KEY ISSUES

• “The decision to use the urinary catheter should be made with the knowledge that it involves the risk of producing a serious disease.” Even though Paul Beeson made this statement about sixty years ago, it is still relevant today for patients, healthcare workers (HCWs) and risk managers.
• Catheter associated urinary tract infections (CAUTI) are one of the most common healthcare associated infection (HAI). The frequency of CAUTI is 12.9%, 19.6%, and 24% in the United States, Europe, and developing countries, respectively.
• Catheter-associated urinary tract infection (CAUTI) is defined as a urinary tract infection (UTI) where an indwelling urinary catheter was in place for more than 2 calendar days on the date of event, with day of device placement being day 1, and an indwelling urinary catheter was in place on the date of event or the day before (CDC). If an indwelling urinary catheter was in place for more than 2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next day for the UTI to be catheter-associated (CDC).
• Worldwide, over 100 million urinary catheters are being used annually, which translates approximately to 200 urinary catheters being used every single minute. In the United States, an estimated 30 million indwelling urethral catheters are sold annually and approximately 20% of hospitalized patients have a urethral catheter at any given time. Although infectious complications associated with indwelling urethral catheters are well described, noninfectious urethral catheter-associated complications can be relevant. Overall, about 30% of initial urinary catheterizations are unjustified, and one-third to one-half of days of continued catheterization are also unjustified. The reduction of inappropriate use of indwelling urinary catheter, the use of closed drainage systems, and the early removal “as soon as possible” of the catheter already in place, are the main tools to reduce CAUTIs.

