successfully adopted by the Michigan Hospital Association Keystone initiative.
      • Fakih M.G.
      • Watson S.R.
      • Greene T.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      Finally, the important role of local hospital leadership and followership for ensuring effective implementation of preventive initiatives has recently been highlighted.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • et al.
      The importance of leadership in preventing healthcare-associated infection: results of a multistate qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • et al.
      How active resisters and organizational constipators affect health-care-acquired infection prevention efforts.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • et al.
      The role of the champion in infection prevention: results from a multisite qualitative study.
      The “ABCDE” for preventing catheter-associated urinary tract infection
      • Adherence to general infection control principles (eg, hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education) is important.
      • Bladder ultrasound may avoid indwelling catheterization.
      • Condom catheters or other alternatives to an indwelling catheter such as intermittent catheterization should be considered in appropriate patients.
      • Do not use the indwelling catheter unless you must!
      • Early removal of the catheter using a reminder or nurse-initiated removal protocol appears warranted.

      Summary

      CAUTIs are common, costly, and cause significant patient morbidity, especially in the ICU setting. CAUTIs are associated with hospital pathogens with a high propensity toward antimicrobial resistance. Despite studies showing benefit of interventions for prevention on CAUTI, many US healthcare facilities have not adopted these practices. Duration of urinary catheterization is the predominant risk for CAUTI; preventive measures directed at limiting placement and early removal of urinary catheters have a significant impact on decreasing CAUTI. Intervention bundles, collaboratives, and hospital leadership are powerful tools for implementation of preventive measures for healthcare-associated infections, including CAUTI.
      CAUTIs account for approximately 40% of all healthcare-associated infections. As urinary catheters account for most healthcare-associated UTIs, the most important interventions are directed at avoiding placement of urinary catheters and promoting early removal when appropriate. Alternatives to indwelling catheters such as intermittent catheterization and condom catheters should be considered. If indwelling catheterization is appropriate, proper aseptic practices for catheter insertion and maintenance and a closed catheter collection system is essential for prevention of CAUTI. The use of anti-infective catheters may also be considered when the rates of CAUTI remain persistently high despite adherence to other evidence-based practices or in patients deemed to be at high risk for CAUTI or its complications. Attention toward prevention of CAUTI will likely increase because CMS and other third-party payers no longer reimburse for hospital-acquired UTIs.

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