كتاب
Prevention of Catheter associated Urinary Tract Infections
- Recommendations
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Recommendations |
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1. Appropriate Urinary Catheter Use |
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Insert catheters only for appropriate indications and leave in place only as long as needed (Strong Recommendation, Moderate Grade Evidence) |
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Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and patients with impaired immunity. (Strong Recommendation, Moderate Grade Evidence) |
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Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. (Strong Recommendation, Moderate Grade Evidence) |
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Use urinary catheters in operative patients only as necessary, rather than routinely (Strong Recommendation, Moderate Grade Evidence) |
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For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Strong Recommendation, Moderate Grade Evidence) |
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2. Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate. |
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Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Good Practice Statement) |
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Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Good Practice Statement) |
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Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Good Practice Statement) |
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Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration. (Good Practice Statement) |
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3. Proper Techniques for Urinary Catheter Insertion |
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Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. (Strong Recommendation, Moderate Grade Evidence) |
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Ensure that only properly trained healthcare workers who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Strong Recommendation, Moderate Grade Evidence) |
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Insert urinary catheters using aseptic technique and sterile equipment. (Strong Recommendation, Moderate Grade Evidence) |
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Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant gel for insertion. (Strong Recommendation, Moderate Grade Evidence) |
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Routine use of antiseptic lubricants is not necessary. (Good Practice Statement) |
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Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Strong Recommendation, Moderate Grade Evidence) |
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Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. (Good Practice Statement) |
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4. Proper Techniques for Urinary Catheter Maintenance |
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Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Strong Recommendation, Moderate Grade Evidence) |
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If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. (Strong Recommendation, Moderate Grade Evidence) |
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Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. (Good Practice Statement) |
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Maintain unobstructed urine flow. (Strong Recommendation, Moderate Grade Evidence) |
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Keep the catheter and collecting tube free from kinking. (Strong Recommendation, Moderate Grade Evidence) |
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Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Strong Recommendation, Moderate Grade Evidence) |
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Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. (Strong Recommendation, Moderate Grade Evidence) |
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Use Standard Precautions, including the use of gloves, during any manipulation of the catheter or collecting system. (Strong Recommendation, Moderate Grade Evidence) |
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Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Good Practice Statement) |
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Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization. (Strong Recommendation, Moderate Grade Evidence) |
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Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. (Strong Recommendation, Moderate Grade Evidence) |
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Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. (Good Practice Statement) |
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If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. (Good Practice Statement) |
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Routine irrigation of the bladder with antimicrobials is not recommended. (Good Practice Statement) |
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Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Good Practice Statement) |
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5. Catheter Materials |
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Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (Good Practice Statement) |
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6. Management of Obstruction |
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If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. (Strong Recommendation, Moderate Grade Evidence Grade) |
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7. Specimen Collection |
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Obtain urine samples aseptically. (Strong Recommendation, Moderate Grade Evidence) |
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If a small volume of fresh urine is needed for examination (i.e., urine analysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Strong Recommendation, Moderate Grade Evidence) |
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Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Strong Recommendation, Moderate Grade Evidence) |
Rationale
Burden of outcomes associated with CAUTI
1. Urinary tract infections are one of the most common healthcare-associated infections.
2. Urinary catheters remain one of the most common medical devices experienced by adults in emergency departments and hospitals worldwide. Often, these devices are placed and maintained in use without an appropriate clinical indication to justify the risk compared to the benefit. Of patients who have a urinary catheter placed in the hospital, up to half are placed in patients who may not have an appropriate indication for a urinary catheter.
3. The daily risk of development of bacteriuria varies from 3% to 7% when an indwelling urethral catheter remains in situ.
4. The high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.
5. Infection is only one of several adverse outcomes of urinary catheter use. Noninfectious complications include nonbacterial urethral inflammation, urethral strictures, mechanical trauma, and mobility impairment, and these are described in this document as well.
6. CAUTI has been associated with increased mortality and length of stay, but the association with mortality may be a consequence of confounding by unmeasured clinical variables.
