1. Prevention of Catheter-Associated Urinary Tract Infections

2. Learning objectives
Describe the relevance of urinary tract infections in health care institutions.
Identify risk factors for urinary tract infections.
Describe measures for prevention.
December 1, 2013

3. Time involved
50 minutes
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4. Introduction Up to 40% of all HAIs
Most involve urinary catheterisation
Risk of bacteriuria
5% per day during the first week to almost 100% at 4 weeks of catheterisation
1 to 4% of patients with bacteriuria will develop infection
December 1, 2013
Urinary tract infections (UTI) are the commonest healthcare-associated infections (HAI), accounting for up to 40% of all HAIs. Most involve urinary drainage devices, such as bladder catheters.
The risk of a catheterised patient acquiring bacteriuria increases with the duration of catheterisation, rising from approximately 5% per day during the first week to almost 100% at 4 weeks. One to four per cent of patients with bacteriuria will ultimately develop clinically significant infection, e.g., cystitis, pyelonephritis, and septicaemia.

5. Urinary tract sites commonly associated with infection
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A urinary tract infection, or UTI, is an infection that can happen anywhere along the urinary tract. Urinary tract infections have different names, depending on what part of the urinary tract is infected.
Bladder -- an infection in the bladder is also called cystitis or a bladder infection.
Kidneys -- an infection of one or both kidneys is called pyelonephritis or a kidney infection.
Ureters -- the tubes that take urine from each kidney to the bladder are only rarely the site of infection.
Urethra -- an infection of the tube that empties urine from the bladder to the outside is called urethritis.

6. Urine Urine is an ultrafiltrate of blood, is normally sterile
Small numbers of perineal/ vaginal/bowel microorganisms in the distal urethra
Constantly washed out by micturition
Bacteriuria = bacteria in the urine
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7. Collection of urine Specimen contamination reduced by
Cleaning external urethral area before collection
Collecting mid-stream urines
Urethral bacteria washed out in the first part of the stream
Processing specimen promptly, or refrigerating, to prevent overgrowth of contaminants
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8. Laboratory diagnosis Urine must be processed promptly
Contaminants can multiply at room temperature and give falsely high colony counts
If delay expected, transport the specimen in an ice box or add boric acid (1% W/V or 1 g/10 ml of urine)
December 1, 2013
Urine must be processed promptly, since even with good technique urine samples may contain small numbers of contaminants. These can multiply at room temperature (especially in hot climates) and give falsely high colony counts. If delay is expected, the specimen should be transported in an ice box and refrigerated on arrival. Alternatively, boric acid (1% W/V or 1 g/10 ml of urine) should be added to the urine. Specimens containing boric acid need not be refrigerated.

9. Microbiology Usually endogenous microorganisms
E. coli and Proteus commonest in community infections
Catheter-associated UTI (CAUTI)
E. coli commonest
Increasingly caused by resistant species
Klebsiella, Pseudomonas, Enterococcus and multiply drug resistant ESBL, VRE
December 1, 2013
UTI usually caused by endogenous microorganisms from the bowel. E. coli and Proteus the commonest in community infections; usually sensitive and easy to treat. Healthcare-associated UTI are more resistant. In communities where indiscriminate antimicrobial use is common, multi-resistant Gram-negative bacteria (e.g., extended spectrum beta-lactamase producers - ESBL) are also prevalent in the human bowel.
E. coli is the commonest cause of catheter-associated UTI (CA-UTI). However, increasingly, CA-UTIs are caused by more resistant Gram-negative species, such as Klebsiella and Pseudomonas. Similarly, ampicillin sensitive Enterococcus faecalis is gradually being replaced by vancomycin-resistant E. faecium (VRE). Then, with additional antibiotic exposure, infections occur with multiply drug resistant versions of these and other species (e.g., ESBL, VRE).

