Summary of Recommendations

Summary of Recommendations from the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009).

Table 1. Modified HICPAC Categorization Scheme* for Recommendations

A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms. (Please refer to Methods for process used to grade quality of evidence)

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.

A weak recommendation supported by any quality evidence 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.

* Please refer to Methods for implications of Category designations.

I. Appropriate Urinary Catheter Use

I.B. Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate.

Table 2.

A. Examples of Appropriate Indications for Indwelling Urethral Catheter Use 1-4

• 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 PACU).
  • Patients anticipated to receive large-volume infusions or diuretics during surgery.
  • Need for intraoperative monitoring of urinary output.

  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 anesthesia, etc.).

  Note: The above indications are based primarily on expert consensus.

  II. Proper Techniques for Urinary Catheter Insertion

  Recommendations for Proper urinary catheter insertion techniques by ID number and category.

  #	Recommendation	Category
  II.A.	Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site.	IB
  II.B.	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.	IB
  II.C.	In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment.	IB
  II.C.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.	IB
  II.C.2.	Routine use of antiseptic lubricants is not necessary.	II
  II.C.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
  II.D.	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.	IA
  II.D.1.	Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization.	No recommendation/ unresolved issue
  II.E.	Properly secure indwelling catheters after insertion to prevent movement and urethral traction.	IB
  II.F.	Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma.	II
  II.G.	If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension.	IB
  II.H.	Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions.	II
  II.H.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.	IB

  III. Proper Techniques for Urinary Catheter Maintenance

  Recommendations for Proper urinary catheter maintenance techniques by ID number and category.

  #	Recommendation	Category
  III.A.	Following aseptic insertion of the urinary catheter, maintain a closed drainage system	IB
  III.A.1.	If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment.	IB
  III.A.2.	Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions.	II
  III.B.	Maintain unobstructed urine flow.	IB
  III.B.1.	Keep the catheter and collecting tube free from kinking.	IB
  III.B.2.	Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.	IB
  III.B.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.	IB
  III.C.	Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system.	IB
  III.D.	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.	II
  III.E.	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.	II
  III.F.	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.	IB
  III.F.1.	Further research is needed on the use of urinary antiseptics (e.g., methenamine) to prevent UTI in patients requiring short-term catheterization.	No recommendation/ unresolved issue
  III.G.	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.	IB
  III.H.	Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended.	II
  III.H.1.	If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction.	II
  III.I.	Routine irrigation of the bladder with antimicrobials is not recommended.	II
  III.J.	Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended.	II
  III.K.	Clamping indwelling catheters prior to removal is not necessary.	II
  III.L.	Further research is needed on the use of bacterial interference (i.e., bladder inoculation with a nonpathogenic bacterial strain) to prevent UTI in patients requiring chronic urinary catheterization.	No recommendation/ unresolved issue

  Catheter Materials

  Recommendations for Catheter materials by ID number and category.

  #	Recommendation	Category
  III.M.	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).	IB
  III.M.1.	Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters.	No recommendation/ unresolved issue
  III.N.	Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization.	II
  III.O.	Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction.	II
  III.P.	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

  Recommendations for Management of catheter obstruction by ID number and category.

  #	Recommendation	Category
  III.Q.	If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter.	IB
  III.R.	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
  III.S.	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
  III.T.	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

  Recommendations for Specimen collection by ID number and category.

  #	Recommendation	Category
  III.U.	Obtain urine samples aseptically.	IB
  III.U.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.	IB
  III.U.2.	Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag.	IB

  Spatial Separation of Catheterized Patients

  Recommendations for Spatial separation of patients by ID number and category.

  #	Recommendation	Category
  III.V.	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

  IV. Quality Improvement Programs

  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.

  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

     V. Administrative Infrastructure

     V.A. Provision of guidelines

     Recommendations for Quality improvement programs by ID number and category.

     #	Recommendation	Category
     V.A.1.	Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance.	IB
     V.A.1.a.	Consider monitoring adherence to facility-based criteria for acceptable indications for indwelling urinary catheter use.	II

     V.B. Education and Training

     Recommendations for Education and training by ID number and category.

     #	Recommendation	Category
     V.B.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.	IB
     V.B.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.	II

     V.C. Supplies

     Recommendations for Urinary catheter supplies by ID number and category.

     #	Recommendation	Category
     V.C.1.	Ensure that supplies necessary for aseptic technique for catheter insertion are readily available.	IB

     V.D. System of documentation

     Recommendations for System of documentation by ID number and category.

     #	Recommendation	Category
     V.D.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.	II
     V.D.1.a.	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.	II

     V.E. Surveillance resources

     Recommendations for Surveillance resources by ID number and category.

     #	Recommendation	Category
     V.E. 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.	IB

     VI. Surveillance

     Recommendations for Surveillance by ID number and category.

     #	Recommendation	Category
     VI.A.	Consider surveillance for CAUTI when indicated by facility-based risk assessment.	II
     VI.A.1.	Identify the patient groups or units on which to conduct surveillance based on frequency of catheter use and potential risk of CAUTI.	–
     VI.B.	Use standardized methodology for performing CAUTI surveillance.

     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) × 100