Indwelling Catheters

Molecular basis of the activity of SinR, the master regulator of biofilm formation in Bacillus subtilis - Abstract

SinR is the master regulator that determines whether Bacillus subtilis switches from a free-living, planktonic lifestyle to form a biofilm, a community of cells attached to a surface by an extracellular matrix. Biofilms are an increasing environmental and healthcare issue, causing problems ranging from the bio-fouling of ocean-going vessels, to dental plaque, infections of the urinary tract and contamination of medical instruments such as catheters. SinR inhibits biofilm formation by repressing a number of extracellular matrix-associated operons. The activity of SinR is controlled by the SinR antagonists, SinI, SlrA and SlrR, which interact with SinR to regulate its function. We have combined isothermal titration calorimetry (ITC) and surface plasmon resonance (SPR) to determine the thermodynamic and kinetic parameters governing the protein:protein and protein:DNA interactions at the heart of this epigenetic switch. Finally, we present the crystal structure of the SinR tetramer in complex with DNA, revealing the molecular basis of base-specific DNA recognition by SinR and the mode by which SinR activity is controlled by interaction with its antagonists.

Written by:
Newman JA, Rodrigues C, Lewis RJ Are you the author?
University of Newcastle, United Kingdom.

Reference: J Biol Chem. 2013 Feb 21. (Epub ahead of print)
doi: 10.1074/jbc.M113.455592

PubMed Abstract
PMID: 23430750

Evidence of Uncultivated Bacteria in the Adult Female Bladder

Clinical urine specimens are usually considered to be sterile when they do not yield uropathogens using standard clinical cultivation procedures. Our aim was to test if the adult female bladder might contain bacteria that are not identified by these routine procedures. An additional aim was to identify and recommend the appropriate urine collection method for the study of bacterial communities in the female bladder. Consenting participants who were free of known urinary tract infection provided urine samples by voided, transurethral, and/or suprapubic collection methods. The presence of bacteria in these samples was assessed by bacterial culture, light microscopy, and 16S rRNA gene sequencing. Bacteria that are not or cannot be routinely cultivated (hereinafter called uncultivated bacteria) were common in voided urine, urine collected by transurethral catheter (TUC), and urine collected by suprapubic aspirate (SPA), regardless of whether the subjects had urinary symptoms. Voided urine samples contained mixtures of urinary and genital tract bacteria. Communities identified in parallel urine samples collected by TUC and SPA were similar. Uncultivated bacteria are clearly present in the bladders of some women. It remains unclear if these bacteria are viable and/or if their presence is relevant to idiopathic urinary tract conditions.

CDC joint statement


PubMed Central®

Nursing interventions to reduce the risk of catheter-associated urinary tract infection. Part 1: Catheter selection - Abstract

BACKGROUND: The urinary system is the most common site for all hospital-acquired infections, accounting for approximately 40% of all nosocomial infections. The US Centers for Medicare & Medicaid Services has enacted 2 policies that have focused considerable attention on the optimal use of indwelling catheters in the acute and long-term care settings and the prevention of complications including catheter-associated urinary tract infection (CAUTI).

OBJECTIVES: This is the first of a 2-part Evidence-Based Report Card reviewing current evidence pertaining to nursing actions for prevention of CAUTIs in patients with short- and long-term indwelling catheters. Part 1 reviews evidence for materials for catheter construction, including incorporation of antimicrobial substances into the catheter, and selection of catheter size.

SEARCH STRATEGY: Nursing actions for prevention of CAUTIs were identified based on search of electronic databases and Web-based search engines for national or international clinical practice guidelines focusing on this topic. Evidence related to 2 common nursing interventions, selection of the material of construction and selection of catheter size, was identified by searching electronic databases MEDLINE, CINAHL, the Cochrane Library, and the ancestry of articles identified in these searches.

RESULTS: We found robust evidence supporting insertion of a silver alloy-coated catheter to reduce the risk of CAUTIs for up to 2 weeks in adult patients managed by short-term indwelling catheterization. We also found evidence supporting the insertion of an antibiotic-impregnated catheter for reduction of CAUTI risk for up to 7 days. There was insufficient evidence to determine whether regular use of an antimicrobial catheter reduces the risk of CAUTIs in adults managed with long-term indwelling catheterization. There was insufficient evidence to determine whether selection of a latex catheter, hydrogel-coated latex catheter, silicone-coated latex catheter, or all- silicone catheter influences CAUTI risk. Expert opinion suggests that selection of a smaller French-sized catheter reduces CAUTI risk, but evidence is lacking.

