Prevention of Catheter-associated Urinary Tract Infections through Evidence-based Management of Indwelling Urinary Catheters in Adult Patients

Urologic nursing management of transurethral or suprapubic (SP) indwelling urinary catheters (IUCs) require an understanding of management and complications that can occur with short and long term use and in different care settings. Catheters in place for <30 day (short-term) are primarily seen in inpatients in acute care and rehabilitation settings.Catheters in place for long-term bladder drainage may be seen in residents in a nursing home (NH) or in individuals in the community who receive routine visits by a home care nurse. There is also a population of patients, with short- or long-term IUCs, who are routinely seen in urology offices for IUC changes and management. It is imperative for health care professionals be knowledgeable about IUC management and be able to implement strategies for prevention of any catheter-related problems, particularly catheter-associated urinary tract infections (CAUTIs).

The current evidence-base and clinical practice recommendations for short and long-term management of IUCs is detailed here. There is evidence to support IUC care practice through the four stages: 1) placement, 2) care, 3) removal and 4) re-insertion of the lifecycle of an IUC as depicted in this Figure.


Prevalence: Approximately 12-16% of hospitalized patients receive a short-term IUC. Twelve to sixteen percent of adult hospitalized patients will have a urinary catheter at some time during admission. Although the overall prevalence of long-term IUC use is unknown, up to 13% of men and 12% of women have an IUC on admission to a NH and a UTI is one of the leading causes of infection among this population (Castle et al, 2017; Tsan et al, 2010; Rogers et al., 2008). Nursing home residents are often catheterized for months or longer (Gibson et al, 2019). Nine percent of older community-dwelling persons in the U.S. receiving home care (2007-2012) reported using a urinary catheter to manage urinary incontinence (UI). In a study of 220, community-based highly disable patients with an IUC, 56% had transurethral catheters and 44% had a SP catheter (Wilde, McDonald, et al., 2013). These catheters were in situ for a mean of 6 years (SD 7 years).

Catheter-associated urinary tract infections: A urinary tract infection (UTI) comprise approximately 36% of all healthcare-associated infections and 70-80% of UTIs are CAUTIs, making it one of the most common IUC-related complication. According to the Infectious Diseases Society of America (IDSA), a CAUTI refers to an infection occurring in a person whose urinary tract is currently catheterized or has been catheterized within the previous 48 hours. A CAUTI is directly related to catheter dwell time as the daily risk of acquisition of bacteriuria caries from 3% to 7% (Lo et al, 2014). A transurethral IUC may put the patient at a higher risk for developing a CAUTI than a SP catheter. A CAUTI is preventable in 55-70% of hospitalized patients if specific evidence-based, patient-centered strategies are implemented.
When assessing a IUC patient for a CAUTI, it is important to understand the following terms of findings in urine.

    • Bacteriuria is the presence of bacteria in urine, the incidence of bacteriuria is 3-7% per day of IUC in situ and nearly 100% of individuals with IUCs will have bacteriuria after one month. It is more common in older adults and females. Bacteriuria is a nonspecific term that refers to UTI and asymptomatic bacteriuria (ASB) combined.
  • Asymptomatic bacteriuria (ASB) refers to significant bacteriuria (on microscopy or culture) and approximately 75% to 90% of patients with ASB do not have signs and symptoms to suggest infection. In the urinary catheter literature, CA-bacteriuria is comprised mostly of CA-ASB and the overuse of antibiotics in the treatment of ASB has been identified as contributing to antibiotic resistance in these patients. Therefore, routine screening for ASB in catheterized patients is not recommended (Gould et al., 2009).
  • Pyuria is presence of white blood cells (WBCs) in a urine specimen with > 10WBCs per high-powered field using urine microscopy and is considered a significant UTI.

Indwelling urinary catheters provide a portal of entry for bacteria which quickly become colonized with microorganisms after insertion. Bacteria can establish colonization of a patient’s bladder by one of two routes: introduction into the urinary tract via the internal or intraluminal (34%), which can occur in a short period of time (< 7days) or external or extraluminal (66%) surface of IUCs (longer period of time > 7 days). This Figure notes the characteristics of each method of bacteria ascension into a IUC


This Figure depicts specific evidence-based IUC nursing care strategies for prevention of a CAUTI.


