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Guideline Summary
Guideline Title
Guideline for prevention of catheter-associated urinary tract infections 2009.
Bibliographic Source(s)
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2009. 67 p. [281 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Catheter-associated urinary tract infections (CAUTI)

Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Screening
Clinical Specialty
Critical Care
Family Practice
Geriatrics
Infectious Diseases
Internal Medicine
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Preventive Medicine
Surgery
Urology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Other
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To update and expand the original Centers for Disease Control and Prevention (CDC) guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI) published in 1981
  • To review the available evidence on CAUTI prevention for patients requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (e.g., intermittent catheterization)
  • To provide specific recommendations for implementation, performance measurement, and surveillance
  • To develop a guideline based on targeted systematic review of the best available evidence, with explicit links between the evidence and recommendations
  • To evaluate who should receive urinary catheters
  • To evaluate what the best practices are for those who may require urinary catheters
  • To evaluate what the best practices are for preventing CAUTI associated with obstructed urinary catheters
Target Population
  • Patients requiring chronic indwelling catheters
  • Individuals who can be managed with alternative methods of urinary drainage
Interventions and Practices Considered
  1. Indications for insertion of urinary catheters
  2. Use of alternatives to indwelling urethral catheterization when appropriate
  3. Proper catheter insertion technique
  4. Proper catheter maintenance techniques (choice of catheter materials, management of obstruction, urine specimen collection)
  5. Quality improvement programs
  6. Best practices for prevention of catheter-associated urinary tract infections (CAUTI)
  7. Implementation of guidelines
  8. Surveillance of CAUTI
Major Outcomes Considered
  • Rate of catheter-associated urinary tract infections (CAUTI)
  • Rate of bloodstream infections secondary to CAUTI
  • Morbidity and mortality associated with CAUTI
  • Hospital costs and length of stay
  • Side effects of antimicrobial use
  • Patient satisfaction

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Development of Key Questions

The authors first conducted an electronic search of the National Guideline Clearinghouse® (Agency for Healthcare Research and Quality), Medline® (National Library of Medicine) using the Ovid® Platform (Ovid Technologies, Wolters Kluwer, New York, NY), the Cochrane® Health Technology Assessment Database (Cochrane Collaboration, Oxford, UK), the National Institutes of Health (NIH) Consensus Development Program, and the United States Preventive Services Task Force database for existing national and international guidelines relevant to catheter-associated urinary tract infections (CAUTI). The strategy used for the guideline search and the search results can be found in Appendix 1A in the original guideline document. A preliminary list of key questions was developed from a review of the relevant guidelines identified in the search. Key questions were finalized after vetting them with a panel of content experts and Healthcare Infection Control Practices Advisory Committee (HICPAC) members.

Literature Search

Following the development of the key questions, search terms were developed for identifying literature relevant to the key questions. For the purposes of quality assurance, the authors compared these terms to those used in relevant seminal studies and guidelines. These search terms were then incorporated into search strategies for the relevant electronic databases. Searches were performed in Medline® (National Library of Medicine) using the Ovid® Platform (Ovid Technologies, Wolters Kluwer, New York, NY), EMBASE® (Elsevier BV, Amsterdam, Netherlands), CINAHL® (Ebsco Publishing, Ipswich, MA) and Cochrane® (Cochrane Collaboration, Oxford, UK) (all databases were searched in July 2007), and the resulting references were imported into a reference manager, where duplicates were resolved. For Cochrane reviews ultimately included in the guideline, they checked for updates in July 2008. The detailed search strategy used for identifying primary literature and the results of the search can be found in Appendix 1B in the original guideline document.

Study Selection

Titles and abstracts from references were screened by a single author and the full text articles were retrieved if they were 1) relevant to one or more key questions, 2) primary analytic research, systematic reviews or meta-analyses, and 3) written in English. Likewise, the full-text articles were screened by a single author (using the same criteria, and included studies underwent a second review for inclusion by another author. Disagreements were resolved by the remaining authors. The results of this process are depicted in Figure 2 in the original guideline document.

Number of Source Documents

249 studies were included for data extraction.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

GRADE definitions are as follows:

  1. High - further research is very unlikely to change confidence in the estimate of effect
  2. Moderate - further research is likely to affect confidence in the estimate of effect and may change the estimate
  3. Low - further research is very likely to affect confidence in the estimate of effect and is likely to change the estimate
  4. Very low - any estimate of effect is very uncertain

After determining the GRADE of the evidence base for each outcome of a given intervention or question, the authors calculated the overall GRADE of the evidence base for that intervention or question. The overall GRADE was based on the lowest GRADE for the outcomes deemed critical to making a recommendation.

