Hospital-Acquired Urinary Tract Infections

Abstract

Hospital-Acquired Infection (HAI/nosocomial infections) nosocomial infections, is gaining importance due to prolonged hospital stays and increased cost of hospital care as a result of infections acquired within the hospital. Organisms are more virulent and drug-resistant responsible for increased morbidity and mortality. Professor (Dr) Ignaz Phillip Semmelweis a Hungarian obstetrician, in 1847 observed this phenomenon. Catheter-associated Urinary Tract Infection (CAUTI) is the second most common infection (most common is Central Line-Associated bloodstream Infection–CLABSI). Development of CAUTI as an outcome, are discussed as pre-catheterization, input and output variable factors, and catheter maintenance. Careful monitoring is needed to understand these processes. Pre-catheterization process starts from the selection of the patient until catheterization is done. Input variables are catheter material, different types of urinary catheters, organisms causing these infections, and mechanism of infection. Catheterization processes variables include the need for catheterization, methods of catheterization, patient preparation, aseptic precautions, steps of catheterization, duration of catheterization, use of antibiotics, and the process of catheter removal. Final analysis of the cost involved makes it a comprehensive approach to the topic. Prevention of CAUTI as part of surveillance serves as an indicator to monitor the quality of services provided by the health care facility.

1. Introduction

Catheter is a device used to drain urine from the bladder under different conditions. In the hospital, urinary catheters are used extensively on a variety of patient populations. During the process, the patient may get an infection other than for which he was admitted. In the hospital setup, urinary tract infection could follow the insertion of the urinary catheter. These infections following urinary catheterization are referred to as Catheter-associated urinary tract infection (CAUTI). CAUTI is a device (catheter) associated infection.

1.1 Urinary tract infections (UTIs)

Urinary tract infections (UTIs) are bacterial infections affecting nearly 150 million people around the world annually [1]. It is estimated that among all ambulatory patients (0.9%), 10.5 million persons have UTI symptoms and 2–3 million persons report to the emergency department in the United States alone [2, 3, 4]. In Infant boys, older men, and females of all ages, significant morbidity is due to UTIs. Frequent recurrences of pyelonephritis with sepsis, renal damage in young, preterm babies, and complications due to frequent antimicrobial use with high-level antibiotic resistance and Clostridium difficile colitis are the common complications of UTI. In the United States, approximately US$3.5 billion per year is spent on societal costs for UTI infections (includes health care costs and time missed from work).

Urinary catheterization is used to evacuate urine by passing a hollow catheter. Catheter is passed through the urethra or sometimes through the suprapubic region. Indwelling urinary catheterization is classified as short-term (in situ less than 28 days), or long-term (in situ greater than 28 days) based on the time interval the catheter is in place.

Clinically, UTIs are classified as uncomplicated or complicated. Uncomplicated UTIs affect individuals who are otherwise healthy with no structural or neurological urinary tract abnormalities [5, 6]. Uncomplicated UTI infections are again classified as cystitis (lower UTIs) and pyelonephritis (upper UTIs) [5, 7]. Risk factors associated with cystitis include female gender, a prior UTI, sexual activity, vaginal infection, diabetes, obesity, and genetic susceptibility [3, 7]. Complicated UTIs are associated with factors that compromise the urinary tract or host defense mechanisms, such as urinary obstruction, urinary retention (associated with neurological disease, immunosuppression, renal failure, renal transplantation, pregnancy and the presence of foreign bodies, including calculi, indwelling catheters or other drainage devices) [8, 9]. Indwelling catheters can be attributed to 70–80% of complications of UTIs [10], which translates to 1 million cases per year in the United States [4].

UTIs are caused by gram-negative bacteria, gram-positive bacteria, and by some fungi [11]. Uropathogenic Escherichia coli (UPEC) is the most common agent causing both uncomplicated and complicated UTIs. Other agents involved, in order of prevalence, causing uncomplicated UTIs are Klebsiella pneumoniae, Staphylococcus saprophyticus, Enterococcus faecalis, group B Streptococcus (GBS), Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and Candida spp [3, 6, 11, 12, 13]. Similarly, complicated UTIs are caused by Enterococcus spp., K. pneumoniae, Candida spp., S. aureus, P. mirabilis, Ps. aeruginosa, and GBS in order of prevalence following UPEC [9, 11, 14, 15, 16].

1.2 Health care-associated infections (HCAI)

By definition, “an infection that was not incubating at the time of admission is considered nosocomial if it develops in a patient who has been hospitalized for 48 to 72 hours or more.” Health care-associated infections (HCAIs) are acquired by patients during their hospital stay [17]. Initially, the term HCAIs was referred only to the infections acquired by patients admitted to an acute-care hospital. At present, HCAI includes infections contracted in various healthcare settings, such as long-term care, family medicine clinics, home care, and ambulatory care, where patients get treated. HCAIs are infections that first appear 48 hours or more or within 30 days following hospitalization (can go up to 90 days for orthopedic implants) [18]. Adverse drug events (ADE), HCAIs and surgical complications are the most common types of complications seen in hospitalized patients [19, 20, 21, 22, 23].

Estimates of the Center for Disease Control and Prevention (CDC) nosocomial infections contribute 0.7 to 10.1% of deaths and cause 0.1 to 4.4% of all deaths occurring in hospitals. US Center for Disease Control and Prevention project a figure of 1.7 million hospitalized patients to acquire HCAIs annually and more than 98,000 of them die [24]. HCAIs are the common complications associated with hospital care and one of the top ten leading causes of death in the USA [25]. Seven out of the 100 hospitalized patients in advanced countries and ten in emerging countries acquire an HCAI [26]. In high-income countries, of the 5–15% hospitalized HCAI patients, 9–37% are admitted to intensive care units (ICUs) [27, 28]. Around 0.5 million episodes of HCAIs are diagnosed every year in ICUs alone [23, 29, 30]. ICU patients are critically ill, immuno-compromised, and susceptible to HCAIs [31, 32]. Nosocomial infections affect more than 1.6 million patients annually costing about $ 4.5 billion in the United States.

Hungarian obstetrician Professor (Dr) Ignaz Phillip Semmelweis, visualized that healthcare providers could transmit disease among themselves or to the patients. He was working in a Maternity Hospital in Vienna when he identified the mode of transmission and spread of puerperal sepsis. In 1847, he observed higher rates of maternal deaths among patients treated by obstetricians and medical students compared to those cared for by midwives. At that time, he found a pathologist while carrying out an autopsy on a patient with puerperal sepsis accidentally wounded with the scalpel and died of sepsis. Semmelweis wrote that “both scalpel and physician’s contaminated hands could transmit organisms to mothers during labor.” He introduced hand washing with chlorinated lime to be used by every staff working in that obstetric hospital. This practice brought a large improvement in maternal mortality rates [33]. Koch’s postulates published in 1890, “the germ theory of disease” gave validity to Semmelweis’ theory of transmission of disease from doctor to patient. Thus, Semmelweis became the first to describe HCAI and also provide intervention through hand hygiene [34].

