Table 1. Acceptable Indications for Indwelling Urinary Catheter Use

Reduction of Inappropriate Urinary Catheter Insertion and Duration

Limiting Unnecessary Catheterization

• Indwelling catheters should be placed only when they are indicated (A-III).
• Indwelling urinary catheters should not be used for the management of urinary incontinence (A-III). In exceptional cases when all other approaches to management
  of incontinence have not been effective, it may be considered at patient request.
• Institutions should develop a list of appropriate indications for inserting indwelling urinary catheters, educate staff about such indications, and periodically assess adherence to the institution-specific guidelines (A-III).
• Institutions should require a physician’s order in the chart before an indwelling catheter is placed (A-III).
• Institutions should consider use of portable bladder scanners to determine whether catheterization is necessary in post-operative patients (B-II).

Discontinuation of Catheter

• To reduce the risk of CA-bacteriuria (A-I) and CA-UTI (A-II), indwelling catheters should be removed as soon as they are no longer required.
• Institutions should consider nurse-based or electronic physician reminder systems to reduce inappropriate urinary catheterization (A-II) and CA-UTI (A-II).
• Institutions should consider automatic stop-orders to reduce inappropriate urinary catheterization (B-I).

Strategies to Consider Prior to Catheter Insertion

Infection Prevention

• Hospitals and long-term-care facilities should develop, maintain, and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies and replacement indications (A-III).
• Strategies should include education and training of staff relevant to these policies and procedures (A-III).
• Institutions may consider feedback of CA-bacteriuria rates to nurses and physicians on a regular basis to reduce the risk of CA-bacteriuria (C-II).
• Comment: Data are insufficient to make a recommendation as to whether such an intervention might reduce the risk of CA-UTI.
• Data are insufficient to make a recommendation as to whether institutions should place patients with indwelling urinary catheters in different rooms from other patients who have indwelling urinary catheters or other invasive devices to reduce the risk of CA-bacteriuria or CA-UTI.

Alternatives to Indwelling Urethral Catheterization

• In men for whom a urinary catheter is indicated and who have minimal post-void residual, condom catheterization should be considered as an alternative to short-term (A-II) and long-term (B-II) indwelling catheterization to reduce CA-bacteriuria in those who are NOT cognitively impaired.
• Comment: Data are insufficient to make a recommendation as to whether condom catheterization is preferable to short-term or long-term indwelling urethral catheterization for reduction of CA-UTI.
• Comment: Data are insufficient to make a recommendation as to whether condom catheterization is preferable to short-term or long-term indwelling urethral catheterization for reduction of CA-bacteriuria in those who are cognitively impaired.
• Intermittent catheterization should be considered as an alternative to short-term (C-I) or long-term (A-III) indwelling urethral catheterization to reduce CA-bacteriuria and an alternative to short-term (C-III) or long-term (A-III) indwelling urethral catheterization to reduce CA-UTI.
• Suprapubic catheterization may be considered as an alternative to
  short-term indwelling urethral catheterization to reduce CA-bacteriuria (B-I) and CA-UTI (C-III).
• Comment: Data are insufficient to make a recommendation as to whether suprapubic catheterization is preferable to long-term indwelling urethral catheterization OR whether intermittent catheterization is preferable to suprapubic catheterization for reduction of CA-bacteriuria or CA-UTI.

Insertion Technique for Indwelling Urethral Catheter

• Indwelling urethral catheters should be inserted using aseptic technique and sterile equipment (B-III).

Intermittent Catheterization Technique

• Clean (non-sterile) rather than sterile technique may be considered in the outpatient (A-III) and institutional (B-I) setting with no difference in risk of CA-bacteriuria or CA-UTI.
• Multiple-use catheters may be considered instead of sterile single-use catheters in the outpatient (B-III) and institutional (C-I) setting with no difference in risk of CA-bacteriuria or CA-UTI.
• Comment: Data are insufficient to make a recommendation as to whether one method of cleaning multiple-use catheters is superior to another.
• Hydrophilic catheters are NOT recommended for routine use to reduce the risk of CA-bacteriuria (B-II) or CA-UTI (B-II).
• Comment: Data are insufficient to make recommendations on whether use of portable bladder scanners or “no-touch” technique reduce the risk of CA-UTI compared with standard care.