IUC Care and Management: There are specific practice recommendations for managing an IUC and preventing a CAUTI with rationale for ensuring best practices for short and long-term IUCs. Unless indicated otherwise, these recommendations are based on guidelines and recommendations from regulatory (Centers for Disease Control and Prevention [CDC] Healthcare Infection Control Practices Advisory Committee [HICPAC], Agency for Healthcare Research and Quality [AHRQ], The Joint Commission) and professional organizations (American Hospital Association, American Nurses Association (ANA), American Urologic Association, IDSA, American for Professionals in Infection Control and Epidemiology [APIC], Society for Healthcare Epidemiology of America, Association of Asia and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection).  The CDC guidelines provide recommendations for catheter use, catheter insertion, catheter care, and implementation of programs to prevent CAUTI.  The AHRQ has online resources to assist caregivers in long term care ( The majority of IUC-related recommendations from evidence-based practice guidelines for the prevention of CAUTI has shown a positive impact on CAUTI rates and decreases in the duration of IUC placement without increasing use of other resources. Initially, these guidelines were designed for the acute care setting but are now recommended for other settings including community-based home care, nursing homes and rehabilitation facilities.

Nursing care management that includes patient education is a major component of IUC care and prevention of catheter-related complications (e.g. CAUTI). However, there are few instruments available that measure healthcare provider’s knowledge of CAUTI prevention (Abubakar et al, 2021).

Education can alleviate the fear and anxiety commonly experienced by patients living with an IUC. A systematic scoping review by Alex and colleagues (2020) on the impact of educational interventions for patients with an IUC found inadequate information on self-management was provided to patients and their caregivers. Here are best practices for care of individuals requiring an IUC in any care setting (acute, community and long term care).

