3. • Developed in the 1920s by
Dr. Frederick Foley
• Originally an open system
with the urethral tube
draining into an open
container
• Closed system (1950’s)
developed in which the
urine flowed through a
catheter into a closed bag
3
6. Most common type of healthcare-associated
infection
◦ > 30% of HAIs reported to NHSN
◦ Estimated > 560,000 nosocomial UTIs annually
Increased morbidity & mortality
◦ Estimated 13,000 attributable deaths annually
◦ Leading cause of secondary BSI with ~10% mortality
Excess length of stay : 2-4 days
Increased cost : $0.4-0.5 billion per year nationally
Unnecessary antimicrobial use
Hidron AI et al. ICHE 2008;29:996-1011 Givens CD, Wenzel RP. J Urol 1980;124:646-8
Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72
Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S
Cope M et al. Clin Infect Dis 2009;48:1182-8 Saint S. Am J Infect Control 2000;28:68-75
7. In patients with indwelling urethral,
indwelling suprapubic, or intermittent
catheterization
Presence of symptoms or signs compatible with UTI
with
No other identified source of infection
103 colony forming units (cfu)/mL of 1 bacterial
species in a single catheter urine specimen
or
in a midstream voided urine specimen from a
patient whose catheter has been removed in previous
48 hrs.
8. Gold standard is urine culture
Dipstick and other non-culture tests are
not reliable
Number of organisms is controversial
9.
10.
11. Source of
microorganisms:
Endogenous - meatal,
rectal, or vaginal
colonization
Exogenous -
contaminated hands
of healthcare worker
Maki DG. Emerg Infect Dis 2001;7:1-6
13. Formation of
biofilms by urinary
pathogens common
on the surfaces of
catheters and
collecting systems
Bacteria within
biofilms resistant
to antimicrobials Scanning electron micrograph of S. aureus
bacteria on the luminal surface of an
and host defenses indwelling catheter with interwoven complex
matrix of extracellular polymeric substances
known as a biofilm
Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp
15. Supplemental
Core Strategies Strategies
◦ High levels of ◦ Some scientific
scientific evidence evidence
◦ Variable levels of
◦ Demonstrated feasibility
feasibility
www.cdc.gov/hicpac
16. Insert catheters only for appropriate indications
Leave catheters in place only as long as needed
Ensure that only properly trained persons insert and
maintain catheters
Insert catheters using aseptic technique and sterile
equipment (acute care setting)
Maintain a closed drainage system
Maintain unobstructed urine flow
Hand hygiene and Standard precautions
http://www.cdc.gov/hicpac/cauti/001_cau
17. Acute urinary retention or obstruction
Accurate measurements in critically ill patients
Selected surgical procedures e.g. urologic
Healing of open sacral or perineal wounds
End of life comfort
Prolonged immobilisation
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf
18. Urinary incontinence
Immobility
Use of diuretics
Ignorance of published guidelines
Clinical uncertainty of the patient’s medical
course
Convenience of staff
Jain et al (1995) Arch Intern Med 155:1425-9
19. Good hand hygiene Don sterile gloves before
before and after procedure
procedure
20. •Sterile technique
must be used
when inserting the
catheter
•Do not use
aggressive
cleaning once
urinary catheter is
in place
21.
22.
23. 12 month control period followed by
12 month intervention with nurse
generated daily reminders after D5
◦ Catheterization rate reduced from 7.0 +
1.1 days to 4.6 +/- 0.7 days; P < .001
◦ CAUTI rate reduced from 11.5 +/- 3.1
to 8.3 +/- 2.5 per 1,000 catheter-days;
P = .009
◦ Antibiotic cost reduced reduced by 69%
(from 4021 dollars +/- 1800 dollars to
1220 dollars +/- 941 dollars; P = .004)
Huang et al Infect Control Hosp Epidemiol. 2004
Nov;25:974-8
24. Maintain a closed drainage system (I B)
◦ If breaks in aseptic technique, disconnection, or
leakage occur, replace catheter and collecting
system
◦ Consider systems with preconnected, sealed
catheter-tubing junctions (II B)
◦ Obtain urine samples aseptically
http://www.cdc.gov/hicpac/cauti/001_cau
27. Maintain unobstructed urine flow (I B)
◦ Keep catheter and collecting tube free from
kinking
◦ Keep collecting bag below level of bladder at all
times (do not rest bag on floor)
◦ Empty collecting bag regularly using a separate,
clean container for each patient. Ensure
drainage spigot does not contact nonsterile
container.
