Infection Control Guidelines for Prevention of Catheter Associated Urinary Tract Infection Dr. NAHLA ABDEL KADERوMD, PhD. INFECTION CONTROL CONSULTANT, MOH INFECTION CONTROL CBAHI SURVEYOR Infection Control Director, KKH.

1. ١

2. Healthcare Associated
Urinary Tract Infections
It is the most common type (± 40%) of NI
involving both LTC and acute hospital settings
Instrumentation is almost always associated
with all cases
Being the most common it is the most
preventable
Adults and children are equally affected
٢

3. Main Types of Infections
Main Types of HAIs
17%
44%
18%
10%
11%
UTI
SSI
BSI
Pneumo
Others
٣

4. Epidemiology of
Catheter Associated Urinary
Tract Infection
 Magnitude
of the problem
 Incidence and cost




15 – 20 % of total hospital admission have
FC
Nearly 900,000 nosocomial UTI in the US
900,
It cost $600 million if LOS increased by 1 day
$600
In reality LOS increased by average of 3.8
days costing $3 billion
$3
٤

5. Epidemiology of
CAUTI
cont….
 Mortality
 Related to bacteremia which accounts for 0.3
– 3.9% of total UTIs
 Out of which fatality exceed 30% (4500
30% (4500
death/year)
 Morbidity
 Spread of infection through out urinary tract
causing; absesses, epididymitis, orchitis…etc.
orchitis…
 Other complications like stones and polyps
٥

6. Epidemiology of
CAUTI
cont….
 Consequences of antibiotic use

Emergence of resistant strains
 Epidemics of HA UTI


Urinary drainage bag act as a reservoir for the
organisms to colonize and to transfer the
resistant plasmid
With poor hand hygiene cross-infection lead to
crosshospital wide organisms
٦

7. Epidemiology of
CAUTI
cont….
Catheter use
It is an instrumentation that is almost used in all
hospitals
Endemics occurs throughout the hospital
The daily IR is 2-16% for the first 10 days in the
close system drainage
Universal infection by 30 days in the close
system drainage
٧

8.  Role of catheter
 Transurethral catheter break the normal defense
mechanism
 The retention balloon prevents complete emptying
 Open channel to the bladder
 Foreign body
٨

9.  Bacterial
factors
 Pili
 Hemolysin
 Urease
 Pathways
of infection
 Intraluminal (exogenous organism)
 Extraluminal (endogenous organism)
٩

10. Source Healthcare Associated
Urinary Tract Infections
Patient’s
Own Flora
CAUTI
Medical
Equipment
Staff Member
١٠

11. Etiological Agents
Etiologic Agents
15%
25%
7%
8%
11%
16%
١١
E.Coli Enterococcus P.aeruginosa C.albican K.Pneumoniae Others

12.  Host







factors
Duration of use
Female gender
Absence of systemic antibiotics
DM
Renal insufficiency
Advanced age
Severe underlying illnesses
١٢

13. CDC DEFENITIONS OF UTI
١٣

14. Diagnosis OF CAUTI
CDC Definition
Exclude infections that acquired prior to admission
Asymptomatic bacteriuia should
have > 100,000 cfu/cc
Culturing the catheter tip is of NO VALUE
Uses of symptoms; only fever
١٤

15. Preliminary Recommendations
For
Prevention Of CAUTI
Appropriate
Catheter
Use
Aseptic
Insertion
Proper
Maintenance
Systems
Intervention
Administrative
Infrastructure
١٥

16. Appropriate Urinary
Catheter Use
Insert catheters only for appropriate indications and leave in
place only as long as needed.
Do not use catheters in patients for management of
incontinence.
Use catheters in operative patients only as
necessary, rather than routinely.
For operative patients who have an indication for an
indwelling catheter, remove the catheter as soon as
possible, preferably within 24 hours, unless there are
appropriate indications for continued use.
١٦

