Guideline for Prevention
of Catheter-associated
Urinary Tract InfectionsWritten by
Edward S. Wong, M.D.
In consultation with Thomas M. Hooton, M.D.
WORKING GROUP
Herbert W. Clegg II, M.D.
Children's Hospital Medical Center
Boston,
Massachusetts
Sheila Cram, R.N., M.P.H.
Infection Control
Nurse
Director of Department of
Infection Control and Epidemiology
Newton-Wellesley Hospital
Newton, Massachusetts
Jane DeGroot-Kosolcharoen, R.N., M.S.
Infection Control Nurse
William
S. Middleton Memorial
Veterans Hospital
Lecturer, University of
Wisconsin
School of Nursing
Madison, Wisconsin
Richard Garibaldi, M. D.
Associate Professor of Medicine
Hospital
Epidemiologist
University of Utah Medical Center
Salt Lake Veterans
Administration
Medical Center
Salt Lake City, Utah
Edward H. Kass, M.D.
William Ellery Channing
Professor of Medicine
Director of Channing Laboratory
Brigham and Women's Hospital
Boston,
Massachusetts
Calvin M. Kunin, M.D.
Professor and Chairman
Department of Medicine
Columbus. Ohio
Rosemary Lindan, M.D.
Assistant Professor of Orthopedics and Medicine
Case Western Reserve School of Medicine
Cuyahoga County Hospital
Cleveland, Ohio
Walter E. Stamm, M.D.
Assistant Professor of Medicine
University of
Washington
School of Medicine
Harborview Medical Center
Seattle,
Washington
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health
Service
Guideline for Prevention of Catheter-associated Urinary Tract
Infections
INTRODUCTION
The urinary tract is the most common site of nosocomial infection, accounting
for more than 40% of the total number reported by acute-care hospitals and
affecting an estimated 600,000 patients per year (1).
Most of these infections--66% to 86%--follow instrumentation of the urinary
tract, mainly urinary catheterization (2). Although not all
catheter-associated urinary tract infections can be prevented, it is believed
that a large number could be avoided by the proper management of the indwelling
catheter. The following recommendations were developed for the care of patients
with temporary indwelling urethral catheters. Patients who require chronic
indwelling catheters or individuals who can be managed with intermittent
catheterization may have different needs. Determination of the optimal catheter
care for these and other patients with different drainage systems requires
separate evaluation.
EPIDEMIOLOGY
The risk of acquiring a urinary tract infection depends on the method and
duration of catheterization, the quality of catheter care, and host
susceptibility. Reported infection rates vary widely, ranging from 1%-5% after a
single brief catheterization (3) to virtually 100% for patients with
indwelling urethral catheters draining into an open system for longer than 4
days (4). Adoption of the closed method of urinary drainage has markedly
reduced the risk of acquiring a catheter-associated infection, but the risk is
still substantial. As recent studies have shown, over 20% of patients
catheterized and maintained on closed drainage on busy hospital wards may be
expected to become infected (5, 6). In these studies, errors in
maintaining sterile closed drainage were common and predisposed patients to
infection. Host factors which appear to increase the risk of acquiring
catheter-associated urinary tract infections include advanced age, debilitation,
and the postpartum state (7,8).
Catheter-associated urinary tract infections are generally assumed to be
benign. Such infection in otherwise healthy patients is often asymptomatic and
is likely to resolve spontaneously with the removal of the catheter.
Occasionally, infection persists and leads to such complications as prostatitis,
epididymitis, cystitis, pyelonephritis, and gram-negative bacteremia,
particularly in high-risk patients (8). The last complication is serious
since it is associated with a significant mortality, but fortunately occurs in
fewer than 1% of catheterized patients (9,10). The natural history of
catheter-associated urinary tract infections has been largely unstudied.