http://www.cdc.gov/hicpac/cauti/001_cau
28. Use smallest catheter
size effective for
patient (14 or 16F)
Catheters should be
properly secured to
prevent movement and
urethral traction
29. Implement quality improvement
programs to enhance appropriate use of
indwelling catheters and reduce risk of
CA-UTI
Eg:
• Alerts or reminders
• Stop orders
• Protocols for nurse-directed removal of
unnecessary catheters
• Guidelines/algorithms for appropriate
perioperative catheter management
http://www.cdc.gov/hicpac/cauti/001_cau
30. Alternatives to indwelling urinary catheterization
(II)
Portable ultrasound devices for assessing urine
volume to reduce unnecessary catheterizations (II)
Antimicrobial/antiseptic-impregnated catheters (I
B)
After first implementing core recommendations
for use, insertion, and maintenance
31. Intermittent catheterization – consider for:
◦ Patients requiring chronic urinary drainage for
neurogenic bladder
Spinal cord injury
Children with myelomeningocele
◦ Postoperative patients with urinary retention
◦ May be used in combination with bladder ultrasound
scanners
External (i.e., condom) catheters – consider for:
◦ Cooperative male patients without obstruction or
urinary retention
32. Rationale: fewer catheterizations = lower risk
of UTI
2 studies of adults with neurogenic bladder
undergoing intermittent catheterization
Fewer catheterizations per day but no reported
differences in UTI
◦ Significant study limitations: likely underpowered;
UTIs undefined
Polliak T et al. Spinal Cord 2005;43:615-19
Anton HA et al. Arch Phys Med Rehab 1998;79:172-5
33. Decreased risk of bacteriuria compared to
standard latex catheters in a meta-analysis of
RCTs
Significant differences for silver alloy but not silver
oxide-coated catheters
Effect greater for patients catheterized < 1 week
Mixed results in observational studies in
hospitalized patients
◦ Most used laboratory-based outcomes (bacteriuria)
◦ 1 positive, 2 negative, 5 inconclusive
http://www.cdc.gov/hicpac/cauti/001_cau
34. Polymyxin
◦ Butler HK, Kunin CM. J Urol 1971;106:928
Cephalothin
◦ Lazarus SM, LaGuerre JN, Kay H, Weinberg S,
Levowitz BS. J Biomed Mater Res 1971;5:129
Both unsuccessful
35. 344 newly catheterised patients studied daily
◦ RR 0.672, P=0.30 overall
◦ OR 0.22, P=0.02 for GNRs
◦ Not effective for yeasts
◦ Little effect beyond 7 days
◦ Maki, Knasinski SHEA 1997
36. Core Measures Supplemental
Measures
Insert catheters only for Alternatives to
appropriate indications indwelling urinary
Leave catheters in place only catheterization
as long as needed Portable ultrasound
Only properly trained persons devices to reduce
insert and maintain catheters unnecessary
Insert catheters using aseptic catheterizations
technique and sterile Antimicrobial/antiseptic
equipment -impregnated catheters
Maintain a closed drainage
system
Maintain unobstructed urine
flow
Hand hygiene and standard (or
appropriate isolation)
precautions
38. Changing catheters or drainage bags at routine, fixed
intervals
Routine antimicrobial prophylaxis
Cleaning of periurethral area with antiseptics while
catheter is in place (use routine hygiene)
Irrigation of bladder with antimicrobials
Instillation of antiseptic or antimicrobial solutions into
drainage bags
Routine screening for asymptomatic bacteriuria (ASB)
http://www.cdc.gov/hicpac/cauti/001_cau
39. Documentation & review of indications for
catheter insertion
Asepsis during catheter insertion
Daily assesment for the need of catheter
Hand hygiene during daily catheter care
Positioning of the drainage bag below the
bladder
Regular emptying of the drainage bags
