Catheter-associated Urinary Tract Infections
Introduction
Catheter-associated urinary tract infections (CAUTI) is one of the most common infections acquired by patients in health care centers. This infection is associated with the use of a urinary catheter, which is a latex or silicone tube inserted into the bladder through the urethra. The primary purpose of a catheter is to facilitate drainage of urine from the bladder when there is a blockage due to kidney stones or postrenal infection. It is also used in the treatment of bladder-related conditions and when there is urinary incontinence due to spinal cord injury. Elderly patients and individuals with impaired immunity are at high risk of acquiring CAUTI.
Significance of CAUTI
According to research, more than 560,000 patients suffer from CAUTI annually, which leads to increased patient morbidity and mortality, increased hospital cost, and extended length of hospital stay (Parker et al., 2019). Also, urinary tract infections (UTI) account for about 36% of infections in hospitals, and CAUTI accounts for 80% of UTIs. Hospitalized adult inpatients are bound to have an indwelling urinary catheter, which increases their risk of acquiring CAUTI between 3%-7% (Parker et al., 2019). UTIs are also prevalent in nursing homes where the majority of the bacteremias are catheter-related. The cumulative burden of infections due to catheters results in infection-related complications and deaths. Therefore, the prevalence of urinary catheter use among patients in long-term care facilities should prompt caregivers to prioritize the unnecessary transfer of infections through catheters.
Current Healthcare Practices Related To CAUTI
There are evidence-based infection-prevention practices that reduce the rate of CAUTI. One of these practices is improved hand hygiene when handling a patient with a urinary catheter. Most caregivers clean their hands before manipulating a urinary catheter or a drainage system before the aseptic procedure and after touching a patient with CAUTI. Hand hygiene prevents contamination of the catheter that is interested in the patient and prevents the transmission of infection to the caregivers and other patients. Closed drainage in aseptically inserted catheters is also a safety practice that increases infection control’s efficacy (Parker et al., 2019). Furthermore, catheters must be cleaned and sterilized regularly, and they may be coated with antimicrobial or antibacterial to prevent infections.
Timely-catheter removal is a practice that is being embraced by a majority of health caregivers. Prolonged catheter removal causes discomfort, bleeding, and pain to a patient. Also, when a catheter stays inserted for longer than necessary, it poses a risk to urinary tract infections (Parker et al., 2019). In contrast, early removal of an indwelling urinary catheter, especially after surgery, results in complications and an increased risk of UTI. Another practice that is applied in this area is the minimization of catheter use in patients at risk of CAUTI and mortality. Reducing unnecessary catheter use reduces the number of UTIs in hospitals and nursing homes. Alternatives to indwelling catheters are useful in lowering CAUTI, for example, intermittent catheterization, external condom catheters, and suprapubic catheters. Also, computerized reminders have been used to increase physician awareness of when to remove catheters.
Values, Health Behaviors, and Preferences Associated with CAUTI
The prevalence of CAUTI affects a patient’s health behaviors and preferences and health care practices. For example, some patients perceive that the catheters are convenient in helping them reduce movements; others feel that the catheter is uncomfortable, while others feel that their mobility is restricted due to the indwelling catheter (Parker et al., 2019). The cultural background of patients influences their perspectives about urinary catheters. For example, most CAUTI patients do not have adequate knowledge about the consequences of indwelling catheters and alternative methods of excretion (Parker et al., 2019). The cultural background also affects their values, beliefs, attitudes, and assumptions about the use of catheters. On the other hand, health care providers are putting in more effort to engage patients so that they become aware of the use of catheters. Despite integrating patient engagement and awareness programs, health care providers are implementing practices that reduce infection associated with hospitalization. Health care workers should provide education to patients about catheter-associated risks. They should also undergo training to help them employ proper practices in handling CAUTI patients. There are organizational values that associate the use of catheters with certain patient characteristics such as type of illness, age, and surgical stay.