The 2021 National and State HAI Progress Report [35] provided a detailed classification of different HAIs – “Central Line-Associated Blood Stream Infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), Ventilator-Associated Events (VAE), Surgical Site Infections (SSI), Methicillin-Resistant S. aureus (MRSA) bloodstream events, and Clostridioides difficile (C. difficile) events.” The report provided details in the form of technical tables with additional statistics about HAIs.

The report included infection-specific standardized infection ratios (SIRs) to measure progress in reducing HAIs compared to the 2015 baseline time period [36]. SIR is the ratio of the observed number of infections (events) to the number of predicted infections for a summarized time period. The report also included the standardized utilization ratios (SURs), which measure the use of a device by comparing the number of observed device days to the number of predicted device days [37]. The risk adjustment methodology of 2015 national baseline is used to calculate the SIR and SUR metrics.

1.2.1 Catheter-associated urinary tract infection (CAUTI)

CAUTI risk factors include catheterization for long periods, female gender, older age, and diabetes [38]. High recurrence rates of antimicrobial resistance among uropathogens that resulted in increased economic burden to the patients were noted in patients suffering from CAUTI. Increased morbidity and mortality of catheter-associated UTIs (CAUTIs) are the common cause of secondary bloodstream infections.

Hospital-acquired infections (HAIs) are associated with the use of devices such as catheters, ventilators, central lines, etc. Major causes of HAIs is due to prolonged hospitalization, use of invasive devices, such as catheters and irrational use of antibiotics [39]. More than 30% of annual infections are seen in the critical care area of the hospital [24]. Among the device-associated hospital-acquired infections, Central line-associated bloodstream infections (CLABSIs) are the most common [40]. It is followed by catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP) [41].

Indwelling urethral catheters account for about 80% of UTI [40]. Catheters may facilitate colonization of the urinary bladder due to poor catheter placement, prolonged catheterization, poor aseptic technique, poor hand hygiene, and poor asepsis of the urethral orifice opening. Hence, catheters are a common source of urinary tract infections [42]. Catheter placement is not directly associated with the development of UTIs.

Each patient, depending on age, comorbidities, and socioeconomic status the test result and frequency of a UTI can differ significantly. Gram-negative bacteria, such as E. coli, Klebsiella spp., P. mirabilis, Ps. aeruginosa, and Citrobacter spp., are the predominant isolates in urinary tract infections. Gram-positive bacteria, such as S. aureus and Enterococcus species, are the most common [43, 44].

A secondary hospital-acquired bloodstream infection may occur as post-catheter-associated urinary tract infection, (17% of nosocomial bacteremia from urinary tract infections) with an associated mortality of 10% [45]. Asymptomatic bacteriuria is the presence of a significant bacterial count, that is, >10⁵ CFU/mL (Colony Forming Units/mL). In a well-collected urine sample with aseptic precautions from a patient who has asymptomatic, bacteriuria is commonly seen in clinical practice [46]. It is associated with low sequelae and low morbidity. In the majority of cases, it is self-limiting. In pregnant women, asymptomatic bacteriuria needs to be treated.

The urinary tract is usually sterile except for the distal urethra. The infection mostly follows instrumentation of the urinary tract, particularly catheterization (66–88%). Each case of hospital-acquired urinary tract infection adds approximately $675 to the cost of hospitalization, which increases to $2800 when bacteremia develops [47]. Patient mortality may be high (∼30%) [48]. The incidence of hospital-acquired urinary tract infection can be reduced by decreasing the use of inappropriate indwelling urinary catheters, using closed drainage and ensuring the removal of the catheter when it is not required [49].

Leaving a urinary catheter for a long time in situ contributes to the development of a catheter-associated urinary tract infection (CAUTI) [50]. Risk of development of CAUTI increases by 5% per day in relation to the length of catheter in situ. Twenty-five percent of hospitalized patients are catheterized at some stage of their admission. It is critical to follow proper practices and procedures to minimize the risk of infection [51, 52].

A history of long-term hospitalization attributable to device-related infections should alert the possibility of CAUTI. Common symptoms are dysuria, fever (>38°C), urgency, frequency, dysuria without any cause, flank pain, supra-pubic pain, urinary urgency, and hematuria. Positive urinary cultures are expected if the patient has not consumed antibiotics prior to the sample collection. The presence of bacteria in the urine without these symptoms is due to colonization [49]. An increase in treatment costs and risk of lethality for patients are observed.

Bacteriuria signifies either colonization (asymptomatic bacteriuria) or infection. Bacteriuria can be found both in catheterized and non-catheterized patients. Of the patients with catheter in situ for more than 30 days, ∼10–30% will develop bacteriuria compared to 1% of non-catheterized patients [53, 54]. Colonization rather than infection is associated with bacteriuria accounting for more than 90% of patients who are on the urinary catheter [55]. Diagnosis of CAUTI is not evidence-based [56]. Established laboratory criteria to differentiate between CAUTI and asymptomatic bacteriuria are not available. Clinicians rely on a combination of clinical signs and symptoms in addition to laboratory-confirmed bacteriuria to reach the diagnosis of CAUTI [57]. Clinical signs and symptoms of CAUTI are fever, new-onset confusion, loin, or suprapubic pain [56, 58]. Fever is the most frequently encountered symptom. However, the absence of fever does not rule out infection [57].

1.2.2 Morbidity and mortality associated with CAUTI

An increased morbidity, mortality, and length of hospitalization are associated with CAUTI [59, 60, 61, 62, 63, 64]. In hospital-acquired bloodstream infection, CAUTI is the primary source of infection (8.5%) [65]. Bacteremia surveillance revealed 3.8% of cases to have resulted from CAUTI [66].

1.3 Etiology

Noncomplicated cystitis (86%) and up to 90% of noncomplicated pyelonephritis are mainly associated with E. coli infection [67]. Though E. coli is the most common infection, complicated UTIs have a more varied etiology. Other gram-negative bacilli like Klebsiella, Citrobacter, and Enterobacter spp. cause 11%; and Ps. aeruginosa, 8%. Gram-positive bacteria also are encountered in catheter-associated urinary tract infections (CAUTI) with D-group Streptococci causing 19% of them, and S. aureus, 4% associated with complications. Polymicrobial UTI cases represent 30% of complicated CAUTI. Other microorganisms such as yeasts cause 18% of UTIs. The significant appearance of Ps. aeruginosa in those of nosocomial origin along with extended-spectrum beta-lactamase (ESBL) and quinolone-resistant Enterobacteriaceae are encountered in those having healthcare-associated acquisition and secondary bloodstream infections [68].

Scottish Intercollegiate Guidelines Network (SIGN) recommends careful recording of associated localizing (loin or supra pubic tenderness) or systemic features of CAUTI. We have to exclude the possibility of other sources of infection. An appropriate sample of urine is to be sent for culture and the antimicrobial susceptibility of the organisms identified. An empiric antimicrobial therapy has to be considered based on the severity of the presentation, comorbid factors, and the local antimicrobial susceptibility patterns and antimicrobial prescribing guidelines [56].

