EVIDENCE- Urinary Catheter Use and Prevention of Infection

BASED CARE
SHEET What We Know
› Catheter-associated urinary tract infections (CAUTIs) are the most common
healthcare-associated infections, accounting for 30–40% of infections in the healthcare
setting and 80% of healthcare-associated urinary tract infections each year(2,5,6)
• CAUTIs are associated with increased hospitalizations, increased morbidity and
mortality, longer inpatient stays, and increased hospital costs(5)
–About 17% of cases of healthcare-associated bacteremia (i.e., the presence of bacteria
in the blood) are from a urinary source; these infections are associated with a mortality
rate of ~ 10%(5)
› Urinary catheters can be used short-term or long-term(9,12)
• Short-term catheterization can involve intermittent catheterization (i.e., inserting and
immediately removing the catheter when the bladder is emptied) or temporary placement
of a catheter that is attached to a drainage bag for urine collection
• Long-term urinary catheters are indwelling catheters that are used primarily for patients
with urinary incontinence or urinary retention; hospitalized patients and patients in
skilled nursing facilities often require an indwelling catheter
› There are many types of catheters (e.g., straight, Foley, coude tip) and catheters can be
made of many different materials (e.g., silicone, latex, Teflon), including materials that are
impregnated with antiseptic or antibiotic agents (e.g., silver)(6,9,12)
ICD-9 › CAUTIs are caused when bacteria is introduced in the bladder. Bacteria can enter the
996.64, E879.6
urinary tract in the following ways:(6,9,12)
• On initial catheter insertion
ICD-10
Y84.6 • By ascending the catheter tubing from the drainage tubing and bag
• When the drainage bag is incorrectly emptied
› Risk factors for CAUTIs include long-term catheter use (the most important risk factor),
Authors female sex, age over 60 years, debilitated condition, and postpartum state(5,6)
Nathalie Smith, RN, MSN, CNP
Cinahl Information Systems, Glendale, CA
• Catheter type has not been found to affect the incidence of CAUTI in patients who have
Tanja Schub, BS an indwelling catheter(6)
Cinahl Information Systems, Glendale, CA › Although many patients are asymptomatic, manifestations of CAUTI (e.g., fever, elevated
white blood cell [WBC] count, hematuria, bladder spasms) are nonspecific and differ
Reviewers from manifestations of urinary tract infection (UTI) that is unrelated to catheter use.
Manifestations of UTI include burning or pain during urination, frequent urination, and
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Teresa-Lynn Spears, RN, MSN lower abdominal pain or pressure(2)
Cinahl Information Systems, Glendale, CA
• Bacteriuria and pyuria (i.e., pus in the urine) occur in most cases of UTI(2)
Nursing Practice Council
Glendale Adventist Medical Center, –Enteric bacteria that most commonly cause CAUTIs include Escherichia coli,
Glendale, CA
Pseudomonas spp., Enterobacter spp., and Proteus spp.(2,5)
› An estimated 17–69% of CAUTIs are thought to be preventable.(5) According to
Editor
Diane Pravikoff, RN, PhD, FAAN joint guidelines published by the Society for Healthcare Epidemiology of America
Cinahl Information Systems, Glendale, CA (SHEA)and the Infectious Diseases Society of America (IDSA), the following strategies
are recommended for preventing infection in catheterized patients:(7)
• Provide and implement written guidelines for catheter use, insertion, and maintenance(7)
February 23, 2018

