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

**•** Insert catheter only for appropriate indications (see Table 2) and leave in place only as long as needed (Category 1B)

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 to insufficient data.

Patient has acute urinary retention or bladder outlet obstruction

Need for accurate measurements of urinary output in critically ill patients

Perioperative use for selected surgical procedures:

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‐

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

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

Category IA A strong recommendation supported by high to moderate

Category IB A strong recommendation supported by low quality evidence

evidence Category IC A strong recommendation required by state or federal regulation. Category II A weak recommendation supported by any quality evidence

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

quality† evidence suggesting net clinical benefits or harms

suggesting a trade off between clinical benefits and harms

Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms

suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality

lines for the diagnosis, prevention and treatment of CAUTI as well [37].

antimicrobials [38].

No recommendation/ unresolved issue

Table 1. They are noted in blue.

12 Recent Advances in the Field of Urinary Tract Infections


4. Need for intraoperative monitoring of urinary output

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

Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)

To improve comfort for end of life care if needed

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

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

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

For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.)

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

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

– 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 preferred the condom catheters [40].

– Intermittent catheterization for the following subgroups (Category II)


– Use appropriate hand hygiene before and after insertion or any manipulation of catheter

Prevention of Urinary Tract Infections in the Outpatient and Inpatient Settings

http://dx.doi.org/10.5772/56709

15

– Properly secure catheters after insertion to prevent movement and urethral trauma and

– Use the smallest bore catheter possible to minimize trauma to the urethra and bladder

– Clean (non-sterile) technique is acceptable for patients requiring chronic intermittent

– Optimal cleaning and storage methods for catheters used for CIC is not determined.

**◦** Empty the collecting bag regularly and avoid contact of the drainage spigot with the

**•** Changing of indwelling catheters or drainage bags at fixed intervals is not recommended. Change is only recommended for infection, obstruction of compromise of the system

**•** Do **NOT** use systemic antibiotics routinely for the prevention of CAUTI in patients requiring

– Further research is needed on the prophylactic use of urinary antiseptics such as methen‐

**•** Do **NOT** use antiseptic solutions to clean the periurethral area while the catheter is in place. Routine hygiene (e.g., cleaning the meatal surface during daily bathing/showering) is

– Perform at regular intervals to prevent bladder overdistension (Category IB)

or site (Category 1B)

traction (Category IB)

neck (Category II)

(Unresolved issue)

**◦** Avoid kinking

(Category II)

collecting container

amine (unresolved issue).

appropriate (Category IB)

– Use a closed drainage system (Category IB)

**•** Intermittent catheter recommendations

catheterization (CIC) (Category IA)

**6. Catheter maintenance techniques**

– Maintain closed drainage system

– Keep urine flow unobstructed:

**•** Maintenance of catheter once inserted (all Category IB)

**◦** Keep collecting bag below level of bladder at all times

either short or long term catheterization (Category IB)


There are studies that have compared suprapubic catheters with urethral catheters. In the gynecology literature, there are few studies. A recent meta-analysis by Healy et al found only 12 randomized controlled trials. They found that although suprapubic catheters had lower overall infection rates when compared to urethral Foleys, (20% compared with 31%), the complication rates were higher (29 % vs 11%) [43]. One study randomized a group of 257 women who underwent anterior repairs with or without vaginal hysterectomy to 3 day suprapubic vs 3 day urethral foley vs 1 day urethral foley. There were fewer infections in the suprapubic group but a significantly higher risk of complications which led to early withdrawal of this arm of the study. Complications included blockage most commonly, urinary retention, and one pyelectasia. They authors concluded that in their trial, the optimal bladder catheter after anterior colporrhaphy was an urethral catheter for 24 hours [44]. Katsumi et al found that men with spinal cord injuries who need chronic catheterization have similar complication rates in terms of UTI, and recurrent bladder and renal calculi with urinary catheters as with suprapubic catheters. Catheter complications rates were similar, though differing in type. Men with urinary catheters had more urethral and scrotal complications, while men with suprapubic tubes had more leakage and 13% required revision [45].

### **5. Catheter insertion techniques**

**•** Indwelling urethral catheters should be inserted with proper sterile technique and sterile equipment by trained personnel (Category IB)

– Use appropriate hand hygiene before and after insertion or any manipulation of catheter or site (Category 1B)

– Properly secure catheters after insertion to prevent movement and urethral trauma and traction (Category IB)

– Use a closed drainage system (Category IB)

– Use the smallest bore catheter possible to minimize trauma to the urethra and bladder neck (Category II)

**•** Intermittent catheter recommendations

**◦** Spinal cord injury patient

14 Recent Advances in the Field of Urinary Tract Infections

placement of a foley [42].

bladder outlet obstruction

revision [45].

**5. Catheter insertion techniques**

equipment by trained personnel (Category IB)

**◦** Children with neurogenic badders, (e.g. myelomeningocele)

patients requiring short or long term catheterization.

– Further research needed on (Unresolved issue)

**◦** Patients with bladder emptying dysfunction. This should include postoperative patients, including women with surgery on the genitourinary tract. Hakvoort et al randomized 87 patients who had recent vaginal prolapse surgery and a post void residual > 150 ccs after first void to either foley placement or clean intermittent catheterization (CIC). They found a significant decrease in bacteruria in the CIC group (12 vs 34%). The CIC patients also noted decreased time until return of spontaneous voiding: 18 hours in the CIC group versus 72 hours in the foley group [41]. Moreover, a subsequent study by this same group surveyed the study patients and found that the great majority preferred CIC instead of

**◦** Benefits of urethral stent as an alternative to indwelling catheter in selected patients with

**◦** Benefits of suprapubic catheters as an alternative to indwelling urethral catheters in

There are studies that have compared suprapubic catheters with urethral catheters. In the gynecology literature, there are few studies. A recent meta-analysis by Healy et al found only 12 randomized controlled trials. They found that although suprapubic catheters had lower overall infection rates when compared to urethral Foleys, (20% compared with 31%), the complication rates were higher (29 % vs 11%) [43]. One study randomized a group of 257 women who underwent anterior repairs with or without vaginal hysterectomy to 3 day suprapubic vs 3 day urethral foley vs 1 day urethral foley. There were fewer infections in the suprapubic group but a significantly higher risk of complications which led to early withdrawal of this arm of the study. Complications included blockage most commonly, urinary retention, and one pyelectasia. They authors concluded that in their trial, the optimal bladder catheter after anterior colporrhaphy was an urethral catheter for 24 hours [44]. Katsumi et al found that men with spinal cord injuries who need chronic catheterization have similar complication rates in terms of UTI, and recurrent bladder and renal calculi with urinary catheters as with suprapubic catheters. Catheter complications rates were similar, though differing in type. Men with urinary catheters had more urethral and scrotal complications, while men with suprapubic tubes had more leakage and 13% required

**•** Indwelling urethral catheters should be inserted with proper sterile technique and sterile

– Clean (non-sterile) technique is acceptable for patients requiring chronic intermittent catheterization (CIC) (Category IA)

– Perform at regular intervals to prevent bladder overdistension (Category IB)

– Optimal cleaning and storage methods for catheters used for CIC is not determined. (Unresolved issue)