Rating the Quality of Evidence Using the GRADE Approach

Type of Evidence Initial Grade Criteria to Decrease Grade Criteria to Increase Grade Overall Quality Grade
RCT High Quality
Serious (-1 grade) or very serious (-2 grades) limitation to study quality
Strong association
Strong (+1 grade) or very strong evidence of association (+2 grades)
High

Moderate

Low

Very Low
Observational study Low Consistency
Important inconsistency (-1 grade)
Dose-response
Evidence of a dose-response gradient (+1 grade)
Any other evidence (e.g., expert opinion) Very low Directness
Some (-1 grade) or major (-2 grades) uncertainty about directness

Precision
Imprecise or sparse data (-1 grade)

Publication bias
High risk of bias (-1 grade)
Unmeasured Confounders
Inclusion of unmeasured confounders increases the magnitude of effect (+1 grade)
Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Data Extraction and Synthesis

Data on the study author, year, design, objective, population, setting, sample size, power, follow-up, and definitions and results of clinically relevant outcomes were extracted into evidence tables. Three evidence tables were developed, each of which represented one of the key questions. Studies were extracted into the most relevant evidence table. Then, studies were organized by the common themes that emerged within each evidence table. Data were extracted by one author and cross-checked by another. Disagreements were resolved by the remaining authors. Data and analyses were extracted as originally presented in the included studies. Meta-analyses were performed only where their use was deemed critical to a recommendation, and only in circumstances where multiple studies with sufficiently homogenous populations, interventions, and outcomes could be analyzed. Systematic reviews were included in the review. To avoid duplication of data, the authors excluded primary studies if they were also included in a systematic review captured by the search. The only exception to this was if the primary study also addressed a relevant question that was outside the scope of the included systematic review. Before exclusion, data from the primary studies that was originally captured was abstracted into the evidence tables and reviewed. The authors also excluded systematic reviews that analyzed primary studies that were fully captured in a more recent systematic review. The only exception to this was if the older systematic review also addressed a relevant question that was outside the scope of the newer systematic review. To ensure that all relevant studies were captured in the search, the bibliography was vetted by a panel of clinical experts.

Grading of Evidence

First, the quality of each study was assessed using scales adapted from existing methodology checklists, and scores were recorded in the evidence tables. Appendix 3 in the original guideline document includes the sets of questions used to assess the quality of each of the major study designs. Next, the quality of the evidence base was assessed using methods adapted from the GRADE Working Group. Briefly, GRADE tables were developed for each of the interventions or questions addressed within the evidence tables. Included in the GRADE tables were the intervention of interest, any outcomes listed in the evidence tables that were judged to be clinically important, the quantity and type of evidence for each outcome, the relevant findings, and the GRADE of evidence for each outcome, as well as an overall GRADE of the evidence base for the given intervention or question. The initial GRADE of evidence for each outcome was deemed high if the evidence base included a randomized controlled trial (RCT) or a systematic review of RCTs, low if the evidence base included only observational studies, or very low if the evidence base consisted only of uncontrolled studies. The initial GRADE could then be modified by eight criteria. Criteria which could decrease the GRADE of an evidence base included quality, consistency, directness, precision, and publication bias. Criteria that could increase the GRADE included a large magnitude of effect, a dose-response gradient, or inclusion of unmeasured confounders that would increase the magnitude of effect (see table in the "Rating Scheme for the Strength of the Evidence" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Narrative evidence summaries were drafted by the working group using the evidence and GRADE tables. One summary was written for each theme that emerged under each key question. The working group then used the narrative evidence summaries to develop guideline recommendations. Factors determining the strength of a recommendation included 1) the values and preferences used to determine which outcomes were "critical," 2) the harms and benefits that result from weighing the "critical" outcomes, and 3) the overall GRADE of the evidence base for the given intervention or question (see table below). If weighing the "critical outcomes" for a given intervention or question resulted in a "net benefit" or a "net harm," then a "Category I Recommendation" was formulated to strongly recommend for or against the given intervention respectively. If weighing the "critical outcomes" for a given intervention or question resulted in a "trade off" between benefits and harms, then a "Category II Recommendation" was formulated to recommend that providers or institutions consider the intervention when deemed appropriate. If weighing the "critical outcomes" for a given intervention or question resulted in an "uncertain trade off" between benefits and harms, then a "No Recommendation" was formulated to reflect this uncertainty.