Practice RecommendationRationale
Surveillance of Appropriateness of IUC
  • Institute a surveillance program to track IUC use and CAUTIs.
  • Implement the use of IUC surveillance programs that includes checklists, electronic monitoring and reminders and automatic “stop orders”.
  • Identify CAUTI champions (e.g. nurses, doctors).
  • A multidisciplinary collaborative surveillance approach that includes daily monitoring has been shown to reduce IUC use and ultimately CAUTIs. These programs have also been shown to: prevent infections and other IUC-related complications, reduce antimicrobial use and multidrug-resistant organisms, and enhance patient/resident safety.
  • Nurse-driven algorithms with automatic IUC removal (stop) orders have been instituted in acute care hospitals and shown to decrease the incidence of CAUTIs and catheter-use (Russell et al, 2019). Unnecessary IUCs are removed and CAUTI rates decrease when physician and nurse reminders and prewritten catheter stop orders are implemented (Meddings et al, 2014)
  • CAUTI champions can provide staff education and support and implement IUC prevention programs.
  • Establish a catheter care bundle of education, catheter insertion/management guidelines, and surveillance
  • Institute a facility-wide catheter care bundle (Table 1) to guide nursing management and promote best practices for CAUTI prevention.
  • Consider a “technical bundle” to decrease CAUTIs in LTC
  • Following a catheter care bundle will insure evidence-based practices for IUC and nursing management strategies to reduce CAUTI (Bernard et al., 2012; Carter et al., 2014; Saint et al., 2009).
  • Mody et al., 2017 reported on the success of a “technical bundle” that included catheter removal, aseptic insertion, using regular assessments and feedback, training for catheter care, and incontinence care planning and hydration practices in reducing CAUTIs in frail nursing home residents.
  • Implement a process in the clinician’s workflow to assess at regular intervals, preferably daily, whether a patient in acute care or home care or a NH resident needs a catheter.
  • Indwelling urinary catheters should only be used where there is a good indication (See Table 2).
  • Catheters in newly admitted (and readmitted) NH residents should be removed to assess if still needed; every NH resident deserves a chance to be “catheter free.”
  • In post-operative patients, consider use of portable bladder scanners to determine bladder volume and whether catheterization is necessary.
  • Bladder scanning is a non-invasive method for determining bladder volume. Personnel can measure the patient’s urine output through scanning, identify any residual left in the bladder (termed post-void residual) to determine if the catheter is no longer necessary.
  • Can reduce unnecessary catheter insertions.
  • Prior to inserting a IUC, consider alternative bladder management (e.g. toileting programs with increased availability of bedside commodes, intermittent catheterization, an external catheter or collection device).
  • Duration of catheterization is the most important risk factor for developing a CAUTI so preventing catheter placement and/or minimizing the duration the catheter remains in place are strategies for preventing an infection.
  • Ensure that nursing staff and other professionals have adequate knowledge and training to implement alternative measures (e.g. intermittent catheterization, external catheters or collection devices) with the required frequency to safely manage patients with urinary retention and UI.
  • Institute a behavioral interventions care plan for NH residents and home care patients with UI (e.g. toileting programs, bladder training).
  • Consider intermittent catheterization for patients with urinary retention and as an alternative to an IUC in spinal cord injury patients and those with neurogenic bladder.
  • Consider using external catheters that collect urine or uses a motorized pump as an alternative to IUC in cooperative male patients without urinary retention or bladder outlet obstruction (Gray, 2016). Saint (2020) compared IUCs and condom (external) catheters in VA hospitalized men and found the external catheter was more comfortable, less painful and lowered bacteriuria, symptomatic UTI, or death.
  • In women, a specifically designed external urinary collection device (EUCD) for women or a female external urinary collection device (FEUC) that uses suction to wick urine away into a container have been shown to reduce CAUTIs in the acute care setting (Rearigh et al., 2020; Eckert et al., 2020; Beeson & Davis, 2018).
  • Ensure that only trained personnel insert urinary catheters, especially SP replacements.
  • Ensures understanding of aseptic technique.
  • Minimizes associated trauma, pain, and discomfort
  • All catheter supplies used for IUC insertion must be sterile.
  • Ensure a closed drainage system.
  • Urinary catheterization should always be performed using an aseptic technique and sterile supplies (e.g. catheter tray, gloves, catheter, etc).
  • Local or institutional infection control guidance should always be followed.
  • Maintaining a sterile, continuously closed urinary drainage system is central to the prevention of CAUTI.
  • A catheter system with pre-connected, sealed catheter-tubing junctions (called closed system or “all-inclusive” kit) may be indicated in certain settings (e.g. acute care).
  • In settings where catheters supplies are gathered separately, choose only those that are sterile and (e.g. sterile gloves, perineal cleansing solution, sterile drape, catheter, drainage bag).
  • An IUC kit that includes all the equipment needed for insertion makes it easier to comply with aseptic insertion.
  • Reducing the occurrence of disconnections of the catheter from the drainage bag can prevent introduction of bacteria into the system and bladder.
  • Guidelines on prevention of CAUTIs recommend aseptic insertion of urinary catheter. The sterile field is set-up and a “one-handed” technique is used throughout the procedure (one hand touches the unsterile area of the patient, while the other hand has contact with the sterile field).
  • Catheters packaged separately from a kit have a protective aseptic sleeve which allow removal without touching the catheter itself.