Catheter-associated urinary tract infections are caused by a variety of
pathogens, including Escherichia coli, Klebsiella, Proteus, enterococcus,
Pseudomonas, Enterobacter, Serratia, and Candida. Many of these
microorganisms are part of the patient's endogenous bowel flora, but they can
also be acquired by cross-contamination from other patients or hospital
personnel or by exposure to contaminated solutions or non-sterile equipment
(11,12). Urinary tract pathogens such as Serratia marcescens and
Pseudomonas cepacia have special epidemiologic significance. Since these
microorganisms do not commonly reside in the gastrointestinal tract, their
isolation from catheterized patients suggests acquisition from an exogenous
source (13,14).
Whether from endogenous or exogenous sources, infecting microorganisms gain
access to the urinary tract by several routes. Microorganisms that inhabit the
meatus or distal urethra can be introduced directly into the bladder when the
catheter is inserted. Generally, however, low rates of infection have been
reported after single brief catheterization (4), suggesting that
microorganisms introduced by this method are usually removed from healthy
individuals by voiding or by antibacterial mechanisms of the bladder mucosa
(15). With indwelling catheters, infecting microorganisms can migrate to
the bladder along the outside of the catheter in the periurethral mucous sheath
(16,17) or along the internal lumen of the catheter after the collection
bag or catheter-drainage tube junction has been contaminated (5, 6). The
importance of intraluminal ascension is suggested by the substantial reduction
in infections that has been achieved through the use of the closed urinary
drainage system. However, if sterile closed drainage can be maintained,
extraluminal migration of microorganisms in the periurethral space becomes a
relatively more important pathway of entry into the bladder (17).
CONTROL MEASURES
An estimated 4 million patients are subjected yearly to urinary
catheterization and, therefore, are at risk for catheter-associated infection
and its related sequelae. One of the most important infection control measures
is to limit the use of urinary catheters to carefully selected patients, thereby
reducing the size of the population at risk. Generally, urinary catheterization
is indicated 1) to relieve urinary tract obstruction, 2) to permit urinary
drainage in patients with neurogenic bladder dysfunction and urinary retention,
3) to aid in urologic surgery or other surgery on contiguous structures, and 4)
to obtain accurate measurements of urinary output in critically ill patients.
Specifically, urinary catheterization should be discouraged as a means of
obtaining urine for culture or certain diagnostic tests such as urinary
electrolytes when the patient can voluntarily void or as a substitute for
nursing care in the incontinent patient.
In selected populations, other methods of urinary drainage exist as possible
alternatives to the use of the indwelling urethral catheter. Condom catheter
drainage may be useful for incontinent male patients without outlet obstruction
and with an intact voiding reflex. Its use, however, requires meticulous nursing
care if local complications such as skin maceration or phimosis are to be
avoided. In addition, frequent manipulation of the condom catheter drainage
system (e.g., by agitated patients) has been associated with an increased risk
of urinary tract infection (18). Another alternative, suprapubic catheter
drainage, is most frequently used in patients on urologic or gynecologic
services. Although preliminary data on the risk of infection are encouraging
(19,20), the benefit of the suprapubic catheter with regard to infection
control has not been proven by controlled clinical studies. For certain types of
patients with bladder-emptying dysfunction, such as those with spinal cord
injuries or children with meningomyelocele, a third alternative, intermittent
catheterization, is commonly employed. The "no-touch" method of intermittent
catheterization advocated by Guttmann (21) is generally reserved for
patients hospitalized during the acute phase of their spinal cord injury, while
the clean, nonsterile method of Lapides (22) is frequently used by
ambulatory patients for whom the practice of aseptic catheter insertion is
difficult to maintain. As with suprapubic catheterization, however,
well-designed clinical trials comparing the efficacy of intermittent
catheterization by either method to indwelling catheterization in minimizing the
risk of infection are lacking.
For patients who require indwelling urethral catheterization, adherence to
the sterile continuously closed system of urinary drainage is the cornerstone of
infection control. For short-term catheterization, this measure alone can reduce
the rate of infection from an inevitable 100% when open drainage is employed to
less than 25% (5). All other interventions can be viewed as adjunctive
measures since none have proven to be as effective in reducing the frequency of
catheter-associated urinary tract infections.
