Prevention Strategies - Indwelling Urinary Catheters

Overview  |  Executive Summary
Summary of Recommendations  |  Appropriate Urinary Catheter Use
Proper Techniques for Urinary Catheter Insertion  |  Proper Techniques for Urinary Catheter Maintenance
Quality Improvement Programs  |  Administrative Infrastructure  |  Surveillance  |  Download  |  References

CAUTI Prevention:

The 2009 Centers for Disease Control and Prevention (CDC) guidelines for the prevention of catheter-associated urinary tract infections (UTIs) recommends catheter use only for appropriate indications. Catheter use and duration should be minimized in all patients, especially those at higher risk for catheter-associated UTIs (e.g., women, elderly persons, and patients with impaired immunity).

The 2009 CDC guidelines recommend that clinicians avoid using systemic antimicrobials routinely to prevent catheter-associated UTIs in patients requiring either short- or long-term catheterization.

Long-term catheterization increases patient satisfaction but also increases mechanical complications. Contraindications include bleeding disorders, previous lower abdominal surgery or irradiation, and morbid obesity. Intermittent catheterization is an option, but most patients become bacteriuric within a few weeks; the incidence of bacteriuria is 1 to 3% per insertion.

According to the 2009 IDSA guidelines, if an indwelling catheter has been in place for more than 2 weeks at the onset of catheter-associated UTI and remains indicated, the catheter should be replaced to promote continued resolution of symptoms and to reduce the risk of subsequent catheter-associated infection.

Best practices should be followed for the prevention of health-care associated infections. UTIs are the most common hospital-acquired infections, with most attributed to the use of an indwelling catheter. Health-care providers should first ensure that there is a medical necessity or an indication for placement of a urinary catheter.

Aseptic indwelling catheter insertion, a properly maintained closed-drainage system (with ports in the distal catheter for needle aspiration of urine), and unobstructed urine flow are essential for prevention of UTIs. Because many of these infections occur in clusters, good hand washing before and after catheter care is essential.

Urinary catheters coated with silver alloy also reduce the risk of infection. An alternative is to use the Lubricath (Bard Medical, Covington, GA), which has a hydrophilic coating that decreases tissue irritation and nosocomial UTIs. It is reasonable to use these more expensive catheters in patients who are at high risk.

The 2009 Infectious Diseases Society of America (IDSA) guidelines advise against the routine addition of antimicrobials or antiseptics to the drainage bag of patients who are catheterized in an effort to reduce the risk of catheter-associated bacteriuria or catheter-associated UTI.

The Executive Summary and the Summary of Recommendations from the CDC 2009 Guidelines follow: 

Executive Summary

This guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI) published in 1981. Several developments necessitated revision of the 1981 guideline, including new research and technological advancements for preventing CAUTI, increasing need to address patients in non-acute care settings and patients requiring long-term urinary catheterization, and greater emphasis on prevention initiatives as well as better defined goals and metrics for outcomes and process measures. In addition to updating the previous guideline, this revised guideline reviews the available evidence on CAUTI prevention for patients requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (e.g., intermittent catheterization). The revised guideline also includes specific recommendations for implementation, performance measurement, and surveillance. Although the general principles of CAUTI prevention have not changed from the previous version, the revised guideline provides clarification and more specific guidance based on a defined, systematic review of the literature through July 2007. For areas where knowledge gaps exist, recommendations for further research are listed. Finally, the revised guideline outlines high-priority recommendations for CAUTI prevention in order to offer guidance for implementation.

This document is intended for use by infection prevention staff, health- care epidemiologists, health-care administrators, nurses, other health-care providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for health-care settings across the continuum of care. The guideline can also be used as a resource for societies or organizations that wish to develop more detailed implementation guidance for the prevention of CAUTI.

Our goal was to develop a guideline based on a targeted systematic review of the best available evidence, with explicit links between the evidence and recommendations. To accomplish this, we used an adapted GRADE system approach for evaluating quality of evidence and determining strength of recommendations. The methodology, structure, and components of this guideline are approved by HICPAC and will be used for subsequent guidelines issued by HICPAC.

To evaluate the evidence on preventing CAUTI, we examined data addressing 3 key questions and related subquestions:

1. Who should receive urinary catheters?
   1. When is urinary catheterization necessary?
   2. What are the risk factors for CAUTI?
   3. What populations are at highest risk of mortality related to urinary catheters?
2. For those who may require urinary catheters, what are the best practices? Specifically, what are the risks and benefits associated with:
   1. Different approaches to catheterization?
   2. Different catheters or collecting systems?
   3. Different catheter management techniques?
   4. Different systems interventions (i.e., quality improvement programs)?
3. What are the best practices for preventing CAUTI associated with obstructed urinary catheters?

