Catheter-Associated Urinary Tract Infections (CAUTI)

Urinary tract infections related to the attachment of a urinary catheter are the most common type of infections that affect patients confined in a hospital. They are also known as nosocomial infections. Catheter-associated urinary tract infections (CA-UTI) are caused by the aggregation of microorganisms that subsequently secrete a glue-like substance called a biofilm that serves as a substrate for movement and transport of materials. A biofilm develops around the tubing of the catheter that is inserted into the urinary tract of a patient. An infection due to this medical device is often diagnosed based on the detection of disease-causing bacteria in the urine of the patient, which is medically described as bacteriuria.

Background

CA-UTIs are one of the most frequent nosocomial infections, accounting for approximately 80 percent of reported cases. Recent reports have shown that a urinary catheter is the most frequently used indwelling device, representing around 18 percent of patients confined in 66 European-based hospitals, and almost 25 percent of 183 hospitals based in the United States. In 2011, it has been determined that 45–80 percent of adult patients in critical care, 17 percent of patients in the regular medical wards, 23 percent of patients admitted to the surgical wards, as well as 9 percent of patients treated in rehabilitation units had an indwelling catheter attached. These findings indicate that urinary catheters are extensively used in healthcare facilities.

Urinary catheters are generally described according to its duration of use. For example, short-term urinary catheters are often utilized for less than 30 days, whereas long-term catheters are attached for more than 30 days. Furthermore, short-term urinary catheters are employed in acute care health facilities, whereas chronic urinary catheters are commonly used for patients admitted to long-term healthcare facilities. In addition, the clinical and microbiologic descriptors for infections associated with urinary catheters also vary in terms of duration of use. For example, patients that have acquired an infection in relation to a urinary catheter but do not manifest any symptoms of infection except for its presence in their urine are diagnosed with catheter-acquired asymptomatic bacteriuria (CA-ASB). On the other hand, those who present symptoms of infection that are associated with the use of a urinary catheter are described to have CA-UTI.

Although the number of bacteriuric patients who present symptoms of infection is relatively low, the high utilization rate of urinary catheters indicates that there is a significant burden attributable to these particular infections. CA-UTIs represent 20 percent of nosocomial infections in acute care health facilities, and at least 50 percent of that in long-term healthcare facilities. They also represent approximately 75 percent of all UTIs acquired in the hospital, according to the Centers for Disease Control and Prevention. Studies have shown that the most effective approach in preventing bacteriuria and other nosocomial infections is to minimize the use of indwelling catheters. However, when a catheter has been determined to be necessary for the treatment of a patient who is confined in a healthcare facility, this should be discontinued as soon as the patient shows recovery and improvement. Healthcare facilities have also designed and implemented strategies to monitor as well as limit the use of catheters, thereby reducing the frequency of CA-UTIs. These monitoring strategies not only include the use of catheters, but also indicators of urinary tract infections that occur during catheter usage, and subsequent complications that develop from the attachment of a catheter in a patient. Developing catheters consisting of novel materials that prevent the formation of biofilms are also envisioned to prevent CA-UTIs.

Impact

Several evidence-based guidelines have now been established to prevent the occurrence of CA-UTI, which include avoiding the use of catheters, implementation of policies regarding the insertion as well as maintenance of catheters, establishment of criteria in selecting the appropriate catheter for a particular patient, surveillance of CA-UTI, proper use of the selected catheter, and identification of indicators of health progress in a patient who received a catheter. Any changes in the incidence of CA-UTIs after the implementation of these institutional preventative programs are then reported in order to determine whether these guidelines are indeed effective in controlling the incidence of CA-UTI. The prevention program should also be customized according to the conditions of the local environment, features of the population it serves, as well as accessible resources. Effective senior leadership also largely contributes to the success of a CA-UTI preventative program.

Healthcare facilities have also evaluated and improved infrastructure in order to monitor and prevent the occurrence of CA-UTIs. In addition to policies governing the selection, insertion, and maintenance of catheters in a patient, the staff of the healthcare institution should also be educated on the etiology, treatment, and prevention of CA-UTIs. The healthcare facility should also have sufficient staff members who will follow the developed guidelines on preventing the occurrence of catheter-related infections. For example, documenting the date of insertion of the catheter in each patient as well as removal may help hospital staff determine whether this particular medical device has been in use for an extended period of time. Recent reports have shown that by following this specific guideline of documenting dates relating to the use of catheters has significantly reduced the incidence of CA-UTIs by almost 40 percent in developing countries. It is also therefore assumed that a similar reduction in the number of CA-UTI cases would result from improved criteria for the selection of catheters for each patient.

One activity that has been observed to decrease the number of CA-UTI cases in hospitals is the attachment of a catheter with the smallest possible gauge. This particular catheter feature not only minimizes the occurrence of CA-UTIs, but also decreases urethral trauma in the patient. On the other hand, studies have shown that the major components of catheters have no significant effect on the incidence of urinary tract infections. For example, similar incidence rates for CA-UTIs were observed using catheters consisting of latex and silicone. In addition, the presence of hydrogel that coats the external surface of a catheter also does not change the incidence rate of CA-UTIs.

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