17. Preliminary Recommendations
For
Prevention Of CAUTI
Catheter Use
Appropriate
Insertion
Aseptic
Maintenance
Proper
١٧

18. Appropriate Urinary
Catheter Use, cont
Use alternatives to indwelling urethral catheters in selected
patients when appropriate.
Condom catheter drainage is preferable to indwelling urethral
catheters in cooperative male patients without retention or bladder
outlet obstruction.
Intermittent catheterization is preferable to indwelling urethral or
suprapubic catheters in those with bladder emptying dysfunction.
An ultrasound to assess urine volume may be used for those
undergoing intermittent catheterization to reduce unnecessary
catheter insertions.
Clean technique for intermittent catheterization is an acceptable
alternative to sterile technique for those requiring chronic
intermittent catheterization.
In the acute setting, use sterile technique and equipment for
intermittent catheterization.
١٨

19. Catheter Insertion
Perform hand hygiene
immediately before and after
insertion or any manipulation of the
catheter or site.
Ensure that only properly trained
persons who know the correct
technique of aseptic catheter
insertion and maintenance are
given this responsibility.
 Insert catheters using aseptic
technique and sterile equipment.
Properly secure indwelling
catheters after insertion to prevent
movement and urethral traction.
Use the smallest bore catheter
possible to minimize urethral
trauma.
Catheter Maintenance
Maintain a sterile, continuously
closed drainage system.
Do not disconnect the catheter
and drainage system unless the
catheter must be irrigated.
Maintain unobstructed urine flow.
Do not use complex urinary
drainage systems as a routine
infection prevention measure.
Do not change indwelling
catheters or bags at arbitrary fixed
intervals.
Do not use systemic
antimicrobials routinely as
prophylaxis for UTI in patients
requiring either short or long-term
catheterization.
١٩

20. ٢٠

21. Systems Interventions
Implement quality improvement (QI) programs to enhance
appropriate use of catheters and to reduce the risk of CAUTI.
The purposes of QI programs should be:
to assure appropriate utilization of catheters
to identify and remove unnecessary catheters
to ensure hand hygiene and proper catheter care
CAUTI PREVENTION BUNDLE
٢١

22. Administrative Infrastructure
Provision of
Guidelines
Education &
Training
Supplies
System of
Documentation
Surveillance
Resources
٢٢

23. WHAT IS A BUNDLE?
A bundle is a structured way of improving
processes of care and patient outcomes.
It is a small straightforward set of practices –
generally three to five that when performed
collectively, reliably and continuously, have
been proven to improve patient outcome.
٢٣

24. CAUTI Insertion Bundle
Documenting Optimal Care
The Bundle
1. All patients with urinary catheters on OUR
ward/clinical area will have a CAUTI insertion
checklist.
2. The CAUTI insertion checklist will be
complete and show that the care at catheter
insertion was optimal.
٢٤

25. CAUTI Maintenance Bundle
Remove catheters as soon as possible,
care for catheters individually
The Bundle
1. Perform a daily review of the need for the urinary catheter.
2.Check the catheter has been continuously connected to the
drainage system.
3. Ensure patients are aware of their role in preventing urinary
tract infection. (Alternative bundle criterion if the patient is unable
to be made aware: Perform routine daily meatal hygiene).
4. Regularly empty urinary drainage bags as separate procedures,
each into a clean container.
5.Perform hand hygiene and don gloves and apron prior to each
catheter care procedure; on procedure completion, remove gloves
and apron and perform hand hygiene again.
٢٥