  • Select an insertion kit with a urimeter drainage bag if accurate urinary output monitoring is required (e.g. post-operative period, intensive care patient)
  • Will prevent disconnections of the catheter from the drainage bag to measure urine output.
  • Maintains sterility of the closed drainage system
Type and size selection
  • Individualize the choice of catheter type (material) and size (gauge).
  • Determining the most appropriate material and gauge should be based on individual patient assessment that includes: allergy or sensitivity to catheter materials, reason for catheterization (e.g. bladder clots), previous catheter history.
  • Standard size in adult patients is transurethral 14 Fr, suprapubic 16 Fr
  • Standard size (14 Fr) for urethral IUC minimizes trauma and risk of infection.
  • Large size catheters (e.g. 18Fr, 20Fr) for transurethral catheterization can obstruct peri-urethral glands, increasing the risk for a CAUTI and increase discomfort and lead to urethral trauma.
  • Larger sizes (20, 22Fr) are needed in certain situations (e.g. post urologic surgery, gross hematuria with blood clots).
  • Use a 10 cc balloon size, instilled with 10 ccs of sterile water, for routine IUCs.
  • The standard size balloon (both 5 mL and 10 mL) should be inflated with 10 mL of sterile water, as the balloon itself requires 5 mL for symmetrical inflation, and 5 mL of water is retained along the filling channel, for a total of 10 mL.
  • A larger balloon is indicated only under certain circumstances (e.g. postoperative hemostasis following GU surgery).
  • A larger balloon (30cc balloon weighs 30 g, almost the size of a chicken egg) can cause several problems: patient discomfort, irritation, trauma and injury to the meatus, urethra, bladder neck, increases risk of catheter expulsion and can increase the amount of undrained urine that pools below the level of the catheter drainage eyelets thus increasing the risk of infection and leading to catheter bypassing as seen in this Figure.
  • Saline is not used to inflate the balloon because the fluid may crystallize in the balloon port, clogging it and preventing balloon deflation and catheter removal.
  • Catheter insertion is always performed using aseptic technique and sterile equipment.
  • If the catheter touches a non-sterile area or part of the body (other than the urethral meatus) during catheterization, discard the catheter and obtain a new sterile one for insertion.
  • Bacteria can be introduced into the bladder during catheterization as a result of poor aseptic technique or a break in the sterile procedure. This can result in a CAUTI.
  • It is important that bacteria from the perineum or vagina not be introduced via the urinary catheter into the bladder. This is causative most often in women, as fecal strains contaminate the perineum and urethral meatus, are harbored in the labia and vaginal vestibule, and then ascend extraluminally (to the bladder along the external surface of the catheter) leading to bacteriuria.
  • Some evidence of the role of some specific antiseptics (chlorhexidine) at time of catheterization, in reducing CAUTIs, and some potential benefit to the role of antiseptics more generally in reducing bacteriuria (Mitchell et ., 2021).
  • Position the male patient on a firm, flat surface, preferably supine.
  • Position male penis in a near vertical position with a gentle upward traction during insertion as shown in this Figure.
  • If resistance to catheter passage is encountered, the penis can be lowered downwards.
  • Position the female patient supine with knees and hips flexed. Hips should be externally rotated.
  • Position female patients so clear visualization of the urethral meatus is obtained.
  • Positioning the male patient with the head flat may discourage contraction of the abdominal, pelvic and sphincter muscles when catheter is passing through the external sphincter.
  • Male position allows passage of the catheter through the bend of the bulbar urethra and decreases the risk for urethral trauma during insertion.
  • Proper positioning, especially in the female patient, maintains optimal conditions for maintaining a sterile catheter insertion
  • Consider 2-person catheter insertion when appropriate.
  • Can provide better meatal visualization and verify sterility during insertion.
  • Although it is not part of the “Bladder Bundle”, it is recommended by the ANA.
  • A 2-person urinary catheter insertion protocol strategy in acute care has been shown to reduce risk of contamination during insertion (Fletcher-Gutowski & Cecil, 2019; Belizario, 2015). However, this may not be possible in all settings (e.g. home care).
  • Perform hand hygiene: immediately before and after insertion, with any manipulation of the catheter or equipment associated with the catheter, and after removal of gloves.
  • Wear medical gloves whenever handling the catheter system and use a new pair with each patient.
  • Bacteria cross-contamination can be introduced via extraluminal path (exogenous infection) via the hands of healthcare staff, family members, when handling any parts of the catheter system.
  • Assess perineum, including genitals, prior to catheterization.
  • Genital and perineal inspection is important to identify anatomical structure (meatal orifice), presence of lesions or rashes and to prevent complications that may arise from insertion
  • Perform perineal care prior to beginning sterile catheterization procedure set-up and then re-perform hand hygiene.
  • Reduces or eliminates peri-meatal bacteria and recommended by the ANA’s Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention and SUNA’s Clinical Practice Procedures: Insertion of an Indwelling Urethral Catheter in the Adult Male, Insertion of an Indwelling Urethral Catheter in the Adult Female.
  • Disinfect and cleanse urethral meatus using water or antiseptic solution (chlorhexidine 0.1%) prior to catheter insertion.
  • Sterile catheter kits usually contain a cleanser.
  • Systematic review and meta-analyses noted that periurethral cleansing with water was as safe as topical antiseptics.
  • Chlorhexidine (0.1%) for meatal cleaning prior to catheter insertion is clinically effective and cost-effective in reducing CA-ASB and infection.
  • Coat the catheter prior to insertion using generous amounts of sterile lubricant.