KNOWN FACTS

• CAUTI accounts for approximately 70% and 95% of UTIs outside and in Intensive care units respectively. According to the International Nosocomial Infection Control Consortium (NICC), from 2012 to 2017, the CAUTI pooled mean rate for 45 countries was 4.8 per 1000 catheter-days, rates ranged of 2.2 UTI per 1000 catheter-days in surgical cardiothoracic ICUs to 6.7 UTI per 1000 catheter-days in respiratory ICUs.
• Overall, the occurrence of CAUTI increases cost and duration of hospital stay by 4 days. The attributable costs of a CAUTI are: $876 inpatient cost to the hospital for additional diagnostic tests and medications; $1,764 for non-ICU patients; $8,398 for hospitalized pediatric patients; and $10,197 for ICU patients.
• The daily rate of acquiring bacteriuria among hospitalized patients with urinary catheters is approximately 3 to 10%, and between 10 to 25% of patients with bacteriuria will develop symptoms of UTI. Of patients with symptomatic CAUTI, about 5% of patients with CAUTI develop a bacteremia. Mortality associated with a blood stream infection secondary to CAUTI is approximately 30%.
• The first step in CAUTI pathogenesis is the development of biofilms on the surfaces of catheters. Microorganisms causing endemic CAUTIs derive from the patient’s own flora or from the hands of HCWs during catheter insertion or manipulation of the collection system. Bacteria can enter the urinary tract in catheterized patients in three ways: introduction of organisms into the bladder at the time of catheter insertion; periurethal route; intraluminal route.
• The most common pathogens associated with CAUTI are gram-negative bacilli. The most frequent pathogens associated with CAUTI in hospitals reporting to National Healthcare Safety Network (NHSN) between 2015-2017 were Escherichia coli (34.3%), Klebsiella (14.2%) and Pseudomonas aeruginosa (12.8%). These pathogens were the 3 most frequently reported for all location types analyzed: hospital ward and ICUs, hospital oncology units, long-term acute-care hospitals, inpatient rehabilitation facilities (IRFs). Frequencies of E. faecium and E. faecalis as CAUTI pathogens differed by location type, with E. faecium rarely identified in IRFs (1%) and E. faecalis commonly reported by oncology units (12%).
• Among CAUTIs, long-term acute-care hospitals had a significantly higher non-susceptibility rate than hospital wards for all pathogens. For example, 23% of Klebsiella were carbapenem-resistant Enterobacteriaceae in long-term acute-care hospitals, compared with 7% in wards. Hospital ICUs had a lower non-susceptibility rate than hospital wards for all Klebsiella spp. and E. coli phenotypes among CAUTIs.
• A continuously closed urinary drainage system is pivotal to the prevention of CAUTI. For short-term catheterization, this measure alone can reduce the rate of infection from an inevitable 100% when open drainage is employed to less than 25%. Breaches in the closed system, such as unnecessary emptying of the urinary drainage bag or taking a urine sample, will increase the risk of catheter-related infection and should be avoided. Before manipulating the closed system, hands must be adequately washed with soap or alcohol-based solutions and gloves worn.
• Non-infectious complications secondary to indwelling urinary catheters are common, and in case of long-term catheterization are 4 times higher than CAUTI. Although the most frequent complications are minor (for example, leakage around the catheter), serious complications, such as urethral strictures and gross hematuria, occur in a substantial proportion of patients. Moreover, long-term catheterization and catheter use in patients with spinal cord injury result in even greater illness, with more than 30% of patients having several complications.
• Studies comparing meatal cleansing with a variety of antiseptic/antimicrobial agents or soap and water demonstrated no reduction in bacteriuria when using any of these preparations for meatal care compared with routine bathing or showering. Meatal cleansing is not necessary and may increase the risk of infection. Daily routine bathing or showering is all that is needed to maintain meatal hygiene.
• Antibiotic prophylaxis in order to prevent CAUTI, is not recommended for patients undergoing catheter-placement or catheter-removal. There are potential disadvantages to antibiotic prophylaxis such as an increased risk of developing of antimicrobial resistance, an increase in costs, and potential side effects. A meta-analysis reported by Marschall et al found that antibiotic prophylaxis was associated with only an absolute reduction in risk of CAUTI of 5.8% (RR 0.45, 95% CI 0.28 to 0.72).  Lusardi et al.  reported limited evidence to support antibiotic prophylaxis reduced the rates of bacteriuria, pyuria, febrile morbidity, or Gram-negative isolates. These findings were in surgical patients who underwent bladder drainage for at least 24 hours postoperatively, as well as non-surgical patients.
• Another proposed approach to prevent CAUTI is to coat catheters with antibacterial materials. In patients with short-term indwelling urethral catheterization, antimicrobial-coated urinary catheters may reduce or delay the onset of catheter-associated bacteriuria, but do not decrease the frequency of CAUTI. The major concern regarding the use of antibiotics in urinary catheters is the development of antimicrobial resistance. An alternative option to the use of antibiotic impregnated catheters, coating the catheter surface with an antiseptic, such as a silver compound, could reduce the presence of the biofilm on the surface of the catheter. Early studies with a silver-oxide coated catheter reported no benefit for preventing bacteriuria, but silver alloy catheters were subsequently reported to decrease acquisition of bacteriuria, although symptomatic infection was not adequately evaluated. Lam et al. found no significant difference in symptomatic CAUTI incidence (RR 0.99, 95% CI 0.85 to 1.16) between silver alloy-coated catheters and standard catheters. Silver alloy catheters achieved a slight but statistically significant reduction in bacteriuria (RR 0.82, 95% CI 0.73 to 0.92).
• The most important risk factor reported in most studies was prolonged catheterization beyond 6 days; by the 30th day of catheterization, infection isalmost 100%. Thus, every operative strategy should aim to reduce to a minimum the duration of urinary catheterization and these must be incorporated into care bundles for managing CA UTI. Computer-generated reminders or automatic stop orders are important tools for early removal of urinary catheters. Meddings et al. observed that the rate of CAUTI was reduced by 52% (RR 0.48; 95% CI 0.28 to 0.68) with use of a reminder or stop order. The mean duration of catheterization decreased by 37%. Felix et al. compared the effectiveness of physician-initiated daily verbal reminders to primary care providers with nurse-initiated daily verbal reminders in decreasing the duration of inappropriate indwelling urinary catheter use in hospitalized patients. Catheter use duration was significantly decreased in the physician-initiated compared with the nurse-initiated group (P = 0.03). Finally, Baillie et al. evaluated the effectiveness of a computerized clinical decision support intervention aimed at reducing the duration of urinary tract catheterizations. The study showed a decrease in the use of urinary catheter (from 0.22 to 0.19, P <0.001) and of CAUTI (from 0.84 to 0.51 CAUTI/1000 patient-days, P<0.001).