Antimicrobial-Coated Catheters

• In patients with short-term indwelling urethral catheterization, antimicrobial (silver alloy or antibiotic)-coated urinary catheters may be considered to reduce or delay the onset of CA-bacteriuria (B-II).
• Comment: Data are insufficient to make a recommendation about whether use of such catheters reduces CA-UTI in patients with short-term indwelling urethral catheterization or reduces CA-bacteriuria or CA-UTI in patients with long-term catheterization.

Prevention Strategies to Consider After Catheter Insertion

Closed Catheter System

• A closed catheter drainage system, with ports in the distal catheter for needle aspiration of urine, should be used to reduce CA-bacteriuria
  (A-II) and CA-UTI (A-III) in patients with short-term indwelling urethral or suprapubic catheters, and to reduce CA-bacteriuria (A-III) and CA-UTI (A-III) in patients with long-term indwelling urethral or suprapubic catheters.
• Institution-specific strategies should be developed to ensure that disconnection of the catheter junction is minimized (A-III) and that the drainage bag and connecting tube are always kept below the level of the bladder (A-III).
• Use of a preconnected system (catheter preattached to the tubing of a closed drainage bag) may be considered to reduce CA-bacteriuria (C-II).
• Comment: Data are insufficient to make a recommendation as to whether such a system reduces CA-UTI.
• Use of a complex closed drainage system or application of tape at the catheter-drainage tubing junction after catheter insertion is NOT recommended to reduce CA-bacteriuria (A-I) or CA-UTI (A-III).

Prophylaxis

• Systemic antimicrobial prophylaxis should NOT be routinely used in short- (A-III) or long-term (A-II) catheterized patients, including surgical patients, to reduce CA-bacteriuria or CA-UTI because of concern about selection of antimicrobial resistance.
• Methenamine salts should NOT be used routinely to reduce CA-bacteriuria or CA-UTI in patients on chronic intermittent (A-II) or chronic indwelling urethral or suprapubic (A-III) catheterization.
• Comment: Data are insufficient to make a recommendation about the use of methenamine salts to reduce CA-UTI in patients with using condom catheterization.
• Methenamine salts may be considered for the reduction of CA-bacteriuria and CA-UTI in patients following gynecologic surgery who are catheterized for no more than 1 week (C-I). It is reasonable to assume that a similar effect would be seen following other types of surgery.
• Comment: Data are insufficient to make recommendations about whether one methenamine salt is superior to another.
• When using a methenamine salt to reduce CA-UTI, the urinary pH should be maintained below 6.0 (B-III).
• Comment: Data are insufficient to recommend how best to achieve a low urinary pH.
• Cranberry products should NOT be used routinely to reduce CA-bacteriuria or CA-UTI in patients with neurogenic bladders managed with intermittent or indwelling catheterization (A-II).
• Comment: Data are insufficient to make a recommendation on the use of cranberry products to reduce CA-bacteriuria or CA-UTI in other groups of catheterized patients, including those using condom catheters.

Enhanced Meatal Care

• Daily meatal cleansing with povidone-iodine solution, silver sulfadiazine, polyantibiotic ointment or cream, or green soap and water is NOT recommended for routine use in men or women with indwelling urethral catheters to reduce CA-bacteriuria (A-I).
• Comment: Data are insufficient to make a recommendation as to whether meatal cleansing reduces the risk of CA-UTI.