10. Bacteria Causing UTIs (%)
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Entero = Enterobacter
Citro = Cirtobacter
Coag -ve staph = coagulase negative staphylococcus 10

11. Microbiological support
The diagnosis of UTI depends on the microbiological support available
In patients with indwelling catheters, infections frequently polymicrobial
Presence of multiple bacteria does not necessarily indicate contamination
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The diagnosis of UTI depends on laboratory support. Where a carefully collected midstream specimen is obtained, finding ≥105 bacterial colony forming units (CFU)/ml in a patient without an indwelling catheter is diagnostic of UTI. Bacterial concentrations >102 CFU/ml suggest infection if the specimen is obtained aseptically by needle aspiration of the proximal drainage tubing in a patient with an indwelling catheter. Although UTIs in non-catheterised patients are usually caused by a single microorganism, in catheterised patients infections can be polymicrobial. The presence of multiple microorganisms does not necessarily indicate contamination. 11

12. Quantitative bacteriology
Small numbers of bacteria are insignificant
True infections have large numbers in bladder urine
Microbiology labs count the number of bacteria in a urine specimen as ‘colony-forming units’ (cfu)
Significant bacteriuria gives a >95% likelihood of true UTI
≥100,000 cfu/mL urine in 2 carefully-collected mid-stream urines (MSUs)
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13. Urethral bacteria contaminate specimens, small numbers
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Quantitative microbiology and potential contamination or overgrowth are illustrated in the figures.

14. Significant bacteriuria
When large numbers of bacteria (>105/mL) in specimens of bladder urine & evidence of true UTI
Smaller (insignificant) numbers may be due to contamination of the urine specimen during collection - urine has to pass through urethra
Contamination can come from perineum/genitalia
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15. True UTI with significant bacteriuria
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Quantitative microbiology and potential contamination or overgrowth are illustrated in the figures.
bacteria in bladder urine multiply to high numbers before collection

16. Quantitative microbiology distinguishes between true UTI & contamination or overgrowth
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17. Clinical diagnosis In non-catheterised patients:
Fever, supra-pubic tenderness, frequency, dysuria
Pyuria
Positive nitrite reaction and a positive leukocyte esterase reaction
In catheterised patients
Fever and leukocytosis or leucopenia additional diagnostic criteria
December 1, 2013
Where microbiological support is poor or unavailable, clinical symptoms (e.g., fever, supra-pubic tenderness, frequency, and dysuria) may be useful in diagnosis, principally in non-catheterised patients. The presence of pyuria on either microscopic examination or by dip-stick (leukocyte esterase) is highly suggestive of UTI. If dip-sticks are available, a positive nitrite reaction in combination with a positive leukocyte esterase reaction is usually diagnostic.
In catheterised patients, a positive urine culture or dip-stick is not sufficient for diagnosis of infection. In such patients, fever and leukocytosis or leucopenia are additional diagnostic criteria.

18. Definition and Surveillance
Surveillance of CAUTI in selected patients
e.g. intensive care or surgical
Definition may be obtained:
USA CDC/NHSN
Centers for Disease Control and Prevention/ National Healthcare Safety Network
HELICS
Hospital in Europe for Link Infection Control through Surveillance
December 1, 2013
Surveillance of CA-UTI can be performed in certain groups of patients, e.g., patients in intensive care units or specific types of surgical patients. The definition for CA-UTI may be obtained from the U.S. CDC/NHSN (Centers for Disease Control and Prevention/ National Healthcare Safety Network) or HELICS (Hospital in Europe for Link Infection Control through Surveillance).
HELICS. Surveillance of nosocomial infections in Intensive Care units. Hospital in Europe for Link Infection Control through Surveillance: September,
NHSN -

19. Pathogenesis of a Catheter-Associated UTI
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Normally urethral flora flushed out
With catheterisation, flushing mechanism circumvented
Flora can pass up through catheter or from drainage bag
Hands of personnel may contaminate the system during insertion or management
Under normal circumstances urethral flora, which tends to migrate into the bladder, is constantly flushed out during urination. When a catheter is inserted this flushing mechanism is circumvented and perineal and urethral flora can pass up into the bladder in the fluid layer between the outside of the catheter and the urethral mucosa. Because of this, bladder colonisation is almost inevitable if catheters are left in place for prolonged periods. In addition, bladder infection can be caused by bacterial reflux from contaminated urine in the drainage bag. Therefore, closed drainage systems should be used to reduce infection, when possible. Hands of personnel may also contaminate the urinary catheter system during insertion or management.