1.4 Pathogenesis

Urethral catheterization interferes with the local natural defense mechanisms of the urinary tract. The length of the urethra and urine flow washes microorganisms away from the bladder. Most organisms that cause CAUTI have to enter the bladder by migrating along the internal (intraluminal) and external (extraluminal) catheter surfaces. Intraluminal migration occurs when there is contamination of the catheter lumen that can occur due to the failure of a closed drainage system or from contaminated urine in the drainage bag. Extra luminal migration of microorganisms occurs from the perineum that can occur at the time after insertion of the catheter or later by capillary action via the outer surface of the catheter [58]. Patient’s flora in the perineum region or the hands of HCWs provides the common pathogens associated with CAUTI, which include E. coli, Enterococcus spp., Pseudomonas spp., Klebsiella spp., Enterobacter spp., or Candida spp [69]. Risk factors of CAUTI are the duration of catheterization [59, 70, 71], underlying predisposing neurological disease, [61] female gender, [71, 72] and diabetes mellitus [71]. The importance of virulence surface proteins such as Type 1 and Type 2 fimbriae and surface attachment proteins such as FimH has been shown to be important in UPEC organisms which have come to light in recent days [72]. Similarly, pathogenicity islands (PAIs) designated ICEPm1, papAH, papEF, fimH, fyuA, and traT genes contribute to genomic variability and virulence that have also been identified and studied [73].

2. Factors to be considered prior to the insertion of a urinary catheter

Catheterization is done to drain the urine from the bladder. The main cause of hospital-acquired urinary tract infection revolves around the process of insertion to removal of the catheter. Draining of the urine can be done not only by transurethral catheterization but also by other routes, such as suprapubic or external drainage, by using a condom. With catheter being a central point of infection, it is important to prioritize the need of catheterization and if it is possible to avoid catheterization. The above facts suggest the need to understand conditions where catheterization is required, and when it can be avoided. There is a need to understand the methods of catheterization for use in different situations. These factors are discussed with the help of available literature on each variable factor.

2.1 Indications for catheterization and can catheterization be avoided?

Urinary catheterization is indicated [74, 75, 76, 77] to relieve acute urinary retention due to bladder outlet obstruction, for assessing the healing of an open sacral or perineum wounds, to assist in achieving patient immobilization due to unstable thoracic, lumbar spine, or pelvic fractures, to monitor urinary output in critically ill patients or when a patient is unable or unwilling to collect urine during prolonged surgical procedures with general or spinal anesthesia, during regional analgesia for labor and delivery, for instillation of drugs or during urology investigations and for patient comfort during end of life care. In spite of delineating the conditions requiring catheterization, a urinary catheter is inappropriate in 21–54% of catheterized patients [78, 79, 80].

CDC guideline highlights the importance of limiting the use of urinary catheters to reduce the risk of UTI [81]. European Prospective Investigation into Cancer and Nutrition (EPIC) guidelines also advocate the selected usage of urinary catheterization and highlight avoidance when possible [82].

The most important measure to prevent CAUTI is to limit the use of urinary catheters and leave them in place only for the period indications persist [75, 82]. Based on comprehensive risk assessment, evaluation and the expected duration of catheterization a decision is to be made regarding whether to catheterize and what type of catheter should be used. Consideration should be given to alternative management methods (e.g., condom) [83].

Urinary catheters are to be used only when indicated and should be removed at the earliest possible time. Complications associated with catheterization are infection, bacteremia, urethritis, urethral strictures, hematuria, and bladder perforation [84, 85, 86, 87]. In practice, it is noted that indwelling urethral catheters are used when it is not indicated or remain in situ for a longer period than necessary [78, 79, 88].

As an alternative, the use of an external catheter (e.g., condom system) should be considered if clinically appropriate and practical.

Urinary catheters should not be used for the convenience of patient care. It should not be used for obtaining urine samples to perform diagnostic tests. Alternative methods include the use of external catheter (e.g., condom system) or intermittent catheterization.

2.2 Methods of catheterization

Catheterization could be external (condom system), or indwelling catheter (a) inserted either in a health care facility or (b) by the patients themselves (self-catheterization). Indwelling catheters are also further classified as (i) short-term (a duration of catheterization intended to be less than or equal to 14 days) or (ii) long-term (when a person uses a urinary catheter for at least four weeks, that is, for 28 days or more or (iii) intermittent indwelling catheters. The selection of method of catheterization should be decided on a patient basis.

Intermittent catheterization is advocated as a method of choice for patients with idiopathic or neurogenic bladder dysfunction due to residual urine in the bladder. Patients often experience urinary frequency, urgency, incontinence, and repeated urine infections [89]. Intermittent catheterization lower the rates of CAUTI as compared to urethral and suprapubic catheterization [75]. Greater patient independence, reduced interference with sexual activity and reduced need for equipment and appliances are the advantages [90].

Suprapubic catheterization is indicated for post-pelvic or urological surgery with difficulty in voiding, urethral trauma, chronic prostatitis, and post-gynecological surgery. Suprapubic catheterization is associated with lower rates of bacteriuria, re-catheterization, and urethral stricture [75].

3. Understanding the contributory factors OF CAUTI

The number of factors associated with the process of catheterization. With the available literature, individual factors are considered in the causation of urinary tract infections. Discussion of the variable factors could be studied as the material or the type of catheter used as input variable factors or the process of insertion to final removal as a process variable factor.

3.1 Input variable factors

Knowledge of different materials has accumulated in the field of material science, which has contributed to the development of a variety of catheters. These could be the use of different metals or antibiotic-incorporated catheters, which could prevent bacterial growth or nonirritant materials, which could prevent damage of the urethral epithelium, thus preventing breach of the surface of the urethral epithelial layer and thereby help in the retention of the catheter for a longer duration of time. These factors finally help the clinician to have a choice of the catheter to be used in different situations. Similarly, the length and size of the catheter are important factors to be considered.

3.1.1 Type of catheter

EPIC guidelines advocated the use of silver-coated catheters to reduce infection rates. This was not addressed in the earlier CDC guideline. A Cochrane Review concluded that the use of silver alloy indwelling catheters reduced the risk of CAUTI [91]. They recommended economic evaluation to confirm the reduction of infection.

Meta-analysis showed silver alloy-coated catheters to be significantly more effective in preventing bacteriuria [91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103]. Antimicrobial-coated catheters preventing catheter-associated bacteriuria/funguria during short-term catheterization were reported consistently [104]. However, no study demonstrated any clinical benefit for the use of different types of catheters.

3.1.2 Selection of a urinary catheter

Urinary catheters are of various types, sizes, and are made up of different materials. Foley’s catheter is the most common type used. The Foley’s catheter may have two or three lumens each of them with a different function to perform; one for the inflation of the balloon, second one for urine drainage of urine, and third one for irrigation.

3.1.3 Catheter size

Catheter size is measured by the diameter of the outer circumference (range from 6Fr-24Fr - French (Fr) metric scale). The smallest gauge that meets the needs of the patient should be the one to be given the choice of selection. It minimizes urethral trauma, reflux bladder spasm, and the amount of residual urine collected in the bladder. All these are predisposing factors to CAUTI [105, 106]. Catheters are manufactured in different lengths. The manufacturer’s instructions are applicable [107].

