Prevention of Catheter-Associated Urinary Tract Infection

 

OVERVIEW

A. CAUTIs are the single most common HAI, accounting for 9.5% of all HAIs and associated with significant morbidity and excess healthcare costs.

B. Since 2008, the CMS no longer reimburses for additional costs required to treat nosocomial UTIs.

C. Multiple EBP strategies, recommendations, and/or guidelines for preventing CAUTI in hospitals and long-term care have been published.

D. In light of these rapid changes in the field, review of policies, procedures, practices, and products is imperative for all healthcare facilities.

 

BACKGROUND/STATEMENT OF PROBLEM

A. Introduction

  1. The vast majority of UTIs are associated with the ubiquitous IUC, also known as Foley catheter.
  2. Risk of CAUTI increases 5% to 10% each day the IUC remains in use (Abubakar et al., 2021).
  3. IUC use is disproportionately reported among older adults and patients in ICUs.

B. Definitions

  1. SUTI: a patient with at least one of the following signs or symptoms with no other recognized cause: fever (>38°C), suprapubic tenderness, costovertebral angle pain or 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 SUTI 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 the 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 take time, most CAUTIs occur after 48 hours of catheterization, increasing approximately 3% to 10% per day.
  4. The mechanisms described earlier provide the rationale for evidence-based care of IUCs. Four potential opportunities for intervention are:
    • Avoidance of the use of catheters
    • Evidence-based care practices and product selection
    • Timely removal
    • Education and surveillance

ASSESSMENT OF CATHETER-ASSOCIATED URINARY TRACT INFECTION

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 include:

  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 contraindicated)
      • 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. Available alternative strategies to manage urine output
    • Bedside commodes
    • EUCD
    • 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. Select the 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.
    • The decision to use a silver-coated or an antibiotic-impregnated catheter should be made with the understanding that it does not substitute for a comprehensive CAUTI prevention program.
  2. Select the smallest size possible (<18 French).
  3. Use aseptic technique and sterile product during catheter insertion.
  4. Cleanse the urethral meatus with soap and water while having a bath and after bowel movement.
  5. Secure catheter to the leg using a catheter securement device.
  6. Maintain a closed system at all times.
  7. Keep drainage bag below the level of the bladder.
  8. Empty the bag when two-thirds full and before transport.

C. Timely removal

  1. Systems that prompt providers to review the need for catheter and encourage early removal; examples include stop orders and reminder systems, audit/feedback, nurse-prompted reminders, and nurse-driven removal protocols

D. Surveillance and education

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

EVALUATION AND 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. Trend unit-specific IUC usage.

RELEVANT PRACTICE RESOURCES

A. Association for Professionals in Infection Control and Epidemiology. (2014). APIC implementation guide: Guide to preventing catheter-associated urinary tract infections. www.apic.org

B. National Healthcare Safety Network. (2023, January). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events. https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf

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

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Updated: January 2025
 

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents


Chapter 25, Kidd, M., Delaney, L., & Hacker, B. (2025) Catheter-Associated Urinary Tract Infection

 

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