Catheter-Associated Urinary Tract Infections Kaleida Health Infection Control and Prevention Suzanne Bradley, RN, BSN

Healthcare-Associated Infections Healthcare-associated infections account for an estimated 1.7 million infections each year. 32 % are urinary tract infections The estimated deaths associated with HAIs in U.S. hospitals were 98,987. 13,088 for urinary tract infections Estimating Healthcare-Associated Infections and Deaths in U.S. Hospitals, 2002, Public Health Reports / March–April 2007 / Volume 122

Healthcare-Associated Infections Transmission of pathogens most commonly occurs on contaminated hands of HCWs Compliance with recommended hand hygiene practices is less than 50%

Catheter-Associated Urinary Tract Infections 10%–20% of CAUTIs are caused by the introduction of microorganisms during catheter insertion. 30%–45% are due to migration of microorganisms on the external surface of the catheter along the catheter–urethra interface to the bladder.

Catheter-Associated Urinary Tract Infections Reflux of microorganisms up the catheter lumen to the bladder from contaminated drainage tubing or collecting bags accounts for approximately 25%–40% of infections. When catheters are left in place greater than 5 days, UTIs occur in approximately half of patients. http://www.hhs.gov/ophs/initiatives/hai/index.html

CDC Definition of Catheter-Associated Urinary Tract Infection CA (catheter associated) infection refers to infection occurring in a person whose urinary tract is currently catheterized or has been catheterized within the previous 48 hours. UTI (urinary tract infection) refers to significant bacteriuria in a patient with symptoms or signs attributable to the urinary tract and no alternate source. ASB (asymptomatic bacteruria) refers to significant bacteriuria in a patient without symptoms or signs attributable to the urinary tract.

CA-UTI Patient had an indwelling urinary catheter in place at the time of or within 48 hours prior to specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>38°C), suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.

Asymptomatic Bacteriuria Patient had an indwelling urinary catheter in place at the time of or within 48 hours prior to specimen collection and a positive urine culture of ≥103 and <105 CFU/ml with no more than 2 species of microorganisms. patient has no fever (>38 C), urgency, frequency or suprapubic tenderness.

Catheter-Associated Urinary Tract Infections The duration of catheterization is the most important risk factor for development of infection! The duration of catheterization is the most important risk factor for development of infection!! The duration of catheterization is the most important risk factor for development of infection!!!

Prevention of CAUTIs Use indwelling catheter only when medically necessary: Urinary obstruction or acute urinary retention Assistance in pressure ulcer healing in some patients Hospice or palliative care, when requested by patient Critical care monitoring Some surgical procedures Physician order is required for insertion of indwelling catheter. Include indication for catheterization.

Prevention of CAUTIs These are not indications for indwelling catheter: Incontinence Immobility Patient request or convenience Obtaining urine specimens

Prevention of CAUTIs Consider alternatives to indwelling catheters Bladder scanner to measure residual Intermittent catheterization External (condom style, Texas catheter, Urosan) Reviews of silver-coated and other antibacterial urinary catheters consistently conclude that evidence does not support a recommendation for the uniform use of such devices.

Prevention of CAUTIs Insertion of indwelling catheters Only when necessary and only left in place as long as indications persist Only trained healthcare providers should insert catheter Aseptic technique for insertion with appropriate hand hygiene and gloves Hand hygiene immediately before insertion of catheter and before and after any manipulation of catheter site or apparatus

Prevention of CAUTIs Maintain sterile continuously closed system. Maintain drainage bag below level of bladder AT ALL TIMES. Properly secure catheter after insertion to prevent movement, friction. Clean periurethral and perianal areas two times per day and as needed with soap and water.

Prevention of CAUTIs Hand hygiene and gloves when emptying drainage bag DO NOT share containers between patients when emptying drainage bag DO NOT allow drainage bag port to touch measuring container

Documentation Document the following on the patient record: Date/time of catheter insertion Indications for insertion Name of individual who inserted catheter Date/time of catheter removal

“Urinary Catheterization Insertion and Maintenance for the Acute Adult and Pediatric Patient” Kaleida Policy TX.GU.6 A physician order must be obtained prior to inserting a urinary catheter. A physician order to maintain an indwelling urinary catheter must be re-written every 24 hours. “Re-order indwelling urinary catheter for 24 hours” is appropriate. Otherwise the catheter will be removed on the day shift following the 24-hour period. The nurse will be responsible to either discontinue the urinary catheter or contact the physician for a reorder based on clinical necessity.

HAI Prevention Healthcare providers can prevent healthcare-associated infections by adhering to recommended infection control practices including standard, contact, droplet, and airborne precautions. To learn more about infection control precautions, see Guideline for Isolation Precautions in Hospitals. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Implementing what we know for prevention can lead to up to a 70% or more reduction in HAIs