Reducing Catheter-Acquired UTIs (CAUTIs)
Catheter-associated urinary tract infections (CAUTIs) are one of the most common hospital-acquired infections (HAIs) that can lead to prolonged hospital stay, increased healthcare costs, and increased morbidity and mortality. According to the National Healthcare Safety Network (NHSN), the standardized infection ratio (SIR) for CAUTIs in the United States was 0.84 in 2018, which means that there were more CAUTIs than expected based on historical data. Reducing CAUTIs is crucial to improve patient safety, quality of care, and antimicrobial stewardship.
CAUTIs are caused by bacteria that enter the urinary tract through the catheter or the insertion site. The most common pathogens are Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus spp., and Candida spp. Risk factors for developing CAUTIs include female sex, older age, diabetes, immunosuppression, prolonged catheterization, inappropriate catheter care, and lack of adherence to infection prevention practices.
Preventing CAUTIs requires a multidisciplinary approach that involves healthcare providers, patients, and caregivers. The following strategies can help reduce CAUTIs in different settings:
1. **Avoid unnecessary catheterization**. Catheters should only be used for specific indications, such as acute urinary retention, bladder outlet obstruction, accurate urine output measurement in critically ill patients, perioperative use for selected surgeries, prolonged immobilization, or end-of-life care. Catheters should not be used for convenience, incontinence, or wound care.
2. **Use appropriate catheter insertion techniques**. Catheters should be inserted by trained and competent staff using aseptic technique and sterile equipment. The catheter size should be the smallest possible to minimize trauma and infection risk. The catheter should be secured to prevent movement and tension. The insertion site should be cleaned daily with soap and water or antiseptic wipes.
3. **Maintain a closed drainage system**. The catheter and the drainage bag should be connected at all times to prevent bacterial entry. The drainage bag should be kept below the level of the bladder to prevent backflow of urine. The drainage bag should be emptied regularly using a separate container for each patient. The drainage bag should not touch the floor or other contaminated surfaces.
4. **Review the need for catheterization daily**. Catheters should be removed as soon as possible when they are no longer needed. A nurse-driven protocol or an electronic reminder system can facilitate timely catheter removal. Patients and caregivers should be educated about the benefits and risks of catheterization and the signs and symptoms of CAUTI.
5. **Manage catheter-associated asymptomatic bacteriuria (CA-ASB) appropriately**. CA-ASB is defined as the presence of bacteria in the urine of a catheterized patient without signs or symptoms of UTI. CA-ASB is very common and does not require antibiotic treatment unless the patient is pregnant, undergoing urologic surgery, or has neutropenia. Antibiotic treatment of CA-ASB can lead to adverse effects, antibiotic resistance, and Clostridioides difficile infection.
6. **Diagnose and treat CAUTI correctly**. CAUTI is defined as a UTI that occurs in a patient with an indwelling urinary catheter or within 48 hours of catheter removal. The diagnosis of CAUTI requires both clinical criteria (such as fever, chills, flank pain, suprapubic tenderness, or altered mental status) and microbiological criteria (such as positive urine culture or urinalysis). A urine sample for culture should be obtained before starting antibiotic treatment and after removing or replacing the catheter if possible. The choice of antibiotic should be based on local guidelines, susceptibility testing, patient characteristics, and potential drug interactions.
7. **Implement evidence-based interventions**. Several interventions have been shown to reduce CAUTIs in different settings, such as guidelines, education, training, audit and feedback, reminders, checklists, bundles, and champions. These interventions should target the barriers and facilitators of CAUTI-related behaviors identified by behavioral science frameworks, such as the COM-B model (capability, opportunity, motivation, and behavior), the Theoretical Domains Framework (TDF), and the Behaviour Change Wheel (BCW). These frameworks can help design and refine interventions that are theoretically congruent with the target behaviors and contexts.
8. **Monitor and evaluate outcomes**. The rate of CAUTI should be measured using standardized definitions and methods, such as the NHSN protocol. The rate of CAUTI should be adjusted for risk factors, such as patient population, catheter utilization ratio (CUR), and device days. The rate of CAUTI should be reported and compared with national and local benchmarks, such as the NHSN SIR. The impact of interventions on CAUTI and other outcomes, such as catheter days, antibiotic use, patient satisfaction, and cost, should be assessed using appropriate statistical methods.
By implementing these strategies, healthcare providers can reduce CAUTIs and improve patient outcomes. Reducing CAUTIs is not only a clinical goal, but also a moral and ethical responsibility.
References:
– Atkins L, Sallis A, Chadborn T, et al. Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions. Implementation Science. 2020;15:44.
– Jain H, Hartigan E, Tschopp J, et al. Catheter-associated urinary tract infections (CAUTIs) reduction: a multidisciplinary approach. Infection Control & Hospital Epidemiology. 2020;41(S1):S43-S44.
– National Institute for Health and Care Excellence. Urinary tract infection (catheter-associated): antimicrobial prescribing. NICE guideline [NG113]. 2018.
– Agency for Healthcare Research and Quality. Toolkit for reducing catheter-associated urinary tract infections in hospital units: implementation guide. 2019.
– Ben’s Natural Health. 8 strategies to prevent a catheter-associated UTI (CAUTI). 2023.