Evidence addressing the key questions was used to formulate recommendations, and explicit links between the evidence and recommendations are available in the Evidence Review in the body of the guideline and Evidence Tables and GRADE Tables in the Appendices. It is important to note that category I recommendations are all considered strong recommendations and should be equally implemented; it is only the quality of the evidence underlying the recommendation that distinguishes between levels A and B. Category IC recommendations are required by state or federal regulation and may have any level of supporting evidence.

The categorization scheme used in this guideline is presented in Table 1 in the Summary of Recommendations and described further in the Methods section.

The Summary of Recommendations is organized as follows: 1) recommendations for who should receive indwelling urinary catheters (or, for certain populations, alternatives to indwelling catheters); 2) recommendations for catheter insertion; 3) recommendations for catheter maintenance; 4) quality improvement programs to achieve appropriate placement, care, and removal of catheters; 5) administrative infrastructure required; and 6) surveillance strategies.

The Implementation and Audit section includes a prioritization of recommendations (i.e., high-priority recommendations that are essential for every health care facility), organized by modules, in order to provide facilities more guidance for the implementation of these guidelines. A list of recommended performance measures that can potentially be used for internal reporting purposes is also included.

Areas in need of further research identified during the evidence review are outlined in the Recommendations for Further Research. This section includes guidance for specific methodological approaches that should be used in future studies.

Readers who wish to examine the primary evidence underlying the recommendations are referred to the Evidence Review in the body of the guideline, and the Evidence Tables and GRADE Tables in the Appendices. The Evidence Review includes narrative summaries of the data presented in the Evidence Tables and GRADE Tables. The Evidence Tables include all study-level data used in the guideline, and the GRADE Tables assess the overall quality of evidence for each question. The Appendices also contain a clearly delineated search strategy that will be used for periodic updates to ensure that the guideline remains a timely resource as new information becomes available.

2009 Cauti Guidelines (407 KB / 67 pages) and Appendices (4.41 MB / 268 pages) are available for download in PDF format.

Summary of Recommendations

Table 1. Modified HICPAC Categorization Scheme* for Recommendations

                      I                      I. Proper Techniques for Urinary Catheter Insertion

1. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. (Category IB) (Key Question 2D)
2. Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB) (Key Question 1B)
3. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. (Category IB) 
   
   1. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. (Category IB)
   2. Routine use of antiseptic lubricants is not necessary. (Category II) (Key Question 2C)
   3. Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue) (Key Question 2C)
4. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization.(Category IA) (Key Question 2A) 
   
   1. Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization. (No recommendation/unresolved issue) (Key Question 2C)
5. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Category IB)
6. Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. (Category II)
7. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. (Category IB) (Key Question 2A)
8. Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II) (Key Question 2C) 
   
   1. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. (Category IB)

                      III. Proper Techniques for Urinary Catheter Maintenance

1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Category IB) (Key Question 1B and 2B) 
   
   1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. (Category IB)
   2. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. (Category II) (Key Question 2B)
2. Maintain unobstructed urine flow. (Category IB) (Key Questions 1B and 2D)
   1. Keep the catheter and collecting tube free from kinking. (Category IB)
   2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Category IB)
   3. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. (Category IB)
3. Use standard precautions, including the use of gloves and gowns as appropriate, during any manipulation of the catheter or collecting system. (Category IB)
4. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use. (Category II) (Key Question 2B)
5. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) (Key Question 2C)
6. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization. (Category IB) (Key Question 2C)
   
   1. Further research is needed on the use of urinary antiseptics (e.g., methenamine) to prevent UTI in patients requiring short-term catheterization. (No recommendation/unresolved issue) (Key Question 2C)
7. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. (Category IB) (Key Question 2C)
8. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. (Category II) (Key Question 2C)
   
   1. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. (Category II)
9. Routine irrigation of the bladder with antimicrobials is not recommended. (Category II) (Key Question 2C)
10. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Category II) (Key Question 2C)
11. Clamping indwelling catheters prior to removal is not necessary. (Category II) (Key Question 2C)
12. Further research is needed on the use of bacterial interference (i.e., bladder inoculation with a nonpathogenic bacterial strain) to prevent UTI in patients requiring chronic urinary catheterization. (No recommendation/unresolved issue) (Key Question 2C)

Catheter Materials

1. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (see Section III. Implementation and Audit). (Category IB) (Key Question 2B)
   
   1. Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters. (No recommendation/unresolved issue) (Key Question 2B)
2. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization. (Category II) (Key Question 2B)
3. Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (Category II) (Key Question 3)
4. Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications. (No recommendation/unresolved issue) (Key Question 2B)

