1. The presentation is solely meant for
Academic purpose

3. • Developed in the 1920s by
Dr. Frederick Foley
• Originally an open system
with the urethral tube
draining into an open
container
• Closed system (1950’s)
developed in which the
urine flowed through a
catheter into a closed bag
3

4. 100%
90%
80%
70%
60%
50% Bacteriuria
40%
30%
20%
10%
0%
At Placement 4th day

5. 100%
90%
80%
70%
60%
50% Bacteriuria
40%
30%
20%
10%
0%
1st week 4th week

6.  Most common type of healthcare-associated
infection
◦ > 30% of HAIs reported to NHSN
◦ Estimated > 560,000 nosocomial UTIs annually
 Increased morbidity & mortality
◦ Estimated 13,000 attributable deaths annually
◦ Leading cause of secondary BSI with ~10% mortality
 Excess length of stay : 2-4 days
 Increased cost : $0.4-0.5 billion per year nationally
 Unnecessary antimicrobial use
Hidron AI et al. ICHE 2008;29:996-1011 Givens CD, Wenzel RP. J Urol 1980;124:646-8
Klevens RM et al. Pub Health Rep 2007;122:160-6 Green MS et al. J Infect Dis 1982;145:667-72
Weinstein MP et al. Clin Infect Dis 1997;24:584-602 Foxman B. Am J Med 2002;113:5S-13S
Cope M et al. Clin Infect Dis 2009;48:1182-8 Saint S. Am J Infect Control 2000;28:68-75

7. In patients with indwelling urethral,
indwelling suprapubic, or intermittent
catheterization
 Presence of symptoms or signs compatible with UTI
with
 No other identified source of infection
 103 colony forming units (cfu)/mL of 1 bacterial
species in a single catheter urine specimen
or
in a midstream voided urine specimen from a
patient whose catheter has been removed in previous
48 hrs.

8.  Gold standard is urine culture
 Dipstick and other non-culture tests are
not reliable
 Number of organisms is controversial

11. Source of
microorganisms:
Endogenous - meatal,
rectal, or vaginal
colonization
Exogenous -
contaminated hands
of healthcare worker
Maki DG. Emerg Infect Dis 2001;7:1-6

12. Tambyah, Halvorson & Maki. Mayo Clin Proc. 1999 Feb;74(2):131-6.

13.  Formation of
biofilms by urinary
pathogens common
on the surfaces of
catheters and
collecting systems
 Bacteria within
biofilms resistant
to antimicrobials Scanning electron micrograph of S. aureus
bacteria on the luminal surface of an
and host defenses indwelling catheter with interwoven complex
matrix of extracellular polymeric substances
known as a biofilm
Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp

14. Maki, Emerg Infect Dis 2001; 7: 1-6

15. Supplemental
Core Strategies Strategies
◦ High levels of ◦ Some scientific
scientific evidence evidence
◦ Variable levels of
◦ Demonstrated feasibility
feasibility
www.cdc.gov/hicpac

16.  Insert catheters only for appropriate indications
 Leave catheters in place only as long as needed
 Ensure that only properly trained persons insert and
maintain catheters
 Insert catheters using aseptic technique and sterile
equipment (acute care setting)
 Maintain a closed drainage system
 Maintain unobstructed urine flow
 Hand hygiene and Standard precautions
http://www.cdc.gov/hicpac/cauti/001_cau

17.  Acute urinary retention or obstruction
 Accurate measurements in critically ill patients
 Selected surgical procedures e.g. urologic
 Healing of open sacral or perineal wounds
 End of life comfort
 Prolonged immobilisation
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/CAUTI_Guideline2009final.pdf

18.  Urinary incontinence
 Immobility
 Use of diuretics
 Ignorance of published guidelines
 Clinical uncertainty of the patient’s medical
course
 Convenience of staff
Jain et al (1995) Arch Intern Med 155:1425-9

19. Good hand hygiene Don sterile gloves before
before and after procedure
procedure

20. •Sterile technique
must be used
when inserting the
catheter
•Do not use
aggressive
cleaning once
urinary catheter is
in place

23.  12 month control period followed by
12 month intervention with nurse
generated daily reminders after D5
◦ Catheterization rate reduced from 7.0 +
1.1 days to 4.6 +/- 0.7 days; P < .001
◦ CAUTI rate reduced from 11.5 +/- 3.1
to 8.3 +/- 2.5 per 1,000 catheter-days;
P = .009
◦ Antibiotic cost reduced reduced by 69%
(from 4021 dollars +/- 1800 dollars to
1220 dollars +/- 941 dollars; P = .004)
Huang et al Infect Control Hosp Epidemiol. 2004
Nov;25:974-8