Literature Review
Research Evidence 1
Various interventions can be implemented to prevent catheter-associated urinary tract infections. According to Fisher (2015), priorities for prevention of CAUTI include physician reminder projects, nurse-driven protocols for removal of catheters, catheter maintenance, and alternatives to catheterization. Physician reminder projects help physicians discontinue indwelling catheters in patients and consequently prevent them from acquiring CAUTI. Catheters would be discontinued after four days of being inserted in a patient (Fisher, 2015). The discontinuation would be done with the help of nurses who would assess Foley catheters’ necessity, especially in ICU patients. This intervention was proven to be useful in reducing unnecessary urinary catheter utilization. The nurse-driven protocols enabled nurses to discontinue indwelling catheters without a physician (Fisher, 2015). This intervention was done after training nurses, and the results showed that there was a decrease in Escherichia coli present in the patient’s urine. E.coli was the pathogen responsible for UTI. Catheter maintenance is vital in CAUTI prevention. Maintenance guidelines included; use of sterile gloves and antiseptics when cleaning urethral meatus, using a closed drainage system, observing hygiene before and after manipulating the catheter apparatus, and regular emptying of the collection bag (Fisher, 2015). Alternatives to catheterization in this research were condom catheters, bladder scanning, and use of intermittent catheterization.
Research Evidence 2
According to Flores-Mireles et al. (2019), understanding the pathogen prevalence and differential mechanisms that cause CAUTI is essential in developing treatment and prevention measures of CAUTI. The research states that CAUTI often leads to secondary bloodstream infections (Flores-Mireles et al., 2019). The duration of indwelling catheterization is a risk factor that causes bacteriuria. A catheterized bladder creates an environment for infection by opportunistic microbes. Also, mechanical damage caused by catheters causes fibrinogen to accumulate in the bladder, which may eventually lead to microbial colonization responsible for CAUTI (Flores-Mireles et al., 2019). Escherichia coli is the predominant uropathogen responsible for CAUTI, and it leads to antibiotic resistance. In this research, antibiotic resistance makes it difficult to treat CAUTI and states that antimicrobial prophylaxis is not recommended during catheter removal (Flores-Mireles et al., 2019). However, this research proposes reducing the use of urinary catheters, especially in patients who are at a higher risk of acquiring CAUTI. It also suggests the use of antimicrobial-coated urinary catheters since biofilm formation causes microbes to resist antibiotic action (Flores-Mireles et al., 2019). Silicon catheters are suitable for long-term catheterization in patients since they prevent biofilm formation.
Non-research evidence 1
According to Connor (2018), CAUTI incidences have risen despite the study of various prevention strategies. In this article, he says there is a better need for documentation to monitor and assess patients under catheterization. Furthermore, he recommends that nurses should use small antimicrobial catheters, document catheterization duration, and develop a reminder system to alert physicians about patient catheter removal (Connor, 2018). Catheters should be discontinued unless there is an appropriate reason for continuing, such as urinary obstruction, urologic surgery, palliative care for terminally ill patients, and instances where soiling can impair healing such as sacral surgery (Connor, 2018). Other interventions proposed in this article are; clinical education and training to reevaluate patient needs, improving safety culture by eliminating the norm that encourages catheterization for specific patients and application of care maintenance bundles.
Connor (2018), highlights that CAUTI is caused by the entry of pathogens through environmental contact or contact with hospital personnel. Bacteria may enter the urinary tract through the catheter lumen, during insertion or through external contact. Bacteria gets firmly attached to the catheter wall due to the surface of the indwelling catheter, which facilitates microbial adhesion (Connor, 2018). This phenomenon causes the formation of biofilm by bacteria, which promotes bacterial growth and antibiotic resistance. The bacteria in the biofilm are virtually impossible to destroy if the catheter is indwelling (Connor, 2018). Another disadvantage of indwelling catheters mentioned is an inflammatory response around the urethral neck and bladder. Trauma may occur to the urinary epithelium, thus compromising the ability of a patient’s bladder to fight bacteria.