3.1.4 Catheter material

Catheter material should be selected based on the patient’s assessment and the clinician’s preference. Duration of catheterization, patient comfort, patient history of allergies to the components (such as latex allergy), ease of insertion and removal, and the ability of the catheter material to reduce the likelihood of complications should decide the type of catheter material selected [108].

Commonly polyvinyl chloride (PVC), hydrogel, latex, silicone catheters, or a combination of these materials are used. Either latex or silicone-based catheters are the standard ones. Latex catheters are strong, elastic, and flexible and are common catheter types used for short-term catheterization. Silicone catheters (synthetic catheters) replace latex catheters in patients with latex sensitivity. There is no significant difference between the latex and silicone catheters and their contribution when it comes to the incidence of bacteriuria [85, 88, 109, 110]. For long-term use of catheters, evidence is insufficient to draw conclusions [111]. CDC advises the use of silicone catheters to reduce the risk of encrustation in long-term catheterized patients [75]. For intermittent catheterization, single-use catheters are preferred and are designed to be cleaned and reused. Manufacturers’ instructions are to be followed strictly.

Antiseptic or antimicrobial-coated catheters are available with a variety of antimicrobial agents, such as gentamicin, [110] silver hydrogel, [93, 112] minocycline, rifampicin, [113] chlorhexidine-silver, sulfadiazine, chlorhexidine-sulfadiazine-triclosan, nitrofurazone, [113] and nitrofuroxone incorporated into the catheters [114]. Antiseptic or antimicrobial-coated catheters significantly prevent or delay the onset of CAUTI [110]. The poor quality of the studies makes decision-making difficult. Silver alloy catheters appear to be associated with a reduced incidence of bacteriuria [74, 115, 116, 117, 118, 119]. A Cochrane Review suggests the use of silver-alloy catheters used for less than one week [93]. The review also showed that antibiotic-impregnated catheters had lower rates of asymptomatic bacteriuria at less than one week of catheterization. When catheterization exceeded one week, the results were not statistically significant. Studies are needed to evaluate cost–benefit effectiveness of antiseptic and antimicrobial-coated catheters [77, 110].

3.2 Process variables

3.2.1 Use of aseptic (standard) precautions during urinary catheterization

To minimize the risk, HCWs are to be trained to perform catheterization and have to be assessed. Their competency in technical aspects and application of the principles of aseptic technique should be documented [74, 110, 120, 121].

Standard precautions “must be applied by all HCWs for all patients at all times.” They are useful to contain transmissible microorganisms that may be present in blood and body fluids, excretions, and secretions (except sweat). Standard precautions “must be applied by all HCWs for all patients at all times” while performing close activities with patients, patients’ surroundings, and handling and disposing clinical waste [122]. HCWs should wear sufficient personal protective equipment (PPE) to prevent skin or clothing contamination. Contaminated body fluids may contain pathogenic microorganisms which may get transferred either to themselves or other patients. While performing urinary catheter insertion, a disposable plastic apron, and sterile gloves will usually be sufficient [110, 122]. Disposable plastic aprons and gloves are single-use items that are to be worn and then discarded after each procedure [122]. Hands should be decontaminated before the procedure, after the procedure, and also after removing PPE [123].

3.2.2 Aseptic technique

During the insertion of indwelling and intermittent urinary catheters, HCWs must practice strict aseptic techniques and use sterile equipment as per the expert opinion, clinical guidance, and principles of best practice [124, 125, 126, 127, 128].

The aseptic technique refers to the practices that help to reduce the risk of post-procedure infections. This decreases the likelihood of microorganisms entering the body during clinical procedures. The aseptic technique reduces the risk of infection by preventing the transmission of microorganisms either directly or indirectly. Wide variations in the practice of aseptic techniques have been found in different surveys. A standardized aseptic non-touch technique (ANTT)™ has been developed [129].

3.2.3 Hand decontamination

Hand hygiene is the single most important procedure. The World Health Organization (WHO) advocates five situations (moments) of hand hygiene performance: [129] (a) Before touching the patient, (b) before a clean or aseptic procedure, (c) after body fluid exposure risk, which also includes emptying a urinary catheter drainage system [125, 130], (d) after touching the patient’s surroundings, and (e) after touching the patient. Except when an aseptic procedure is being performed, non-sterile single-use gloves should be worn. Hands should be decontaminated before and after removing PPE [124, 125, 130].

3.2.4 Patient preparation

Patients should be provided with adequate information regarding the need for catheter insertion, catheter maintenance, and removal of the catheter by the caregiver. The patient should be given the opportunity to discuss the implications of the procedure [120].

3.2.4.1 Skin/meatus cleaning and disinfection

Patient preparation to prevent infection during catheterization depends on the method of catheterization, skin or meatus cleaning and disinfection. This process is also carried out for daily maintenance of the catheter.

3.2.4.1.1 Meatus cleaning prior to catheterization

As infection can get transmitted via the external surface of the catheter during catheter insertion especially when an indwelling or intermittent catheter is used. Here, the urethral meatus should be cleaned prior to catheterization [77], which involves the mechanical removal of exudate and smegma washing the meatus area with soap and water [128]. The use of antiseptic solution versus sterile saline wash prior to catheter insertion needs more evidence [64, 108, 131, 132, 133, 134].

The standard practice of cleansing the urethral meatus is to retract the foreskin (where possible), cleaning the glans penis, and return the foreskin to normal position after insertion of the catheter. A front-to-back cleaning technique should be adopted after the labia minora are separated for women. After a thorough cleaning, the urethral opening should be washed and cleaned with sterile water or sterile saline solution. The area should be wiped dry using sterile swabs. The gauze ball or swab should be discarded after a single use. The same procedure is to be performed before self-intermittent catheterization.

3.2.4.1.2 Suprapubic catheterization

The skin over the insertion site should be washed with soap and water. Then, the site is dried thoroughly. Then, it is cleaned with an aqueous or alcohol-based surgical site disinfectant solution (e.g., chlorhexidine or povidone-iodine) as per local guidelines [135].

3.2.5 Maintaining a sterile field

Before each procedure, environmental surfaces should be effectively cleaned and disinfected as practiced for any other minor surgical procedure [136]. Maintaining the integrity of the sterile field is important. HCWs should use sterile gloves and a drape to create a sterile field [74]. Sterile catheter packs, which contain all needed materials should be used [110].

3.2.6 Steps of catheterization

Steps of catheterization start from the process of insertion till the catheter is removed. Since infection could occur at any step of catheterization, each of them are analyzed with the available scientific data.

3.2.6.1 Catheter insertion

The CDC guideline stresses that catheters should be inserted using sterile equipment and an aseptic technique [81]. The use of aseptic technique was not shown to reduce CAUTI in a systematic review, [137] and following principles of good practice, clinical guidance [81, 138], and expert opinion [119, 139, 140, 141, 142]. However, the EPIC guidelines concluded that urinary catheters must be inserted aseptically [82].

In a study focused on the influence of sterile versus clean technique for catheter insertion found no statistical difference between the two groups, while there was a considerable cost difference [143]. The sterile method was found to be more than twice as expensive as the clean method. It was concluded that strict sterility was not necessary for preoperative short-term urethral catheterization.

