Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute-Care Hospitals
Publication Date: August 24, 2023
Last Updated: November 15, 2023
Recommendations
Recommendations to Prevent CAUTI (Table 1)
Essential Practices
Infrastructure and resources
1. Perform a CAUTI risk assessment and implement an organization-wide program to identify and remove catheters that are no longer necessary using 1 or more methods documented to be effective.
- Develop and implement institutional policy requiring periodic, usually daily, review of the necessity of continued catheterization.
- Consider utilizing electronic or other types of reminders (see Supplementary Content, Appendices 2 [https://doi.org/10.1017/ice.2023.137] and 3 [https://doi.org/10.1017/ice.2023.137]) online) of the presence of a catheter and required criteria for continued use.
- Conduct daily review during rounds of all patients with urinary catheters by nursing and physician staff to ascertain necessity of continuing catheter use.
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2. Provide appropriate infrastructure for preventing CAUTI.
- Ensure that the supplies for following best practices for managing urinary issues are readily available to staff in each unit, including bladder scanners, non-catheter incontinence management supplies (urinals, garments, bed pads, skin products), male and female external urinary catheters, straight urinary catheters, and indwelling catheters including the option of catheters with coude tips.
- Ensure that non-catheter urinary management supplies are as easy to obtain for bedside use as indwelling urinary catheters.
- Ensure the physical capability for urinary catheters with tubes attached to patients (eg, indwelling urinary catheters, some external urinary catheters [EUCs]) to be positioned on beds, wheelchairs, at an appropriate height and without kinking for patients in their rooms and during transport.
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3. Provide and implement evidence-based protocols to address multiple steps of the urinary catheter life cycle (Fig. 1): catheter appropriateness (step 0), insertion technique (step 1), maintenance care (step 2), and prompt removal (step 3) when no longer appropriate.
- Adapt and implement evidence-based criteria for acceptable indications for indwelling urethral catheter use, which may be embedded as standardized clinical-decision support tools within electronic medical record (EMR) ordering systems. Expert-consensus-derived indications for indwelling catheter use have been developed, although there is limited research that assesses the appropriateness of these uses.
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4. Ensure that only trained healthcare personnel (HCP) insert urinary catheters and that competency is assessed regularly.
- Require supervision by experienced HCP when trainees insert and remove catheters to reduce the risk of infectious and traumatic complications related to urinary catheter placement.
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5. Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located. (L)
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6. Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal and justification for continued use.
- Record in a standard format for data collection and quality improvement purposes and keep accessible documentation of catheter placement (including indication) and removal.
- If available, utilize electronic documentation that is searchable.
- Consider nurse-driven urinary catheter removal protocols for first trial of void without an indwelling catheter when the indication for placement has resolved (see Essential Practices, 3).
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7. Ensure that sufficiently trained HCP and technology resources are available to support surveillance for catheter use and outcomes. (L)
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8. Perform surveillance for CAUTI if indicated based on facility risk assessment or regulatory requirements. (L)
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9. Standardize urine culturing by adapting an institutional protocol for appropriate indications for urine cultures in patients with and without indwelling catheters. Consider incorporating these indications into the EMR, and review indications for ordering urine cultures in CAUTI risk assessment. (L)
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Education and training
1. Educate HCP involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters, and procedures for catheter insertion, management, and removal. (L)
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2. Assess healthcare professional competency in catheter use, catheter care, and maintenance. (L)
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3. Educate HCP about the importance of urine-culture stewardship and provide indications for urine cultures.
- Consider requiring clinicians to identify an appropriate indication for urine culturing when placing an order for a urine culture.
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4. Provide training on appropriate collection of urine. Specimens should be collected and arrive at the microbiology lab as soon as possible, preferably within an hour. If delay in transport to the laboratory is expected, samples should be refrigerated (no more than 24 hours) or collected in preservative urine transport tubes. (L)
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5. Train clinicians to consider other methods for bladder management such as intermittent catheterization, or external male or female collection devices, when appropriate before placing an indwelling urethral catheter. (L)
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6. Share data in a timely fashion and report results to appropriate stakeholders. (L)
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Insertion of indwelling catheters
1. Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain. (M)
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2. Consider other methods for bladder management such as intermittent catheterization, or external male or female collection devices, when appropriate. (L)
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3. Use appropriate technique for catheter insertion. (M)
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4. Consider working in pairs to help perform patient positioning and monitor for potential contamination during placement. (L)
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5. Practice hand hygiene (based on CDC or World Health Organization [WHO] guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus. (L)
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6. Insert catheters following aseptic technique and using sterile equipment. (L)
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7. Use sterile gloves, drape, and sponges, a sterile antiseptic solution for cleaning the urethral meatus, and a sterile single-use packet of lubricant jelly for insertion. (L)
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8. Use a catheter with the smallest feasible diameter consistent with proper 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, sometimes traumatic, catheterization attempts. (L)
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Management of indwelling catheters
1. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (L)
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2. Maintain a sterile, continuously closed drainage system. (L)
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3. Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur. (L)
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4. For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant. (L)
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5. Facilitate timely transport of urine samples to laboratory. If timely transport is not feasible, consider refrigerating urine samples or using sample collection cups with preservatives. Obtain larger volumes of urine for special analyses (eg, 24-hour urine) aseptically from the drainage bag. (L)
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6. Maintain unobstructed urine flow.