IMPLICATIONS FOR PRACTICE: Insertion of an antimicrobial catheter, either silver alloy or antimicrobial coated, is recommended for patients with short-term indwelling catheterization. There is insufficient evidence to recommend their use in patients managed by long-term indwelling catheterization. Selection of smaller French sizes for short- or long-term catheterization is thought to improve comfort and reduce CAUTI risk, but further research is needed to substantiate these best practice recommendations.

Written by:
Parker D, Callan L, Harwood J, Thompson DL, Wilde M, Gray M. Are you the author?
St Joseph Hospital, Bellingham, Washington, USA.

Reference: J Wound Ostomy Continence Nurs. 2009 Jan-Feb;36(1):23-34.
doi: 10.1097/01.WON.0000345173.05376.3e.


Reduction in catheter-associated urinary tract infections by bundling interventions - Abstract

OBJECTIVE: Urinary tract infections (UTIs) are the most common type of hospital-acquired infection, and most are associated with indwelling urinary catheters, that is, catheter-associated UTIs (CAUTIs). Our goal was to reduce the CAUTI rate.

DESIGN/SETTING/INTERVENTIONS: We retrospectively examined the feasibility and cost-effectiveness of a bundle of four evidence-based interventions upon the incidence rate (IR) of CAUTIs in a community hospital. The first intervention was the exclusive use of silver alloy catheters in the hospital's acute care areas. The second intervention was a securing device to limit the movement of the catheter after insertion. The third intervention was repositioning of the catheter tubing if it was found to be touching the floor. The fourth intervention was removal of the indwelling urinary catheter on postoperative Day 1 or 2, for most surgical patients.

MAIN OUTCOME MEASURE: Rates of CAUTI per 1000 catheter days were estimated and compared using the generalized estimating equations Poisson regression analysis.

RESULTS: During the study period, 33 of the 2228 patients were diagnosed with a CAUTI. The CAUTI IR for the pre-intervention period was 5.2/1000. For the 7 months following the implementation of the fourth intervention, the IR was 1.5/1000 catheter days, a significant reduction relative to the pre-intervention period (P = 0.03). The annualized projection for the cost of implementing this bundle of four interventions is $23,924.

CONCLUSION: A bundle of four evidence-based interventions reduced the incidence of CAUTIs in a community hospital. It is relatively simple, appears to be cost-effective and might be sustainable and adaptable by other hospitals.

Written by:
Clarke K, Tong D, Pan Y, Easley KA, Norrick B, Ko C, Wang A, Razavi B, Stein J. Are you the author?
Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, 1365 Clifton Road, Suite A4326, Atlanta, GA 30322,, USA.

Reference: Int J Qual Health Care. 2012 Dec 6.



Joint statement on antibiotic resistance from 25 national health organizations and the Centers for Disease Control and Prevention

Studies indicate that nearly 50% of antimicrobial use in hospitals is unnecessary or inappropriate. There is no doubt that this overuse of antibiotics is contributing to the growing challenges posed by Clostridium difficile and other antibiotic-resistant bacteria in many hospitals. However, studies also demonstrate that improving the use of antibiotics in hospitals can not only help reduce rates of Clostridium difficile infection and antibiotic resistance, but can also improve individual patient outcomes, all while saving hundreds of thousands of dollars in healthcare costs. "Get Smart for Healthcare" is a CDC campaign focused on improving antibiotic use in inpatient health care facilities, starting with hospitals and then expanding to long-term care facilities.

As part of the 2012 Get Smart About Antibiotics Week activities, CDC and the nation’s leading health care organizations have united to issue an important policy statement focused on preserving antibiotic effectiveness and combating resistance.

CDC joint statement


(2012) Centers for Disease Control and Prevention

National Healthcare Safety Network (NHSN) report, data summary for 2009, device-associated module

This report is a summary of device-associated module data collected by hospitals participating in the National Healthcare Safety Network (NHSN) for events occurring from January through December 2009 and reported to the Centers for Disease Control and Prevention (CDC) by October 18, 2010. This report updates previously published device-associated module data from NHSN and provides contemporary comparative rates. Procedure-associated module data will be reported separately: surgical site infection (SSI) data will be reported as standardized infection ratios utilizing new logistic regression models; post-procedure pneumonia rates for 2009 are available on the NHSN public website. This report complements other NHSN reports, including national and state-specific standardized infection ratios (SIRs) for select health-care associated infections (HAIs).



