Risk Factors

Preventable risk factors include contamination, the duration of catheterization, slow detection of bacteriuria, fecal incontinence, limited training of the person inserting the catheter, and inadvertent system disconnection. Other risk factors related to CAUTI include female gender, older age, antibiotics given within three days, a history of malignant cancer, diabetes, renal disease, neutropenia, impaired immunity or immune-suppressing therapy within two weeks, corticosteroids within seven days, and smoking within the past five years.

Prevention

It has been suggested that avoiding unnecessary use and prompt removal of catheters as soon as it is indicated may be the most important strategy to preventing CAUTI. Therefore, prevention may concentrate on assuring that catheters are used only for appropriate indications, are properly maintained, and are removed in a timely manner when indicated. Each of the stages of catheter use can be targeted for specific prevention strategies: insertion, care, removal, and reinsertion. It is suggested to assure that only properly trained persons using appropriate technique, including hand hygiene, should be allowed to insert and maintain catheters. The use of antibiotic or antiseptic impregnated catheters, sterile equipment and technique, and maintenance of a closed system are also among core strategies. Maintenance to prevent UTIs will include monitoring to assure the continuation of unobstructed urine flow.

In addition, alternatives with lower risks for infection could be considered. For instance, intermittent or external catheters (eg condom catheters) may be considered in some cases. The use of gender appropriate devices, absorbent products, and proper toileting programs may help to prevent CAUTI.  

In healthcare facilities, the use of wipes is indicated rather than bath basins. However, it should be noted that these alternatives have not yielded evidence of decreased incidence of CAUTI where they have been studied (eg ICUs, burn units, trauma units, or medical/surgical units). A “bladder bundle” that includes education, restriction and removal protocols, building skill levels in catheter techniques, and using technology (eg ultrasound scanners to reduce unnecessary catheterization and re-catheterization) can all help to reduce the risk for infection.

CAUTI guidelines and tools are offered by several agencies, including the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC), the Agency for Healthcare Research and Quality (AHRQ), and the American Nurses Association (ANA).

Generally, treatment options include a review of prevention strategies and protocols. For instance, removing unnecessary catheters or removing those left in (or even forgotten) beyond the appropriate length of time may be the first steps. Management of fecal incontinence will also be important, should that be an issue. The use of antimicrobial medications is only recommended for symptomatic infections according to the pathogen’s sensitivities. Antimicrobial treatment is not recommended in cases of asymptomatic CA-bacteriuria (except in circumstances involving plans for invasive urinary tract interventions). Bladder instillations of antimicrobials are also not recommended. In cases of candida infections, consideration for the removal of a catheter should be made, but antifungal therapies are not recommended. In some cases, the use of bladder inoculation with non-pathogenic bacteria to compete with and reduce symptoms can be used with success.

CAUTI is an important complication that should be prevented and/or treated in order to prevent adverse health and economic consequences. Because signs and symptoms have a low predictive value in diagnosing CAUTI, careful consideration of other causes for signs and symptoms should be made. In older adults, less typical presentation of CAUTI may include some nonspecific symptoms, including cognitive changes, loss of appetite, weakness and lethargy, increased respiratory rate, and hypotension. There may also be an inability to mount a fever response and some patients may even exhibit hypothermia. These may not be as apparent as signs of CAUTI due to lower baseline temperatures, multiple types of medications (corticosteroids, antibiotics, antipyretics, and chemotherapy), and several medical conditions (eg malnutrition, alcoholism, renal insufficiency, and hypothyroidism). Repeated measures of temperatures may be helpful in recognizing the inability to mount a fever response, such as low-grade fevers and increases over baseline. CAUTI can also be a cause of secondary bloodstream infections.

With mortality rates of 14-19%, CAUTI accounts for more than 13,000 deaths per year. In fact, patients with urinary tract infections (or UTIs) are three times more at risk for death than those without UTIs. Interestingly, between 17% and 69% of infections and about 9,000 deaths could be prevented each year.7