Catheter Associated Urinary Tract Infections - How Do You Prevent CAUTI?

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Published: 08 November 2020

Urinary tract infections (UTI) are the most common hospital-acquired infection affecting individuals today (CDC 2015).

About 75% of hospital-acquired UTIs are associated with the use of an indwelling urinary catheter (IDC). This is a significant number, considering that there is a 15 to 25% chance of a hospitalised patient needing a catheter inserted at some point during their stay (CDC 2015). These infections, due to their aetiology, are commonly referred to as catheter-associated urinary tract infections (CAUTI).

IDCs are associated with many negative outcomes, and in addition to potentially developing an infection, the patient may also experience urethral strictures, mechanical trauma, nonbacterial urethral inflammation or impaired mobility. CAUTIs have also been found to result in an increased length of stay in hospital for the patient, and are associated with an increased risk of mortality (Lo et al. 2014).

This increased risk of mortality may be linked to the fact that CAUTIs are one of the most common causes of secondary bloodstream infections that occur in acute care hospitals. And, when we look at patients in long-term care facilities, the numbers may shock you. Patients with IDCs in-situ in long-term care facilities are between 3 and 36 times more likely to have bacteriuria present than those without catheters (Nicolle 2014).

Urinary Catheters in situ
Urinary Catheters in-situ.

Symptoms of CAUTI

It can be difficult to detect CAUTIs. This is because the symptoms of infection may be absent due to the catheter being in-situ, meaning the patient wouldn’t know if they were experiencing the symptoms of a UTI (e.g. urinary urgency or a burning sensation on voiding). CAUTIs can also be difficult to recognise because of other comorbidities present in the patient, and even more so if the patient has a decreased ability to communicate due to illness or age (Lo et al. 2014).

Generally the most common clinical presentation when a patient has a CAUTI is the presence of a fever as well as a positive urine culture result. Other signs or symptoms include catheter obstruction, haematuria, recent trauma and suprapubic pain, however, these symptoms are only present in a minority of people with a CAUTI. It is important to acknowledge that many patients who have bacteraemia present often do not develop an associated symptomatic infection (Lo et al. 2014; Nicolle 2014).

How to Prevent CAUTI

The focus on CAUTIs is on prevention. If the risk of infection increases with the use of an IDC, then we can minimise catheter use on patients. When catheters are necessary, they should be removed as soon as possible.

By lowering the causative factor of the infections, we are decreasing the rate of infections occurring. It has been found that for each day a catheter remains in, the patient's risk of acquiring a CAUTI increases by 7% (Gould 2017; Lo et al. 2014).

The increased risk of prolonged IDC use can be attributed to the development of a biofilm on the catheter. As with any device that has the potential to develop a biofilm, the longer the device stays in-situ, the longer the biofilm will be in place and be a harbour for potential microorganism growth.

Biofilm is a complex material and consists of many microorganisms growing on the surface of the object. In the case of a catheter, the biofilm will not only be present on the outside of the catheter but will also be present on the inside of the tubing. This biofilm formation will begin immediately after insertion of the catheter, hence the focus on removing the catheter as soon as it is no longer needed (Nicolle 2014).

It is also important to recognise those who are at a higher risk of developing a CAUTI. Those with an increased risk include women, older adults and patients with impaired immunity. In these population groups, we need to ensure that we minimise both catheter use and catheter duration to help decrease their risk of developing a CAUTI (Gould 2009).

An IDC should not be used on patients for a prolonged period of time without the appropriate indications for use, or as a substitute for nursing care on a patient with incontinence. Generally, catheters should be used in the following situations:

  • Acute urinary retention;
  • Bladder outlet obstruction;
  • When there is a need for accurate measurements of urinary output in critically ill patients;
  • Perioperative use for specific surgical procedures (such as urological surgery, prolonged duration of surgery, patients receiving large volume infusions or if there is a need for intra-operative monitoring or urinary output);
  • To assist in the healing of wounds in the sacral or perineal area in incontinent patients;
  • When patients may require long periods of immobilisation (such as if they have traumatic injuries like pelvic fractures); and
  • To improve end of life care if required.

(Gould 2009)

cauti urine drainage bag

Nursing Considerations

Prevention of CAUTIs also relies on the provision of appropriate nursing care. This means ensuring the use of proper techniques for inserting the catheter and performing ongoing maintenance.

Only trained practitioners should be inserting IDCs, and this must be performed using aseptic technique and sterile equipment. The smallest catheter size appropriate for the patient should be chosen. It is also important to note that infections risks are similar with both latex and silicone-based catheters. After insertion of the IDC, it should be maintained as a closed drainage system and if there is a disconnection, replacement of the items should occur (Gould 2017; Nicolle 2014).

It is also important that nurses ensure that the catheter remains free from any kinks and that the collecting bag remains below the level of the bladder at all times to maintain unobstructed urine flow, which will also help to prevent infections (Gould 2017).

IDC management should also include ensuring the catheter is properly secured in order to prevent movement and urethral traction. The collection bag should be emptied regularly, with the nurse avoiding touching the draining spigot to the collecting container.

Note that the drainage bag of a patient with a CAUTI can act as a reservoir for organisms. These can then be transmitted to other patients through the hands of healthcare personnel. Outbreaks of infections that are associated with resistant gram-negative organisms that are attributable to bacteriuria in patients with catheters have been reported (Lo et al. 2014).

Maintaining perineal hygiene is also important when caring for a patient with an IDC. This can be done during the patient's regular shower, and if your patient does not require assistance with showering, education is essential to ensure they are cleaning this area (Gould 2017).

The main consideration for IDC nursing care is based on the primary principle of treating of CAUTIs: prevention. If the IDC is not clinically indicated, we should not be inserting it, and if it is no longer needed, it is time to remove it.


References
  • Centers for Disease Control and Prevention 2015, Catheter-associated Urinary Tract Infections, CDC, US Department of Health, viewed 9 August 2017, https://www.cdc.gov/hai/ca_uti/uti.html
  • Gould, CV 2017, Guideline for Prevention of Catheter Associated Urinary Tract Infections, Healthcare Infection Control Practices Advisory Committee, viewed 9 August 2017,  https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html
  • Lo, E, Nicolle, E, Coffin, SE, Gould, C, Maragakis, LL, Meddings, J, Pegues, DA, Pettis, AM, Saint, S & Yokoe, DS 2014, ‘Strategies to Prevent Catheter-associated Urinary Tract Infections in Acute Care Hospitals: 2014 update,’ Infection Control and Hospital Epidemiology, vol. 35, no. 5, pp. 464-479, viewed 9 August 2017, http://www.jstor.org/stable/10.1086/675718
  • Nicolle, LE 2014, ‘Catheter associated urinary tract infections’, Antimicrobial Resistance and Infection Control, vol. 3, no. 23 available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4114799/

Author

Portrait of Sally Moyle
Sally Moyle

Sally Moyle is a rehabilitation nurse educator who has completed her masters of nursing (clinical nursing and teaching). She is passionate about education in nursing so that we can become the best nurses possible. Sally has experience in many nursing sectors including rehabilitation, medical, orthopaedic, neurosurgical, day surgery, emergency, aged care, and general surgery. See Educator Profile

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