Efforts have been made to improve the design of the closed urinary drainage
system by modifying or adding to the basic unit introduced and widely adopted in
the 1960s. Two modifications, the addition of a urine sampling port in the
drainage tubing and the preconnected catheter/collecting tube system seem to
have been logical advances since they discourage or prevent opening the closed
system which has been well-documented to predispose patients to infection
(6). Other alterations have included the insertion of air vents, drip
chambers, and one-way valves that were designed to prevent the reflux of
contaminated urine. Although these modifications have some theoretical basis,
none have been shown to be effective in reducing the frequency of
catheter-associated infections. Additionally, overly complex drainage systems
can affect the ease of operation or more easily malfunction (5). These
latter factors can influence the acceptance of different systems by hospital
personnel and ultimately affect infection control.
Other efforts to reduce the incidence of catheter-associated infections have
been directed toward 1) preventing microorganisms at the meatus from entering
the bladder and 2) eradicating microorganisms that gain entry into the urinary
tract before they can proliferate (23). Measures directed toward the
first objective include aseptic catheter insertion, daily meatal cleansing, and
daily application of antimicrobial ointments or solutions. On the basis of
recent studies that have shown that catheterized patients colonized at the
meatus with gram-negative bacilli or enterococci are at increased risk for
subsequent infection (17,24), these measures have some theoretical value
and can be expected to delay or prevent the onset of infection. Generally,
clinical trials that have attempted to demonstrate their efficacy have not been
well designed or did not include the use of the closed system of urinary
drainage. However, 2 recent prospective, controlled studies conducted by the
same research group have shown that meatal care as it is currently commonly
practiced (either twice-a-day cleansing with povidone-iodine solution followed
by povidone-iodine ointment or daily cleansing with soap and water) was
ineffective in reducing the frequency of catheter-associated infections in
patients on closed urinary drainage (25, 26). The value of different
regimens (e.g., more frequent application, other concentrations, or other
antimicrobial agents) is not known and requires further evaluation.
Infection control measures for purposes of eradicating microorganisms in the
urinary tract before they can proliferate and cause infection include irrigation
of the bladder and the use of prophylactic systemic antibiotics. In one
controlled study, continuous irrigation of the bladder with nonabsorbable
antibiotics was associated with frequent interruption of the closed drainage
system and did not bring about a reduction in the frequency of
catheter-associated infections (27). It is not known, however, whether
such irrigation would be effective if the integrity of the closed drainage
system could be maintained. Several recent studies have shown that prophylactic
systemic antibiotics delay the emergence of catheter-related infection
(6,28), but this protective effect was transient and was associated with
the selection of antibiotic-resistant microorganisms. Thus, controversy
regarding the value of prophylactic systemic antibiotics remains.
When cross-infection is likely to be responsible for the spread of
catheter-associated infections, additional measures have been proposed
(29). In several outbreaks of nosocomial urinary tract infections,
catheterized patients with asymptomatic infections served as unrecognized
reservoirs of infecting organisms, and the mechanism of transmission appeared to
be carriage on the hands of patient-care personnel (13,14). In these
outbreaks, the implementation of control measures to prevent cross-infection,
including renewed emphasis on handwashing and spatial separation of catheterized
patients, particularly infected from uninfected ones, effectively ended the
outbreak. In the absence of epidemic spread or frequent cross-infection, spatial
separation of catheterized patients is probably less effective in controlling
catheter-associated infections.
Regular bacteriologic monitoring of catheterized patients has been advocated
to ensure early diagnosis and treatment of urinary tract infections (8).
Its possible value as an infection measure lies in its potential usefulness in
detecting and initiating treatment of clinically inapparent infections, which
may serve as reservoirs of hospital pathogens, and thus, reducing the likelihood
of cross-infection. However, the potential benefit of bacteriologic monitoring
for such a purpose has not been adequately investigated.
