Prevention of
Catheter-Associated
Urinary Tract
Infections
1. Describe the relevance of urinary tract
infections in health care institutions.
2. Identify risk factors for urinary tract
infections.
3. Describe measures for prevention.
December 1, 2013
Learning objectives
2
• 50 minutes
December 1, 2013
Time involved
3
• Up to 40% of all HAIs
• Most involve urinary catheterisation
• Risk of bacteriuria
December 1, 2013
Introduction
• 5% per day during the first week to almost 100% at 4
weeks of catheterisation
• 1 to 4% of patients with bacteriuria will
develop infection
4
December 1, 2013
Urinary tract sites commonly
associated with infection
5
• Urine is an ultrafiltrate of blood, is normally
sterile
• Small numbers of perineal/ vaginal/bowel
microorganisms in the distal urethra
• Constantly washed out by micturition
December 1, 2013
Urine
• Bacteriuria = bacteria in the urine
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• Specimen contamination reduced by
• Cleaning external urethral area before collection
• Collecting mid-stream urines
• Urethral bacteria washed out in the first part of the stream
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Collection of urine
• Processing specimen promptly, or refrigerating, to
prevent overgrowth of contaminants
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• Urine must be processed promptly
• Contaminants can multiply at room temperature and
give falsely high colony counts
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Laboratory diagnosis
• If delay expected, transport the specimen in an
ice box or add boric acid (1% W/V or 1 g/10 ml
of urine)
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• Usually endogenous microorganisms
• E. coli and Proteus commonest in community
infections
• Catheter-associated UTI (CAUTI)
December 1, 2013
Microbiology
• E. coli commonest
• Increasingly caused by resistant species
• Klebsiella, Pseudomonas, Enterococcus and multiply drug
resistant ESBL, VRE
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Organism
December 1, 2013
Bacteria Causing UTIs (%)
Community Hospital
E. coli
Proteus
Klebsiella
Entero/Citro
Pseudomonas
Acinetobacter
80-90
5-8
1-2
45-55
10-12
15-20
2-5
10-15
<1
Coag -ve staph
Staph aureus
Enterococci
1-2
1-2
<1
10-12
<1
10
10
December 1, 2013
Microbiological support
• The diagnosis of UTI depends on the
microbiological support available
• In patients with indwelling catheters, infections
frequently polymicrobial
• Presence of multiple bacteria does not necessarily
indicate contamination
11
11
• Small numbers of bacteria are insignificant
• True infections have large numbers in bladder
urine
• Microbiology labs count the number of bacteria in a
urine specimen as ‘colony-forming units’ (cfu)
• Significant bacteriuria gives a >95% likelihood of true
UTI
December 1, 2013
Quantitative bacteriology
• ≥100,000 cfu/mL urine in 2 carefully-collected mid-stream
urines (MSUs)
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December 1, 2013
Urethral bacteria contaminate
specimens, small numbers
- -
-
- -
Incubation
Contamination
-
---
-
-
102 -103 cfu/mL
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• When large numbers of bacteria (>105/mL) in
specimens of bladder urine & evidence of true
UTI
December 1, 2013
Significant bacteriuria
• Smaller (insignificant) numbers may be due to
contamination of the urine specimen during collection
- urine has to pass through urethra
• Contamination can come from perineum/genitalia
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December 1, 2013
True UTI with significant bacteriuria
-
-
- -
-
- -
Infection
Infection
Natural
incubation
between
micturitions
- - - - - - - - -- -- - - - - - - -- - - - ---
- - - - -- - - - - - - - -- - - - -
>105 cfu/mL
bacteria in bladder urine multiply to high numbers before collection
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Number of patients
103 - 104
900
800
700
600
500
400
300
200
100
0
PROBABLE
Mainly Gram+ves
CONTAMINATION
mixed species
December 1, 2013
Quantitative microbiology
distinguishes between true UTI &
contamination or overgrowth
104 - 105
PROBABLE
Mainly GramGram-ves
INFECTION
single species
NOT INFECTED
10
1
10
2
INFECTED
3
10
10
4
10 5
Bacteria/mL
10
6
10
7
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• In non-catheterised patients:
• Fever, supra-pubic tenderness, frequency, dysuria
• Pyuria
• Positive nitrite reaction and a positive leukocyte
esterase reaction
December 1, 2013
Clinical diagnosis
• In catheterised patients
• Fever and leukocytosis or leucopenia additional
diagnostic criteria
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• Surveillance of CAUTI in selected patients
• e.g. intensive care or surgical
• Definition may be obtained:
December 1, 2013
Definition and Surveillance
• USA CDC/NHSN
• Centers for Disease Control and Prevention/ National
Healthcare Safety Network
• HELICS
• Hospital in Europe for Link Infection Control through
Surveillance
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• Normally urethral flora flushed out
• With catheterisation, flushing mechanism
circumvented
• Flora can pass up through catheter or from
drainage bag
• Hands of personnel may contaminate the system
during insertion or management
December 1, 2013
Pathogenesis of a CatheterAssociated UTI
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from Damani N N, Keyes JK. Infection Control Manual, 2004
December 1, 2013