(2011) American Journal of Infection Control

National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009

This report is a summary of device-associated (DA) and procedure-associated (PA) module data collected and reported by hospitals and ambulatory surgical centers participating in the National Healthcare Safety Network (NHSN) from January 2006 through December 2008 as reported to the Centers for Disease Control and Prevention (CDC) by July 6, 2009. This report updates previously published DA and PA module data from the NHSN.



(2009) American Journal of Infection Control

Surgical Care Improvement Project (SCIP) best practices initiative change package

This change package is a collection of recommendations for changing processes of surgical care.



(2009) Healthcare Quality Strategies

The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention

This report uses results from the published medical and economic literature to provide a range of estimates for the annual direct hospital cost of treating health-care associated infections (HAIs) in the United States. Applying two different Consumer Price Index (CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services). After adjusting for the range of effectiveness of possible infection control interventions, the benefits of prevention range from a low of $5.7 to $6.8 billion (20% of infections preventable, CPI for all urban consumers) to a high of $25.0 to $31.5 billion (70% of infections preventable, CPI for inpatient hospital services).

scott costpaper



Scott, D. R. II. (2009). "Economist." Centers for Disease Control and Prevention. 

Guideline for prevention of catheter-associated urinary tract infections 2009

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.




Healthcare Infection Control Practices Advisory Committee (HICPAC)

Guide to the elimination of catheter-associated urinary tract infections (CAUTIs)

PURPOSE: The purpose of this document is to provide evidence-based practice guidance for the prevention of catheter-associated urinary tract Infections (CAUTI) in acute and long-term care settings.

BACKGROUND: Health-care associated infections (HAIs) are infections acquired during the course of receiving treatment for other conditions within a health care setting. HAIs are one of the top 10 leading causes of death in the United States, according to the Centers for Disease Control and Prevention (CDC), which estimates that 1.7 million infections were reported annually among patients. It has long been acknowledged that CAUTI is the most frequent type of infection in acute care settings. In a study that provided a national estimate of health-care associated infections, urinary tract infections comprised 36% of the total HAI estimate.




Association for Professionals in Infection Control and Epidemiology (APIC)

CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting

What follows are the NHSN criteria for all healthcare-associated infections (HAIs). These criteria include those for the “Big Four” (surgical site infection (SSI), pneumonia (PNEU), bloodstream infection (BSI) and urinary tract infection (UTI)), outlined in earlier chapters of this NHSN manual, as well as criteria for other types of HAIs. Of particular importance, this chapter provides further required criteria for the specific event types that constitute organ/space SSIs (e.g. mediastinitis (MED) following coronary artery bypass graft, intra-abdominal abscess (IAB) following colon surgery, etc.).

CDC-NHSN survey def



National Healthcare Safety Network, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention

Healthcare-associated infections in Pennsylvania - 2011 Report

The 2011 report on the occurrence and patterns of health care-associated infections (HAIs) is the fourth to be released by the Pennsylvania Department of Health (PADOH) since the passage of Act 52 in 2007. The overall findings for 2011 show a continued pattern of steady decline in the incidence of HAIs in Pennsylvania. Declines were also seen in the incidence of each of the three categories of HAIs used by PADOH for hospital benchmarking. These categories are: catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and selected types of surgical site infections (SSIs). The declining numbers are likely the result of ongoing efforts undertaken by infection preventionists, health care providers and systems, professional societies and governmental agencies to control and prevent HAIs. The impact of these efforts should be improved health status and outcomes of patients cared for in Pennsylvania hospitals, which are the primary motivation for HAI prevention and control, along with reduced health care expenditures.

pa doh 2011 hai report



Pennsylvania Department of Health
August 2012

IHI - How-to guide: prevent catheter-associated urinary tract infections

The estimated number of hospital-acquired infections (HAIs) in US hospitals exceeds 1.7 million events annually, leading to an estimated 99,000 deaths. Urinary tract infections account for approximately 40% of all HAIs annually. Fully 80% of these hospital-acquired urinary tract infections are attributable to indwelling urethral catheters. If nursing homes are considered along with acute care hospitals, it is estimated that there are more than one million cases of catheter-associated urinary tract infections (CAUTI) annually.

In the US, up to five million urinary catheters are placed annually. Between 12% and 25% of all hospitalized patients will receive a urinary catheter during their hospital stay, with as many as half not having an appropriate indication. In one study, almost 40% of attending physicians caring for patients with unnecessary urinary catheters were not aware that their patients had a urinary catheter in place.

