Catheter-associated bacteriuria, the most common healthcare-associated infection, results from the widespread use of urinary catheterization. Oftentimes, the use of urinary catheters is inappropriate in hospitals and long-term care facilities. “Considerable personnel time and other costs are expended by healthcare institutions throughout the world to reduce the rate of catheter-associated infections, especially those that occur in patients with urinary tract symptoms,” says Thomas M. Hooton, MD. Strategies to reduce the use of catheterization have been shown to be effective in published literature. The data demonstrate that use of such strategies is likely to have a significant impact on the incidence of catheter-associated urinary tract infections (CA-UTI).

An expert panel of the Infectious Diseases Society of America (IDSA) released new guidelines that address CA-UTI in adults aged 18 and older. Published in the March 1, 2010 issue of Clinical Infectious Diseases, the guidelines are aimed at assisting physicians in all specialties who perform direct patient care, especially of patients in hospitals or long-term care facilities. “These evidence-based IDSA guidelines provide diagnostic criteria and strategies to reduce the risk of CA-UTIs,” explains Dr. Hooton, who was the lead author of the guidelines. “They also provide strategies that have not been found to reduce the incidence of urinary infections. Management strategies are presented to assist clinicians who treat patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. Implementing the strategies outlined in the guidelines should be a priority for all healthcare facilities.”

Reducing the Incidence

According to the guidelines, the most effective way to reduce the incidence of CA-UTI is to reduce the use of urinary catheterization (Table 1). This requires restricting its use to patients who have clear indications for these devices and removing catheters as soon as they are no longer needed. “Clinicians need to become educated on the appropriate indications for catheter use,” says Dr. Hooton. Institutions should develop a list of appropriate indications for inserting indwelling urinary catheters. All healthcare staff should be given this list and educated to the point that at least 90% of catheters are placed according to those indications. At least 95% of catheter placements should be by a physician’s order. The guidelines note that using nurse-based or electronic physician reminder systems and automatic stop-orders to reduce inappropriate urinary catheterization are strategies to be considered by institutions.

The IDSA guidelines note that providers should recognize that there are several indications for indwelling urinary catheter use. For example, it is appropriate to use catheters when patients exhibit clinically significant urinary retention but medical therapy is ineffective and surgical correction is not indicated. They can also be used for urinary incontinence to give terminally-ill patients comfort if less invasive measures fail and collecting devices are an unacceptable alternative. In critically-ill patients, it is appropriate to use catheters when accurate urine output monitoring is needed. “During longer surgical procedures with general or spinal anesthesia, patients may be unable or unwilling to collect urine,” explains Dr. Hooton. “In these cases, catheter use is appropriate. However, physicians should also understand when indwelling urinary catheters shouldn’t be used. One contraindication would be for the management of general urinary incontinence. Catheter use in these cases should be considered only if all other approaches have failed and the patient requests it.”

Have Policies in Place

A key point in the guidelines is that hospitals and long-term care facilities should have policies and procedures in place for catheter insertion, maintenance, discontinuation, and replacement. To reduce infection, clinicians are recommended to minimize disconnection of the catheter junction and to keep the drainage bag and connect tube below the level of the bladder at all times. “It’s essential that institutions have protocols in place to minimize and prevent infection,” Dr. Hooton says (Table 2). “Institutions need to take measures to ensure that staff are appropriately educated and trained. Healthcare personnel need to recognize that there are many gaps in the knowledge about CA-UTI. The cost of managing CA-UTI is increasingly falling on hospitals and long-term care facilities, so the time is ripe to make efforts to prevent them in the first place.”

The continued development of intraurethral alternatives to indwelling catheterization and external urine collection alternatives are needed. “More evaluations on how well these devices reduce the risk of CA-UTI would be helpful,” Dr. Hooton adds. “Another important area of research is in the development of biomaterials that can prevent or limit biofilm formation. The available research is promising in this area, and the hope is that this will have a greater impact on reducing the incidence of CA-UTI in the future.”

References

Hooton TM, Bradley SF, Cardenas DD, 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;50:625-663. Available at: http://www.journals.uchicago.edu/doi/pdf/10.1086/650482.

Smith PW, Bennett G, Bradley S, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol. 2008;29:785-814.

Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46:243-250.

Tambyah PA. Catheter-associated urinary tract infections: diagnosis and prophylaxis. Int J Antimicrob Agents. 2004; 24(Suppl 1):S44-S48.

Screening for asymptomatic bacteriuria in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2008; 149:43-47.

Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643-654.