3.2.6.2 Insertion procedure

3.2.6.2.1 Indwelling urethral catheterization

The entry point for microorganisms into the blood and lymphatic system was a bruise or trauma to the urethral mucosa that occurred during catheterization [144]. To minimize urethral trauma and infection, it is recommended to apply sterile lubricant or anesthetic gel from a single-use container [110]. Once the catheter is inserted, urine is allowed to drain and the balloon is inflated to secure the catheter in place. The indwelling catheter is then connected to a closed sterile drainage bag, which is placed below the level of the bladder to facilitate drainage.

Documentation of the patient information is recorded, which includes an indication for catheter insertion, date and time of catheter insertion, type and size of catheter, amount of water used to inflate the balloon, any complications encountered, review date and name of HCW who inserted catheter [145].

3.2.6.2.2 Intermittent catheterization

Intermittent catheterization is affected by the use of sterile or clean technique, coated or uncoated catheters, single (sterile) or multiple-use (clean) catheters, self-catheterization or catheterization by others, or by any other strategy that need further clarification [89]. Many guidelines recommend an aseptic technique and sterile equipment for intermittent catheterization in a healthcare setting. A clean technique is recommended for self-intermittent catheterization [75, 110, 145].

3.2.6.2.3 Suprapubic catheterization

Suprapubic catheter is commonly done in a theater by a urologist/surgeon, with all sterile precautions. Some catheters are secured to the abdominal wall by a suture. A small sterile dressing may be placed over the site, which can be removed after 24 hours.

3.2.6.3 Catheter maintenance and dwell time

The CDC guideline addresses adherence to a sterile closed system as the cornerstone of infection control. Irrigation should be avoided unless there is a need to prevent or relieve the obstruction [81]. The EPIC guidelines state that a sterile, continuously closed urinary drainage system is central to the prevention of CAUTI [121]. The use of a closed urinary drainage system is effective [126, 140, 141, 146, 147, 148, 149, 150].

The CDC guidelines [82] stress the need to avoid meatus care using povidone-iodine. The EPIC guidelines, based on expert opinion [81, 140, 141] and one systematic reviews [74] recommend against vigorous meatus cleansing. The EPIC guideline recommends daily routine bathing or showering to maintain meatus hygiene [82, 117]. In three earlier studies that investigated meatus care to prevent bacteriuria, little or no benefit was found other than standard personal hygiene in patients with indwelling catheters [151, 152, 153].

The literature review concluded that flushing catheters and daily perineum care do not prevent infection [147].

Only one study which examined different types of catheters showed that substances in the latex urinary catheter were toxic to E. coli [88].

There is a direct relationship between dwell time and incidence of infection [81, 149, 154, 155, 156]. Urinary tract catheterization of at least 3 days was sufficient to increase the risk of urinary tract infection [97]. Early removal is key to the prevention of UTI [77, 151, 157, 158]. Early removal is also associated with shorter hospital stays [91, 155].

3.2.6.4 Catheter removal

Neither the CDC nor the EPIC guidelines discuss catheter removal. Best strategies for the removal of catheters were reviewed through 26 trials involving a total of 2933 participants [155]. Inconclusive evidence of the benefit for midnight removal of indwelling catheters and the need for re-catheterization have been noted. There is only a little evidence for the effectiveness of catheter clamping [91].

4. Management of urinary catheters

Care of drainage system needs proper care for infection prevention. Care of urinary bag, catheter position, and handling of the wound are important in infection prevention.

4.1 Drainage systems

Urinary drainage is done through a catheter connected to a drainage tube, which opens into a drainage bag. In a closed system, the catheter is to be connected to the drainage tube and that is not disturbed. Urine is emptied into the bag through a valve or a port that reduces the risk of ascending infection from intraluminal transmission. Irrespective of the drainage system, daily care is needed to prevent infection. Its effectiveness is dependent on good catheter hygiene [77, 82, 109, 136, 159, 160]. Closed system is the best method to manage the drainage system to prevent CAUTI [110, 117].

4.1.1 Drainage bags

Four main types of drainage bags are used with indwelling catheterization. A leg drainage bag with a drainage tap directly attached to the catheter, a drainage bag with a drainage tap secured to a catheter stand, a non-drainable bag with no drainage tap which is secured to a catheter stand (useful for overnight drainage), and a combined drainage bag and urinary catheter, which is pre-connected to the catheter during the manufacturing process.

4.1.2 Management of catheterized patients

For catheterized patients with spinal cord injury and patients admitted to long-term care facilities advocate reusing drainage bags after cleaning and disinfection is advocated (Best practice guidelines) [160, 161]. It does not increase the risk of CAUTI [161, 162, 163]. This practice is an unacceptable procedure since it does not provide a validated method for decontamination [164, 165]. This practice is not discussed in other evidence-based guidelines [74, 76, 77, 110, 117]. The recommendation is for the use of single-use drainage bags.

Sterile and non-sterile (i.e., clean) drainage bags are available in the market. A sterile bag is used for directly connecting the bag to the catheter which is accepted by evidence-based guidelines [74, 75, 83, 110, 162]. Non-sterile Catheters are used in some healthcare settings [165]. No studies comparing the CAUTI rate with sterile and non-sterile night drainage bags were available in the literature and require further studies. The use of pre-connected urinary catheters and drainage bags reduces the risk of CAUTI [166]. However, there is no conclusive data [75, 77, 166, 167, 168].

A good practice is to maintain the bag below the level of the bladder, [136, 169] minimize contamination of the drainage bag outlet port by avoiding contact with the floor or other surfaces, [136, 159] access the catheter drainage system only when absolutely necessary (e.g., changing the drainage bag as per the manufacturer’s instructions), [80] empty the drainage bag regularly to prevent reflux and use a separate clean container for each patient and prevent the container touching the drainage tap when emptying the drainage bag [80, 98].

4.2 Collecting catheter specimens of urine (CSU)

A sampling port is made available for the collection of urine samples. The sampling port should be disinfected with an appropriate disinfectant (e.g., 70% alcohol) and allowed to dry fully before collecting the sample. Manufacturer’s instructions should be followed. Single-step, needle-free urine collection containers that are suitable for laboratory use should be used to reduce HCW exposure to urine splash and needle stick injuries [170].

4.3 Catheter valves

A catheter valve is a device connected to the end of the catheter and its value is being evaluated. The catheter valve allows urine to be stored in the bladder and eliminates the need for a urine drainage bag. The valve is released at regular intervals to prevent over-distension of the bladder or dilation of the renal tract. The catheter valves may reduce the risk of CAUTI, [171, 172, 173] reduce bladder irritation [172] and maintain bladder tone and capacity. This helps to improve the rehabilitation process after catheter removal.

Evidence suggests that patients prefer to use the catheter valves [157]. But the use of a catheter valve is contraindicated in patients with limited bladder capacity, [174] reflux or renal impairment, [173] detrusor muscle instability, [165, 166] mental disorientation, [171] impaired bladder sensation, [171] poor manual dexterity [175], and immobility.