Table. Formulating Recommendations
HICPAC Recommendation Weighing Benefits and Harms for Critical Outcomes Quality of Evidence
STRONG (I) Interventions with net benefits or net harms IA – High to Moderate

IB – Low or Very Low (Accepted Practice)

IC – High to Very Low (Regulatory)
WEAK (II) Interventions with trade offs between benefits and harms High to Very Low
No recommendation/
unresolved issue
Uncertain trade offs between benefits and harms Low to Very Low

For Category I recommendations, levels A and B represent the quality of the evidence underlying the recommendation, with A representing high to moderate quality evidence and B representing low quality evidence or, in the case of an established standard (e.g., aseptic technique, education and training), very low quality to no evidence based on the literature review. For IB recommendations, although there may be low to very low quality or even no available evidence directly supporting the benefits of the intervention, the theoretical benefits are clear, and the theoretical risks are marginal. Level C represents practices required by state or federal regulation, regardless of the quality of evidence. It is important to note that the strength of a Category IA recommendation is equivalent to that of a Category IB or IC recommendation; it is only the quality of the evidence underlying the IA recommendation that makes it different from a IB.

In some instances, multiple recommendations emerged from a single narrative evidence summary. The new Healthcare Infection Control Practices Advisory Committee (HICPAC) categorization scheme for recommendations is provided in the "Rating Scheme for the Strength of the Recommendations" field below.

Category I recommendations are defined as strong recommendations with the following implications:

  1. For patients: Most people in the patient’s situation would want the recommended course of action and only a small proportion would not; request discussion if the intervention is not offered.
  2. For clinicians: Most patients should receive the recommended course of action.
  3. For policymakers: The recommendation may be adopted as a policy.

Category II recommendations are defined as weak recommendations with the following implications:

  1. For patients: Most people in the patient’s situation would want the recommended course of action, but many would not.
  2. For clinicians: Different choices will be appropriate for different patients, and clinicians must help each patient to arrive at a management decision consistent with her or his values and preferences.
  3. For policymakers: Policy making will require substantial debate and involvement of many stakeholders.

It should be noted that Category II recommendations are discretionary for the individual institution and are not intended to be enforced.

The wording of each recommendation was carefully selected to reflect the recommendation's strength. In most cases, the guideline authors used the active voice when writing Category I recommendations - the strong recommendations. Phrases like "do" or "do not" and verbs without auxiliaries or conditionals were used to convey certainty. They used a more passive voice when writing Category II recommendations - the weak recommendations. Words like "consider" and phrases like "is preferable," "is suggested," "is not suggested," or "is not recommended" were chosen to reflect the lesser certainty of the Category II recommendations. Rather than a simple statement of fact, each recommendation is actionable, describing precisely a proposed action to take.

The category "No recommendation/unresolved issue" was most commonly applied to situations where either 1) the overall quality of the evidence base for a given intervention was low to very low and there was no consensus on the benefit of the intervention or 2) there was no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention. If the latter was the case, those critical outcomes will be noted at the end of the relevant evidence summary.

The evidence-based recommendations were cross-checked with those from guidelines identified in the original systematic search. Recommendations from previous guidelines for topics not directly addressed by the systematic review of the evidence were included in the "Summary of Recommendations" if they were deemed critical to the target users of this guideline. Unlike recommendations informed by the literature search, these recommendations are not linked to a key question. These recommendations were agreed upon by expert consensus and are designated either IB if they represent a strong recommendation based on accepted practices (e.g., aseptic technique) or II if they are a suggestion based on a probable net benefit despite limited evidence.

All recommendations were approved by HICPAC. Recommendations focused only on efficacy, effectiveness, and safety. The optimal use of these guidelines should include a consideration of the costs relevant to the local setting of guideline users.

Rating Scheme for the Strength of the Recommendations

Categorization Scheme for Recommendations

Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation/unresolved issue Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

After a draft of the tables, narrative summaries, and recommendations was completed, the working group shared the draft with the expert panel for in-depth review. While the expert panel was reviewing this draft, the working group completed the remaining sections of the guideline, including the executive summary, background, scope and purpose, methods, summary of recommendations, and recommendations for guideline implementation, audit, and further research. The working group then made revisions to the draft based on feedback from members of the expert panel and presented the entire draft guideline to Healthcare Infection Control Practices Advisory Committee (HICPAC) for review. The guideline was then posted on the Federal Register for public comment. After a period of public comment, the guideline was revised accordingly, and the changes were reviewed and voted on by HICPAC. The final guideline was cleared internally by Centers for Disease Control and Prevention (CDC) and published and posted on the HICPAC website.