  • Minimizes urethral trauma and maximizes patient’s comfort during insertion.
  • Use an analgesic as a lubricant in select patients (e.g. male catheterization), although use is controversial and should be determined by individual setting policy (e.g. urology practice, hospital, home care agency, nursing home) or individualized to a specific patient.
  • Routine urethral instillation of 2% lidocaine gel prior to catheter insertion is not recommended. Toxicity has been reported in patients with a disrupted mucosal barrier who have received Lidocaine gel.
  • To be beneficial, the lubricant should be indwelling in the urethra for 5-15 minutes. Trossle and colleagues (2020) conducted a pilot study of a clamp that facilitated gel instillation during IUC changes.
  • Do not pretest the balloon- this is not recommended by the manufacturers.
  • Pretesting of the balloon may create cuffing and discomfort and/or trauma during insertion.
  • If a large volume of urine (e.g., > 500 mls) is found when catheterizing, do not clamp the catheter but drain the entire amount.
  • Clamping has been shown in clinical studies to have no effect on bladder reconditioning (Wang et al., 2016).
  • Practice of clamping a catheter, to intermittently or incrementally drain a distended bladder (> 500 ml), is not recommended. Rapid complete emptying of the bladder following urinary retention can result in complications. Hematuria, although rare, can occur as well as post-obstructive diuresis (Etafy et al, 2017). Both can be easily managed and rarely of clinical significance.
Securement (anchoring, stabilization)
  • Secure the catheter to prevent movement and urethral traction by using a catheter-stabilizing device. This Figure depicts an anchor strap or securement device on the upper thigh.
  • Prevent tension by providing 1 inch of slack on the catheter.
  • There are different types of securement devices: a manufactured plate with adhesive backing with a catheter attachment device, non-adhesive thigh or abdominal Velcro straps with catheter attachment.
  • Securement of a IUC is strongly recommended for adoption by the CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections.
  • Leuck and colleagues (2012) reported that genitourinary trauma events have been reported to occur in 1.5% of catheter-days. Urethral injuries, including penile laceration in men and urethral erosion (or ventral erosion) in both men and women secondary to catheter tension, has been reported as a complication of long-term IUCs (Hollingsworth et al, 2013). Here is an example of an urethral erosion from an IUC on a male patient.
  • Securement has many benefits: 1) prevents the catheter or its balloon from exerting tension and traction on the bladder neck, urethra, and helps prevent urethral trauma and meatal tear, 2) helps reduce irritation of the bladder wall and lining, 3), reduces catheter-related pain, 4) promotes better drainage of urine, 5) maintains catheter in a position that prevents accidental disconnection and inadvertent removal, and 6) promotes patient comfort (Holroyd, 2019a; Newman et al., 2018; Newman, 2017).
  • Catheter securement by applying gentle traction may be used post-urologic surgery.
  • Postoperatively, securement by applying gentle traction, is used to apply pressure to tamponade and reduce postoperative bleeding, and to support a surgical anastomosis.
  • Always apply a securement device to a dry, clean area without lesions or redness.
  • Skin must be clean and dry for an adhesive device to successfully adhere.
  • Any moisture under the securement device may cause skin breakdown.
  • Catheter securement device should always be placed in an appropriate manner (e.g. upper thigh in women, upper thigh or abdomen in men, abdominal strap for an SP catheter as shown in this Figure.
  • Anchoring the device so that the catheter is not taunt will decrease chances of trauma and unwanted removal.
  • Anchoring the device appropriately prevents: traction on the bladder neck, meatal trauma, decreases risk of inadvertent catheter dislodgment or balloon displacement into the urethra
  • In men, securing the penis in an upright position may prevent ulceration from occurring at the curve in the urethra and prevent formation of hypospadias at the urethral meatus.
Maintenance and changing schedule
  • Do not disconnect the catheter and drainage tubes and maintain a closed, sterile catheter system.
  • All catheter changes by professionals must use aseptic technique.
  • Disconnecting the catheter from the bag should be minimized in order to best maintain the closed catheter system and minimize risk of introduction of intraluminal bacteria.
  • In patients with recurrent CAUTIs, more frequent catheter changes may be necessary when a catheter becomes disconnected from the drainage tubing or catheter occlusion and blockage occurs.
  • Bacterial biofilms develop within 5 to 7 days of microbial colonization of a IUC. Biofilms (which can be mucoid or crystalloid) can develop intraluminally or extraluminally in urinary catheters, adhering to catheter (eyelets, balloon) and tubing surfaces. They cannot be eradicated by antimicrobial therapy or by irrigation so IUC removal or a more frequent changing schedule in at-risk patients is recommended.
  • Avoid catheter irrigation for the prevention of infection.
  • Only consider IUC irrigation for presence of blood clots obstructing the catheter.
  • Continuous or periodic irrigation of the bladder with antimicrobials is not recommended as a routine infection prevention measure (Lo et al, 2014).
  • 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 has not been shown.
  • Changing a chronic IUC or drainage bag at routine, fixed intervals is not recommended.
  • If patient has multiple problems with catheter use; leakage, obstruction and infections; consider changing catheter more frequently.
  • Evidence-based research does not support or refute a specific time interval for changes of chronic IUCs.
  • IUC changes should be based on clinical indications (e.g. development of a CAUTI, catheter blockage, urine bypassing) as opposed to routine changing schedules (e.g. monthly changes based on reimbursement policy).
Catheter hygiene
  • Meatal (urethral) or stoma (SP) cleansing should only be performed daily. Soap and water or a perineal or incontinence cleanser can be used.