4.4 Securing indwelling urethral catheters

Use of adhesive, nonadhesive devices (e.g., elastic/Velcro® straps) to secure the urinary catheter to the leg, or abdomen is recommended (best practice guidelines and expert opinion) [75, 169, 175, 176]. By securing the catheters, trauma and bleeding are reduced, dislodgement is prevented and bladder spasms, which may result from pressure and traction are also prevented. These are seen as advantages [177, 178]. A systematic literature review [178] has shown no evidence suggestive of catheter-securing system capable of preventing CAUTI. Though no statistically significant differences were found, the clinical significance of 45% reduction in the rate of symptomatic UTI was noted in patients who received the securing device [179].

It is recommended to place the securement device at the stiffest part of the catheter (usually just below the bifurcation where the balloon is inflated) to prevent occlusion of the lumen. The securement device can be placed on the abdomen or thigh [176]. To prevent skin trauma from excess traction, a regular assessment is necessary. In addition, adhesive material may result in skin irritation and dermatitis and elasticized / Velcro® straps should be used with caution, especially in patients with peripheral vascular disease [176, 180]. The skin site used for the securing device should be regularly changed.

4.5 Suprapubic catheters

The suprapubic catheter emerges at right angles to the abdomen. It needs to be secured in this position. Dressing and tapes should only be used on the healed insertion site when it is absolutely necessary.

4.6 Meatus and insertion site care

4.6.1 Indwelling urethral catheters

There is no advantage in using antiseptic preparations for meatus care over routine bathing or showering [136, 144, 181, 182]. Vigorous meatus cleansing beyond normal hygiene practice is not recommended. It may increase the risk of infection. Washing the meatus with soap and water during daily routine bathing or showering is all that is required. If this forms part of a bed bath, the water should be changed and a clean cloth should be used [183]. Prevention of contamination of the entry site of the catheter during cleaning is important. For women adopting a front-to-back approach, washing toward the anus is to be practiced. For uncircumcised men, the foreskin should be retracted before the area underneath is cleaned. This is often a reservoir for bacteria, particularly in the elderly [169].

4.6.2 Suprapubic catheter

An aseptic technique with a suitable cleansing solution and a sterile dressing should be used for wound care until the insertion site is healed [145]. Once healed, the site should be washed daily with warm water and soap.

4.7 Catheter irrigation

There is no evidence to suggest routine irrigation of a urinary catheter. Using antiseptic or antimicrobial agents to decrease CAUTI has no place in the management [10, 121]. A closed continuous irrigation system should be used if irrigation is required for other reasons (e.g., post-surgery). An aseptic technique should be used for intermittent irrigation (e.g., flushing or installation of drugs).

4.7.1 Catheter blockage

Each patient should have an individualized care regimen designed to minimize the problems of blockage and encrustation. The recurrent blockage is due to the encrustation of the catheter from mineral salt deposits. It is a complication in approximately 50% of all long-term catheterized patients [184]. Catheter blockage causes leakage, bypassing of urine and urinary retention. This condition results in the increased number of catheter changes. Encrustation on the external surface can cause trauma to the urethra during catheter removal.

Catheter maintenance solutions (CMS) are acidic washout solutions. CMS is commonly used to prolong catheter life by reducing pH, which helps in the dissolution of existing encrustations [82]. Disruption of the closed system increases the risk of infection. Frequent blockage leads to frequent re-catheterization. Potential infection risks associated with CMS use are outweighed by increased catheter life and reduced patient discomfort [185]. HCWs should be alert for the signs and symptoms of autonomic dysreflexia in patients with spinal cord injuries. Autonomic dysreflexia is a life-threatening condition.

4.8 Catheter removal

The risk of acquiring bacteriuria has been estimated at 5% for each day of catheterization, accumulating to 100% in 4 weeks. The longer the catheter remains in situ, higher is the risk of infection [133]. Catheterization should be reviewed daily and removed as soon as possible [75, 121, 182]. Clamping urinary catheters prior to removal is not to be followed [75].

4.8.1 Strategies for limiting the duration of short-term catheters

Success strategy in limiting catheter use and duration of catheterization is achieved by implementing procedure-specific guidelines for postoperative catheter removal, and providing reminders to physicians to review and limit the duration of catheterization [186, 187, 188, 189, 190]. Providing guidelines to manage postoperative retention may include the use of bladder scanners [187]. Care plans/protocols directing nurses to remove catheters need to be developed [187, 189, 191].

The effectiveness of reminder systems has helped in reducing CAUTI and urinary catheter use. Rate of re-catheterization was reduced by 52% following the use of reminder or stop orders. Duration of catheterization decreased by 37% and re-catheterization rates were similar in control and intervention groups, respectively [192].

4.8.2 Changing long-term catheters

Long-term catheterization is defined as a catheter in situ for greater than 28 days. No consensus exists on how frequently such catheters need to be changed. Manufacturer’s instructions should be followed in addition to individual patient’s requirements (e.g., before blockage occurs or is likely to occur) [76].

4.8.3 CAUTI preventive care bundles

Care bundles are useful in identifying the cause of CAUTI in each patient due to a breach in the process of catheter care. It analyses the clinical, laboratory, bacteriological, and radiological data and through root cause analysis (RCA) suggest corrective and preventive actions (CAPA) needed to prevent CAUTI infection. It follows the surveillance activity.

“A care bundle is a group of evidence-based practices that improve the quality of care.” Care bundles have been developed for a range of conditions and disease processes [193, 194, 195, 196]. Implementation of care bundles is helpful in improving the care of all patients in both multidisciplinary teams and individual wards/units. The decrease is significant when adjusted for device utilization [197].

Compliance with a care bundle for an individual patient is measured as either 100% or 0%. To achieve 100%, all of the evidence-based components of the bundle must be implemented. If one of the components of the care bundle is not in place, a score of zero is allocated. The ward or team score is calculated as the percentage of all patients with a urinary catheter that achieved 100% compliance with the care bundle.

4.9 Antimicrobial prophylaxis

There is no role for routine antimicrobial prophylaxis. Prophylaxis after the change or instrumentation of urinary catheters (both short and long-term) is not indicated. Despite a lack of evidence, the use of prophylactic antimicrobial (aminoglycosides are commonly used). This has resulted in overuse and increased resistance to antibiotics. The benefits of antimicrobial prophylaxis must be balanced against possible adverse effects like selection pressure for the development of antibiotic-resistant bacteria. C. difficile infection and antimicrobial toxicity are the other two effects of prophylactic overuse. Risk–benefit analysis cannot be reliably estimated. The effectiveness of prophylactic antimicrobials at the time of urinary catheter insertion, change, or removal is variable. There is a specific need for guidelines to be established [198].

All reviews showed limited evidence for the use of prophylactic antibiotics for both short-term and long-term catheters [155, 199]. Majority of best practice guidelines do not recommend the use of prophylactic antimicrobials before the removal of catheters. A comprehensive review also did not show any conclusion [200]. There is also little data regarding the patient with a previous episode of septicemia associated with catheter manipulations. The use of short-term catheterization to prevent bacteriuria appear to be a better strategy than the use of antimicrobials.

The asymptomatic bacteremia rate is approximately 10% per catheter change. It is unwise to recommend the use of prophylactic antimicrobials for long-term catheterized patients [200, 201]. Recently published guidelines from the US do not recommend the routine use of systemic antimicrobials at the time of catheter placement, removal, or replacement. According to CDC, unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post-urologic surgery), routine use of systemic antimicrobials is not required.