It is well established that the duration of catheterization is directly related to risk for developing a urinary tract infection. With a catheter in place, the daily risk of developing a urinary tract infection ranges from 3% to 7%. When a catheter remains in place for up to a week, bacteriuria risk increases to 25%; at one month, this risk is nearly 100%. Among those with bacteriuria, 10% will develop symptoms of UTI (fever, dysuria, urgency, frequency, suprapubic tenderness) and up to 3% will further develop bacteremia.




How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; 2011. (Available at

IHI - How-to guide: prevent surgical site infections

Surgical site infections are a frequent cause of morbidity following surgical procedures. Surgical site infections have also been shown to increase mortality, re-admission rates, length of stay, and costs for patients who incur them. While nationally the rate of surgical site infection averages between 2 and 3% for clean cases (class I/clean as defined by CDC), an estimated 40 to 60% of these infections are preventable.

A review of the medical literature shows that the following care components reduce the incidence of surgical site infection: appropriate use of prophylactic antibiotics; appropriate hair removal, controlled postoperative serum glucose for cardiac surgery patients, and immediate postoperative normothermia for colorectal surgery patients. These components, if implemented reliably, can drastically reduce the incidence of surgical site infection, resulting in the nearly complete elimination of preventable surgical site infection in many cases.




(2012). "How-to Guide: Prevent Surgical Site Infections." Institute for Healthcare Improvement; Cambridge, MA (Available at

IHI Innovation Series 2012 - Using care bundles to improve health care quality

In 2001, the Institute for Healthcare Improvement (IHI) developed the “bundle” concept in the context of an IHI and Voluntary Hospital Association (VHA) joint initiative—Idealized Design of the Intensive Care Unit (IDICU)—involving 13 hospitals focused on improving critical care. The goal of the initiative was to improve critical care processes to the highest levels of reliability, which would result in vastly improved outcomes. The theory was that enhancing teamwork and communication in multidisciplinary teams would create the necessary conditions for safe and reliable care in the ICU. We focused on areas with potential for great harm and high cost, and where the evidence base was strong.

While there were many changes the teams in the initiative worked toward implementing, care of patients on ventilators and those who had central lines became a strong focus, as it satisfied all of our criteria; the evidence for the clinical changes was robust, and there was little or no controversy concerning their efficacy. Further, teams would need to find new and better ways to work together to produce reliable change and superior patient outcomes. We found that by using a “bundle”—a small set of evidence-based interventions for a defined patient population and care setting—the improvements in patient outcomes exceeded expectations of both teams and faculty.

Thus began an innovative approach to improving care: the use of bundles. This white paper describes the history, theory of change, design concepts, and outcomes associated with the development and use of bundles over the past decade. We reflect on what we have learned and make suggestions for further research and implementation of the bundle approach to improving care.




Resar, R., F. A. Griffin, et al. (2012). "Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper." Institute for Healthcare Improvement; Cambridge, MA (Available at

New York hospitals team up to reduce Clostridium difficile infections

There is an urgent need to implement evidence-based strategies that effectively prevent Clostridium difficile (C. difficile) transmission and infection because of the increasing incidence, severity, and costs in the United States. In March 2008, the Greater New York Hospital Association (GNYHA) and United Hospital Fund (UHF) collaborated with New York State Department of Health to begin the Clostridium difficile Collaborative. The collaborative project aimed to reduce hospital-associated C. difficile by implementing an evidence-based “prevention bundle” and standardized daily and terminal environmental cleaning protocols. The prevention bundle included the following:

  • Placing patients on contact precautions at symptom onset
  • Monitoring the availability and use of personal protective equipment
  • Monitoring hand hygiene
  • Dedicating thermometers for C. difficile patients
  • Implementing a patient placement strategy to optimize the use of private rooms or cohort patients when necessary (no sharing of bathrooms)

PHPSFF New York State v2



(2012) Centers for Disease Control and Prevention

Compliance with handwashing in a teaching hospital - Abstract

BACKGROUND: Transmission of microorganisms from the hands of health care workers is the main source of cross-infection in hospitals and can be prevented by handwashing.

OBJECTIVE: To identify predictors of noncompliance with handwashing during routine patient care.

DESIGN: Observational study.

SETTING: Teaching hospital in Geneva, Switzerland.