Risk Factors for CAUTI and Reduction Strategies
Risk factors for CAUTI include catheter duration, female anatomy, age related changes of the genitourinary tract, pregnancy, poor nutrition, fecal incontinence, illness severity, paraplegia, cerebrovascular disease, immunocompromised status, comorbid conditions resulting in neurogenic bladder, and equipment required to manage bladder voiding.
Reservoirs of transmission
1. The drainage bag of the bacteriuric patient is a reservoir for organisms that may be transmitted through the hands of healthcare personnel (HCP).
2. The drainage bag can also become contaminated by contact with hands due to inadequate hand hygiene, contact with the patient’s skin or hands, or contact with the floor or vessel used to empty the bag.
3. Outbreaks of infections associated with resistant gram-negative organisms attributable to bacteriuria in catheterized patients have been reported.
Effective methods to reduce risk include:
1. Not inserting an IUC unless strict criteria are met (e.g., neurogenic bladder, obstructive uropathy)
2. Using external urinary catheters when appropriate for the patient
3. Limiting the duration of the IUC by using facility-specific removal criteria
4. Following aseptic techniques for insertion and maintenance of IUC
5. Additional approaches to prevent CAUTI:
a. Define and monitor catheter harm in addition to CAUTI, including catheter obstruction, unintended removal, catheter trauma, or reinsertion within 24 hours of removal. Catheter harm includes infectious complications in addition to CAUTI (eg, secondary bacteremia, asymptomatic bacteriuria consequences) and noninfectious catheter complications. Patients with an indwelling urethral catheter are 5 times more likely to experience noninfectious complications (eg, urethral injury, pain, or inadvertent catheter removal) than infectious complications.
b. Establish a system for defining, analyzing, and reporting data on non–catheter-associated UTIs, particularly UTIs associated with devices used as alternatives to indwelling urethral catheters. Non–catheter-associated UTIs are defined as UTIs that occur in hospitalized patients without an indwelling urethral catheter. These include but are not limited to patients who have had no urinary device at all, as well as those with external urinary catheters, urinary stents, or urostomies, or who undergo intermittent catheterization, and thus are not captured by the National Healthcare Safety Network (NHSN) CAUTI definition.
Case Definitions
Surveillance definitions and clinical definitions are intended for different purposes and should not be used interchangeably. Infection preventionists should be able to effectively explain the differences between these three types of definitions.
1. Clinical definitions: These are intended to be used for diagnosis and treatment purposes. Diagnostic criteria for a urinary tract infection vary by care setting and patient population. Clinical diagnosis and treatment for a urinary tract infection should be rendered by a physician.
2. Surveillance definitions: These are intended to define the incidence of a condition and are useful in the measurement and monitoring of performance improvement efforts. NHSN and WHO provides standardized definitions and methodology for performing surveillance for CAUTIs through the Patient Safety Component.
Indwelling urinary devices procedures:
● Bacteria associated with infection in the setting of urinary catheterisation gain access to the urinary tract either through extraluminal contamination - from the health care worker’s hands or from the person’s own colonic or perineal flora.
● This can occur if there is a break in aseptic technique during insertion of the catheter or servicing of the drainage system.
● Intraluminal contamination can occur through reflux of bacteria from a contaminated urine drainage bag
● Education of healthcare workers – healthcare workers performing catheterization should be trained and competent in the technique and familiar with policies and procedures for insertion, maintenance and changing of indwelling urinary devices.
● Aseptic technique protects patients during catheterization by employing infection control measures that minimise, as far as practicably possible, the presence of pathogenic microorganisms.
● While the principles of aseptic technique remain constant for all clinical procedures, the level of practice will change depending upon a standard aseptic technique risk assessment.
Implementation strategies
Preventing CAUTI requires a focus on both technical and socioadaptive (or behavioral) components. Interventions to assist with program implementation and evaluation that have been reported to be associated with improved outcomes are provided. The intervention used a 2-tier system of interventions to determine each hospital’s specific needs relative to their CAUTI rates. Tier 1 describes data gathering needs and a nursing template in the medical record to prompt staff to consider removing catheters at the earliest possible point. This tier alone can create sufficient visibility within the organization to reduce CAUTI rates to the desired level. Tier 2 is a more intensive tier of steps that hospitals can implement for stubborn rates that will not come down, including root-cause analysis.
