Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

AND FULL-TEXT SCREENING To identify studies which were a) relevant to one or more key questions b) primary analytic research, systematic review or meta-analysis and c) written in English DATA EXTRACTION AND SYNTHESIS Data abstracted into evidence tables; study quality assessed DRAFT RECOMMENDATIONS Strength of evidence graded; summaries and recommendations drafted FINALIZE RECOMMENDATIONS Recommendations finalized; guideline published


I. EXECUTIVE SUMMARY
This guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) published in 1981. Several developments necessitated revision of the 1981 guideline, including new research and technological advancements for preventing CAUTI, increasing need to address patients in nonacute care settings and patients requiring long-term urinary catheterization, and greater emphasis on prevention initiatives as well as better denned goals and metrics for outcomes and process measures. In addition to updating the previous guideline, this revised guideline reviews the available evidence on CAUTI prevention for patients requiring chronic indwelling catheters and individuals who can be managed with alternative methods of urinary drainage (eg, intermittent catheterization). The revised guideline also includes specific recommendations for implementation, performance measurement, and surveillance. Although the general principles of CAUTI prevention have not changed from the previous version, the revised guideline provides clarification and more specific guidance based oil a defined, systematic review of the literature through July 2007. For areas where knowledge gaps exist, recommendations for further research are listed. Finally, the revised guideline outlines high-priority recommendations for CAUTI prevention in order to offer guidance for implementation.
This document is intended for use by infection prevention staff, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection prevention and control programs for healthcare settings across the continuum of care. The guideline can also be used as a resource for societies or organizations that wish to develop more detailed implementation guidance for prevention of CAUTI.
Our goal was to develop a guideline based on a targeted systematic review of the best available evidence, with explicit links between the evidence and recommendations. To accomplish this, we used an adapted GRADE system approach for evaluating quality of evidence and determining strength of recommendations. The methodology, structure, and components of this guideline are approved by HICPAC and will be used for subsequent guidelines issued by HICPAC. A more detailed description of our approach is available in the Methods section.
To evaluate the evidence on preventing CAUTI, we examined data addressing three key questions and related subquestions: 1.  3. What are the best practices for preventing CAUTI associated with obstructed urinary catheters? Evidence addressing the key questions was used to formulate recommendations, and explicit links between the evidence and recommendations are available in the Evidence Review in the body of the guideline and Evidence Tables and GRADE Tables in the Appendices. It is important to note that Category I recommendations are all considered strong recommendations and should be equally implemented; it is only the quality of the evidence underlying the recommendation that distinguishes between levels A and B. Category IC recommendations are required by state or federal regulation and may have any level of supporting evidence. The categorization scheme used in this guideline is presented in Table 1 in the Summary of Recommendations and described further in the Methods section.
The Summary of Recommendations is organized as follows: (1) recommendations for who should receive indwelling urinary catheters (or, for certain populations, alternatives to indwelling catheters); (2) recommendations for catheter insertion; (3) recommendations for catheter maintenance; (4) quality improvement programs to achieve appropriate placement, care, and removal of catheters; (5) administrative infrastructure required; and (6) surveillance strategies.
The Implementation and Audit section includes a prioritization of recommendations (ie, high-priority recommendations that are essential for every healthcare facility), organized by modules, in order to provide facilities more guidance on implementation of these guidelines. A list of recommended performance measures that can potentially be used for internal reporting purposes is also included.
Areas in need of further research identified during the evidence review are outlined in the Recommendations for Further Research. This section includes guidance for specific methodological approaches that should be used in future studies.
Readers who wish to examine the primary evidence underlying the recommendations are referred to the Evidence Review in the body of the guideline, and the Evidence Tables and GRADE Tables in the Appendices. The Evidence Review includes narrative summaries of the data presented in the Evidence Tables and GRADE Tables. The Evidence Tables include all study-level data used in the guideline, and the GRADE Tables assess the overall quality of evidence for each question. The Appendices also contain a clearly delineated search strategy that will be used for periodic updates to ensure that the guideline remains a timely resource as new information becomes available.

I. Appropriate Urinary Catheter Use
A. Insert catheters only for appropriate indications (see Table 2 for guidance), and leave in place only as long as needed. (Category IB) (Key Questions IB and 2C) 1. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and patients with impaired immunity. ( L. Further research is needed on the use of bacterial interference (ie, bladder inoculation with a nonpathogenic bacterial strain) to prevent UTI in patients requiring chronic urinary catheterization. (No recommendation/unresolved issue) (Key Question 2C)

Catheter Materials
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). (Category IB) (Key Question 2B) 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. (

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

Spatial Separation of Catheterized Patients
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) (Key Question 2D)

IV. Quality Improvement Programs
A. Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment. (Category IB) (Key Question 2D) 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 (eg, 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 perioperative catheter management, such as: a. Procedure-specific guidelines for catheter placement and postoperative catheter removal.
b. Protocols for management of postoperative urinary retention, such as nurse-directed use of intermittent catheterization and use of bladder ultrasound scanners.

V. Administrative Infrastructure
A. Provision of guidelines 1. Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance. (Category IB) a. Consider monitoring adherence to facility-based criteria for acceptable indications for indwelling urinary catheter use. (Category II) B. Education and Training 1. Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters. (Category IB) 2. When feasible, consider providing performance feedback to these personnel on what proportion of catheters they have placed meet facility-based criteria and other aspects related to catheter care and maintenance.

Prioritization of Recommendations
In this section, the recommendations considered essential for all healthcare facilities caring for patients requiring urinary catheterization are organized into modules in order to provide more guidance to facilities on implementation of these guidelines. The high-priority recommendations were chosen by a consensus of experts based on strength of recommendation as well as on the likely impact of the strategy in preventing CAUTI. The administrative functions and infrastructure listed above in the summary of recommendations are necessary to accomplish the high priority recommendations and are therefore critical to the success of a prevention program. In addition, quality improvement programs should be implemented as an active approach to accomplishing these recommendations and when process and outcome measure goals are not being met based on internal reporting. a. Rates of CAUTI: Use NHSN definitions (see http://www.cdc.gov/nhsn/library.html). Measurement of rates allows an individual facility to gauge the longitudinal impact of implementation of prevention strategies: • Numerator: number of CAUTIs in each location monitored • Denominator: total number of urinary catheterdays for all patients that have an indwelling urinary catheter in each location monitored • Standardization factor: Multiply by 1,000 so that the measure is expressed as cases per 1,000 catheter-days • b. Rate of bloodstream infections secondary to CAUTI: Use NHSN definitions for laboratory-confirmed bloodstream infection, available at http:// www.cdc.gov/nhsn/library.html.
• Numerator: number of episodes of bloodstream infections secondary to CAUTI • Denominator: total number of urinary catheterdays for all patients that have an indwelling urinary catheter in each location monitored • Standardization factor: Multiply by 1,000 so that the measure is expressed as cases per 1,000 catheter-days • B. External Reporting. Current NHSN definitions for CAUTI were developed for monitoring of rates within a facility; however, reporting of CAUTI rates for facility-to-facility comparison might be requested by state requirements and external quality initiatives.