RECOMMENDATIONS
1. Personnel
a. Only persons (e.g., hospital personnel, family members, or patients
themselves) who know the correct technique of aseptic insertion and
maintenance of the catheter should handle catheters (5, 6, 8).
Category I
b. Hospital personnel and others who take care of catheters should be given
periodic in-service training stressing the correct techniques and potential
complications of urinary catheterization. Category II
2. Catheter Use
a. Urinary catheters should be inserted only when necessary and left in
place only for as long as necessary. They should not be used solely for the
convenience of patient-care personnel. Category I
b. For selected patients, other methods of urinary drainage such as condom
catheter drainage, suprapubic catheterization, and intermittent urethral
catheterization can be useful alternatives to indwelling urethral
catheterization (8,19, 21, 22). Category III
3. Handwashing
Handwashing should be done immediately before and after any manipulation of
the catheter site or apparatus (14,30). Category I
4. Catheter Insertion
a. Catheters should be inserted using aseptic technique and sterile
equipment (8,16,31). Category I
b. Gloves, drape, sponges, an appropriate antiseptic solution for
periurethral cleaning, and a single-use packet of lubricant jelly should be
used for insertion. Category II
c. As small a catheter as possible, consistent with good drainage, should
be used to minimize urethral trauma (8). Category II
d. Indwelling catheters should be properly secured after insertion to
prevent movement and urethral traction (31). Category I
5. Closed Sterile Drainage
a. A sterile, continuously closed drainage system should be maintained
(5,6,27). Category I
b. The catheter and drainage tube should not be disconnected unless the
catheter must be irrigated (see Irrigation Recommendation 6). Category
I
c. If breaks in aseptic technique, disconnection, or leakage occur, the
collecting system should be replaced using aseptic technique after
disinfecting the catheter-tubing junction. Category III
6. Irrigation
a. Irrigation should be avoided unless obstruction is anticipated (e.g., as
might occur with bleeding after prostatic or bladder surgery); closed
continuous irrigation may be used to prevent obstruction. To relieve
obstruction due to clots, mucus, or other causes, an intermittent method of
irrigation may be used. Continuous irrigation of the bladder with
antimicrobials has not proven to be useful (28) and should not be
performed as a routine infection prevention measure. Category II
b. The catheter-tubing junction should be disinfected before disconnection.
Category II
c. A large-volume sterile syringe and sterile irrigant should be used and
then discarded. The person performing irrigation should use aseptic technique.
Category I
d. If the catheter becomes obstructed and can be kept open only by frequent
irrigation, the catheter should be changed if it is likely that the catheter
itself is contributing to the obstruction (e.g., formation of concretions).
Category II
7. Specimen Collection
a. If small volumes of fresh urine are needed for examination, the distal
end of the catheter, or preferably the sampling port if present, should be
cleansed with a disinfectant, and urine then aspirated with a sterile needle
and syringe (5,8). Category I
b. Larger volumes of urine for special analyses should be obtained
aseptically from the drainage bag. Category I
8. Urinary Flow
a. Unobstructed flow should be maintained (6,8). Category I
(Occasionally, it is necessary to temporarily obstruct the catheter for
specimen collection or other medical purposes.)
b. To achieve free flow of urine 1) the catheter and collecting tube should
be kept from kinking; 2) the collecting bag should be emptied regularly using
a separate collecting container for each patient (the draining spigot and
nonsterile collecting container should never come in contact ) (33); 3
) poorly functioning or obstructed catheters should be irrigated (see
Irrigation Recommendation 6) or if necessary, replaced; and 4) collecting bags
should always be kept below the level of the bladder. Category I
9. Meatal Care
Twice daily cleansing with povidone-iodine solution and daily cleansing
with soap and water have been shown in 2 recent studies not to reduce
catheter-associated urinary tract infection (25,26). Thus, at this
time, daily meatal care with either of these 2 regimens cannot be endorsed.
