Urinary tract infections (UTIs) are the most common hospital-acquired infections (HAIs) in the United States. It has been estimated that about 80% of these infections are attributable to indwelling urethral catheters. “About 15% of hospitalized inpatients will have a urinary catheter at some time during their hospital stay,” says Lindsay E. Nicolle, MD, FRCPC. “The daily risk for patients acquiring a urinary infection ranges between 3% and 7% when indwelling urethral catheters remain in situ. When compared with other HAIs, however, UTIs are associated with the lowest mortality and virtually no prolongation of hospital stay. ”
UTIs are the most important adverse outcome of urinary catheter use. “Most UTIs that occur with catheters are asymptomatic, but bacteremia and sepsis may occur in a small number of infected patients,” explains Dr. Nicolle. “While the risk of symptomatic catheter-associated UTIs (CAUTI) is less than 1%, the high frequency of catheter use means the actual number of patients developing infection is quite high.” In published studies, catheter use has also been associated with negative outcomes other than infection. These include nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.
New Recommendations
The Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and other partners created a concise compendium of recommendations for the prevention of common HAIs—including CAUTI—in 2008. These were developed by a task force of infectious disease and healthcare-acquired infection experts. The resulting recommendations were published in the October 2008 supplement to Infection Control and Hospital Epidemiology and are available online at www.preventingHAIs.com. “The compendium recommendations can help hospitals focus and prioritize their efforts to implement evidence-based practices,” Dr. Nicolle says.
The compendium recommendations outline several key risk factors for the development of CAUTI. Dr. Nicolle says the presence of a catheter and total duration of catheterization are overwhelmingly the most important risk factors for the development of infection. “The primary strategy for preventing CAUTI is to limit catheter use. If there are clear indications for catheter use, it’s always important to minimize the duration for which the catheter remains in situ.” The recommendations note that other risk factors for CAUTI include female sex, older age, and not maintaining a closed drainage system.
Important Prevention Strategies
In addition to limiting catheter use, the compendium recommendations indicate that clinicians should provide and implement written guidelines for catheter use, insertion, and maintenance to prevent the development of CAUTI (Table). “Hospitals should make efforts to develop and implement criteria for acceptable indications for indwelling urinary catheter use in their institution,” adds Dr. Nicolle.
The diagnosis of CAUTI for surveillance of infection may be problematic because most patients with these infections are asymptomatic. “It can be challenging to detect symptomatic CAUTI,” says Dr. Nicolle. “That’s because of the high prevalence of positive urine cultures and because patients who develop a symptomatic infection lack localizing genitourinary symptoms when a catheter is in place. Further evaluation of diagnostic criteria for symptomatic CAUTI is necessary.”
The compendium recommendations emphasize that urinary catheters should only be inserted when necessary and should be left in place only as long as indications persist. “Clinicians should consider other methods for managing UTIs when appropriate,” Dr. Nicolle says. “It’s also important to practice good hand hygiene before inserting a catheter and before and after manipulating it. Use of aseptic techniques and sterile equipment as well as gloves, a drape, and sterile sponges are other prevention measures. When managing indwelling catheters, they should be properly secured after insertion to prevent movement and urethral traction.”
Special Strategies
In hospitals with unacceptably high CAUTI rates despite implementation of basic prevention strategies, the compendium recommendations indicate that risk assessments should be performed. “Implementing organization-wide programs to identify and remove catheters that are no longer necessary are important,” says Dr. Nicolle. “Several methods have been effective in the literature, including electronic and other types of reminders [Figure]. The key is to develop and implement institutional policies that require continual—usually daily—reviews of the necessity of continued catheterization.” Another approach is to include the issue at daily ward rounds by nurses and physicians so that all patients with urinary catheters can be assessed regarding their need for continued catheterization.
Dr. Nicolle says systems and protocols need to be established so that CAUTI can be prevented. “Hospitals must collect, analyze, and report data on catheter use and adverse events. They need to monitor adverse outcomes and stratify measurements of catheter use by relevant risk factors. Data should be reviewed in a timely fashion and reported to the appropriate stakeholders. This can serve as an opportunity to educate healthcare personnel involved in the insertion, care, and maintenance of urinary catheters to further prevent CAUTI.”
Lindsay E. Nicolle, MD, FRCPC, has indicated to Physician’s Weekly that she has no financial disclosures to report.
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