Prevention Of Catheter Acquired Urinary Tract Infections

Recent prevalence surveys report a urinary catheter is the most common indwelling device, with 17.5% of patients in 66 European hospitals having a catheter and 23.6% in 183 US hospitals. In the NHSN 2011 surveillance report, 45–79% of patients in adult critical care units had an indwelling catheter, 17% of those on medical wards, 23% on surgical wards, and 9% on rehabilitation units. Thus, indwelling urethral catheter use is exceedingly common in health care facilities. Prevention of infections attributable to these devices is an important goal of health-care infection prevention programs.

CA-UTI is an important device-associated health care acquired infection. The use of an indwelling urethral catheter is associated with an increased frequency of symptomatic urinary tract infection and bacteremia, and additional morbidity from non-infectious complications. Infection control programs must develop, implement, and monitor policies and practices to minimize infections associated with use of these devices. A major focus of these programs should be to limit the use of indwelling urethral catheters, and to remove catheters promptly when no longer required. Ultimately, however, the avoidance of catheter associated urinary tract infections will likely require development of biofilm resistant catheter materials.

Guidelines to Prevention

Several evidence-based guidelines provide recommendations for the development and maintenance of prevention programs for CA-UTI. Approaches to prevention include avoidance of catheter use, policies for catheter insertion and maintenance, catheter selection, surveillance of CA-UTI and catheter use, and recommendations for quality indicators.

Program implementation

The facility infection prevention and control program should incorporate measures to limit CA-UTI. Improved outcomes following implementation of these programs have been reported. The program for a given institution should be individualized to be relevant to local experience, population characteristics, and resources. An essential element of any program is leadership at the senior management level.

Infrastructure to support an effective program includes development of policies for catheter indications, catheter selection, and catheter insertion and maintenance. There must be sufficient staffing and staff education, together with access to adequate and appropriate supplies. A means for documentation of urinary catheter use, including indications and dates of insertion and removal, should be established. Where an electronic patient record is used, documentation of catheter use and automatic reminders for removal should be incorporated into this record. The development and implementation of "bundles" for prevention of catheter acquired urinary tract infections has been described. Introduction of a urinary catheter bundle which included education, catheter insertion and management guidelines, and CA-UTI surveillance, in intensive care units in 15 developing countries was followed by a 37% reduction in CA-UTI rate. A state wide initiative in Michigan introduced a CA-UTI bundle with specific practical recommendations addressing implementation under the concepts of "engage and educate", "execute" and "evaluate".

Avoidance of catheter use

The single most important intervention to prevent CA-UTI is to avoid use of an indwelling urinary catheter. There are only a limited number of accepted indications for catheter use:

• Monitoring of hourly urine output in acutely ill patients.
• Perioperative use for selected surgical procedures

• Management of acute urinary retention and urinary obstruction.

• To facilitate healing of open pressure ulcers or skin grafts in selected patients with urinary incontinence.

• In exceptional circumstances (e.g. end-of-life care), at patient request to improve comfort.

Alternate voiding management strategies such as intermittent catheterization or, for men, external condom catheters, should be used when possible. Institutional policies should also minimize perioperative catheter use by promoting early post-procedure catheter removal and monitoring of bladder volume with ultrasound bladder scanners, where available, to limit catheter reinsertion for potential urinary retention. When a catheter is indicated, it should be removed promptly once it is no longer required. Patients with indwelling catheters should be identified and reviewed on a continuing basis, preferably at daily rounds, and the catheter removed when no longer indicated. Catheters have been reported to frequently remain in situ beyond necessary, sometimes because health-care personnel are not aware the catheter is present. A systematic review of catheter discontinuation strategies for hospitalized patients reported that the intervention of a "stop order" to facilitate prompt removal of unnecessary catheters reduced the duration of catheter use by 1.06 days, and use of either catheter reminders or stop orders decreased the CA-UTI rate by 53% .

Selection of urinary catheter

The smallest gauge catheter possible should be used, to minimize urethral trauma. Infection risks are similar with latex or silicone catheters, and whether or not there is hydrogel coating of the catheter. Residents with chronic catheters have a decreased frequency of obstruction with silicone catheters, but this observation is attributed to the larger bore size of the catheter, rather than the catheter material. The use of silver alloy coated catheters does not decrease the frequency of CA-UTI [12,61-63]. Nitrofurazone coated catheters have been reported to be associated with a small decrease in CA-UTI, but are accompanied by more frequent catheter removal and increased catheter discomfort. Thus, current evidence does not support the routine use of antimicrobial coated catheters.

Catheter insertion and maintenance

Recommended practices for catheter insertion and maintenance include.These recommendations are primarily based on consensus, but there is strong evidence supporting a decreased rate of acquisition of bacteriuria by maintaining a closed drainage system. There are no benefits with routine daily periurethral cleaning using normal saline, soap, or an antiseptic, or with the addition of antiseptics to the drainage bag.

• Catheter insertion:

• Catheter maintenance
Monitoring of infection

The surveillance of catheter use and complications is important to document the facility CA-UTI rate, the effectiveness of interventions, and to allow comparison with benchmark rates . Surveillance with benchmarking was reported, by itself, to decrease infection rates in German intensive care units, although the impact for CA-UTI was not as great as observed for ventilator-associated pneumonia or primary blood stream infections. Standardized surveillance definitions for infection should be used. Core data elements which must be collected to support effective surveillance include recording of catheter indication, catheter insertion and removal dates, urine culture results, and monitoring of bacteremia. Relevant quality indicators are CA-UTI incidence, CA-UTI bacteremia incidence, and the proportion of indwelling catheter use meeting accepted indications.

The outcomes of CA-UTI and bacteremic infection are described using a denominator of device days. However, an effective infection prevention program will minimize catheter use, potentially leading to overall higher device day infection rates as fewer low-risk patients will have catheters. Thus, an outcome based on total patient days, the standardized infection ratio, should also be reported. Surveillance data should be reviewed by appropriate individuals and committees, and observations reported back to caregivers on patient wards.

Prevention of CA-UTI in long term care facilities

The prevention of CA-UTI in long term care facilities addresses primarily residents with a chronic indwelling catheter. There should be frequent, systematic review of any resident with a chronic indwelling catheter to determine whether the catheter remains necessary. Bacteriuria in these residents is not avoidable. Interventions should focus on removing the catheter, whenever feasible, minimizing catheter trauma, and early identification of catheter obstruction. Chronic indwelling catheters should not be changed routinely. They should be replaced only if there is obstruction or other malfunction, or prior to initiating antimicrobial therapy when symptomatic urinary infection is treated. Residents with chronic catheters may use a leg bag for drainage to facilitate mobility. Facility policies should address reuse and cleaning or replacement of the leg bags. Antimicrobial therapy for the treatment of bacteriuria in long term care residents with chronic indwelling catheters does not decrease CA-UTI, but there is an increased isolation of resistant organisms with the antimicrobial therapy. Thus, treatment of asymptomatic bacteriuria should be avoided.

The complete original article and references by Lindsay E Nicolle may be found Antimicrobial Resistance and Infection Control Journal website in the article "Catheter Associated Urinary Tract Infections"