Catheter-associated urinary tract infections, a worldwide, leading hospital-acquired infection, have substantial impact on patient safety and antibiotic consumption. These urinary catheter-related infections are associated with morbid events, such as delirium, and with longer lengths of stay and higher costs of medical care. It has been estimated that 65 to 70% of CAUTIs may be preventable with recommended evidence-based practices. For this reason, the Centers for Medicare & Medicaid Services no longer reimburses acute care and rehabilitation hospitals for the cost associated with treating these infections, and has a national goal to reduce these infections by 25% in 2014. An expanding body of literature has demonstrated methods for ensuring the practices and processes for decreasing these infections. This article will provide a synopsis of current practices and multimodal prevention strategies for catheter-associated urinary tract infections.
Diane K. Newman,1 Robyn Strauss2
1Division of Urology, Penn Medicine, University of Pennsylvania; 2Department of Nursing, Hospital of the University of Pennsylvania
Submitted September 26, 2013 - Accepted for Publication October 20, 2013
KEYWORDS: catheter associated urinary tract infections, indwelling urinary catheter, prevention, evidence-based guidelines, bladder bundle
CORRESPONDENCE: Diane K. Newman, Adjunct Associate Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania; Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, Penn Medicine, 34th and Civic Center Boulevard, Philadelphia, PA 19104 ()
CITATION: UroToday Int J. 2013 October;6(5):art 64. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.11
The elimination of hospital-acquired infections (HAIs) is a key aspect of patient safety initiatives in many countries. These infections are primarily caused by instrumentation of the bladder. The United States National Healthcare Safety Network (NHSN) reports that indwelling urinary catheters (IUC) are used in close to two-thirds of patients in the intensive care units, and in about one-fifth of patients on the general medical-surgical units . In hospitalized older medical patients without a specific medical indication, an IUC has been associated with a greater risk of death: 4 times as great during hospitalization and 2 times as great within 90 days after discharge . Saint and colleagues  have described inappropriate catheter use as a form of physical restraint as they are associated with discomfort leading to immobility, a cause of pressure ulcers. Catheter-associated urinary tract infections (CAUTI) are costly, making the business case for prevention of these HAIs a key component of a cost-control program . Despite CAUTIs being described as “never events,” as in “they never should occur,” the cause, an IUC, is still commonly used in the acute care setting.
CAUTIs are considered to be complicated infections, because normal host defense mechanisms are compromised by the presence of a foreign body. Although frequently asymptomatic, up to one-third of patients with catheter-associated bacteriuria will develop symptoms of CAUTI, especially if the catheter remains in place long-term (defined as > 30 days) . The length of time IUCs remain in situ is directly related to increases in CAUTIs. Antimicrobial therapy is only transiently effective if the catheter remains in place.
Meddings and Saint  describe a conceptual model to outline the “lifecycle” of an IUC (Figure 1). Each part of the cycle describes an actionable target that begins with catheter placement (1), continues when the catheter remains in-situ (2), can stop when the catheter is removed (3), but in many patients resumes if another IUC is re-inserted. These authors note there is an opportunity for an intervention at each stage of the cycle. In addition to the length of the time the IUC is in place, there are other risk factors for development of a CAUTI, including improper catheter insertion techniques, female gender, older age, compromised immune system, and comorbid conditions (e.g., diabetes, renal dysfunction). Other contributing factors to the development of a CAUTI are non-evidence-based (EB) nursing care practices for managing catheters. Procedures such as meatal cleansing with antiseptics, unsecured catheters, catheter irrigation, disconnecting the catheter from the drainage tubing, and others, are routinely performed by nurses, are not supported by EB research and, in many cases, have been shown to contribute to the development of a CAUTI. The fact that nurses are not following specific practices to prevent CAUTIs was shown in a survey about prevention of hospital-acquired UTIs and other device-associated infections distributed to both nonfederal and federal U.S. hospitals .
CAUTI Prevention Guideline
The latest guideline, which was revised by the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC), is the Guideline for Prevention of CAUTIs , and it provides updated recommendations on catheter use and maintenance to prevent UTIs. Recommendations in this guideline were also included in the International Clinical Practice Guidelines of the Infectious Diseases Society of America . The HICPAC CAUTI guideline was developed through a systematic review of the best available evidence and includes new research and technological advancements for the prevention of CAUTIs (Table 1). The guideline emphasizes quality improvement initiatives and provides suggestions for implementation. HICPAC has estimated that up to 69% of hospital-acquired CAUTIs may be prevented by implementation of an EB prevention program. Although patients who have IUCs in place long term will most certainly develop a CAUTI, evidence suggests that certain interventions can reduce the incidence of CAUTI in patients who have IUCs in place for short-term duration, and certain catheter-care strategies can prevent infections. The cornerstone of any CAUTI prevention program would be to remove the IUC as soon as possible. In addition, components identified that can decrease IUC use and prevent hospital-acquired CAUTIs include: instituting hospital-wide administrative interventions, implementing quality improvement programs, educating physician and nursing staff on indications, and evidence-based nursing care of the IUC to prevent infection . What is missing is the lack of integration of EB research with clinical expertise to minimize IUC use and prevent infections. Conway and colleagues  noted that EB practice and adoption of policies to prevent CAUTI was lacking in intensive care units (ICUs) studied, as only 42% of ICUs reporting having written policies in place for at least 1 of 4 prevention practices: use of portable bladder ultrasound scanners, condom catheters for men with urinary incontinence, reminders, or stop orders.
