Urinary tract infections (UTIs) are the most common type of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals.
The majority of healthcare-associated UTIs are caused by instrumentation of the urinary tract. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay. The presence of bacteria in the urine commonly leads to unnecessary antibiotic use, and urinary drainage systems are often one of the greatest reservoirs for multidrug-resistant bacteria and can be a source of transmission of these resistant pathogens to other patients.
An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system.
A number of years ago, guidelines suggested that a closed collection system was one of the single most important factors in preventing CAUTI. Despite the fact that today virtually all systems are closed drainage systems, healthcare providers must be especially cautious in assuring that these systems do not become accidentally disconnected. Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters. In many cases, catheters are placed for inappropriate indications, and healthcare providers are often unaware that their patients have catheters, leading to prolonged, unnecessary catheter use. Patients who have indwelling urinary catheters will develop bacteria in their urine. It is estimated that the daily risk for bacteruria (the presence of bacteria in the urine) is 3% to 10%, and after 30 days, 100% of patients will develop bacteria in their urine. Bacteruria is not necessarily indicative of infection, especially in the absence of other signs and symptoms. This is called “asymptomatic bacteruria.”
Prevention Practices Should Include the Following:
- Ensure that urinary catheters are used only when indicated.
- Remove urinary catheters as soon as soon as possible when no longer indicated.
- If a patient requires a urinary catheter, assuring that strict aseptic technique is followed during insertion.
- Maintain urinary catheters to ensure that they are securely fastened, placed below the level of the bladder, and that they do not become accidentally disconnected.
Indications for Urinary Catheters:
- Hemodynamic monitoring in critically ill patients
- Pressure ulcer healing in patients with decubitis
- In select circumstances, end-of-life care
- Select surgical procedures
- Urinary retention or obstruction
Removal of Urinary Catheters
Catheters should be removed as soon as possible. Several studies have shown that catheters are often left in place for long periods of time because they are often forgotten by physicians. It is critically important that nurses and healthcare providers assess patients’ need for a urinary catheter on a regular basis. Many organizations utilize a daily checklist. There is also recent evidence to suggest that electronic reminders or automatic stop orders have value in reducing the duration of catherization and, subsequently, the incidence of UTIs.
Urinary catherization should generally be considered a sterile procedure. Because the bladder is sterile, it is important that bacteria from the genital tract not be introduced via the urinary catheter into the bladder. In select circumstances, such as in patients with chronic indwelling catheters or those who must self catheterize, a clean procedure may be used. Healthcare providers must wash hands before insertion, and a sterile, single packet of lubricant should be used. Care must be taken to not accidentally contaminate the catheter during insertion.
Maintenance of Catheters
It is important that catheters be maintained in a manner that prevents accidental disconnection and kept below the level of the bladder to prevent accidental backflow of urine. Catheters should be properly secured after insertion to prevent movement and urethral traction. Care must be taken to ensure that the catheter is not accidentally disconnected. Urine specimens should be collected aseptically and should be sent to the lab as soon as possible. The Clinical and Laboratory Standards Institute (CLSI) Guidelines recommend that the urine specimen be cultured within 2 hours of its collection. Overgrowth of bacteria can readily occur with mishandled specimens, which will cause a false positive or unreliable culture result. Catheters and drainage bags should be changed not on a routine basis but based only on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine irrigation should be avoided unless obstruction is suspected
It is vital that only trained personnel insert catheters and that all healthcare providers who care for patients with urinary catheters understand their role in the prevention of CAUTI. Likewise, patients and families need to understand their role in prevention as well. Infection prevention is a team effort—understanding your role in this important initiative is essential for infection prevention and safe patient care.
Bringing Evidence to the Bedside: Interactive Scenarios
As a care giver, you will be called upon to apply your knowledge to practical situations and which arise during the course of providing patient care. Taking evidence and applying it to your everyday practice can be challenging. The following scenarios represent real life situations and decisions which could ultimately affect whether or not a patient develops a CAUTI. Read the scenarios and decide which of the options is the best choice. Once you have made your selection, review the correct answer, rationale, and learning points associated with that section. Remember that bringing evidence to the bedside requires not only knowledge but the ability to apply that knowledge to your everyday practice. It will require the combination of knowledge, interpersonal and problem solving skills.