Non-research evidence 2
According to Cortese et al. (2018), the primary challenge of indwelling catheters is encrustation and biofilm formation. Encrustation result from long-term urinary catheterization and cause problems during catheter removal. The encrustations that occur on the outer surface are extraluminal and lead to infections upon removal. Encrustations on the inner surface are intraluminal and can impair the balloon’s deflation during catheter removal or lead to urine retention, which is painful to a patient. However, encrustations can occur due to metabolic dysfunction (Cortese et al., 2018). On the other hand, he explains biofilms as microorganisms which bind to catheters.
The organisms within the biofilm are responsible for causing CAUTI, and using urinary catheters for long increases the ability of these organisms to cause CAUTI. Also, the biofilm facilitates gene expression of the microorganisms, which makes them resistant to antimicrobial agents (Cortese et al., 2018). Cortese recommends in vitro urinary tract models can be used to promote research and development for CAUTI prevention. He highlights the role of Escherichia coli in CAUTI. The mobility of E.coli facilitates its movement into the bladder, which can be a potential cause of kidney infections. In vitro tests can help doctors understand the structure of the urinary tract and use them in clinical testing (Cortese et al., 2018). This method is advantageous because it offers intersample variability; it is less time consuming and relatively low in cost.
PICO QUESTION
Does antimicrobial/antiseptic solutions effectively reduce catheter acquired urinary tract infections compared to other hygiene measures?
Problem- catheter acquired urinary tract infections (CAUTI)
Intervention- antimicrobial/antiseptic solutions
Comparison- other hygiene measures
Outcome- reduce CAUTI
Article
1
2
3
4
5
Author, Journal, Year
Mitchell et al (2017) Reducing catheter-associated urinary tract infections in hospitals
Andrade & Fernandez (2016) Prevention of catheter-associated urinary tract infection
Menegueti et al (2019) Long-term prevention of catheter-associated urinary tract infections
Henry (2018)
Evaluation of evidence-based practice of catheter-associated urinary tract infections prevention in a critical care setting
Wang et al (2019) In-vitro antibacterial and anti-encrustation performance of silver-polytetrafluoroethylene nanocomposite coated urinary catheters.
Research design
Experimental
Systematic Review
Quasi-experimental
Systematic review
Experimental
Sample size
A randomized trial in three large hospitals for 32 weeks
13 articles
Patients in a general intensive care unit for 12 years
20 articles
103 cells/mL
Outcome variables
Chlorhexidine in meatal cleaning
Urinary catheterization
CAUTI incidences in general intensive care units
CAUTI prevention practices
Ag-PTFE coated Foley catheters
Quality
B
A/B
A
B
A
Results & Conclusion
The use of Chlorhexidine solution for meatal cleaning before catheter insertion was found to be effective in infection control and cost-effectiveness. This study also showed that antiseptic meatal cleaning agents were more effective in preventing CAUTI than non-antiseptic cleaning agents. The use of Chlorhexidine is cost-effective because it reduces the number of bed-days of patients
Reminder systems were useful in reminding nurses about the necessity of indwelling catheters and prompt removal. The removal time of catheters was based on appropriate indicators in the application bundles for CAUTI prevention. Bundle in CAUTI prevention is a set of interventions for patients who are under inherent risks, and the Institute for Healthcare Improvement developed them.
Insertion techniques and maintenance of catheters were necessary practices in reducing CAUTI. The most successful maintenance of catheters was based on an evidence-based algorithm for UC maintenance.
Health Care workers (HCWs) Training and implementation of checklists for patients with urinary catheters reduce rates of CAUTI in ICU units. Other practices that reduce infection were; education of clinical staff, feedback on CAUTI prevention practices, and active surveillance of CAUTI patients. Documentation of the necessity of using catheters helped nurses evaluate the indication and need for catheters, thus reducing unnecessary catheter use.
Analyzed data from the literature showed that lack of compliance of CAUTI infection control practices causes CAUTI prevalence among patients. Nurse education and knowledge improvement is essential in reducing the rate of CAUTI.