Category II
10. Catheter Change Interval
Indwelling catheters should not be changed at arbitrary fixed intervals
(34). Category II
11. Spatial Separation of Catheterized Patients
To minimize the chances of cross-infection, infected and uninfected
patients with indwelling catheters should not share the same room or adjacent
beds (29). Category III
12. Bacteriologic Monitoring
The value of regular bacteriologic monitoring of catheterized patients as
an infection control measure has not been established and is not recommended
(35). Category III
Summary of Major Recommendations
Category I. Strongly Recommended for Adoption*
- Educate personnel in correct techniques of catheter insertion and
care.
- Catheterize only when necessary.
- Emphasize handwashing.
- Insert catheter using aseptic technique and sterile equipment.
- Secure catheter properly.
- Maintain closed sterile drainage.
- Obtain urine samples aseptically.
- Maintain unobstructed urine flow.
Category II. Moderately Recommended for Adoption
- Periodically re-educate personnel in catheter care.
- Use smallest suitable bore catheter.
- Avoid irrigation unless needed to prevent or relieve obstruction.
- Refrain from daily meatal care with either of the regimens discussed
in text.
- Do not change catheters at arbitrary fixed intervals.
Category III. Weakly Recommended for Adoption
- Consider alternative techniques of urinary drainage before using an
indwelling urethral catheter.
- Replace the collecting system when sterile closed drainage has been
violated.
- Spatially separate infected and uninfected patients with indwelling
catheters.
- Avoid routine bacteriologic monitoring.
*Refer to
Introduction of manual for full explanation of the ranking scheme for
recommendations. |
REFERENCES
1. Center for Disease Control. National Nosocomial
Infections Study Report, Atlanta: Center for Disease Control, November 1979:
2-14.
2. Martin CM, Bookrajian EN. Bacteriuria prevention after indwelling
urinary catheterization. Arch Intern Med 1962;110:703-11.
3. Turck M, Goffe
B, Petersdorf RG. The urethral catheters and urinary tract infection. J Urol
1962;88:834-7.
4. Kass EH. Asymptomatic infections of the urinary tract.
Trans Assoc Am Physicians 1956;69:56-63.
5. Kunin CM, McCormack RC.
Prevention of catheter-induced urinary tract infections by sterile closed
drainage. N Engl J Med 1966;274:1155-62.
6. Garibaldi RA, Burke JP, Dickman
ML, Smith CB. Factors predisposing to bacteriuria during indwelling urethral
catheterization. N Engl J Med 1974;291:215-8.
7. Brumfitt W, Davies BL,
Rosser E. The urethral catheter as a cause of urinary tract infection in
pregnancy and puerperium. Lancet 1961;2:1059-61.
8. Kunin CM. Detection,
prevention, and management of urinary tract infections. 3rd ed. Philadelphia:
Lea and Febiger, 1979.
9. Steere AC, Stamm WE, Martin SM, Bennett JV.
Gram-negative rod bacteremia. In: Bennett JV, Brachman PS, eds. Hospital
infections. Boston: Little, Brown and Company. 1979:507-18.
10. Kreger BE,
Craven DE. McCabe WR. Gram-negative bacteremia IV. Re-evaluation of clinical
features and treatment in 612 patients. Am J Med 1980,68:344-55.
11. Selden
R, Lee S, Wang WLL, et al. Nosocomial Klebsiella infections: intestinal
colonization as a reservoir. Ann Intern Med 1971;74:657-64.
12. McLeod JW.
The hospital urine bottle and bedpan as reservoirs of infection by
Pseudomonas. Lancet 1958;1:394-5.
13. Maki DG, Hennekens CH, Bennett
JV, et al. Nosocomial urinary tract infection with Serratia marcesens: an
epidemiologic study. 1973; J Infect Dis 128:579-87.
14. Kaslow RA, Lindsey
JO, Bisno AL, Price A. Nosocomial infection with highly resistant Proteus
rettgeri. Report of an epidemic. Am J Epidemiol 1976; 104:278-86.
15.
Norden CW, Green GM, Kass EH. Antibacterial mechanisms of the urinary bladder. J
Clin Invest 1968;47:2689-700.