Management of Obstruction

1. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. (Category IB)
2. Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. (No recommendation/unresolved issue) (Key Question 3)
3. Further research is needed on the use of a portable ultrasound device to evaluate obstruction in patients with indwelling catheters and low urine output. (No recommendation/unresolved issue) (Key Question 2C)
4. Further research is needed on the use of methenamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. (No recommendation/unresolved issue) (Key Question 2C)

Specimen Collection

1. Obtain urine samples aseptically. (Category IB)
   
   1. If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Category IB)
   2. Obtain the large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Category IB)

Spatial Separation of Catheterized Patients

1. Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems. (No recommendation/unresolved issue) (Key Question 2D)

                      IV. Quality Improvement Programs

1. Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment. (Category IB) (Key Question 2D) The purposes of QI programs should be: 1) to assure appropriate utilization of catheters 2) to identify and remove catheters that are no longer needed (e.g., daily review of their continued need) and 3) to ensure adherence to hand hygiene and the proper care of catheters. Examples of programs that have been demonstrated to be effective include:
   1. A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization
   2. Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters
   3. Education and performance feedback regarding appropriate use, hand hygiene, and catheter care
   4. Guidelines and algorithms for appropriate peri-operative catheter management, such as:
      1. Procedure-specific guidelines for catheter placement and postoperative catheter removal
      2. Protocols for the management of postoperative urinary retention, such as the nurse-directed use of intermittent catheterization and the use of bladder ultrasound scanners

                      V. Administrative Infrastructure

1. Provision of guidelines
   
   1. Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance. (Category IB)
      
      1. Consider monitoring adherence to facility-based criteria for acceptable indications for indwelling urinary catheter use. (Category II)
2. Education and Training
   
   1. Ensure that health care personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters. (Category IB)
   2. When feasible, consider providing performance feedback to these personnel on what proportion of catheters they have placed meet facility-based criteria and other aspects related to catheter care and maintenance. (Category II)
3. Supplies
   
   1. Ensure that supplies necessary for aseptic technique for catheter insertion are readily available. (Category IB)
4. System of documentation
   
   1. Consider implementing a system for documenting the following in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal. (Category II)
      
      1. Ensuring that documentation is accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes is suggested. Electronic documentation that is searchable is preferable. (Category II)
5. Surveillance resources
   
   1. If surveillance for CAUTI is performed, ensure that there are sufficiently trained personnel and technology resources to support surveillance for urinary catheter use and outcomes. (Category IB)

                      VI. Surveillance

1. Consider surveillance for CAUTI when indicated by facility-based risk assessment. (Category II)
   
   1. Identify the patient groups or units on which to conduct surveillance based on frequency of catheter use and potential risk of CAUTI.
2. Use standardized methodology for performing CAUTI surveillance. (Category IB)
   
   1. Examples of metrics that should be used for CAUTI surveillance include:
      
      1. Number of CAUTI per 1000 catheter days
      2. Number of bloodstream infections secondary to CAUTI per 1000 catheter days
      3. Catheter utilization ratio: (urinary catheter days/patient days) x 100
   2. Use CDC/NHSN criteria for identifying patients who have symptomatic UTI (SUTI) (numerator data) (see NHSN Patient Safety Manual: http://www.cdc.gov/nhsn/library.html).
   3. For more information on metrics, please see the U.S. Department of Health & Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections: http://www.hhs.gov/ophs/initiatives/hai/infection.html.
3. Routine screening of catheterized patients for asymptomatic bacteriuria (ASB) is not recommended. (Category II) (Key Question 2D)
4. When performing surveillance for CAUTI, consider providing regular (e.g., quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff. (Category II) (Key Question 2D)                      

 

References:

1. Vergidis P. and R. Patel. Novel approaches to the diagnosis, prevention, and treatment of medical device-associated infections. Infect Dis Clin North Am, 2012, 26(1): 173-186.
2. [Guideline] Gould C.V, C. A. Umscheid, et al. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol, 2010, 31(4): 319-326. 
3. [Guideline] Hooton TM, SF Bradley, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis, 2010, 50(5) :625-663.
4. (2011). "New infection-related National Patient Safety Goal for 2012: catheter-associated urinary tract infections pose high risk." Jt Comm Perspect 31(7): 6-7.
5. Joint Commission on Accreditation of Healthcare Organizations. Approved: New infection-related National Patient Safety Goal for 2012: catheter-associated urinary tract infections pose high risk. Jt Comm Perspect. 2011 Jul;31(7):6-7
6. Lo E, L Nicolle, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals." Infect Control Hosp Epidemiol, 2008, 29 Suppl 1: S41-S50.
7. Munasinghe RL, H Yazdani, et al. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol, 2001, 22(10): 647-649.