PARTICIPANTS: Nurses (66%), physicians (10%), nursing assistants (13%), and other health care workers (11%).

MEASUREMENTS: Compliance with handwashing.

RESULTS: In 2834 observed opportunities for handwashing, average compliance was 48%. In multivariate analysis, noncompliance was higher among physicians (odds ratio [OR], 2.8 (95% CI, 1.9 to 4.1)), nursing assistants (OR, 1.3 (CI, 1.0 to 1.6)), and other health care workers (OR, 2.1 (CI, 1.4 to 3.2)) than among nurses and was lowest on weekends (OR, 0.6 (CI, 0.4 to 0.8)). Noncompliance was higher in intensive care than in internal medicine units (OR, 2.0 (CI, 1.3 to 3.1)), during procedures that carry a high risk for contamination (OR, 1.8 (CI, 1.4 to 2.4)), and when intensity of patient care was high (compared with < or = 20 opportunities for handwashing per hour of care, 21 to 40 opportunities: OR, 1.3 (CI, 1.0 to 1.7); 41 to 60 opportunities: OR, 2.1 (CI, 1.5 to 2.9); and > 60 opportunities: OR, 2.1 (CI, 1.3 to 3.5)).

CONCLUSIONS: Compliance with handwashing was moderate. Variation across hospital ward and type of health care worker suggests that targeted educational programs may be useful. Even though observational data cannot prove causality, the association between noncompliance and intensity of care suggests that understaffing may decrease quality of patient care.

Written by:
Pittet D, Mourouga P, Perneger TV. Are you the author?
University of Geneva Medical School and University of Geneva Hospitals, Switzerland.

Reference: Ann Intern Med. 1999 Jan 19;130(2):126-30. 


A randomized crossover study of silver-coated urinary catheters in hospitalized patients - Abstract

BACKGROUND: Urinary tract infections (UTIs) account for 30% to 40% of nosocomial infections resulting in morbidity, mortality, and increased length of hospital stay.

OBJECTIVE: To assess the efficacy of a silver-alloy, hydrogel-coated latex urinary catheter for the prevention of nosocomial catheter-associated UTIs.

METHODS: A 12-month randomized crossover trial compared rates of nosocomial catheter-associated UTI in patients with silver-coated and uncoated catheters. A cost analysis was conducted.

RESULTS: There were 343 infections among 27,878 patients (1.23 infections per 100 patients) during 114,368 patient-days (3.00 infections per 1000 patient-days). The relative risk of infection per 1000 patient-days was 0.79 (95% confidence interval, 0.63-0.99; P =.04) for study wards randomized to silver-coated catheters compared with those randomized to uncoated catheters. Infections occurred in 291 of 11,032 catheters used on study units (2.64 infections per 100 catheters). The relative risk of infection per 100 silver-coated catheters used on study wards compared with uncoated catheters was 0.68 (95% confidence interval, 0.54-0.86; P =.001). Fourteen catheter-associated UTIs (4.1%) were complicated by secondary bloodstream infection. One death appeared related to the secondary infection. Estimated hospital cost savings with the use of the silver-coated catheters ranged from $14,456 to $573,293.

CONCLUSIONS: The risk of infection declined by 21% among study wards randomized to silver-coated catheters and by 32% among patients in whom silver-coated catheters were used on the wards. Use of the more expensive silver-coated catheter appeared to offer cost savings by preventing excess hospital costs from nosocomial UTI associated with catheter use.

Written by:
Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. Are you the author?
PO Box 800473, University of Virginia Health System, Charlottesville, VA 22908, USA.

Reference: Arch Intern Med. 2000 Nov 27;160(21):3294-8.


Adherence to urethral catheters by bacteria causing nosocomial infections - Abstract

Previous clinical studies of catheters with hydrophilic coating have, in some instances, shown a delay in the onset of significant bacteriuria, while others reported no such effect. To attempt to determine reasons for these differences we decided to study bacterial adherence of bacteria obtained from nosocomial urinary tract infections associated with catheters. Almost all strains adhered to the silicone catheter and none of them adhered to the catheter with the hydrophilic surface whether incubated in urine or serum. When incubated in urine, all strains adhered to the red rubber catheters. Adherence was variable to the Teflon and elastomer surfaces.

Written by:
Roberts JA, Kaack MB, Fussell EN. Are you the author?
Department of Urology, Tulane Regional Primate Research Center, Covington, Louisiana.

Reference: Urology. 1993 Apr;41(4):338-42.


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