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professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 –Authors of a study of 71 acute care hospitals in the United States reported that the majority of hospitals had established
policies for insertion and maintenance of urinary catheters, but only 19 (26.8%) had developed annual nursing
competencies for catheter placement and maintenance(3)
–In a study involving 926 acute care units in the U.S., a CAUTI prevention program resulted in a reduction in the rate
of CAUTIs, from 2.40 per 1,000 catheter days to 2.05 per 1,000 catheter days. The program involved education on key
aspects of CAUTI prevention, including daily nursing rounds to review urine-collection strategies, consideration of
alternatives to indwelling catheters, and the importance of aseptic technique in catheter insertion and care(11)
• Avoid unnecessary catheterization and remove the catheter as soon as possible (e.g., within 24 hours after surgery)(7)
–Authors of a systematic review and meta-analysis of 30 studies found that use of interventions to prompt the removal of
urinary catheters such as chart reminders and stop orders reduce CAUTI rates by 53%(8)
–Researchers in a 300-bed teaching hospital reported that implementation of a multidisciplinary program to reduce CAUTI
that incorporated a nurse-directedurinary catheter removal protocol (e.g., the protocol prompted nurse removal of the
catheter after a pre-established period of time) combined with a catheter insertion protocol that required that minimal
catheter insertion criteria be met before insertion, reduced both urinary catheter insertion rates and CAUTI rates by 50%
and 70%, respectively, during a 36-month period(10)
• Use sterile technique to insert the catheter, maintain the catheter as a sterile and closed system, and promptly remove and
replace the urinary catheter when a break in asepsis is identified(7)
–The rate of CAUTIs was significantly lowered in one postoperative unit by implementing a two-nurse urinary insertion
protocol—one nurse to perform the procedure and a second nurse to ensure that sterile technique was maintained
throughout the procedure. CAUTI rates were reduced from 6.7 cases per 1,000 device days before implementing the
procedure to 4.11 cases per 1,000 catheter days 6 months after implementation(1)
–Researchers reported that direct observation of the urinary catheter insertion procedure was associated with a reduction in
the CAUTI rate in an intensive care unit from 2.24 per 1,000 catheter days to 0 per 1,000 catheter days(4)
• Perform hand hygiene before and after all handling of the catheter, tubing, and drainage bag(7)
• Properly secure the indwelling catheter using a facility-approved commercial securement device to prevent traction on the
catheter(7)
–Types of catheter securement devices include Velcro closure straps and adhesive catheter anchors (e.g., Cath-Secure,
K-Lock, StatLock Foley stabilization device)
• Routinely (e.g., daily) clean the patient’s urethral meatus and the catheter with soap and water. Use of antibacterial
solutions is unnecessary(7)
• Use the smallest gauge catheter possible to minimize urethral damage(7)
• Obtain small volume urine specimens aseptically by aspirating from the needleless sampling port; obtain larger specimens
aseptically from the drainage bag(7)
• Empty the drainage bag when it becomes full or at least once every 8 hours to prevent migration of bacteria(7)
• Use a separate, clean collecting container for each patient(7)
• Keep the drainage bag lower than the level of the patient’s bladder to prevent backflow of urine in the bladder; verify that
the bag does not rest on the floor(7)
• Avoid kinks in the catheter and drainage tubing(7)
› Strategies that are not recommended by SHEA/IDSA for the prevention of CAUTI include(7)
• routine use of antimicrobial- or antiseptic-impregnated catheters
• prophylactic systemic antibiotic therapy during catheter use (SHEA/IDSA provided no recommendation regarding the use
of systemic antibiotic therapy after catheter removal)
• continuous catheter irrigation as a means to prevent infection (irrigation used for the purpose of maintaining catheter
patency should be performed in a closed, sterile system)
• routinely changing the catheter even in the absence of signs and symptoms of infection
• assessment for and treatment of asymptomatic bacteriuria
What We Can Do
› Learn about evidence-based recommendations for preventing CAUTIs so you can accurately assess your patients’ personal
characteristics and health education needs; share this information with your colleagues
› Collaborate with your hospital’s education department to provide serial education and training regarding indications for
catheter use, procedures for insertion and securing catheters, and strategies for preventing and monitoring infections
› Perform hand hygiene frequently, use aseptic technique and sterile barriers when inserting a catheter and obtaining urine
samples, and follow facility protocols for catheter care, including for consistently securing the catheter and maintaining a
closed drainage system
› Assess your patients’ risk of CAUTI; risk factors include female sex, age over 60, immobility, and history of bladder stones
› Monitor for signs of complications in your patients who have a catheter, including a strong smell, cloudy or thick urine,
blood around the catheter, urethral swelling around the catheter, urinary incontinence, elevated levels of WBCs, and the
presence of bacteriuria and pyuria. Be aware that patients with a CAUTI can be asymptomatic

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
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(R)
2. Brusch, J. L. (2017, September 8). Catheter-related urinary tract infection. Medscape. Retrieved February 6, 2018, from
http://emedicine.medscape.com/article/2040035-overview (GI)
3. Fakih, M. G., Heavens, M., Ratcliffe, C. J., & Hendrich, A. (2013). First step to reducing infection risk as a system: Evaluation of infection prevention processes for 71 hospitals.
American Journal of Infection Control, 41(11), 950-954. doi:10.1016/j.ajic.2013.04.019 (R)
4. Galiczewsi, J. M., & Shurpin, K. M. (2017). An intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: Direct observation of
catheter insertion procedure. Intensive & Critical Care Nursing, 40, 26-34. doi:10.1016/j.iccn.2016.12.003 (R)
5. Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009). Guideline for
prevention of catheter-associated urinary tract infections, 2009. CDC. Guideline for prevention of catheter-associated urinary tract infections 2009. Retrieved February 6, 2018,
from https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf (G)
6. Jahn, P., Beutner, K., & Langer, G. (2012). Types of indwelling urinary catheters for long-term bladder drainage in adults. Cochrane Database of Systematic Reviews, Issue 10.
Art. No.: CD004997. doi:10.1002/14651858.CD004997.pub3 (SR)
7. Lo, E., Nicolle, L., Calssen, D., Arias, K. M., Podgorny, K., Anderson, D. J., ... Yokoe, D. S. (2014). Strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infection Control and Hospital Epidemiology, 35(5), 464-467. doi:10.1086/675718 (G)
8. Meddins, J., Rogers, M. A., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent
catheter-associated urinary tract infection: An integrative review. BMJ Quality & Safety, 23(4), 277-289. doi:10.1136/bmjqs-2012-001774 (M)
9. Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Urinary elimination. In A. G. Perry, P. A. Potter, & W. R. Ostendorf (Eds.), Clinical nursing skills & techniques (9th ed., pp.
873-904). St. Louis, MO: Elsevier. (GI)
10. Parry, M. F., Grant, B., & Sestovic, M. (2013). Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. American Journal
of Infection Control, 41(12), 1178-1181. doi:10.1016/j.ajic.2013.03.296 (R)
11. Saint, S., Greene, M. T., Krein, S. L., Rogers, M. A. M., Ratz, D., Fowler, K. E., ... Fakih, M. G. (2016). A program to prevent catheter-associated urinary tract infection in acute
care. New England Journal of Medicine, 374(22), 2111-2119. doi:10.10156/NEJMoa1504906 (R)
12. Sobol, J. (2017, February 5). Urinary catheters. MedlinePlus. Retrieved February 6, 2018, from http://www.nlm.nih.gov/medlineplus/ency/article/003981.htm (GI)