Clinical Notes : Urology

90. Catheter-associated urinary tract infections (CAUTI)

In the OOH setting the on-call GP is most likely to be called upon to :

A. change a blocked indwelling catheter. and prevent a catheter-associated UTI (CAUTI)

B. Manage a catheter-associated UTI (CAUTI)

 

A. In the context of prevention :

 

Avoid urinary catheterisation :

Limit the use of urinary catheters to carefully selected patients and remove a urinary catheter promptly, when no longer required.

  • The presence of a urinary catheter and the length of time it remains in situ are contributory factors to the development of a catheter-associated urinary tract infection

  • It has been estimated that the risk of acquiring an infection increases by 5% each day the catheter remains in situ.

 

Indications for catheterisation :

  • In the OOH setting

    • For patient comfort during end of life care.

    • To relieve acute urinary retention or bladder outlet obstruction.

    • To assist healing of an open sacral or perineal wound.

    • As an exception, at patient request to improve comfort

    • As an exception, at patient request to improve comfort.

  • In the hospital setting (may be carried through to residential care on discharge, and hence into an OOH setting)

    • To assist in achieving patient immobilisation (e.g., required for unstable thoracic, lumbar spine or pelvic fractures).

    • To monitor urinary output (e.g., in critically ill patients or when a patient is unable or unwilling to collect urine).

    • During prolonged surgical procedures with general or spinal anaesthesia.

    • During regional analgesia for labour and delivery.

    • To allow instillation of drugs or during urology investigations (e.g., cystogram).

 

Method of catheterisation :

  • Intermittent catheterisation should be used in preference to an indwelling catheter if it is clinically appropriate and a practical solution.

 

Type of catheter :

  • Use a catheter with the smallest gauge suitable for the patient’s needs.

 

Insertion of urinary catheters :

  • Apply Standard Precautions when inserting urinary catheters

  • Antiseptic hand hygiene should be performed immediately before insertion of the catheter.

  • Sterile saline or sterile water solution should be used to cleanse the urethral meatus.

  • The indication for and procedure of insertion of a urinary catheter should be clearly documented in the patient’s medical chart.

 
 
 
 
 
 

Inserting a catheter

 

Catheter insertion

Step by step pictorial guide to catheter insertion

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Management of short-term and long-term indwelling urinary catheters :

  • Apply Standard Precautions when caring for patients with a urinary catheter insitu.

  • A closed drainage system should be used for all patients with an indwelling catheter.

  • Using a pre-connected urinary catheter and drainage bag may reduce CAUTI.

  • The drainage bag should be maintained below the level of the bladder and secured to the leg (leg bag) or a catheter stand to avoid contamination of the drainage tap..

  • Single-use sterile drainage bags (including night drainage bags) should be used with indwelling urinary catheter drainage systems.

  • Catheter specimens of urine should only be taken when clinically indicated.

 

  • Ensure that a protocol is in place to :

  • Empty the drainage bag regularly, using a clean container for each patient. Avoid touching the drainage tap with the container

  • The meatal area and suprapubic insertion site (once healed) should be cleaned daily using soap and water.

  • An aseptic technique should be used for intermittent irrigation (e.g., flushing or instillation of drugs).

 
 

Catheter Care

Emptying a Catheter Bag

 

Removal of indwelling catheters :

Short-term catheters (in situ less than 28 days)

  • Ensure indwelling catheters are removed promptly when no longer required

  • Long-term catheters (in situ greater than 28 days).

  • Regularly review the need for long-term catheterisation.

  • Change catheters used for long-term catheterisation as per the manufacturer’s instructions and individual patient requirements (e.g., before blockage occurs or is likely to occur).

 

In the OOH setting, when

1. the clinical reason for insertion

2. short term removal instructions and long term review instructions

are not clearly documented,

request that the attending regular GP provide these for the record.

 

Antibiotic prophylaxis

  • There is no role for routine antibiotic prophylaxis in patients with urinary catheters.

  • Prophylactic use of antibiotics upon change or instrumentation of urinary catheters (both short and long­term) are not indicated in the majority of patients.

 

Patient information

Where indicated in the home setting, provide a patient information leaflet..

 
 
 
 

Indwelling Urinary Catheters

Advice and support to patients and carers about indwelling urinary catheters

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B. In the context of management of CAUTI

 

It has been estimated than more that 90% of catheter-associated bacteriuria may reflect colonisation rather than infection.

However a definitive diagnosis of CAUTI is not evidence-based.

Laboratory criteria for differentiating between CAUTI and asymptomatic bacteriuria have not been established.

Clinicians rely on a combination of clinical signs and symptoms in addition to laboratory-confirmed bacteriuria to reach a diagnosis of CAUTI.

 

Pathogenesis :

The most common organisms to cause CAUTI derive from the patient’s perineal flora or from the hands of HCWs; these organisms may include:

  • Escherichia coli,

  • Enterococcus spp.,

  • Pseudomonas spp.

  • Klebsiella spp.

  • Enterobacter spp.

  • Candida spp.

 

Risk factors for acquiring CAUTI :

  • Duration of catheterisation

  • Underlying neurological disease

  • Female gender

  • Diabetes mellitus

 

Diagnosis and Management :

Look for Clinical signs and symptoms of CAUTI :

  • fever

    • the absence of fever does not rule out infection

  • new-onset confusion

  • loin or supra-pubic pain

  • Send an appropriately taken urine sample for culture to determine the infecting organisms and the antimicrobial susceptibility pattern of any organisms identified.

  • Consider empiric antimicrobial therapy if clinically indicated taking into account

    • the severity of the presentation,

    • any co-morbid factors

    • the local antimicrobial susceptibility patterns

    • antimicrobial prescribing guidelines

 
 
 
 
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journals.png

Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.

Lo E, Nicolle L, et al.

Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S41-S50.

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Management of suspected bacterial urinary tract infection in adults. A national Clinical Guideline.

Scottish Intercollegiate Guideline Network.

Published 2006.

Updated 2022

view/access

Catheter-associated urinary tract infection: what is it, what causes it and how can we prevent it?

Elvy J, Colville A.

Journal of Infection Prevention 2009 Mar 1;10(2):36-41.

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Guideline for prevention of catheter-associated urinary tract infections 2009.

Gould CV, Umscheid CA, Agarwai RK, Kuntz G, Pesueo DA. (2009).

Centre of Disease Control . 2009.

view/access

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.

Hooton TM,  et al.

Clin Infect Dis 2010 Mar 1;50(5):625-63.

view/access

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