**3. Prevention of UTIS in the inpatient and institutional setting**

UTIS are the most common nosocomial infection worldwide, accounting for about 40% of these. The great majority of these infections are due to the presence of an indwelling urethral catheter in hospitals and long-term care facilities (LTCF) and are commonly referred to as catheter-associated UTI (CAUTI). These infections add significantly to morbidity and some‐ times even mortality for the patient. The cost of these infections is substantial, estimated at 2.66 billion dollars in 2007 US dollars [32].

More than 1.5 million people in the United States live in nursing homes. Within the last decade, the severity of illness of nursing home residents has increased such that these residents (average age 80) have a risk of developing health care-associated infection (HAI) that ap‐ proaches that seen hospital inpatients. The use of indwelling foley catheters has decreased in this setting and is currently about 5 to 10%, but UTI remains the leading infection in long term care facilities (LTCFs). Guidelines for prevention of CA-UTI applies to both these settings [33]. Of note, the catheter literature commonly reports on catheter-associated asymptomatic bacteruria (CA-ASB) and catheter associated bacteruria if no distinction is made between CA-ASB and CA-UTI. CA-bacteruria is the predominant outcome measure reported in most clinical trials.

Undoubtedly, the best way to prevent UTI is to avoid long term catheterization. The risk of UTI goes up markedly about 72 hours after a foley catheter is inserted. As long term foley use is often unavoidable in the hospitalized or nursing home patient, much attention has been devoted to efforts to prevent CAUTI worldwide. The Department of Public Health in England developed guidelines in 2001 and updated them in 2007 [34]. A short time later, in 2008 the European Association of Urology (EAU), the Urological Association of Asia (UAA), and others published *European and Asian Guidelines on Management and Prevention of Catheter-Associated Urinary Tract [35].* Within the United States, the Center for Disease Control (CDC) first published guidelines in 1981 and these have been intermittently revised, most recently in 2009 [36]. During this same year, the the Infectious Diseases Society of America published guide‐ lines for the diagnosis, prevention and treatment of CAUTI as well [37].

**4. Recommendations for the prevention of CAUTI indications for use**

as needed (Category 1B)

Patient has acute urinary retention or bladder outlet obstruction

Perioperative use for selected surgical procedures:

4. Need for intraoperative monitoring of urinary output

To improve comfort for end of life care if needed

**B. Examples of Inappropriate Uses of Indwelling Catheters**

structures, prolonged effect of epidural anaesthesia, etc.)

preferred the condom catheters [40].

Need for accurate measurements of urinary output in critically ill patients

3. Patients anticipated to receive large-volume infusions or diuretics during surgery

To assist in healing of open sacral or perineal wounds in incontinent patients

As a substitute for nursing care of the patient or resident with incontinence

**•** Use alternative to indwelling catheters when appropriate

to insufficient data.

injuries such as pelvic fractures)

**•** Insert catheter only for appropriate indications (see Table 2) and leave in place only as long

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Catheters should NOT be placed for incontinence or nursing convenience. For the postoper‐ ative patient who needs an indwelling catheter, remove within 24 hours unless there are indications for continued use, such as surgery on the urinary tract or an open perineal wound. Then remember to remove as soon as medically feasible. The use of condom catheters in incontinent male patients should be considered but this is considered an unresolved issue due

1. Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract 2. Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU)

Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic

As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void

**Table 2.** Examples of Appropriate Indications for Indwelling Urethral Catheter Use (Reprinted from CDC [39]).

– Intermittent catheterization for the following subgroups (Category II)

For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous

– Condom catheters in male patients without obstruction or retention (Category II). The use of condom catheters vs indwelling catheter has been studied in a randomized controlled trial of hospitalized men aged 40 and over. Results showed condom catheter use is less likely to lead to bacteruria, symptomatic UTI, or death than the use of indwelling catheters. This was especially apparent in men without dementia, and the patients overwhelmingly

Recently Conway and Larsen reviewed and compared a total of 8 guidelines worldwide to prevent CAUTI. They found broad agreement between the guidelines overall but noted that different grading systems for the level of evidence to support each recommendation made comparisons difficult. They also noted that most of the guidelines didn't distinguish between true catheter associated infections as opposed to catheter associated asymptomatic bacteruria. They wisely noted that "For clinicians seeking to prevent CAUTI, the distinction is a moot point, because all symptomatic CAUTI begins as asymptomatic bacteruria". Their article included an excellent, concise summary of all 8 of these guidelines. This included an overview of recommendations for catheter use, catheter types, insertion techniques, maintenance, and antimicrobials [38].

Within the United States, the guidelines for prevention are very similar between the CDC and ISDA 2009 guidelines. These guidelines are summarized below. The ISDA guidelines note that most of their recommendations pertain to the prevention of catheter-associated bacteruria as this is the reported outcome in most trials, whereas the CDC doesn't differentiate between bacteruria and symptomatic UTI. Both guidelines provided evidence for strength of each recommendation. The CDC evidence levels were used in this summary and are defined in Table 1. They are noted in blue.


**Table 1.** Modified HICPAC Categorization Scheme\* for Recommendations (Reprinted from CDC [39]).