UK National Institute for Health and Clinical Excellence (NICE) guidelines on antimicrobial prophylaxis against infective endocarditis also does not support the use of antibiotic prophylaxis to prevent endocarditis in patients undergoing urological procedures, including catheterization [202]. The British Society for Antimicrobial Chemotherapy state that the risk of bacteremia increases in presence of bacteriuria. Hence, treatment is recommended for pre-procedures [203]. US guidelines on the prevention of infective endocarditis, state that no published data is available to demonstrate a conclusive link between procedures of the gastrointestinal or genitourinary tract to be related to the development of endocarditis [204].

Prophylactic use of antimicrobials has no relation to change or instrumentation of urinary catheters (both short and long-term). In patients with bacteriuria, high risk of endocarditis or significantly immune compromised (e.g., patients with neutropenia, hematological malignancy, post solid organ transplantation), definitive randomized-controlled trials are needed.

5. Surveillance for CAUTI

Surveillance is “the ongoing systematic collection, analysis, and interpretation of data and the timely dissemination of the data to those who need to know to prevent and control infection” [205]. Prevalence studies are used to do surveillance of CAUTI [206, 207, 208]. Prospective CAUTI surveillance is useful for high-risk groups: (e.g., patients admitted to intensive care surgical or obstetric units) [10]. Rates of CAUTI range from 3.3 to 17.4/1000 catheter days among ICU patients [209, 210, 211, 212]. Much lower infection rates (1.24–2.26/1000 catheter days) are reported in long-term care institutions [213]. Including CAUTI as part of the hospital’s regular surveillance program should be considered by all hospitals depending on the risk profile of their patients and available resources. CAUTI rate should be reported as the number of CAUTI per 1000 urinary catheter days.

5.1 CAUTI definition for surveillance

The CDC or the HELICS definitions are most commonly used for HCAI surveillance [214, 215]. HELICS definition of urinary tract infection is specifically designed for use in intensive care units only. CDC definitions are to be used in acute facilities. CAUTI surveillance should only include symptomatic CAUTI, as the prevalence of asymptomatic bacteriuria is high among elderly care residents [216].

5.2 Forms and protocol for data collection

Data collectors should be trained in the definitions, surveillance, and protocols to be utilized. An example of data collection forms for CAUTI surveillance needs to be standardized and used.

Calculation of the denominator: Denominator value data is collected in this form. This is a daily count of all the urinary catheters in the area/patient group under surveillance. The number of patients with urinary catheter device in situ is known as urinary catheter days. Data should be collected at a specified time each day.

Calculation of the numerator: The numerator data is collected in this form. It represents the number of patients with CAUTI. This form is used to collect and report each suspected or confirmed CAUTI in the area/patient group under surveillance. Additional information that is to be collected includes patient demographics, signs and symptoms of infection, laboratory results if applicable and the presence or absence of a urinary catheter.

The CAUTI rate per 1000 catheter days is calculated by using the following formula:

$$\frac{\mathrm{No}\text{of CAUTIs}}{\mathrm{\text{No. of U. Catheter days (denominator)}}}\mathrm{\times }1000$$

Example: Calculation of CAUTI rate per 1000 catheter days.

1. One patient in the ICU met the case definition of a CAUTI in the month of January (numerator = 1).

2. To calculate the number of catheter days (denominator data); add the number of patients with a urinary catheter in situ on each day in the month of January (e.g., 4 patients on the first day of January had a urinary catheter in situ; 6 on day 2; 5 on days 3 to 8, 6 on days 9 to 16, 4 on day 17 to 23 and 7 on days 24 to 31 (4 + 6+ 5 + 5 + 5 + 5 + 5 + 5 + 6 + 6 + 6 + 6 + 6 + 6 + 6 + 6 + 4 + 4 + 4 + 4 + 4 +4 + 4 + 7 + 7 + 7 + 7 + 7 + 7 + 7 + 7 = 144).

   144 = denominator data (number of catheter days in the month of January in the ICU).

3. The CAUTI rate for the month of January in the ICU (per 1000 urinary catheter days) is thus:

$$\frac{1\mathrm{x}1000}{144}=6.9\text{CAUTIs}/1000\text{catheter days}$$

CAUTI surveillance should be a part of routine hospital surveillance.

5.3 Surveillance result feedback

Regular CAUTI rate feedback to the relevant area(s) of the healthcare facility is very important along with any comments or suggestions for improvement. Ideally, it is monthly or at least once in a quarter. Feedback helps the healthcare facility to monitor the trends, identify outbreaks, and in addition to monitor the effectiveness of preventative programs.

6. Clinical presentation

Clinically, CAUTI presents with fever, new-onset confusion, loin, or suprapubic pain. Fever, though the most common symptom, absence of fever does not rule out infection. The Scottish Intercollegiate Guidelines Network (SIGN) recommends follow-up of catheterized patients with fever to be looked for associated localizing loin or suprapubic tenderness or systemic features, exclude other sources of infection, send an appropriate sample of urine for culture, consider empiric antimicrobial therapy as required by clinical presentation and severity and existing comorbid factors if any. Local antimicrobial susceptibility patterns and antimicrobial prescribing guidelines should be the guide for the suggestion of empirical treatment [56, 57, 58].

7. Laboratory findings

Bacteria in urine (bacteriuria) signifies either colonization (asymptomatic bacteriuria) or infection. Bacteriuria is detected in both catheterized and non-catheterized patients. An un-centrifuged sample of urine shows plenty of WBCs with motile or nonmotile bacteria on microscopic examination of urine. It is significant to note that in patients with catheter in situ greater than 30 days, 10–30% will develop bacteriuria compared to 1% of non-catheterized patients [53, 54]. More than 90% of catheter-associated bacteriuria are cases of colonization rather than infection [55]. Definitive diagnosis of CAUTI is not evidence-based [56]. Laboratory criteria for differentiating between CAUTI and asymptomatic bacteriuria have not been established. The use of molecular techniques for not only diagnosis of CAUTI but also for antibiotic sensitivity for treatment may become important in the present scenario. Multiplexed RTPCR probes can be prepared and would be used in these situations. LAMP is another technology that is useful. Pathogenic bacteria can be tested for virulence using specific PCR probes and by surface active proteins known as adhesion proteins [72, 73].

A UTI can be tested by routine urine examination for the presence of bacteria, and inflammatory cells. This could be followed by culture and sensitivity for testing their sensitivity to different antimicrobials. With modern tools, phenotypic and genotypic expressions could be analyzed. Same time secondary bloodstream infections with the same organism detected in the urine could be noted. Their phenotypic and genotypic expression would give the possibility of selection for antibiotic sensitivity or secondary infection with a hospital-acquired organism could be identified. Molecular tools could be helpful in HAI surveillance of CAUTI.

8. Health education and training of HCWs

All HCWs and caregivers require education regarding the insertion and the removal of urinary catheter to prevent infection in the hospital setup. This is a continuous process and should be conducted at regular intervals. A similar education regarding the urinary catheter is to be given to the relatives and patient carers regarding the need for catheterization, catheter maintenance, chance of patient developing CAUTI, and importance of catheter care and how long the patient needs catheterization. They also need to be trained in meatus care with bathing, use of soap and water, and aseptic procedures used. This is not only an education to maintain the catheter in home care, intermittent and self-catheterization but also to induce confidence among the care givers.