Recommendations

Major Recommendations

The categorization scheme for the recommendations (IA, IB, IC, II, no recommendation/unresolved issue) is defined at the end of the "Major Recommendations" field.

  1. Appropriate Urinary Catheter Use
    1. Insert catheters only for appropriate indications (see table below for guidance), and leave in place only as long as needed. (Category IB)
      1. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for catheter-associated urinary tract infection (CAUTI) or mortality from catheterization such as women, the elderly, and patients with impaired immunity. (Category IB)
      2. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. (Category IB)
        1. Further research is needed on periodic (e.g., nighttime) use of external catheters (e.g., condom catheters) in incontinent patients or residents and the use of catheters to prevent skin breakdown. (No recommendation/unresolved issue)
      1. Use urinary catheters in operative patients only as necessary, rather than routinely. (Category IB)
      2. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB)
    A. Examples of Appropriate Indications for Indwelling Urethral Catheter Use
    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:
    • Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract
    • Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in post anesthesia care unit [PACU])
    • Patients anticipated to receive large-volume infusions or diuretics during surgery
    • 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.)

    Note: These indications are based primarily on expert consensus.

    1. Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate.
      1. Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Category II)
      2. Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Category II)
      3. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II)
      4. Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration. (Category II)
      5. Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction. (No recommendation/unresolved issue)
      6. Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization, particularly with respect to complications related to catheter insertion or the catheter site. (No recommendation/unresolved issue)
  1. Proper Techniques for Urinary Catheter Insertion
    1. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. (Category IB)
    2. Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB)
    3. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. (Category IB)
      1. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. (Category IB)
      2. Routine use of antiseptic lubricants is not necessary. (Category II)
      3. Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue)
    1. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. (Category IA)
      1. Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization. (No recommendation/unresolved issue)
    1. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Category IB)
    2. Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. (Category II)
    3. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. (Category IB)
    4. Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II)
      1. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. (Category IB)
  1. Proper Techniques for Urinary Catheter Maintenance
    1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system (Category IB)
      1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. (Category IB)
      2. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. (Category II)
    1. Maintain unobstructed urine flow. (Category IB)
      1. Keep the catheter and collecting tube free from kinking. (Category IB)
      2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Category IB)
      3. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. (Category IB)
    1. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. (Category IB)
    2. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use. (Category II)
    3. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II)
    4. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization. (Category IB)
      1. Further research is needed on the use of urinary antiseptics (e.g., methenamine) to prevent urinary tract infection (UTI) in patients requiring short-term catheterization. (No recommendation/unresolved issue)
    1. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. (Category IB)
    2. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. (Category II)
      1. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. (Category II)
    1. Routine irrigation of the bladder with antimicrobials is not recommended. (Category II)
    2. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Category II)
    3. Clamping indwelling catheters prior to removal is not necessary. (Category II)
    4. Further research is needed on the use of bacterial interference (i.e., bladder inoculation with a nonpathogenic bacterial strain) to prevent urinary tract infection in patients requiring chronic urinary catheterization. (No recommendation/unresolved issue)

    Catheter Materials

    1. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (see "Section III. Implementation and Audit" in the original guideline document). (Category IB)
      1. Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic urinary tract infection, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters. (No recommendation/unresolved issue)
    1. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization. (Category II)
    2. Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (Category II)
    3. Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications. (No recommendation/unresolved issue)

    Management of Obstruction

    1. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. (Category IB)
    2. Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. (No recommendation/unresolved issue)
    3. Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output. (No recommendation/unresolved issue)
    4. Further research is needed on the use of methenamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. (No recommendation/unresolved issue)

    Specimen Collection

    1. Obtain urine samples aseptically. (Category IB)
      1. If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Category IB)
      2. Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Category IB)

    Spatial Separation of Catheterized Patients

    1. Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems. (No recommendation/unresolved issue)
  1. Quality Improvement Programs
    1. Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment. (Category IB)

      The purposes of QI programs should be: 1) to assure appropriate utilization of catheters; 2) to identify and remove catheters that are no longer needed (e.g., daily review of their continued need); and 3) to ensure adherence to hand hygiene and proper care of catheters. Examples of programs that have been demonstrated to be effective include:

      1. A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization
      2. Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters
      3. Education and performance feedback regarding appropriate use, hand hygiene, and catheter care
      4. Guidelines and algorithms for appropriate peri-operative catheter management, such as:
        1. Procedure-specific guidelines for catheter placement and postoperative catheter removal
        2. Protocols for management of postoperative urinary retention, such as nurse-directed use of intermittent catheterization and use of bladder ultrasound scanners.
  1. Administrative Infrastructure
    1. Provision of guidelines
      1. Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance. (Category IB)
        1. Consider monitoring adherence to facility-based criteria for acceptable indications for indwelling urinary catheter use. (Category II)
    1. Education and Training
      1. Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters. (Category IB)
      2. When feasible, consider providing performance feedback to these personnel on what proportion of catheters they have placed meet facility-based criteria and other aspects related to catheter care and maintenance. (Category II)
    1. Supplies
      1. Ensure that supplies necessary for aseptic technique for catheter insertion are readily available. (Category IB)
    1. System of documentation
      1. Consider implementing a system for documenting the following in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal. (Category II)
        1. Ensuring that documentation is accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes is suggested. Electronic documentation that is searchable is preferable. (Category II)
    1. Surveillance resources
      1. If surveillance for CAUTI is performed, ensure that there are sufficient trained personnel and technology resources to support surveillance for urinary catheter use and outcomes. (Category IB)
  1. Surveillance
    1. Consider surveillance for CAUTI when indicated by facility-based risk assessment. (Category II)
      1. Identify the patient groups or units on which to conduct surveillance based on frequency of catheter use and potential risk of CAUTI.
    1. Use standardized methodology for performing CAUTI surveillance. (Category IB)
      1. Examples of metrics that should be used for CAUTI surveillance include:
        1. Number of CAUTI per 1000 catheter-days
        2. Number of bloodstream infections secondary to CAUTI per 1000 catheter-days
        3. Catheter utilization ratio: (urinary catheter days/patient days) x 100
      1. Use Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) criteria for identifying patients who have symptomatic urinary tract infection (SUTI) (numerator data) (see NHSN Patient Safety Manual: http://www.cdc.gov/nhsn/library.html External Web Site Policy).
      2. For more information on metrics, please see the U.S. Department of Health & Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections: http://www.hhs.gov/ophs/initiatives/hai/infection.html External Web Site Policy.
    1. Routine screening of catheterized patients for asymptomatic bacteriuria (ASB) is not recommended. (Category II)
    2. When performing surveillance for CAUTI, consider providing regular (e.g., quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff. (Category II)

Definitions:

Categorization Scheme for Recommendations

Category IA A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms
Category IB A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidence
Category IC A strong recommendation required by state or federal regulation
Category II A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms
No recommendation/unresolved issue Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is specifically stated for each recommendation (see "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate use of indwelling urinary catheters
  • Prevention of catheter-associated urinary tract infections (CAUTI)
  • Decreased morbidity and mortality associated with CAUTI
Potential Harms

The evidence was reviewed in the original guideline document for risk factors for catheter-associated urinary tract infections (CAUTI), populations at high risk of mortality from urinary catheters, risks associated with different catheterization approaches and different catheters and collecting systems, different catheter management techniques, and different systems interventions.

Qualifying Statements

Qualifying Statements

The limitations and heterogeneity of definitions of catheter-associated urinary tract infections (CAUTI) used in various studies present major challenges in appraising the quality of evidence in the CAUTI literature. Study investigators have used numerous different definitions for CAUTI outcomes, ranging from simple bacteriuria at a range of concentrations to, less commonly, symptomatic infection defined by combinations of bacteriuria and various signs and symptoms. Furthermore, most studies that used Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) definitions for CAUTI did not distinguish between symptomatic urinary tract infection (SUTI) and asymptomatic bacteriuria (ASB) in their analyses. The heterogeneity of definitions used for CAUTI may reduce the quality of evidence for a given intervention and often precludes meta-analyses.