20. Four main sites through which bacteria may reach the bladder in a catheterised patient
December 1, 2013
The four main sites through which bacteria may reach the bladder of a patient with urinary catheter:
Urethral meatus-catheter junction
Connection between catheter and drainage tube
Connection between drainage tube and collecting bag
Tap outlet of drainage bag
from Damani N N, Keyes JK. Infection Control Manual, 2004

21. Principles to Prevent UTI - 1
Care bundle approach
Evidence-based interventions
When implemented together result in reduction in CAUTIs
December 1, 2013
Care bundle approach
A care bundle is a package of evidence-based interventions that, when implemented together for all patients with urinary catheters, has resulted insubstantial and sustained reductions in CAUTIs. Care bundle intervention plans for CAUTIs have been developed by the US Institute for Healthcare Improvement and the UK Department of Health.

22. Principles to Prevent UTI - 2
Staff training
Training on procedures for insertion and maintenance of urinary catheters based on local written protocols
Catheter size
Smallest diameter catheter that allows free flow of urine
December 1, 2013
Staff training
Healthcare personnel performing urinary catheterisation should receive training on correct procedures for insertion and maintenance of urinary catheters based on local written protocols.
Catheter size
Catheters are available in different sizes. The smallest diameter catheter that allows free fl ow of urine should be used. Larger diameter catheters are more likely to cause unnecessary pressure on the urethral mucosa which may result in trauma and ischaemic necrosis. Urological patients and some other patient groups may require larger sized catheters; these should only be used on the advice of specialists.

23. Principles to Prevent UTI - 3
Antimicrobial coated catheters
Reduce asymptomatic bacteriuria
For placement less than 1 week
No evidence they decrease symptomatic infections
Should not be used routinely
Should be considered in selected high risk patients
December 1, 2013
Antimicrobial coated catheters
Several studies support the use of antimicrobial coated urinary catheters (latex-coated silver alloy) as an adjunct for the prevention of CA-UTI. These catheters significantly reduce the incidence of asymptomatic bacteriuria, however only for placement less than 1 week. There is no evidence that they decrease symptomatic infections and therefore they should not be used routinely. However, their use should be considered in selected high risk catheterised patients.

24. Principles to Prevent UTI - 4
Catheter insertion and care
Sterile equipment and aseptic technique
Sterile lubricant or local anaesthetic gel
Meatal cleansing with soap and water
Antimicrobial ointment harmful
Should be avoided
December 1, 2013
Catheter insertion
Urinary catheterisation should always be performed using sterile or high-level disinfected equipment and aseptic technique. To minimise trauma to the urethra and discomfort to the patient, a sterile lubricant or local anaesthetic gel should be used.
Meatal cleansing
Meatal cleansing should be performed regularly to ensure that the meatus is free from encrustations. Cleansing with soap and water is sufficient; application of antimicrobial ointment or disinfectant to the urethral meatus is harmful and should be avoided.

25. Principles to Prevent UTI - 5
Drainage tubing and bag
Secure to the patient
Catheter drainage bag below the bladder
Bag and tap not in contact with the floor
Clamp drainage during movements
Not disconnect the drainage bag
Bag emptied when ¾ full
Hand hygiene
Alcohol impregnated swabs
No disinfectant added to bag
December 1, 2013
Drainage tubing
To help prevent trauma to the urethra, the urinary drainage tubing should be secured to the patient’s thigh with straps and adjusted to a comfortable fit. The catheter drainage bag must always be placed below the level of the bladder to promote good drainage. If a catheter stand is used, the drainage bag and drainage tap must not come in contact with the floor.
During patient movement, the drainage tube should be temporarily clamped to prevent back-flow of urine. Do not disconnect the drainage bag unnecessarily to interrupt the closed drainage system.
The drainage bag should be emptied regularly via the drainage tap at the bottom of the bag (i.e., when ¾ full or sooner if it fills rapidly). If the bag does not have a tap, it must be replaced when ¾ full using aseptic technique. Extreme care must be taken when emptying a drainage bag to prevent cross-infection between patients. Hands must be washed or disinfected with an alcohol-based hand rub and non-sterile/clean disposable gloves should be worn when emptying the bag.
Alcohol impregnated swabs should be used to decontaminate the outlet of the drainage tap (inside and outside). After emptying the bag, gloves must be removed and hands must be washed.

26. Principles to Prevent UTI - 6
Specimen collection
Samples from the port
Aseptic technique
Disinfection of port with alcohol
Sterile needle, syringe, container
Never a sample from the bag.
No routine testing
December 1, 2013
Specimen collection
Samples of urine for bacteriological examination should be obtained from the sampling port or sleeve using aseptic technique. The sampling port should be disinfected by wiping with a 70% isopropyl alcohol impregnated swab. The sample may then be aspirated using a sterile needle and syringe and transferred into a sterile universal container. Never obtain a sample from the drainage bag. In asymptomatic patients, routine bacteriological testing is of no clinical benefit.