SUGGESTED PRACTICE

Information

Provide patients with information about the need, insertion, maintenance, and removal of their catheter.

Education

• Educate HCWs about:
  1. Appropriate indications for indwelling urinary catheters in:
     1. patients with anatomic or physiologic outlet obstruction;
     2. patients undergoing surgical repair of the genitourinary tract;
     3. critically ill patients who need to measure the daily urinary output.
  2. Alternative strategies for the management of urinary incontinence at home and in hospital (e.g. condom or intermittent catheter use).
  3. Infectious complications and adverse events associated with urinary catheterization.
  4. Optimum selection of the smallest gauge catheter for free urinary outflow.
  5. Correct techniques for catheter insertion and care.
  6. Adopting and maintaining the sterile continuously closed system of urinary drainage.
  7. Maintaining unobstructed urine flow.
  8. Minimizing the duration of the urinary catheterization by daily evaluation of the patient’s condition.
  9. Identifying care bundle as group of individual evidence-based best practice interventions is an integrated multidisciplinary strategy to reduce CAUTI infections and improve patient outcomes.

Care and Maintenance

• Maintain adequate urine flow at all times. Ideally, sufficient fluid to maintain urine output of greater than 100 ml/h should be given if it is not contraindicated by the patient’s clinical condition.
• Emptying of urine drainage bag in a sterile single patient use jug or container.
• Bag kept below the pelvis but off the floor or a contaminated surface.
• Do not change catheters unnecessarily or as part of routine practice.
• Consider the use of catheters with anti-infective surface at least for those patients at high risk of serious complications of catheter-associated bacteriuria.

Stop order

Consider computer-generated reminders or automatic “stop orders” for indwelling urinary catheters; these orders should require that the catheter either be removed or reordered after a specified period of catheterization.

Quality Control, Surveillance and Documentation

• Use quality-control evidence-based patient audits to design programs to improve catheterization techniques, quality of urinary catheters and decrease inappropriate use of indwelling urinary catheters.
• Develop and implement a periodic one-day prevalence or other surveillance system of CAUTI
• Document all procedures involving the catheter or drainage system in the patient’s records.

SUGGESTED PRACTICE IN UNDER-RESOURCED SETTINGS

There are no specific guidelines for the management and prevention of CAUTI in LMICs. The cornerstones of CAUTI prevention are:

• HCW education.
• Use of aseptic technique during insertion of the catheter.
• Use of continuously closed urinary drainage systems.
• Early removal of indwelling catheters based on daily evalution of the patient’s condition.
• Consider alternatives to indwelling catheterization.
• Consider automatic computer-generated reminders or “stop orders” for indwelling urinary catheters.

SUMMARY

Overall, protocols should be implemented to promote the proper indications for urinary catheter placement and management. A continuously closed system of urinary drainage is the cornerstone of infection control and clear criteria for the removal of urinary catheters are part of bundled strategies for the reduction of CAUTI. Novel urinary catheters impregnated with antibiotic drugs or coated with anti-infective material exhibit antimicrobial activity that may reduce the risk of CA UTI for short-term catheterizations; however, their routine use is not recommended. In the future, a major biotechnology effort to reduce the prevalence rate of CA UTIs and indeed of all hospital-related nosocomial infections is likely to be represented by vaccines against important multidrug-resistant microorganisms, such as enteric Gram-negative bacilli.

REFERENCES

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2. Beeson PB. The Case Against the Catheter. Am J Med. 1958; 24(1):1-3.
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