- Remind bedside caregivers, patients, and transport personnel to always keep the collecting bag below the level of the bladder.
- Do not place the bag on floor.
- Keep the catheter and collecting tube free from kinking, which can impair urinary flow and increase stasis within the bladder, increasing infection risk.
- Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container.
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7. Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is an unresolved issue, though emerging literature supports chlorhexidine use prior to catheter insertion. Alcohol-based products should be avoided given concerns about the alcohol causing drying of the mucosal tissues. (L)
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Additional Approaches
1. Develop a protocol for standardizing diagnosis and management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners when appropriate as alternatives to indwelling urethral catheterization.
- If bladder scanners are used, clearly state indications, train nursing staff in their use, and disinfect between patients according to the manufacturer’s instructions.
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2. Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use.
- Use cumulative attributable difference to identify high-risk units or hospitals.
- Measure process and outcomes measures (eg, standardized utilization ratio and standardized infection ratio).
- Define and monitor catheter harm in addition to CAUTI, including catheter obstruction, unintended removal, catheter trauma, or reinsertion within 24 hours of removal.
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3. Establish a system for defining, analyzing, and reporting data on non-catheter-associated urinary tract infections (UTIs), particularly UTIs associated with the use of devices being used as alternatives to indwelling urethral catheters.
- Non-catheter-associated UTIs are defined as UTIs that occur in hospitalized patients without an indwelling urethral catheter. These include but are not limited to patients that have had no urinary device at all, as well as those with EUCs, urinary stents, or urostomies, or who undergo intermittent catheterization, that are not captured by the National Healthcare Safety Network (NHSN) CAUTI definition.
- As the incidence of CAUTI continues to decline, the proportion of non-catheter-associated UTIs is increasing in some hospitals. However, the national incidence of non-catheter-associated UTIs is not known, as surveillance and reporting of these UTIs are not required by US federal agencies.
- As non-catheter-associated UTIs are a common indication for antibiotics in hospitalized patients, this metric could provide important information as healthcare facilities consider the risks and benefits of newer alternatives to urinary catheters with currently limited published data on adverse events (eg, EUCs for women) to help inform when the benefit outweighs the potential risk for specific patient populations.
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Approaches that Should Not be Considered a Routine Part of CAUTI
1. Routine use of antimicrobial/antiseptic impregnated catheters. (H)
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2. Breaking a closed system. (L)
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3. Screening for asymptomatic bacteriuria in catheterized patients except in the few patient populations for which this is anticipated to have more benefit than harm, as detailed in the 2019 IDSA Guideline for Management of Asymptomatic Bacteriuria and the 2019 US Preventative Services Task Force Recommendation on Asymptomatic Bacteriuria in Adults (eg, pregnant women, patients undergoing endoscopic urologic procedures associated with mucosal trauma).
- Treatment of asymptomatic bacteriuria is not an effective strategy to prevent CAUTI in other patient groups, as it increases the risk of antibiotic-associated complications more than any potential benefit for the prevention of symptomatic CAUTI. The conditions that predisposed the patient to have bladder colonization (anatomic, immunologic) are not resolved by antibiotics, and so the bacteriuria recurs.
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4. Catheter irrigation as a strategy to prevent infection.
- Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure.
- If continuous irrigation is being used to prevent obstruction, maintain a closed system.
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5. Routine use of systemic antimicrobials as prophylaxis. (L)
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6. Routine changing of catheters to avoid infection.
- The case of a patient with a long-term catheter in place (ie, >7 days), catheter replacement can be considered at the time of specimen collection for urine testing to obtain a fresh sample.
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7. Alcohol-based products on the genital mucosa. (L)
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Unresolved Issues
- Use of antiseptic solution versus sterile saline for meatal and perineal cleaning prior to catheter insertion.
- Use of urinary antiseptics (eg, methenamine) to prevent UTI.
- Spatial separation of patients with urinary catheters in place to prevent transmission of pathogens that could colonize urinary drainage systems.
- Standard of care for routine replacement of urinary catheters in place >30 days for infection prevention.
- Best practices for optimizing and tailoring implementation of CAUTI prevention and urine-culture stewardship from the adult acute-care setting to the pediatric acute-care setting.
Overview
Title
Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute-Care Hospitals
Authoring Organizations
Infectious Diseases Society of America
Society for Healthcare Epidemiology of America