  • Additional cleaning is necessary if soiling of the catheter and/or meatus with fecal material occurs. Urethral and suprapubic catheters can be cleaned during showering, but avoid soaking in a tub bath. Do not use antiseptic solutions, antimicrobial ointments, or creams when cleansing the meatus
  • Bacteria can enter the urinary tract (extraluminal) from the patient via the periurethral area by migrating from the catheter into the bladder (endogenous infection).
  • Daily catheter hygiene is important in preventing ascending infection and there is insufficient evidence to recommend more often meatal cleansing.
  • Meatal disinfectants or antibacterial urethral lubricants do not prevent infection and may lead to resistant bacteria at the meatus.
  • Gently wash around the urethral meatus at the catheter entry site and down the catheter (meatus) to the hub (Y-connection) using a clean washcloth or wipe as shown here.
  • Aggressive cleaning may be associated with increased complications.
  • Use of plain wipes (disposable wipes that contain purified water, aloe and vitamin E) in adult catheterized patients can potentially decrease CAUTI incidence.
Urine drainage
  • Periodically inspect and ensure that the catheter is draining.
  • If catheter is not draining urine, determine if the catheter is malpositioned (e.g. in the male patient, one-half or more of the catheter is exposed outside of the meatus.
  • Urine stasis in the bladder can lead to pain, a CAUTI and other problems (e.g. urine bypassing, etc).
  • Palpate the bladder for distension and if present, scan the bladder to determine for presence of urine.
  • When unsure about catheter patency, use a bladder scanner to determine the volume of urine in the bladder. Minimal or no urine output is seen if the bladder is full or distended.
  • Empty the drainage bag regularly to ensure it does not overflow.
  • An overfilled drainage bag will prevent urine from draining. leading to urine stasis, bladder overdistension, etc.
  • Place drainage bag in a dependent position, below the level of the bladder at all times (e.g. during travel, surgery, when transferring) to ensure unobstructed drainage.
  • Bag can be placed as close to the end or foot of the bed as possible by securing the tubing to the bottom sheet using the clip on the drainage tube and hook the bag on the bottom bed rail or on a stand.
  • Do not attach to bed side rails.
  • Ensures an unobstructed urine flow and prevents urine stasis and reflux of urine into the bladder, all of which increases the risk of a CAUTI. See Table 2. Urinary Drainage Bags in Clinical Practice Procedures: Insertion of an Indwelling Urethral Catheter in the Adult Male, Insertion of an Indwelling Urethral Catheter in the Adult Female.
  • Bags attached to moveable objects, such as a side rail, increase risk for trauma because of pulling or accidental dislodgement.
  • Do not allow the bag to touch or rest on the floor.
  • Maintain unobstructed urine flow by keeping the drainage tube above the collection bag and free of kinks such that urine drains directly into the bag.
  • Utilize designated loop on bed or stretcher to place the urinary catheter drainage bag hook.
  • Avoid dependent loops.
  • Prevents contamination of the system (extraluminal ascension).
  • A drainage tube that sags below the level of the collection bag can increase the risk for a CAUTI due to stasis of the urine, leading to backflow of urine into the bladder from the tubing and bag, especially if raised above the bladder.
  • A dependent loop is a configuration of catheter tubing where the drainage tube dips below the entry point into the catheter bag. These loops can increase the bladder pressure required to push urine through the tubing into the drainage bag, increasing the length of time it takes for urine to travel through the tubing.
  • Patients who have long-term catheters may choose to attach the catheter to a catheter valve. The valve is attached to the drainage port.
  • Catheter valves are commonly inserted in patients with short term SPs, especially post genito-urinary surgery.
  • A catheter valve has advantages including discreteness and can reduce trauma to the bladder neck and meatus as the weight of a drainage bag is eliminated.
  • A valve may help maintain bladder function, capacity and tone by allowing the filling and emptying of the bladder, mimicking normal function.
Drainage Bags
  • Always don gloves when emptying drainage bags.
  • Drainage bag is a reservoir for organisms that may be transmitted to other patients through the hands of healthcare personnel.
  • Drainage bags should be emptied on a routine basis (e.g. at least every 4 to 6 hours) or when the bag reaches 400 mLs, and before transporting the patient.
  • Do not place bag on the floor.
  • Drainage bag represents a large reservoir of pathogens and stasis of urine promotes proliferation of bacteria with intraluminal ascension to the bladder. Routine bladder emptying will avoid bacteria migration.
  • Weight of a large volume of urine in a full drainage bag increases tension on drainage tube and catheter, potentially increasing risk of bladder neck and urethral trauma.
  • Avoid contact of the drainage port with the non-sterile collecting container and wipe tap with alcohol.
  • Avoid splashing when emptying the bag.
  • Avoids cross-contamination of drainage port with container.
  • Drainage bags have integrated anti-reflux valves to prevent bacteria migration.
  • When emptying the bag, use a separate, clean collecting container for each patient, date and label container, and replace every 24 hrs.
  • Rinse the collection container with tap water and store in a manner that facilitates drying after each use.
  • Keep drainage devices on opposite sides of the bed and keep drainage devices in semi-private rooms on opposite sides of the room.
  • Separate containers avoid cross-contamination of bacteria from one patient to another, although this is not a typical issue in non-acute care settings.
  • Avoid reusing drainage bags, if possible.
  • As most insurers only cover 2 bags per month, drainage bags are usually cleaned and reused but there is no cleaning standard to guide practice (Wilde, Fader, et al., 2013). Reported cleaning methods include the use of dilute bleach or vinegar solutions.
