BACKGROUND/STATEMENT OF PROBLEM

A.  Introduction

1. The vast majority of UTIs are associated with the ubiquitous IUC, also known as a Foley catheter.
2. Risk of CAUTI increases 3% to 7% each day the IUC remains in use.
3. IUC use is disproportionately reported among older adults and patients in intensive care units.

B.  Definitions

1. Symptomatic UTI: A patient has at least one of the following signs or symptoms with no other recognized cause: Fever (>38°C), suprapubic tenderness, and a positive urine culture; urgency, frequency, and dysuria may or may not be catheter associated.
2. Asymptomatic bacteriuria: A positive urine culture in a patient who does not have fever or symptoms referable to the urinary tract; may or may not be catheter associated.
3. CAUTI: A symptomatic UTI that occurs while a patient has an IUC inserted for at least 2 days or within 24 hours of its removal.

C.  Essential elements

1. The urinary tract is normally a sterile body site. In the presence of an IUC, microorganisms can gain access to the urinary tract on either the extraluminal surface of the IUC or intraluminal surface through breaks in the catheter system.
2. Once bacteria gain access to the urinary tract, microorganisms can thrive in a “biofilm” layer on either the extra or intraluminal surface of the IUC.
3. Because the formation of a biofilm and colonization with bacteria takes time, most CAUTI occurs after 48 hours of catheterization and increases approximately 3% to 7% per day.
4. The mechanisms described earlier provide the rationale for evidence-based care of IUCs. Four potential opportunities for intervention are:
   • Avoid the use of catheters
   • Evidence-based care practices and product selection
   • Timely removal
   • Education and surveillance

ASSESSMENT OF CAUTI

A.  The CDC has developed explicit surveillance criteria for CAUTI. In brief, the patient must have:

1. A positive urine culture sent more than 48 hours after admission to the healthcare facility
2. An IUC at the time of or within 24 hours before the culture
3. One of the following: suprapubic tenderness, costovertebral angle pain or tenderness, or a fever more than 38°C without another recognized cause; or a positive blood culture with the same organism as in the urine

B.  Measures

1. Outcomes
   • CAUTIs/1,000 catheter days
2. Processes
   • Catheter days/hospital days
   • Surgical patients with catheter removed on postoperative day 1 or 2 (unless surgically contra-indicate)

C.  Indications for IUCs can be operationalized using algorithms or protocols.

NURSING CARE STRATEGIES

CAUTIs are preventable through the application of evidence-based care strategies.

A.  Catheter avoidance

1. Established insertion guidelines
2.  Alternative strategies to manage urine output available:
   • Bedside commodes
   • Exdwelling catheters
   • Moisture-wicking incontinence pads
   • Intermittent straight catheterization
   • Bladder scanner for monitoring and assessment
   • Bedpans and urinals that are functional
3. Toileting schedules and frequent nursing rounds

B.  Product selection and routine care

1. Catheter material:
   • Antimicrobial catheter materials have been shown to reduce catheter-associated bacteriuria (colonization), but impact on prevention of symptomatic CAUTIs during short-term insertions is unproven.
   • There is insufficient evidence to determine whether selection of a latex catheter, hydrogel-coated latex catheter, silicone-coated latex catheter, or all-silicone catheter influences CAUTI risk.
2. Select the smallest size possible (<18 French).
3. Use aseptic technique and sterile product during catheter insertion.
4. Cleanse urethral meatus with soap and water while having a bath and after bowel movement.
5. Secure catheter to leg using a catheter securement device.
6. Maintain a closed system at all times.
7. Keep drainage bag below level of bladder.
8. Empty the bag when two thirds full and before transport.

C.  Timely removal

1. Systems that prompt providers to review need for the catheter and encourage early removal. Examples include stop orders and reminder systems; audit/feedback, nurse-prompted reminders, nurse-driven removal protocols.
2. Measure of removal: SCIP, SCIP-inf-9 measure; catheter removal on postoperative day 1 or 2.

D.  Surveillance and education

1. Measurement of processes and outcomes
2. Ongoing system evaluation, nursing reeducation, practice reminders, and public reporting of unit-based CAUTI-rate data are strategies to inform the healthcare team of current practice outcomes and effectiveness of CAUTI prevention strategies.

EVALUATION/EXPECTED OUTCOMES

A.  Plan of care

1. Assessment that patient meets established insertion criteria
2. Adherence to prompts for early catheter removal
3. Standardized catheter care guidelines followed

B.  Documentation

1. Dates of insertion and removal
2. Type of catheter (new indwelling, chronic indwelling, reinsertion, change of device)
3. Reason for catheter insertion
4. Justification that catheter is still necessary
5. Postvoid residual catheter removal if patient is unable to void in 4 to 6 hours; bladder volume; intervention

C.  Catheter usage

1. Monitor unit-specific CAUTI rates.
2. Monitor average catheter duration (catheter days).
3. Monitor SCIP postoperative catheter removal on catheterization day 1 or 2.
4. Trend unit-specific IUC usage.

ABBREVIATIONS

CAUTI        Catheter-associated urinary tract infection

CMS            Centers for Medicare & Medicaid Services

EBP             Evidence-based practice

HAI             Healthcare-associated infection

IUC             Indwelling urinary catheters

SCIP            Surgical Care Improvement Project

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 26:  Kidd, M. & Makic, M. (2021) Prevention of Catheter-Associated Urinary Tract Infection.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 467-483).   New York: Springer.