16. Kass EH, Schneiderman LJ. Entry of
bacteria into the urinary tract of patients with inlying catheters. N Engl J Med
1957;256:556-7.
17. Garibaldi RA, Burke JP, Britt MR, Miller WA, Smith CB.
Meatal colonization and catheter-associated bacteriuria. N Engl J Med
1980;303:316-8.
18. Hirsh DD, Fainstein V, Musher DM. Do condom catheter
collecting systems cause urinary tract infection? JAMA 1979;242:340-1.
19.
Hodgkinson CP, Hodari AA. Trocar suprapubic cystostomy for postoperative bladder
drainage in the female. J Obstet Gynecol 1966;96:773-83.
20. Marcus RT.
Narrow-bore suprapubic bladder drainage in Uganda. Lancet 1967;1:748-50.
21.
Guttman L, Frankel H. The value of intermittent catheterization in the early
management of traumatic paraplegia and tetraplegia. Paraplegia 1966;4:63-83.
22. Lapides J, Diokno AC, Gould FR, Lowe. BS. Further observations on
self-catheterization. J Urol 1976; 116:169-71.
23. Sanford JP.
Hospital-acquired urinary tract infections. Ann Intern Med 1964;60:903-14.
24. Garibaldi RA, Britt MR, Miller WA, Steinmuller P, Burke JP. Evaluation
of periurethral colonization as a risk factor for catheter-associated
bacteriuria. In: Proceedings of the 16th Interscience Conference on
Antimicrobial Agents and Chemotherapy, 1976;142.
25. Britt MR, Burke JP,
Miller WA, Steinmiller P, Garibaldi RA. The non-effectiveness of daily meatal
care in the prevention of catheter-associated bacteriuria. In: Proceedings of
the 16th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1976;
141.
26. Burke JP, Garibaldi RA, Britt MR, Jacobson JA, Conti M, Alling DW.
Prevention of catheter-associated urinary tract infections. Efficacy of daily
meatal care regimens. In: Proceedings of the 2nd International Conference on
Nosocomial Infections. Atlanta, August 4-8, 1980. Am J Med 1981;70:655-8.
27. Warren JW, Platt R, Thomas KJ, Rosner B, Kass EH. Antibiotic irrigation
and catheter-associated urinary tract infections. N Engl J Med 1978;299:570-73.
28. Britt MR, Garibaldi RA, Miller WA, Hebertson RM, Burke JP. Antimicrobial
prophylaxis for catheter-associated bacteriuria . Antimicrob Agents Chemother
1977;11:240- 3.
29. Maki DG, Hennekens CH, Bennett JV. Prevention of
catheter-associated urinary tract infection: an additional measure. JAMA
1972;221:1270-1.
30. Steere AC, Mallison GF. Handwashing practices for the
prevention of nosocomial infections. Ann Intern Med 1975; 83:683-90.
31.
Desautels RF, Walter CW, Graves RC. et al. Technical advances in the prevention
of urinary tract infection. J Urol 1962;87:487-90.
32. Viant AC, Linton KB,
Gillespie WA. Improved method for preventing movement of indwelling catheters in
female patients. Lancet 1971;1:736-7.
33. Marrie TJ, Major H, Gurwith M, et
al. Prolonged outbreak of nosocomial urinary tract infection with a single
strain of Pseudomonas aeruginosa. Can Med J 1978;119:593-6.
34. Stamm
WE. Guidelines for the prevention of catheter-associated urinary tract
infections. Ann Intern Med 1975;82:386-90.
35. Mooney BS, Garibaldi RA,
Britt MR. Natural history of catheter-associated bacteriuria (colonization,
infection, bacteremia): implication for protection. In: Proceedings of the 11th
International Congress of Chemotherapy and the 19th Interscience Conference on
Antimicrobial Agents and Chemotherapy. Boston. October 8-12, 1979. Washington,
D.C.; American Society of Microbiology 1980:1083-5.
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