UTI Overview

 

Urinary tract infections (UTIs) affect millions of people each year and rank as the second most common type of body infection. Women are more likely to get a urinary tract infection than men, but when they occur in men they can be very serious. Up to 50% of women will develop at least one UTI in their life time and some will experience more than one. UTIs account for over 8 million doctor visits a year.

 

Catheter associated urinary tract infections (CAUTIs) are the most common nosocomial (acute care and extended care facilities) infection. They are costly, and potentially lethal. CAUTIs account for approximately 40% of all nosocomial infections.

 

Urinary catheters are inserted in more than 5 million patients per year. One out of four hospitalized patients will have a urinary catheter placed during their hospital stay.

 

  • CAUTI (bacteriuria or candiduria) develop in up to 25% of patients requiring a urinary catheter for > 7 days.
  • CAUTI risk increases at 5% per day of indwell time.
  • CAUTI is the second most common cause of nosocomial bloodstream infection.
  • CAUTIs are associated with substantially increased institutional death rates.
  • CAUTIs are asymptomatic (most).
  • CAUTIs rarely extend hospitalization.
  • CAUTIs add $500 to $1,000 to the direct costs of acute-care hospitalization.
  • CAUTIs commonly precipitate unnecessary antimicrobial-drug therapy.
  • CAUTIs comprise perhaps the largest institutional reservoir of nosocomial antibiotic- resistant pathogens.
  • CAUTIs pathogens:
    - Enterobacteriaceae ( Escherichia coli, Klebsiella, Enterobacter, Proteus, Citrobacter)
    - Pseudomonas aeruginosa

    - Enterococci
    - Staphylococci
    - Candida spp.

 

Definition of CAUTI

 

Urine collected with a needle from the sampling port of the urinary catheter with concentrations >102 or 103 CFU/mL, is indicative of true CAUTI. This concentration can be reproducibly detected in the laboratory, and this definition is useful for therapeutic decisions and epidemiologic research.

 

Pathogenesis

 

The pathogenesis of a CAUTI can be either endogenous or exogenous in nature. Organisms gain access to the urinary tract by several routes; hematogenous (rare and associated with pyelonephritis); extraluminal contamination (at the time of catheter insertion and or later, by organisms ascending from the perineum by capillary action in the thin mucous film contiguous to the external catheter surface); and intraluminal contamination (occurs by reflux of microorganisms gaining access to the catheter lumen from failure of closed drainage or contamination of urine in the collection bag).

 

Almost exclusively most microorganisms causing endemic CAUTI are derived from the patient’s own colonic and perineal flora or from the hands of health-care personnel during catheter insertion or manipulation of the collection system. (1)

 

Understanding the pathogenesis of CAUTI allows effective strategies to emerge. The Guideline for Prevention of Catheter-associated Urinary Tract Infections was written by Edward S. Wong, M.D. in consultation with Thomas M. Hooton, M.D. and published in February of 1981 from the Centers for Disease Control and Prevention. A 2001 study by Maki reviewed technologies thought to potentially reduce the risk of CAUTI their risk reduction shown in randomized trials.

 

The 1981 CDC Guidelines are listed followed by the research by Dennis Maki.

 

Reference:

 

(1) Maki DG., Tambyah PA. Engineering out the risks of infection with urinary catheters. Emerging Infectious Diseases 2001;7(2):1-6.

 

Prevention

 

CDC 1981: The Guideline for Prevention of Catheter-associated Urinary Tract Infections

 

Recommendations: These recommendations are designed to prevent transmission of infectious agents among patients and healthcare personnel in all settings where healthcare is delivered. As in other CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and when possible, economic impact.

 

The CDC/HICPAC system for categorizing recommendations is as follows:

 

Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB
Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC Required for implementation, as mandated by federal and/or state regulation or standard.

Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

 

1. Personnel
a. Only persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic insertion and maintenance of the catheter should handle catheters (5, 6, 8).
Category I


b. Hospital personnel and others who take care of catheters should be given periodic in-service training stressing the correct techniques and potential complications of urinary catheterization. Category II

 

2. Catheter Use
a. Urinary catheters should be inserted only when necessary and left in place only for as long as necessary. They should not be used solely for the convenience of patient-care personnel. Category I

b. For selected patients, other methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, and intermittent urethral catheterization can be useful alternatives to indwelling urethral catheterization (8, 19, 21, 22). Category III

 

3. Handwashing
Handwashing should be done immediately before and after any manipulation of the catheter site or apparatus (14, 30). Category I

 

4. Catheter Insertion
a. Catheters should be inserted using aseptic technique and sterile equipment (8, 16, 31). Category I

b. Gloves, drape, sponges, an appropriate antiseptic solution for periurethral cleaning, and a single-use packet of lubricant jelly should be used for insertion. Category II

c. As small a catheter as possible, consistent with good drainage, should be used to minimize urethral trauma (8). Category II

d. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction (31). Category I

 

5. Closed Sterile Drainage
a. A sterile, continuously closed drainage system should be maintained (5, 6, 27). Category I

b. The catheter and drainage tube should not be disconnected unless the catheter must be irrigated (see Irrigation Recommendation 6). Category I

c. If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using aseptic technique after disinfecting the catheter-tubing junction. Category III

 

6. Irrigation
a. Irrigation should be avoided unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery); closed continuous irrigation may be used to prevent obstruction. To relieve obstruction due to clots, mucus, or other causes, an intermittent method of irrigation may be used. Continuous irrigation of the bladder with antimicrobials has not proven to be useful (28) and should not be performed as a routine infection prevention measure. Category II


b. The catheter-tubing junction should be disinfected before disconnection. Category II


c. A large-volume sterile syringe and sterile irrigant should be used and then discarded. The person performing irrigation should use aseptic technique. Category I


d. If the catheter becomes obstructed, and can be kept open only by frequent irrigation, the catheter should be changed if it is likely that the catheter itself is contributing to the obstruction (e.g., formation of concretions). Category II

 

7. Urinary Flow
a. Unobstructed flow should be maintained (6,8). Category I (Occasionally, it is necessary to temporarily obstruct the catheter for specimen collection or other medical purposes.)

b. To achieve free flow of urine: 1) the catheter and collecting tube should be kept from kinking; 2) the collecting bag should be emptied regularly using a separate collecting container for each patient (the draining spigot and nonsterile collecting container should never come in contact ) (33); 3 ) poorly functioning or obstructed catheters should be irrigated (see Irrigation Recommendation 6) or if necessary, replaced; and 4) collecting bags should always be kept below the level of the bladder. Category I

 

8. Meatal Care
Twice daily cleansing with povidone-iodine solution and daily cleansing with soap and water have been shown in two recent studies not to reduce catheter-associated urinary tract infection (25, 26). Thus, at this time, daily meatal care with either of these two regimens cannot be endorsed. Category II

 

9. Catheter Change Interval
Indwelling catheters should not be changed at arbitrary fixed intervals (34). Category II

 

10. Spatial Separation of Catheterized Patients
To minimize the chances of cross-infection, infected and uninfected patients with indwelling catheters should not share the same room or adjacent beds (29). Category III

 

11. Bacteriologic Monitoring
The value of regular bacteriologic monitoring of catheterized patients as an infection control measure has not been established and is not recommended (35). Category III

 

Summary of Major Recommendations

 

Category I - Strongly Recommended for Adoption

  • Educate personnel in correct techniques of catheter insertion and care.
  • Catheterize only when necessary.
  • Emphasize hand washing.
  • Insert catheter using aseptic technique and sterile equipment.
  • Secure catheter properly.
  • Maintain closed sterile drainage.
  • Obtain urine samples aseptically.
  • Maintain unobstructed urine flow.

Category II - Moderately Recommended for Adoption

  • Periodically re-educate personnel in catheter care.
  • Use smallest suitable bore catheter.
  • Avoid irrigation unless needed to prevent or relieve obstruction.
  • Refrain from daily meatal care with either of the regimens discussed in text.
  • Do not change catheters at arbitrary fixed intervals.


Category III - Weakly Recommended for Adoption

  • Consider alternative techniques of urinary drainage before using an indwelling urethral catheter.
  • Replace the collecting system when sterile closed drainage has been violated.
  • Spatially separate infected and uninfected patients with indwelling catheters.
  • Avoid routine bacteriologic monitoring.

 

 

References

To review the complete document and references see the CDC Guidelines for Prevention of Catheter-associated Urinary tract infections