  • Avoid routine addition of antimicrobials or antiseptics to the drainage bag of catheterized patients.
  • These will not reduce CA-bacteriuria or CAUTIs and are not recommended by all guidelines.
  • Large capacity bags are usually used in hospitals or other facilities, whereas small capacity bags are used by patients in the community. Some patients may use both types of bags.
  • Patients with long-term catheters may attach a smaller capacity leg bag to the catheter during the day when active, switching to a larger capacity bag at night.
Catheter removal, changing and reinsertion
  • Following IUC removal, implement a bladder management protocol that includes a trial of voiding.
  • An algorithmic approach to bladder management following catheter removal should be followed and a “Trial of Voiding” initiated. This approach is commonly used in acute care and rehab settings. Voiding trials are performed in urology practices in patients referred following hospitalization (e.g. discharged with a IUC).
  • Do not clamp the catheter or drainage tube before removal.
  • A systematic and meta-analysis of clinical studies demonstrated that clamping a short-term IUC has no benefit and may result in patient discomfort and infection.
  • Use a portable bladder volume ultrasound (BladderScan) to assess adequate bladder emptying.
  • Bedside bladder scanning technology (e.g. bladder scan) is preferred as it is noninvasive and accurate.
  • Based on assessment of bladder function (e.g. incomplete bladder emptying/urinary retention, UI), investigate alternatives to an IUC (intermittent catheterization, external catheters or external collection devices, toileting assistive devices, incontinence absorbent products).
  • Consider alternatives to chronic IUCs, such as toileting assistance and/or prompted voiding or external collection devices or products in patients with UI, intermittent catheterization, in spinal cord injury patients and neurogenic bladder to ensure complete bladder emptying and reduce the risk of urinary tract deterioration.
  • Consider external catheters or collection devices as an alternative to IUC in cooperative patients with UI but without urinary retention or bladder outlet obstruction.
  • Ensure that staff in the acute care setting have adequate time, training, and equipment to implement alternative measures (e.g. intermittent catheterization, external catheters or collection devices) with the required frequency to safely manage patients with urinary retention.
  • Prophylactic antimicrobials should not be administered routinely to patients in any setting at the time of catheter placement, removal or replacement.
  • Does not reduce CA-bacteriuria or CAUTIs.
  • Insufficient data to make a recommendation as to whether administration of prophylactic antimicrobials reduces bacteremia.
Obtaining a urine specimen, urine culture and treatment of UTI
  • Obtain a urine specimen for culture only if patient exhibits symptoms of a UTI (see CDC definition for a CAUTI in Table 3).
  • Bacteria in the urine is not a sign of a CAUTI.
  • Follow CDC definition for a CAUTI as outlined in Table 3.
  • Possible signs in an older adult patient can include a combination of increased restlessness or altered mental status that is not attributable to any other cause (e.g. pneumonia).
  • Presence of bacteria in the urine is asymptomatic in most patients with an IUC. It is present in the urine of one-third of patients after 2–10 days from catheterization and in all patients catheterized for more than 30 days.
  • Education on IUC monitoring and management to specifically include urine flow and the color of the urine and their relation to fluid intake maybe beneficial in preventing CAUTIs.
  • Diagnostic stewardship programs, based on education and audit and feedback can reduce inpatient urine culture orders and CAUTIs (Luu et al., 2020).
  • Self-monitoring of urine flow, its smell and color, and increasing fluid intake may identify early signs of a CAUTI.
  • Ensuring an adequate fluid intake, will alert patients to early signs of infection and blockage and enhance self-management practices, helping avoid problems in the future.
  • Obtain urine specimen through a needleless aspiration or sampling port if available.
  • Cleanse the port with disinfectant (e.g. alcohol) for 15 seconds, allow to dry and aspirate the urine with a sterile syringe or cannula adaptor.
  • This method avoids interrupting the closed sterile catheter system and minimizes risk of infection.
  • According to ISDA guideline, this will reduce CA-bacteriuria and CAUTI in patients with either short-term or long-term transurethral or SP IUCs.
  • Consider changing the catheter, especially if existing catheter has been in place for > 2 weeks, before obtaining a specimen for culture, since cultures obtained through the existing catheter may be inaccurate.
  • In certain situations (e.g. post GU surgery), it may not be possible or safe to remove, change a urinary catheter, or both prior to collecting all urine cultures.
  • If the catheter and drainage system was not changed prior to obtaining a urine culture and UTI is diagnosed, consider changing it prior to initiation of antimicrobials.
  • Because of the presence of biofilms, leaving the catheter in place during the treatment of a CAUTI makes eradicating bacteriuria or candiduria difficult and can lead to the development of antimicrobial resistance and increase the likelihood of relapse or recurrence.
  • Removal of the ‘bioburden’ of the catheter-associated biofilm helps to decrease the severity of inflammation, the probability of recurrence, allowing eradication of the bacteria by antimicrobial treatment.
  • Urine specimen should be cultured within 2 hours of its collection.
  • Overgrowth of bacteria can readily occur with mishandled specimens, which will cause a false positive or unreliable culture result.
  • Systemic antimicrobial prophylaxis should not be routinely used in patients with short-term or long-term catheterization, including patients who undergo surgical procedures.
  • This practice is not recommended by CDC and IDSA guidelines as it has not been shown to reduce CA-bacteriuria or CAUTI and there is concern about the occurrence of antimicrobial resistance.


