Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009
Urinary tract infections are the most common type of healthcare-associated infection, accounting for more than 30% of infections reported by acute care hospitals.19 Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay.6-9 In addition, bacteriuria commonly leads to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients.10,11
An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system. Alternative methods of urinary drainage may be employed in some patients. Intermittent ("in-and-out") catheterization involves brief insertion of a catheter into the bladder through the urethra to drain urine at intervals. An external catheter is a urine containment device that fits over or adheres to the genitalia and is attached to a urinary drainage bag. The most commonly used external catheter is a soft flexible sheath that fits over the penis ("condom" catheter). A suprapubic catheter is surgically inserted into the bladder through an incision above the pubis.
Although UTIs associated with alternative urinary drainage systems are considered device-associated, CAUTI rates reported to the National Healthcare Safety Network (NHSN) only refer to those associated with indwelling urinary catheters. NHSN has recently revised the UTI surveillance definition criteria. Among the changes are removal of the asymptomatic bacteriuria (ASB) criterion and refinement of the criteria for defining symptomatic UTI (SUTI). The time period for follow-up surveillance after catheter removal also has been shortened from 7 days to 48 hours to align with other device-associated infections. The new UTI criteria, which took effect in January 2009, can be found in the NHSN Patient Safety Manual (http://www.cdc.gov/nhsn/library.html).
The limitations and heterogeneity of definitions of CAUTI used in various studies present major challenges in appraising the quality of evidence in the CAUTI literature. Study investigators have used numerous different definitions for CAUTI outcomes, ranging from simple bacteriuria at a range of concentrations to, less commonly, symptomatic infection defined by combinations of bacteriuria and various signs and symptoms. Futhermore, most studies that used CDC/NHSN definitions for CAUTI did not distinguish between SUTI and ASB in their analyses.30 The heterogeneity of definitions used for CAUTI may reduce the quality of evidence for a given intervention and often precludes meta-analyses.
The clinical significance of ASB in catheterized patients is undefined. Approximately 75% to 90% of patients with ASB do not develop a systemic inflammatory response or other signs or symptoms to suggest infection.6,31 Monitoring and treatment of ASB is also not an effective prevention measure for SUTI, as most cases of SUTI are not preceded by bacteriuria for more than a day.25 Treatment of ASB has not been shown to be clinically beneficial and is associated with the selection of antimicrobial-resistant organisms.
Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters.12,13 In many cases, catheters are placed for inappropriate indications, and healthcare providers are often unaware that their patients have catheters, leading to prolonged, unnecessary use.14-16 In acute care hospitals reporting to NHSN in 2006, pooled mean urinary catheter utilization ratios in ICU and non-ICU areas ranged from 0.23-0.91 urinary catheter-days/patient-days.17 While the numbers of units reporting were small, the highest ratios were in trauma ICUs and the lowest in inpatient medical/surgical wards. The overall prevalence of long-term indwelling urethral catheterization use is unknown. The prevalence of urinary catheter use in residents in long-term care facilities in the United States is on the order of 5%, representing approximately 50,000 residents with catheters at any given time.18 This number appears to be declining over time, likely because of federally mandated nursing home quality measures. However, the high prevalence of urinary catheters in patients transferred to skilled nursing facilities suggests that acute care hospitals should focus more efforts on removing unnecessary catheters prior to transfer.18
Reported rates of UTI among patients with urinary catheters vary substantially. National data from NHSN acute care hospitals in 2006 showed a range of pooled mean CAUTI rates of 3.1-7.5 infections per 1000 catheter-days.17 The highest rates were in burn ICUs, followed by inpatient medical wards and neurosurgical ICUs, although these sites also had the fewest numbers of locations reporting. The lowest rates were in medical/surgical ICUs.
Although morbidity and mortality from CAUTI is considered to be relatively low compared to other HAIs, the high prevalence of urinary catheter use leads to a large cumulative burden of infections with resulting infectious complications and deaths. An estimate of annual incidence of HAIs and mortality in 2002, based on a broad survey of US hospitals, found that urinary tract infections made up the highest number of infections (> 560,000) compared to other HAIs, and attributable deaths from UTI were estimated to be over 13,000 (mortality rate 2.3%).19 And while fewer than 5% of bacteriuric cases develop bacteremia,6 CAUTI is the leading cause of secondary nosocomial bloodstream infections; about 17% of hospital-acquired bacteremias are from a urinary source, with an associated mortality of approximately 10%.20 In the nursing home setting, bacteremias are most commonly caused by UTIs, the majority of which are catheter-related.21
An estimated 17% to 69% of CAUTI may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9000 deaths related to CAUTI per year could be prevented.22
Pathogenesis and Microbiology
The source of microorganisms causing CAUTI can be endogenous, typically via meatal, rectal, or vaginal colonization, or exogenous, such as via contaminated hands of healthcare personnel or equipment. Microbial pathogens can enter the urinary tract either by the extraluminal route, via migration along the outside of the catheter in the periurethral mucous sheath, or by the intraluminal route, via movement along the internal lumen of the catheter from a contaminated collection bag or catheter-drainage tube junction. The relative contribution of each route in the pathogenesis of CAUTI is not well known. The marked reduction in risk of bacteriuria with the introduction of the sterile, closed urinary drainage system in the 1960's23 suggests the importance of the intraluminal route. However, even with the closed drainage system, bacteriuria inevitably occurs over time either via breaks in the sterile system or via the extraluminal route.24 The daily risk of bacteriuria with catheterization is 3% to 10%,25,26 approaching 100% after 30 days, which is considered the delineation between short and long-term catheterization.27
Formation of biofilms by urinary pathogens on the surface of the catheter and drainage system occurs universally with prolonged duration of catheterization.28 Over time, the urinary catheter becomes colonized with microorganisms living in a sessile state within the biofilm, rendering them resistant to antimicrobials and host defenses and virtually impossible to eradicate without removing the catheter. The role of bacteria within biofilms in the pathogenesis of CAUTI is unknown and is an area requiring further research.
The most frequent pathogens associated with CAUTI (combining both ASB and SUTI) in hospitals reporting to NHSN between 2006-2007 were Escherichia coli (21.4%) and Candida spp (21.0%), followed by Enterococcus spp (14.9%), Pseudomonas aeruginosa (10.0%), Klebsiella pneumoniae (7.7%), and Enterobacter spp (4.1%). A smaller proportion was caused by other gram-negative bacteria and Staphylococcus spp 5.
Antimicrobial resistance among urinary pathogens is an ever increasing problem. About a quarter of E. coli isolates and one third of P. aeruginosa isolates from CAUTI cases were fluoroquinolone-resistant. Resistance of gram-negative pathogens to other agents, including third-generation cephalosporins and carbapenems, was also substantial 5. The proportion of organisms that were multidrug-resistant, defined by non-susceptibility to all agents in 4 classes, was 4% of P. aeruginosa, 9% of K. pneumoniae, and 21% of Acinetobacter baumannii. 29