26. CAUTI Insertion Bundle Standard Operating Procedure
Statement
UCs are used frequently in healthcare, however, the use of UCs can lead to serious life-threatening complications.
UCs cause urinary tract infections and are the second leading cause of blood stream infections. To minimise the
risk of complications, the insertion procedure must be optimal.
We have a duty to our patients to optimise UC insertion care and to ensure that our UC care does not cause the
patients harm. Monitoring our UC insertion care will assist us to optimise procedures, reduce the risk to patients
and demonstrate the quality of care we provide.
Objectives
Objectives:
1.To optimise Urinary Catheter insertion procedures in OUR ward/clinical area and thereby minimise the risk of
catheter associated urinary tract infections and secondary bacteraemias.
2.To be able to demonstrate quality urinary catheter insertion care in OUR ward/clinical area.
Requirements
Before the CAUTI Insertion Bundle Procedure can be considered:
Signed commitment from the clinical team: consultants; junior doctors, ward manager and nurse team to
optimising UC care.
Procedure
Perform hand hygiene..١
2.Collect a bundle form and complete the top boxes: name, location, etc.
3.Identify all patients in the ward/clinical area who have a urinary catheter.
4.Review the medical/nursing notes of all patients with a urinary catheter and identify whether a CAUTI Insertion
Checklist is present.
5.Note the presence/absence of the CAUTI Insertion Checklist on the CAUTI bundle form.
6.Review the CAUTI Insertion Checklist; if complete and the catheter insertion procedure was recorded as optimal
Record as appropriate on the CAUTI Insertion Bundle form. Optimal is all the actions recorded as Yes and
catheter size, balloon size, sterile water amount and reason for catheterisation being completed.
7.For each patient with a urinary catheter, repeat steps 4-6 until all notes and CAUTI Insertion Checklists have
been identified and reviewed.
8.Complete the remaining CAUTI Insertion bundle form sections.
After care
٢٦
Complete form.
Give it to:
Discuss and display the data when it has been returned.
Keep Bundle forms for _____(time)

27. Patient Name
Hospital Number
Date the catheter was inserted
Resident Ward
Before the procedure
Alternatives to indwelling catheterisation have been considered and the need for urinary catheterisation in this patient outweighs possible complications.
Yes
No
The clinical reason for insertion is specified and documented (see box below).
Yes
No
The operator has been deemed competent in performing this procedure, or the role is being performed with supervision from a competent person.
Yes
No
The operator has explained the need for a urinary catheter, and the potential complications to the patient, and gained the patient’s consent.
Yes
No
The operator, and supervisor, removed jewellery, put on a clean plastic apron and performed a hygienic hand hygiene procedure and donned sterile gloves.
Yes
No
The smallest gauge for effective drainage has been selected: state size; _______
Yes
No
The balloon is <10mls in size: state size of balloon; ____mls, and amount of sterile water inserted into balloon ____mls.
Yes
No
Prior to starting the procedure: the procedure process was explained to the patient and the patient was reassured.
Yes
No
During the procedure did the operator
Clean the urethral meatus with sterile saline
Yes
No
Lubricate the catheter with sterile lubricant
Yes
No
Insert the catheter a little further once urine starts to drain before inflating the balloon (to ensure catheter is inserted in the bladder and not urethra).
Yes
No
Aseptically connect the catheter to a sterile approved drainage bag.
Yes No
After the procedure did the operator
Check drained urine for cloudiness and send a specimen to the laboratory if the urine was cloudy or offensive or if the patient had symptoms suggestive of a urinary tract
infection.
Yes
No
Position the catheter below the level of the bladder on a clean stand that prevents any part of the catheter drainage system coming into contact with the floor.
Yes
No
Name of Operator:
Name of Observer (if present):
Valid clinical reasons for indwelling urinary catheterisation
The clinical team need to closely monitor urinary output (haemodynamic monitoring)
The patient cannot sufficiently empty his/her bladder (bladder outlet obstruction)
The patient has a lack of bladder control and signs that the kidneys are not working well
The patient has open wounds or pressure sores around the buttocks that are frequently soiled/contaminated with urine.
٢٧
The patient is severely ill, or has a disability that makes moving or changing very painful.
State the reason for catheterisation if not one of the above:
Tick

28. Ward
Named
individual
performing
bundle
Date
Signature
Patient Observation
Was the urinary catheter
inserted in this clinical
area?
Is there a Urinary
Catheter Insertion
Checklist for this patient?
If present, does the Urinary Catheter Insertion
Checklist indicate optimal insertion care?
1.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
2.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
3.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
4.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
5.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
6.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:
٢٨7.
Yes
No
Don’t know
Yes
No
Yes
No
What, if anything, was missing or incorrect:

29. Total
Comment (if
required)
Summary Table of UC Maintenance Bundle Findings
Total number of UCs in situ at start of the Bundle
Total number of UCs inserted in our clinical area
Total number of UCs inserted in our clinical area with insertion checklists
Total number of UCs with optimal care documented on insertion checklist
All or None Table – Was UC insertion care optimal
Tick if achieved
100%
100% of UCs inserted in our clinical area had an insertion checklist
100%
100% of UCs inserted in our clinical area had an insertion checklist showing optimal care
Insertion care was optimal if there was a complete and optimal insertion catheter checklist for
each urinary catheter inserted in this clinical area.
If insertion care was not optimal for urinary catheters inserted in other clinical areas, consider what can be done to
communicate this to the clinical leaders responsible.
responsible.
٢٩

30. What date should be
recorded as the
“Date of CAUTI onset”?
٣٠

31. The day the first positive
urine specimen is taken
OR
The day the physician diagnoses
the CAUTI and institutes antibiotics
٣١

32. A patient is admitted to the
hospital and has a catheter inserted on
admission (Day 1).The following day
(Day 2) this patient presents with a fever,
loin tenderness and the physician
diagnoses a UTI and
prescribes antibiotics
Does the patient meet the criteria
for a CAUTI?
٣٢

33. NO
The first positive urine specimen must be
taken or physician diagnosis of UTI
must be more than 48 hours after the
catheter was inserted
٣٣

34. A patient is admitted to the
hospital with a catheter in
situ
Are they included in CAUTI
surveillance?
٣٤

35. NO
With the exception of patients
who have a catheter inserted in ER
or theatre prior to being admitted to
the specialty
٣٥

36. A patient is undergoing
treatment for a UTI
and has a urinary catheter
inserted
Are they included in the CAUTI
surveillance?
٣٦

37. NO
Patients are excluded from CAUTI
surveillance if they are
undergoing treatment for a
UTI at the time the catheter is
inserted
٣٧

38. A patient had a catheter removed
and 2 days later they develop
signs and symptoms for UTI
Do they have a CAUTI?
٣٨

39. YES
A UTI is considered to be
catheter associated if the
patient had a catheter
removed within the three
days prior to the onset of the
UTI
٣٩

40. A patient has a catheter
inserted in theatre before
transfer to the ward
Are they included in the
CAUTI surveillance?
٤٠

41. YES
Patients who have a catheter
inserted in ER or theatre prior to
being admitted to the specialty are
included
٤١

42. A patient has a catheter inserted.
5 days later the catheter is removed
and immediately replaced
Is this considered to be a “new” or
“continuous” catheterisation?
٤٢

43. Continuous catheterisation
Any catheter replaced within 24 hours of
removal of the previous catheter is
a continuous catheterisation
If the interval between catheter removal
and catheter replacement is more than 24
hours, a new period of catheterisation
should be started
٤٣

44. Following catheter
removal, for how many
days should the patient
be followed up?
٤٤

45. 3 Days
Unless they are discharged,
transferred or die, develop a
CAUTI or the 30 day surveillance
period ends before the end of the 3
day follow up period
٤٥

46. A patient has intermittent
catheterisation
Are they included in
surveillance?
٤٦

47. NO
Patients are excluded if the
catheter is intermittent
٤٧

48. A patient is transferred to the
surveillance specialty where a catheter is
inserted.
Transfer notes state that the patient had
a catheter in situ previously and it was
removed 5 days prior to transfer.
Does the patient meet the criteria for a
“Previous Period of Catheterisation”
٤٨

49. YES
A patient who has has a previous
catheter removed more than 24
hours but less than 7 days before
the insertion of the present catheter
meets the criteria for “Previous
Period of Catheterisation”
٤٩

50. ٥٠

51. ٥١