Does the Composition of Urinary Catheters Influence Clinical Outcomes and the Results of Research Studies?

Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Burden of CAUTIs

a. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.

b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.

c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ.

2. Outcomes associated with CAUTI

a. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.

b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.

c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Prevention and treatment of urinary catheter-associated infections

Catheter-associated urinary tract infections (CA-UTIs) are the most common nosocomial infection worldwide. Prolonged catheterization is the most important risk factor for CA-UTIs. As is the case with all device-related infections, the biofilm plays a central role in the pathogenesis of CA-UTIs. The diagnosis is often difficult, given the lack of good diagnostic tests. The most effective way to prevent infection is to limit catheter use and discontinue the catheter when no longer needed. Catheter removal or exchange is also useful in management. This review summarizes and analyzes the results of published studies of CA-UTIs and assesses the role of prevention approaches and management strategies.

Urinary catheter-associated infections

Catheter-acquired urinary infection is the most common device-associated healthcare-acquired infection. Although most patients are asymptomatic, symptomatic infection may occur and is associated with increased morbidity and costs. Long-term indwelling catheters are associated with more complex microbiology and greater morbidity than short-term catheters. The most effective way to prevent these infections is to restrict indwelling urinary catheter use to limited indications, and to discontinue use of a catheter as soon as feasible. Alternate means of managing bladder emptying, including external condom catheters for men and intermittent catheterization for patients with neurologic impairment of bladder emptying, should be used when possible.

Silver or nitrofurazone impregnation of urinary catheters has a minimal effect on uropathogen adherence

PURPOSE

Bacterial adherence to the urinary catheter is an early step in biofilm formation and the pathogenesis of catheter associated urinary tract infection. We studied in vitro the effect of silver or nitrofurazone impregnation of urinary catheters on uropathogen ability to adhere to urinary catheters.

MATERIALS AND METHODS

We studied commercially available nitrofurazone-silicone, silicone only, silver-silicone-hydrogel, silicone-hydrogel, silver-latex-hydrogel and latex-hydrogel catheters. Catheters were incubated in sterile broth for 0, 3, 5, 7 and 10 days, respectively, before inoculation and overnight incubation with Escherichia coli or Enterococcus faecalis.

RESULTS

Adherence of E. coli and E. faecalis to nitrofurazone catheters was significantly decreased compared to that of silicone-only catheters when catheters were fresh. The anti-adherence effect of nitrofurazone on E. coli decreased with time but was still significant at 5 days. For E. faecalis the effect of nitrofurazone was lost by 3 days of pre-incubation. E. coli adherence was not significantly decreased on silver impregnated catheters compared to that on control catheters of the same base material. Silver was associated with a significant decrease in E. faecalis adherence to latex-hydrogel catheters but not to silicone-hydrogel catheters. The adherence of each species to silicone catheters with hydrogel was significantly lower than that to silicone-only control catheters.

CONCLUSIONS

Silver impregnation had little effect on bacterial adherence in our model and nitrofurazone impregnation had a significant effect only for the first 5 days. Our results do not support a role for silver urinary catheters to prevent catheter associated urinary tract infection by decreasing bacterial adherence.

A program to limit urinary catheter use at an acute care hospital

BACKGROUND

Urinary catheters are the major cause of catheter-associated urinary tract infections (CAUTIs) and often may be unnecessary. We attempted to reduce the number of CAUTIs by limiting the use of urinary catheters.

METHODS

The number of catheters and CAUTIs were recorded during a control period of 7 months. A program was implemented limiting these catheters to patients who had urinary tract obstruction, orders for hourly output measurements, breakdown of skin in areas exposed to urine in patients with documented urinary tract infections, or urine- associated skin irritation that was unresponsive to barrier measures. In patients who did not meet these criteria, the physician was asked for a catheter removal order, and superabsorbent pads or diapers were used. Urinary catheter use and CAUTIs were then recorded during a subsequent 5-month intervention period. Nursing personnel were queried regarding their experience after 4 months of the intervention period.

RESULTS

Urinary catheter use decreased by 42% (P < .01), and the incidence of CAUTIs decreased by 57% (P < .05). There was some improvement in nursing satisfaction.

CONCLUSION

Limiting urinary catheter use can reduce the incidence of CAUTI with no deterioration in nursing satisfaction.

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

Management of catheter-associated urinary tract infection

PURPOSE OF REVIEW

The aim of this article is to review recent publications concerning the management of catheter-associated urinary tract infection (CAUTI), including the issues of diagnosis and prevention. Articles reviewed include the various guidelines concerning CAUTI released recently by multiple organizations.

RECENT FINDINGS

There has been a recent upsurge of interest in prevention of CAUTI and a proliferation of guidelines in this area. Social changes in US government reimbursement to hospitals and public reporting of hospital-acquired infections may underlie this interest. The awareness that CAUTI and catheter-associated asymptomatic bacteriuria are distinct conditions is increasing, but unnecessary treatment of asymptomatic bacteriuria remains quite prevalent. The focus in recent CAUTI literature is on prevention, often through strategies to minimize urinary catheter use. Very little new evidence is available to guide diagnosis and treatment strategies.

SUMMARY

Interpretation of many studies of CAUTI is impeded by the failure to distinguish between symptomatic CAUTI and asymptomatic bacteriuria in the study outcomes. This distinction currently relies on clinical symptoms and is not easily made, even with the help of various guidelines. Many aspects of the management of CAUTI merit further study, and the current interest in CAUTI is likely to lead to exciting advances in this field.