8.1 Education for healthcare workers

A number of studies have demonstrated staff education programs can reduce HCAI [217, 218]. Best practice guidelines recommend staff education as a key factor in preventing CAUTI [10, 75, 110, 117, 181]. Education is a continuous process. It is to be done compulsorily at the time of induction of new staff. It should also become a regular education for HCWs. An induction education program should provide information regarding indications for catheterization, safe insertion technique, catheter maintenance, catheter removal, obtaining a urine specimen, and signs and symptoms of urinary infection. Attendance records of education sessions should be maintained.

The retraining education program should include technical topics, such as indications for catheterization, management of catheters, and removal of catheters, when no longer required. Some deficits in the knowledge and practice of HCWs have been identified.

The deficits in knowledge form the need for the next training. Some of the training needs identified include inappropriate use of a drainage tap to collect urine samples, [219] inappropriate use of lubricants for insertion, [220] daily changing of catheter bags [220], and poor documentation of the process [82, 221].

8.2 Education for patients/relatives/carers

Appropriate education of patients, relatives, and carers should focus on the management of urinary catheters, so that they can take part during home care [10, 75, 110, 119]. They should be trained for intermittent catheterization, insertion technique, and care of reusable catheters where appropriate. Support should be available for the entire duration of the catheterization [83].

Well-designed and appropriately written patient educational materials can augment other educational efforts, which ultimately improve patient care [222, 223]. These patient information leaflets should have a description of catheter care, emptying the catheter bag, when the catheter and catheter bag requires to be changed, signs and symptoms of complications (e.g., infection, leakage, and blockage), and whom to contact should complications develop.

9. CAUTI prevention

Numerous guidelines to prevent CAUTI highlight the importance of educational measures for all healthcare professionals [51]. Hand hygiene is the most important preventive step. If a patient is found to be colonized or infected, contact precautions along with a good environmental cleaning to avoid the Multi-Drug Resistant (MDR) organism transmission should be emphasized.

Unnecessary catheter insertion should not be encouraged. Reducing the period of catheterization is a relevant prevention strategy [78].

In a prospective study, initial indication was judged to be inappropriate in 21%, and continued catheterization was judged to be inappropriate for almost one-half of catheter days [80]. Surveillance is important [224]. A nationwide study showed 56% of hospitals were not having a system for monitoring and 74% did not monitor the duration of catheterization. A French prospective interventional study showed a reduction in CAUTI from 10.6 to 1.1 episodes per 100 patients when nurses and physicians were reminded daily to remove unnecessary urinary catheters four days after insertion [154]. It also decreased the incidence of CAUTI from 12.3 to 1.8 per 1000 catheter days. Alternative prevention strategies (use of antimicrobial-coated catheters, catheter irrigation with antimicrobials, antimicrobials in the drainage bag, or prophylaxis with cranberry products) can also be considered but they need more studies. In conclusion, simple practices, such as hand hygiene, limited and judicious use of catheters, and the use of some preventive additive procedures, can prevent CAUTI.

10. Treatment

Treatment of asymptomatic bacteriuria is needed only in pregnant women, before transurethral resection of the prostate or any traumatic genitourinary procedures associated with mucosal bleeding, in immunosuppressed patients, or after the first year of renal transplantation [225]. Treating nonpregnant women is to be considered if there is asymptomatic bacteriuria in the first 48 hours after urinary catheterization. In other cases, antibiotics only eliminate bacteriuria transitorily. Antibiotic administration neither decreases the frequency of symptomatic infection nor prevents further episodes of asymptomatic bacteriuria. Drug pressure could select MDR microorganisms.

Symptomatic bacteriuria needs withdrawal or replacement of the urinary catheter before initiating antibiotics [226]. To choose an empirical treatment, underlying conditions and the local epidemiology should be considered (risk of MDR). Carbapenems should be used in patients with high-risk Multi-Drug Resistant empirical treatment. It is important not to recommend or administer empirical antimicrobial treatment where antibiotics have more than 20% of resistant strains for non-complicated UTIs or 10% for complicated ones (Ex.: Quinolones). Treatment must be adjusted once an antimicrobial susceptibility report is available. Other antimicrobial agents are used in accordance with the aetiological agent involved (yeasts or other bacterial species). Fluconazole is the first-line antifungal agent recommended. Amphotericin B is to be used only when fluconazole resistance is suspected. The optimal treatment duration has been classically 14 days, but this can be shortened up to 5 days if there is an adequate clinical response. Follow-up urine cultures are not needed except if there is no clinical improvement 72 hours after the treatment is started.

MDR microorganisms have emerged as a potential threat to infection control. Piperacillin/tazobactam is not recommended in monotherapy as empirical treatment of CAUTI if Multi-Drug Resistant microorganism is suspected. Carbapenems can be used in monotherapy although higher dose regimens have fosfomycin [227]. Carbapenems with β-lactams/β-lactamase inhibitor combinations (BLBIC) for treatment of bacteremia due to ESBL infections. E. coli had no significant differences in urinary bacteremia or mortality when carbapenems with BLBIC was administered as definitive or empirical treatment. For the treatment of carbapenemases (CBP) Enterobacteriaceae; [228] Klebsiella pneumonia, combination therapy with at least two drugs displaying in vitro activity against the isolate is recommended. Combinations that included meropenem were associated with significantly higher survival rates when the meropenem MIC was ≤8 mg/L. Thus, for the treatment of UTI caused by MDR microorganisms, either monotherapy or bi-therapy should be decided considering the severity of infection, severity of underlying conditions, MIC values, and clinical response. Monotherapy can safely be used when no severity of signs is present. Quinolones and cotrimoxazole can be used safely as a definitive treatment only if MIC is optimal. New drugs like ceftazidime/avibactam and ceftolozane/tazobactam need further studies.

11. Conclusion

The chapter analyzes various aspects from causation to prevention and treatment of CAUTI with detailed literature for each factor involved. It addresses the various views of different researchers on each of the subtopic of catheterization keeping the cost factor also.

The final conclusion is that catheterization is inevitable but used only when it is needed. While using an appropriate method of catheterization, appropriate catheter, simple procedures of asepsis, and keeping it in situ only till the period that is needed are to be kept in mind. If an intermittent catheterization is needed, it should be accepted as the procedure that is needed for that particular patient (patient-centric). To keep patient care as an important priority, the HAI surveillance program is to be adopted by the hospital and carried out regularly and reviewed periodically. Appropriate corrective measures are required to prevent HAI in general and CAUTI in particular.

Acknowledgments

The author wishes to thank the Management of PESIMSR, Kuppam, Andhra Pradesh. India for their support and encouragement to bring out this chapter. The author is also thankful to Dr. Guru Vijay Kumar, Senior Resident, Community Medicine department, PESIMSR, Kuppam, AP for helping in editing the manuscript.

Conflict of interest

There is no conflict of interest in bringing out this chapter.