The Infectious Diseases Society of America has released its newest guidelines on CAUTI’s “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 2010). The guidelines were developed in collaboration with multiple other specialty societies. The recommendations are presented in the first few pages, then reiterated with summaries of the evidence for each recommendation in the rest of the document.
These guidelines reinforce most of the important concepts that have been put forward in 2 other recent guidelines on CAUTI: (1) CDC HICPAC’s “Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009” (Gould 2009) and (2) “Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals” (Lo 2008) that is part of the Hospital Acquired Infections Compendium in the supplement to October 2008 issue of Infection Control & Hospital Epidemiology.
As in all the guidelines, the IDSA CAUTI guideline stresses that the most effective way to reduce the occurrence of CAUTI is to reduce the use of urinary catheterization, both by restricting catheterization to appropriate indications and by limiting duration of catheterization to the minimum time needed. Each facility should develop a list of appropriate indications, educate all healthcare workers on those indications, require a physician’s order for catheterization, and monitor closely compliance with these indications. Particularly for post-operative patients facilities should consider use of portable bladder ultrasound scanners to determine whether catheterization is necessary. Their list of acceptable indications:
Most importantly, the guideline stresses that indwelling urethral catheters should not be used for management of incontinence except under very unique circumstances, such as for comfort in terminally ill patients in whom less invasive measures are inadequate.
To minimize duration of urinary catheterization in those cases with legitimate indications, facilities should consider nurse-based discontinuation protocols or electronic physician reminder systems or automatic stop-orders.
In our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” we again offered the following suggestion: treat the Foley catheter like a drug! Have it ordered through your CPOE or medication ordering system. That column lists out some of the potential benefits of using such a system such as:
In our April 21 column we also noted that one of the problems with failure to remove indwelling urethral catheters postoperatively may be that the OR IT systems are often poorly integrated with the other hospital IT systems. The other problem is that multiple handoffs occur in the perioperative patient. They typically go from a med/surg floor (or pre-op intake area) to the OR, then to the PACU or recovery room, then back to a med/surg floor or ICU. We strongly recommend that your structured handoff tools include a specific item related to indwelling urethral catheters.
The IDSA CAUTI guideline also stresses that screening for asymptomatic bacteruria in the catheterized patients should not be done, except in certain selected clinical situations such as pregnant women. Testing becomes indicated when patients have signs or symptoms suggestive of urinary tract infection.
They have good sections on proper techniques for urinary catheter insertion and maintenance of catheter drainage systems and on alternatives to indwelling urethral catheter use (such as intermittent catheterization and suprapubic catheterization). They also have good recommendations of interventions that should not be routinely used.
And don’t forget our other columns on urinary catheter-associated UTI’s:
Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010; 50: 625-663
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. CDC.
Lo E, Nicolle L, Classen D, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29:S41–S50
Hospital Acquired Infections Compendium. In supplement to October issue of Infection Control & Hospital Epidemiology 2008; 29: 901-994