Implementation of the Guideline

Description of Implementation Strategy

Prioritization of Recommendations

The recommendations considered essential for all healthcare facilities caring for patients requiring urinary catheterization are organized into modules in order to provide more guidance to facilities on implementation of these guidelines. The high-priority recommendations were chosen by a consensus of experts based on strength of recommendation as well as on the likely impact of the strategy in preventing catheter-associated urinary tract infection (CAUTI). The administrative functions and infrastructure listed above in the summary of recommendations are necessary to accomplish the high priority recommendations and are therefore critical to the success of a prevention program. In addition, quality improvement programs should be implemented as an active approach to accomplishing these recommendations and when process and outcome measure goals are not being met based on internal reporting.

Priority Recommendations for Appropriate Urinary Catheter Use (Module 1)

  • Insert catheters only for appropriate indications (see Table 2 in the original guideline document), and leave in place only as long as needed.
    • Avoid use of urinary catheters in patients and nursing home residents for management of incontinence.
    • For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use.

Priority Recommendations for Aseptic Insertion of Urinary Catheters (Module 2)

  • Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility.
  • In the acute care hospital setting, insert catheters using aseptic technique and sterile equipment.

Priority Recommendations for Proper Urinary Catheter Maintenance (Module 3)

  • Following aseptic insertion of the urinary catheter, maintain a closed drainage system.
  • Maintain unobstructed urine flow.

Performance measures are provided in the original guideline document.

Implementation Tools
Audit Criteria/Indicators
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2009. 67 p. [281 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009
Guideline Developer(s)
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Healthcare Infection Control Practices Advisory Committee (HICPAC)

Composition of Group That Authored the Guideline

Committee Chair: BRENNAN, Patrick J., MD

Executive Secretary: BELL, Michael R., MD

Committee Members: BURNS, Lillian A., MPH; ELWARD, Alexis, MD, MPH; ENGEL, Jeffrey, MD; LUNDSTROM, Tammy, MD, JD; GORDON, Steven M., MD; MCCARTER, Yvette S., PhD; MURPHY, Denise M., MPH, RN, CIC; OLMSTED, Russell N., MPH; PEGUES, David Alexander, MD; RAMSEY, Keith M., MD; SINGH, Nalini, MD, MPH; SOULE, Barbara M., RN, MPA, CIC; SCHECTER, William, P., MD; STEVENSON, Kurt Brown, MD, MPH

Ex-officio Members: Agency for Healthcare Research and Quality Ex-Officio: BAINE, William B., MD; National Institute of Health Ex-Officio: HENDERSON, David, MD; Health Resources and Services Administration Ex-Officio: JAY, Lorine J., MPH, RN, CPHQ; Food and Drug Administration Ex-Officio: MURPHEY, Sheila A., MD; Center for Medicare & Medicaid Services (CMS) Ex-Officio: MILLER, Jeannie RN, MPH; Department of Veterans Affairs (VA): ROSELLE, Gary A., MD

Liaisons: Association of Professionals of Infection Control and Epidemiology, Inc.: BJERKE, Nancy, BSN, RN, MPH, CIC; Council of State and Territorial Epidemiologists: KAINER, Marion MD, MPH; American Health Care Association: FITZLER, Sandra L., RN; American College of Occupational and Environmental Medicine: RUSSI, Mark, MD, MPH; Advisory Council for the Elimination of Tuberculosis: STRICOF, Rachel L., MPH; American Hospital Association: SCHULMAN, Roslyne, MHA, MBA; Association of perioperative Registered Nurses: BLANCHARD, Joan C., RN, BSN, MSS, CNOR, CIC; Society for Healthcare Epidemiology of America: MARAGAKIS, Lisa, MD; Joint Commission on Accreditation of Healthcare Organizations: WISE, Robert A., MD; Consumers Union: MCGIFFERT, Lisa

Financial Disclosures/Conflicts of Interest

The authors C.V.G., C.A.U., R.K.A., and G.K. report no actual or potential conflicts of interest. D.A.P. is on the Speakers Bureau of Merck, Pfizer, Schering, and Cubist and is a consultant for Dow Pharmaceuticals, DaVita, and Vasonova. C.A.U. and R.K.A. received funding from the CDC to support the guideline development process.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Centers for Disease Control and Prevention (CDC) Web site External Web Site Policy.

Print copies: Available from the CDC, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Availability of Companion Documents

The following is available:

  • Guideline for prevention of catheter-associated urinary tract infections 2009. Appendices. Centers for Disease Control (CDC). 268 p. Electronic copies: Available from the CDC Web site External Web Site Policy.

Print copies: Available from the CDC, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

In addition, performance measures are provided in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 6, 2010.

Copyright Statement

No copyright restrictions apply.

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