Implementing Practices to Prevent CAUTIs
There is EB research that suggests that certain interventions can reduce the incidence of CAUTIs in patients managed by short-term IUC. They include staff education about catheter management, combined with regular monitoring of CAUTI incidence, a hospital-wide program to ensure catheterization only when indicated, and prompt removal of IUC. One of the first strategies that hospitals should employ to prevent CAUTIs is the development of an appropriate infrastructure that includes some type of surveillance. Urinary catheters should be used only if necessary and should be removed as soon as practical. Table 2 outlines appropriate and inappropriate IUC use.
Some studies have indicated that early removal of IUCs can reduce UTI rates by up to 40%. To achieve this, nurse-directed IUC removal protocols on prevention of CAUTIs have shown positive outcomes. Fakih et al.  reported on the effect of nurse-led multidisciplinary rounds on 10 medical-surgical units on reduction in the unnecessary use of IUCs. The group reviewed the patients’ records to determine appropriate indication for the IUC and if it was not found, the patient’s nurse was asked to contact the physician to request discontinuation. In this study, more than two-thirds of IUCs with no indication for placement did not have a clear reason for placement. So through a simple monitoring intervention, unnecessary catheter use was reduced by 10%. Wenger  described a 3-pronged approach that included education, testing new and better catheter products, and ending with a nurse-driven protocol for catheter removal. This hospital’s leadership gave nurses the authority to remove IUC through the use of a protocol of specific criteria defining medical necessity. Parry et al.  showed that aggressive implementation of the nurse-directed catheter removal protocol was associated with lower catheter use rates and reduced infection rates. Some acute care hospitals have created “catheter champions,” a group of nurses who are a daily resource to all medical and nursing staff for any catheter-related problems that arise. Developing protocols that describe steps to take following catheter removal, so as to deter the reinsertion of a catheter, may be necessary.
Staff should develop policies that detail criteria for IUC indications and inappropriate use (Table 2). As part of surveillance, the hospital should provide and implement written guidelines for catheter use, insertion, and maintenance .
Stop Orders for Catheter Removal
The most important strategies for prevention of CAUTIs is to avoid insertion of an IUC and, if necessary, limit the duration to as short a time as possible. Given that the rate of infection is closely related to the duration of catheterization, the high frequency of inappropriate catheterization, and the finding that physicians are often unaware of catheter presence, it is possible that an automatic urinary catheter “stop order” or reminder would be useful. Such an innovative system-wide administrative intervention, similar to an antibiotic stop order, would ideally remind physicians that their patient has an indwelling catheter, which in turn might help reduce inappropriate catheterization . In 2008, Saint noted that only 9% of hospitals reported using an IUC stop order or reminder. Meddings et al.  note that a stop order requires action, as they prompt the clinician, usually a bedside nurse, to remove the catheter by default after a certain time period (e.g., with 24 hours). Fakih et al.  evaluated the effect of 3 interventions over a 5-year period. The interventions included:
- a nurse-driven multidisciplinary effort for early IUC removal,
- an intervention in an emergency department to promote appropriate placement, and
- twice-weekly assessment of IUC prevalence with periodic feedback on performance for non-intensive care units.
These researchers found that once given the responsibility for IUCs, bedside nurses become “champions” for catheter removal, and supporting bedside nurses with alternatives (e.g., condom catheter) can reduce IUC use. However, although the implementation of this automatic order is becoming more popular  and are part of CAUTI prevention programs, Loeb et al.  noted that stop orders for IUC safely reduced duration of inappropriate urinary catheterization in hospitalized patients but did not reduce UTIs.
Use of a “Bladder Bundle”
Saint  noted that there is no “magic bullet” for CAUTI prevention. However, in 2009, he described a “bundle” of best practices for IUC and labeled them the “Bladder Bundles.” A bundle is a set of EB practices that are designed to be implemented together to optimize treatment, prevent or reduce complications, and improve outcome . The Bladder Bundle is the mnemonic ABCDE described by Saint et al.  in their discussion on translating CAUTI prevention research into practice via a bladder bundle. These bundles are a simplified list of the key points (Table 3) of the HIPAC EB clinical practice guideline, and are educational interventions around appropriate IUC use and clinical skill in IUC placement, use of non-invasive technology to determine bladder volume, and protocols to aid clinical decision-making for IUC use and removal . Others have used this bundle. Krien et al.  noted bladder bundle implementation involved educating health-care workers about appropriate indications, establishing a process for regular catheter assessment and removal, use of a nursing-based discontinuation protocol, and collecting data for monitoring IUC use and indication. Venkatram and colleagues  reported on successful implementation of the UTI bundle in medical IUCs, which resulted in an almost 90% reduction of IUC-related UTIs. Fakih and colleagues  reported on a statewide initiative in Michigan that used bladder bundles to decrease inappropriate IUC use. This EB research needs to be adopted by acute care hospitals.
Indwelling urinary catheters are a significant source of all hospital infections. The best prevention is to remove the catheter as soon as possible. Strong surveillance programs, nurse-directed protocols, automatic removal orders, and the use of a bundle can control catheter-related infections. Evidence-based research and guidelines, professional organizations, and federal agencies (Table 4) are assisting clinicians in managing these problematic devices.
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