Catheter Irrigation

• Catheter irrigation with antimicrobials should NOT be used routinely to reduce or eradicate CA-bacteriuria (A-I) or CA-UTI (A-II) in patients with indwelling catheters.
• Catheter irrigation with antimicrobials may be considered in selected surgery patients undergoing short-term catheterization to reduce
  CA-bacteriuria (C-I).
• Comment: Data are insufficient to make a recommendation about whether bladder irrigation in such patients reduces CA-UTI.
• Catheter irrigation with normal saline should NOT be used routinely to reduce CA-bacteriuria, CA-UTI or obstruction in patients on long-term indwelling catheterization (B-II).

Antimicrobials in the Drainage Bag

• Routine addition of antimicrobials or antiseptics to the drainage bag of catheterized patients should NOT be used to reduce CA-bacteriuria (A-I)
  or CA-UTI (A-I).

Routine Catheter Change

• Data are insufficient to make a recommendation as to whether routine catheter change, such as every two to four weeks, in patients with functional long-term indwelling urethral or suprapubic catheters reduces the risk of CA-ASB or CA-UTI, even in patients who experience repeated early catheter blockage from encrustation.

Prophylactic Antimicrobials at Time of Catheter Removal or

Replacement

• Prophylactic antimicrobials, given systemically or by bladder irrigation, should NOT be administered routinely to patients at the time of catheter placement to reduce CA-UTI (A-I) or at the time of catheter removal (B-I) or replacement (AIII) to reduce CA-bacteriuria.
• Comment: Data are insufficient to make a recommendation as to whether prophylactic antimicrobials in such patients reduce bacteremia.

Screening and Treatment of CA-ASB in Catheterized Patients to Reduce CA-UTI

• Screening and treatment of CA-ASB are NOT recommended to reduce subsequent CA-bacteriuria or CA-UTI in patients with short-term (A-II) or
  long-term (A-I) indwelling urethral catheters.
• Screening and treatment of CA-ASB are NOT recommended to reduce subsequent CA-bacteriuria or CA-UTI in patients with neurogenic bladders managed with intermittent catheterization (A-II).
• Screening and treatment of CA-ASB are NOT recommended to reduce subsequent CA-bacteriuria or CA-UTI in other catheterized patients (A-III),
  except in pregnant women (A-III) and patients undergoing urologic procedures for which visible mucosal bleeding is anticipated (A-III).

Screening and Treatment of CA-ASB at Catheter Removal to Reduce CA-UTI

• Antimicrobial treatment of CA-ASB that persists 48 hours after short-term indwelling catheter removal in women may be considered to reduce the risk of subsequent CA-UTI (C-I).
• Comment: Data are insufficient, however, to make a recommendation as to whether
  all women should be uniformly screened for CA-ASB at catheter removal.
• Comment: Data are insufficient to make a recommendation about screening or treatment of persistent CA-ASB in men.

Urine Culture and Catheter Replacement Before Treatment

• A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed CA-UTI due to the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance (A-III).
• If an indwelling catheter has been in place for more than 2 weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to hasten resolution of symptoms and to reduce the risk of subsequent
  CA-bacteriuria and CA-UTI (A-I).
• The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy to help guide treatment (A-II).
  
• If the catheter can be discontinued, a voided midstream urine culture should be obtained prior to the initiation of antimicrobial therapy to help guide treatment (A-III).

Duration of Treatment

• Seven days is the recommended duration of antimicrobial treatment for patients with CA-UTI who have prompt resolution of symptoms (A-III), and 10 to 14 days is recommended in those with a delayed response (A-III), regardless of whether the patient remains catheterized or not.
• A 5-day regimen of levofloxacin may be considered in patients with CA-UTI who are not severely ill (B-III). Data are insufficient to make such a recommendation about other fluoroquinolones.
• A 3-day antimicrobial regimen may be considered for women age 65 or younger who develop CA-UTI without upper tract symptoms after an indwelling catheter has been removed (B-II).

Urinary Catheters