Table 1.  The mnemonic ABCDE Bladder Bundle for Prevention of CAUTIs (Adapted from Saint et al., 2009; Mody et al., 2017) 



Adherence to general infection control principles (e.g., hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education) is important. Only trained personnel should insert catheters.


Bladder ultrasound should guide management as knowing the amount of urine in the bladder may avoid unnecessary catheter use


Condom and external catheters/collection devices or other alternatives to an IUC, such as intermittent catheterization or incontinence products should be considered in appropriate patients.


Do not use the IUC unless medically appropriate.


Early removal of the catheter using a reminder or nurse-initiated removal protocol

Table 2. IUC Indications (Adapted from Meddings et al., 2014; Gould et al., 2010)Appropriate indications for an IUC include:
  • Postoperative urinary retention (per facility catheter-removal policy).
  • Acute urinary retention which requires immediate attention (e.g. bladder outlet obstruction).
  • Need for accurate measurements of urinary output in critically ill patients for which urine cannot be measured in another way.
  • Patients who require prolonged immobilization (e.g. potentially unstable thoracic, or lumbar spine, multiple traumatic injuries such as pelvic fractures)
  • Assist in healing of open sacral or perineal wounds in patients with urinary incontinence
  • Continuous bladder irrigation (CBI) for clot retention.
  • Administration of drugs directly into the bladder (e.g. chemotherapeutic medication to treat bladder cancer).
  • Palliative care for terminally ill at the end of life
  • Perioperative use in selected surgical procedures:
  • Urologic/gynecologic/perineal procedure and other surgeries on contiguous structures of GU tract.
  • Anticipated prolonged duration of surgery (should be removed in PACU once patient is awake).
  • Patients anticipated to receive large volume infusions or diuretics during surgery.
  • Operative patients with urinary incontinence.
  • Need for intra-operative hemodynamic monitoring of fluids.
It is of note that UI is not a valid reason for insertion of an IUC unless there is a perineal wound that is being contaminated or the patient is at the end of life and wishes to have a catheter for comfort.According to the guidelines, examples of inappropriate catheter insertion areInappropriate uses of IUCs include:
  • As a substitute for nursing care of the patient with incontinence
  • As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void
  • For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc)
Table 3.   CDC: Catheter-Associated Urinary Tract Infection
  • IUC was in place for more than two days on the date of event, with day of device placement being day one, and an IUC was in place on the date of event or the day before. If an IUC was in place for more than 2 consecutive days in an inpatient location and then removed, the date of event for the UTI must be the day of device discontinuation or the next day for the UTI to be catheter-associated.
  • Must have at least one of the following signs or symptoms
  • Fever with temperature >38°◦C (if > 65 years of age, the IUC needs to be in place for more than 2 consecutive days in an inpatient location on date of “event”
  • Suprapubic tenderness*
  • Costovertebral angle pain or tenderness
  • Urinary urgency+
  • Urinary frequency+
  • Dysuria+
  • Patient has an aseptically obtained urine culture with no more than two species of organisms identified, at least one of which is a bacterium of > 105 CFU/ml.
Signs not directly associated with a CAUTI:
  • Pyuria—not a good indicator as it is common in catheterized individuals
  • Odor—the persistent bacteria in the urine of catheterized patients will produce odor
Possible signs in an elderly patient:
  • Increased restlessness or altered mental status
  • Change in health status not attributable to any other cause (pneumonia, medication side effects)
Treatment of CAUTI once diagnosis is established:
  • If possible, remove the catheter and follow bladder management at least until the antibiotic course is completed.
  • If not possible to leave the catheter out, change the catheter prior to starting antibiotics so that there is the least amount of biofilm present.
  • Start antibiotics—typical course of antibiotics is 7 to 14 days, usually a fluoroquinolone.
  • Chart symptom improvement.
*With no other recognized cause+ These symptoms cannot be used when a catheter is in place, but can be used if symptoms occur after urinary catheter removal, on the day of removal or day after removal
Adapted from CDC, Retrieved from 


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