24.  Maintain a closed drainage system (I B)
◦ If breaks in aseptic technique, disconnection, or
leakage occur, replace catheter and collecting
system
◦ Consider systems with preconnected, sealed
catheter-tubing junctions (II B)
◦ Obtain urine samples aseptically
http://www.cdc.gov/hicpac/cauti/001_cau

25. •Sampling Port:
Disinfect port
before sampling
urine
•Look for possible
disconnection of
catheter from
drainage bag

26. System may
become an
open system
if outlet is left
hanging or is
unclamped

27.  Maintain unobstructed urine flow (I B)
◦ Keep catheter and collecting tube free from
kinking
◦ Keep collecting bag below level of bladder at all
times (do not rest bag on floor)
◦ Empty collecting bag regularly using a separate,
clean container for each patient. Ensure
drainage spigot does not contact nonsterile
container.
http://www.cdc.gov/hicpac/cauti/001_cau

28.  Use smallest catheter
size effective for
patient (14 or 16F)
 Catheters should be
properly secured to
prevent movement and
urethral traction

29.  Implement quality improvement
programs to enhance appropriate use of
indwelling catheters and reduce risk of
CA-UTI
Eg:
• Alerts or reminders
• Stop orders
• Protocols for nurse-directed removal of
unnecessary catheters
• Guidelines/algorithms for appropriate
perioperative catheter management
http://www.cdc.gov/hicpac/cauti/001_cau

30.  Alternatives to indwelling urinary catheterization
(II)
 Portable ultrasound devices for assessing urine
volume to reduce unnecessary catheterizations (II)
 Antimicrobial/antiseptic-impregnated catheters (I
B)
 After first implementing core recommendations
for use, insertion, and maintenance

31.  Intermittent catheterization – consider for:
◦ Patients requiring chronic urinary drainage for
neurogenic bladder
 Spinal cord injury
 Children with myelomeningocele
◦ Postoperative patients with urinary retention
◦ May be used in combination with bladder ultrasound
scanners
 External (i.e., condom) catheters – consider for:
◦ Cooperative male patients without obstruction or
urinary retention

32.  Rationale: fewer catheterizations = lower risk
of UTI
 2 studies of adults with neurogenic bladder
undergoing intermittent catheterization
 Fewer catheterizations per day but no reported
differences in UTI
◦ Significant study limitations: likely underpowered;
UTIs undefined
Polliak T et al. Spinal Cord 2005;43:615-19
Anton HA et al. Arch Phys Med Rehab 1998;79:172-5

33.  Decreased risk of bacteriuria compared to
standard latex catheters in a meta-analysis of
RCTs
 Significant differences for silver alloy but not silver
oxide-coated catheters
 Effect greater for patients catheterized < 1 week
 Mixed results in observational studies in
hospitalized patients
◦ Most used laboratory-based outcomes (bacteriuria)
◦ 1 positive, 2 negative, 5 inconclusive
http://www.cdc.gov/hicpac/cauti/001_cau

34.  Polymyxin
◦ Butler HK, Kunin CM. J Urol 1971;106:928
 Cephalothin
◦ Lazarus SM, LaGuerre JN, Kay H, Weinberg S,
Levowitz BS. J Biomed Mater Res 1971;5:129
 Both unsuccessful

35.  344 newly catheterised patients studied daily
◦ RR 0.672, P=0.30 overall
◦ OR 0.22, P=0.02 for GNRs
◦ Not effective for yeasts
◦ Little effect beyond 7 days
◦ Maki, Knasinski SHEA 1997

36. Core Measures Supplemental
Measures
 Insert catheters only for  Alternatives to
appropriate indications indwelling urinary
 Leave catheters in place only catheterization
as long as needed  Portable ultrasound
 Only properly trained persons devices to reduce
insert and maintain catheters unnecessary
 Insert catheters using aseptic catheterizations
technique and sterile  Antimicrobial/antiseptic
equipment -impregnated catheters
 Maintain a closed drainage
system
 Maintain unobstructed urine
flow
 Hand hygiene and standard (or
appropriate isolation)
precautions

37. Supplemental measures Core measures

38.  Changing catheters or drainage bags at routine, fixed
intervals
 Routine antimicrobial prophylaxis
 Cleaning of periurethral area with antiseptics while
catheter is in place (use routine hygiene)
 Irrigation of bladder with antimicrobials
 Instillation of antiseptic or antimicrobial solutions into
drainage bags
 Routine screening for asymptomatic bacteriuria (ASB)
http://www.cdc.gov/hicpac/cauti/001_cau

39.  Documentation & review of indications for
catheter insertion
 Asepsis during catheter insertion
 Daily assesment for the need of catheter
 Hand hygiene during daily catheter care
 Positioning of the drainage bag below the
bladder
 Regular emptying of the drainage bags