1. Definition.

The definition of catheter-associated urinary tract infections (CAUTI) according to the CDC is a UTI where an indwelling urinary catheter was in place for more than two calendar days on the date of event (day 1 being the day of device placement).

2. Burden of disease.

Catheter-associated urinary tract infections (CAUTI) are the most prevalent health-care associated infections (HAIs) accounting for one third (27%) of HAIs in developed countries according to the ECDCs annual report from 2008. The attributable mortality of CAUTI is low but the high frequency of catheter use in health care settings resulting in CAUTI, means that the burden of CAUTI is substantial with regard to prolonged hospital stays and increased antibiotic use. According to European studies, 15-25% of hospitalised patients and 5% of patients in elderly homes have a urinary catheter. More studies estimate that 41-58% of catheters in place are probably unnecessary. The risk for CAUTI increases by 5% for each day with a catheter. The annual costs for CAUTI accounts for £ 99 million every year (£ 1968 per episode) in the United Kingdom. A strong leadership and a systematic approach engaging all healthcare staff are crucial in order to achieve maximum effect.

 

3. How to prevent-specific requirements.

In addition to standard measures for the prevention of health-care associated infections (HAIs) described elsewhere  up to 70% of CAUTI can be prevented by following evidence-based guidelines focusing on the catheter use [1]. A bundling strategy using selected evidence based activities undertaken simultaneously, can reduce significantly the incidence of CAUTI as well as the use of urinary tract catheter-days. Such bundled actions should focus on five clearly defined activities [2-4]:

  • Avoid unnecessary urinary tract catheterisation by providing access to an evidence-based list of indications;
  • Selection of catheter-material and size;
  • Aseptic insertion techniques;
  • Aseptic maintenance routines;
  • Assess the need for maintaining the urinary catheter on a daily basis during rounds and promptly remove unnecessary urinary catheters. 

3.1 Avoid unnecessary urinary catheterisation.

Minimize urinary catheter use and consider alternatives, for example suprapubic catheters, intermittent catheterisation, external condom catheters for males and diapers. Avoid bladder distension. Use portable bedside ultrasound device to assess urine volume. Make the indication for the urinary catheters clear among doctors and nurses. Urinary catheterisation is indicated in the following cases:

  1. Acute urinary retention with or without obstruction;
  2. Critically ill patients in need of precise measurement of urinary output;
  3. During urological surgery;
  4. Preoperatively for example in long operations, urologic surgery, large infusions during surgery;
  5. Prolonged immobilization for example in cases with pelvic fractures and unstable thorax;
  6. Improve comfort at end of life care;
  7. Painful pressure ulcers and other wounds in genital area.

Clearly document the clinical indication for the urinary catheter, the time and date of insertion, the expected duration, the type of catheter and drainage system. Also note the planned date of removal of the catheter and the reasons for keeping the catheter.

3.2 Selection of catheter-material and size.

Use as small a catheter as possible ensuring proper drainage, to minimize trauma and risk of infection.

3.3 Aseptic insertion techniques.

  • Insert catheters following aseptic techniques using sterile equipment;
  • Perform hand hygiene before and after insertion or any manipulation of the catheter device or site;
  • Gloves, drape and sponges should be sterile;
  • Use a single-use packet of sterile lubricant jelly for insertion to minimise urethral trauma and discomfort;
  • Urethral meatus cleaned with soap and water or sterile saline (0,9% NaCl).

3.4 Aseptic maintenance routines.

  • Perform hand hygiene before and after any manipulation of the catheter device or the collecting bag;
  • Maintain a sterile, continuously closed drainage system with a sampling port;
  • Keep catheter properly secured to prevent movement and urethral traction;
  • Keep collection bag below the level of the bladder at all times to prevent reflux;
  • Maintain unobstructed urine flow and keep the catheter and collecting tube free from kinking;
  • Empty collection bag when filled ¾ to prevent reflux, using a clean collecting container for each patient, using appropriated hand hygiene, non-sterile gloves and gown. Avoid splashing and use goggles and a protective mask if necessary;
  • Avoid contact of the draining spigot with the collecting container; 
  • Routine daily personal hygiene is all that is required for meatal and perineal cleansing;
  • Collect urinary samples for cultures by aspirating urine from the needle-less sample port with a sterile syringe after disinfecting the port. Obtain larger volumes for special analyses aseptically from the tap of the drainage bag;
  • Only change bag and catheter based on clinical indication such as infection, leakage, obstruction and when collecting system is damaged;
  • If bladder irrigation is necessary due to anticipated obstruction, use closed continuous irrigation systems. 

3.5 Daily review of urinary-catheter.

  • Revise the need of catheter at daily rounds;
  • Apply effective reminder systems to remove catheter, for example alerts and reminders for doctors or  automatic stop orders 48-72 hours after insertion;
  • If the catheter is judged to stay, clearly document why it is still in place and when is should be removed.

References.

  1. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection control and hospital epidemiology. 2011;32(2):101-14.
  2. Institute for healthcare improvement IHI. How to guide: Prevent catheter-associated uirnary tract infections. Available from: www.ihi.org. 2011 [accessed 5th April 2016]
  3. Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. The Journal of hospital infection. 2014;86 Suppl 1:S1-70.
  4. Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection control and hospital epidemiology. 2014;35(5):464-79.

Originally contributed by Birgitta Lytsy (Department of clinical microbiology and infection control, Uppsala University Hospital, Sweden)