27. Principles to Prevent UTI - 7
Antimicrobial agents
Routine administration not recommended
Single dose prophylactic may be used in selected patients
No routine use while the catheter in situ
Treatment may not be successful
December 1, 2013
Use of antimicrobial agents
The routine administration of systemic antibiotics at the time of catheter insertion/removal is not recommended. The administration of a prophylactic antibiotic as a single dose at catheter change may be used in selected patients who either have clinical infection or a higher risk of developing UTIs. Routine use of prophylactic antibiotics while the catheter is in situ must not be used to prevent CAUTI as it breeds resistant bacteria. For the same reason, the antibiotic treatment of CAUTIs in the presence of long-term indwelling catheters may not be successful because the causative bacteria are often embedded in biofilm on the surface of the catheter and protected from the action of antibiotics

28. Principles to Prevent UTI - 8
Condom catheters
May be used for short-term drainage
Frequent changes
Removed if irritation or skin breakdown
Condom for 24 hour continuous use should be avoided
December 1, 2013
Condom catheters
There may be a place for the use of condom catheters for short-term drainage in cooperative patients. Frequent changes, e.g., daily, may avoid complications, together with penile care. They should be removed at the first sign of penile irritation or skin breakdown. Condom use for 24 hour periods should also be avoided and other methods, such as napkins or absorbent pads, used at night.

29. Key points Avoid urinary catheterisation
not for incontinence
consider intermittent catheterisation
Remove catheters as soon as possible
Aseptic technique and sterile equipment
Don’t change catheters routinely
Closed drainage system
No irrigation or instillation
Empty drainage bag
December 1, 2013
Urinary catheterisation should be avoided if possible. They must only be inserted when there are clear medical indications, such as problems with emptying the bladder or measurement of urine production. They should be removed as soon as no longer needed. Do not use urinary catheters for incontinence of urine. In suitable patients, clean intermittent urinary catheterisation should be considered, as it has a much lower risk of infection.
The catheter should be removed as soon as clinically possible, preferably within 5 days. Urinary catheterisation should be performed using sterile equipment. Aseptic technique should always be maintained during insertion and after care procedures. Catheters should not be changed routinely as this exposes the patient to increased risk of bladder and urethral trauma.
Maintain a closed drainage system; open systems should be avoided if at all possible. Bladder irrigation or washout and instillation of antiseptics or antimicrobial agents does not prevent catheter-associated urinary tract infection and should not be used. The drainage bag should be emptied once per nursing session into a clean receptacle used only on one patient.

30. References
APIC Elimination Guide: Guide to the Elimination of Catheter- Associated Urinary Tract Infections (CA-UTIs); Developing and applying facility-based prevention interventions in acute and long-term care settings, EliminationGuides/CAUTI_Guide.pdf
HICPAC. Guidelines for prevention of Catheter-associated Urinary Tract infections Atlanta, GA: CDC,
European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Intern J Antimicrobial Agents 2008: 31S; S68-S78.
December 1, 2013

31. References
SHEA /IDSA Practice Recommendation: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hospital Epidemiol 2008; 29 (Supplement 1): S 41-S50.
High Impact Intervention No 6. Urinary Catheter Care Bundle. London, Department of Health,
UK Dept. of Health epic2: Guidelines for preventing infections associated with the use of short-term urethral catheters. J Hospital Infect 2007; 65S: S28-S33. infection.pdf
December 1, 2013

32. References
Infectious Diseases Society of America Guidelines. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice
Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:625–663.
December 1, 2013

33. Quiz Incontinence is an indication for urinary catheterisation. T/F?
For a general strategy to prevent UTI, what measure you would consider first:
Treatment of infected patients
Avoid unnecessary catheterisation
Replacement permanent catheterisation for intermittent
Use of condom catheters
Regarding prevention of UTI, which of the following is incorrect
Keep system closed
Hand hygiene before insertion/management of urinary devices
Maintain catheter drainage bag below the bladder
Use of antimicrobial prophylaxis in patients with urinary catheterisation
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False B
3. D

34. International Federation of Infection Control
IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .
The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.
For more information go to
December 1, 2013