Four main sites through which
bacteria may reach the bladder
in a catheterised patient
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Care bundle approach
• Evidence-based interventions
• When implemented together result in reduction in
CAUTIs
December 1, 2013
Principles to Prevent UTI - 1
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Staff training
• Training on procedures for insertion and
maintenance of urinary catheters based on local
written protocols
December 1, 2013
Principles to Prevent UTI - 2
Catheter size
• Smallest diameter catheter that allows free flow of
urine
22
Antimicrobial coated catheters
• Reduce asymptomatic bacteriuria
• For placement less than 1 week
December 1, 2013
Principles to Prevent UTI - 3
• No evidence they decrease symptomatic infections
• Should not be used routinely
• Should be considered in selected high risk patients
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Catheter insertion and care
•
•
•
•
Sterile equipment and aseptic technique
Sterile lubricant or local anaesthetic gel
Meatal cleansing with soap and water
Antimicrobial ointment harmful
December 1, 2013
Principles to Prevent UTI - 4
• Should be avoided
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Drainage tubing and bag
•Secure to the patient
•Catheter drainage bag below the bladder
•Bag and tap not in contact with the floor
•Clamp drainage during movements
•Not disconnect the drainage bag
•Bag emptied when ¾ full
•Hand hygiene
•Alcohol impregnated swabs
•No disinfectant added to bag
December 1, 2013
Principles to Prevent UTI - 5
25
Specimen collection
• Samples from the port
• Aseptic technique
• Disinfection of port with
alcohol
• Sterile needle, syringe,
container
• Never a sample from the bag.
• No routine testing
December 1, 2013
Principles to Prevent UTI - 6
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Antimicrobial agents
• Routine administration not recommended
• Single dose prophylactic may be used in selected
patients
• No routine use while the catheter in situ
• Treatment may not be successful
December 1, 2013
Principles to Prevent UTI - 7
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Condom catheters
• May be used for short-term drainage
• Frequent changes
• Removed if irritation or skin
breakdown
• Condom for 24 hour continuous use
should be avoided
December 1, 2013
Principles to Prevent UTI - 8
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• Avoid urinary catheterisation
• not for incontinence
• consider intermittent catheterisation
• Remove catheters as soon as possible
• Aseptic technique and sterile equipment
• Don’t change catheters routinely
• Closed drainage system
• No irrigation or instillation
• Empty drainage bag
December 1, 2013
Key points
29
1.
2.
3.
APIC Elimination Guide: Guide to the Elimination of CatheterAssociated Urinary Tract Infections (CA-UTIs); Developing and
applying facility-based prevention interventions in acute and
long-term care settings, 2008.
http://www.apic.org/Content/NavigationMenu/PracticeGuidance
/APIC EliminationGuides/CAUTI_Guide.pdf
HICPAC. Guidelines for prevention of Catheter-associated Urinary
Tract infections 2009. Atlanta, GA: CDC, 2009.
http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html
European and Asian guidelines on management and prevention
of catheter-associated urinary tract infections. Intern J
Antimicrobial Agents 2008: 31S; S68-S78.
http://www.escmid.org/fileadmin/src/media/PDFs/4ESCMID_Lib
rary/2Medical_Guidelines/other_guidelines/Euro_Asian_UTI_Gui
delines_ISC.pdf
December 1, 2013
References
30
4.
5.
6.
SHEA /IDSA Practice Recommendation: Strategies to Prevent
Catheter-Associated Urinary Tract Infections in Acute Care Hospitals.
Infect Control Hospital Epidemiol 2008; 29 (Supplement 1): S 41-S50.
http://www.jstor.org/stable/10.1086/591066
High Impact Intervention No 6. Urinary Catheter Care Bundle.
London, Department of Health, 2007.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@
dh/@en/documents/digitalasset/dh_078125.pdf
UK Dept. of Health epic2: Guidelines for preventing infections
associated with the use of short-term urethral catheters. J Hospital
Infect 2007; 65S: S28-S33. http://www.vidyya.com/2pdfs/0124
infection.pdf
December 1, 2013
References
31
7.
8.
Infectious Diseases Society of America Guidelines. Diagnosis,
Prevention, and Treatment of Catheter-Associated Urinary Tract
Infection in Adults: 2009 International Clinical Practice
Guidelines from the Infectious Diseases Society of America. Clin
Infect Dis 2010; 50:625–663.
http://www.idsociety.org/content.aspx?id=4430#uti
December 1, 2013
References
32
1.
2.
Incontinence is an indication for urinary catheterisation. T/F?
For a general strategy to prevent UTI, what measure you would
consider first:
a)
b)
c)
d)
3.
Treatment of infected patients
Avoid unnecessary catheterisation
Replacement permanent catheterisation for intermittent
Use of condom catheters
December 1, 2013
Quiz
Regarding prevention of UTI, which of the following is
incorrect
a)
b)
c)
d)
Keep system closed
Hand hygiene before insertion/management of urinary devices
Maintain catheter drainage bag below the bladder
Use of antimicrobial prophylaxis in patients with urinary
catheterisation
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• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
December 1, 2013
International Federation of
Infection Control
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