The evidence from the analyzed data showed that best practices to reduce CAUTI rates were; use of urine cultures to identify CAUTI, reducing the use of indwelling catheters, hand washing by nurses handling CAUTI patients and use of CAUTI prevention bundles.
The findings showed that there is need for Ag-PTFE coated Foley catheters to undergo clinical trials to determine their ability to prevent CAUTI. Coated catheters inhibit biofilm formation on external catheter surfaces. The results showed that coated catheters inhibited the migration of E.coli along the external surface of the catheter. However, E.coli was found to take two days to cause bacteriuria. Coated catheters also reduced encrustation but did not inhibit the increase of bacterial density.
Recommended Practices for the PICO Question
The findings from the research study show that there are various safety practices to reduce the rate of CAUTI. However, the methods employed should incorporate hygiene and antimicrobial interventions to realize positive outcomes. Since most urinary catheters are made of latex, polyurethane, and silicon, studies show that these materials exhibit weak chemical resistance and cause the formation of biofilms. Coated urinary catheters have been studied to be useful in preventing the risk of CAUTI (Wang et al., 2019). For example, coating a UCs with antimicrobial substances prevents the growth of pathogenic microbes. Antimicrobial agents inhibit the colonization of antimicrobial agents in various ways. These include; preventing adherence of microbes, releasing antimicrobial agents, disrupting biofilms on catheters and contact killing. According to Mitchell et al. (2017), chlorhexidine is an antiseptic with antibacterial properties used in the coating of UCs. Silver-polytetrafluoroethylene (Ag-PTFE) coating provides antibacterial and antiadhesive qualities in UCs (Wang et al., 2019). These qualities are useful in the prevention of infection by E.coli and S.aureus. The intense antibiofilm activity of Ag-PTFE reduces biofilm formation by 97.4% compared to commercial silicone catheters (Wang et al., 2019). In addition, these coating depicts efficacy in preventing bacteriuria. I would recommend the adoption of Ag-PTFE coated UCs and further in-vitro testing to determine its biocompatibility with the human bladder.
Hospitals need to have specific instructions for catheter use on their patients. For example, short-term catheters should be used for a maximum of two days, while long term catheters should be used for a maximum of 28 days. Standard protocols for insertion, maintenance, and removal of catheters must be implemented and followed to improve patient safety (Henry, 2018). These protocols are vital in preventing microbial contamination that cause CAUTI. In-vitro models should be employed when researching CAUTI prevention measures due to their advantages and convenience of time-saving. Ensuring that medical professionals are up to date with sustainable practices to prevent CAUTI is crucial for reducing infections.
Process for Implementing Practice Change
Implementing safety practices that reduce CAUTI will require the involvement of stakeholders, strategies, and indicators to measure the outcome. I identified three key stakeholders as geriatricians, nurses, and infection prevention and control practitioners. Geriatricians are essential stakeholders because elderly patients at a higher risk of CAUTI. Also, older adults mostly require UCs due to impairment of body functions and the long periods of stay in health care facilities or nursing homes. Nurses are at the core of CAUTI prevention because they are primarily involved with monitoring and attending to patients using UCs (Andrade & Fernandes, 2016). Nurses are also responsible for recommending removal and discontinuation of catheters to physicians (Henry, 2018). Therefore, they should be equipped with knowledge on how to handle patients with UCs and how to recommend alternatives to UCs.
Since CAUTI accounts for 30% of hospital-acquired infections, infection prevention and control practitioners should focus on implementing prevention strategies and guidelines to minimize infection rates. They should also be involved in research concerning CAUTI and factors that contribute to its spreading. Implementing the recommended strategies may face barriers such as hospital culture of unnecessary catheter use, non-compliant nurses who lack sufficient knowledge on CAUTI, lack of implementing bundles for CAUTI prevention by hospitals, and insufficient evidence on proper UC practices. If these obstacles are overcome, an indicator measure that can be used to measure the outcome is evaluation of the number of CAUTI cases in hospitals and nursing homes.
References
Andrade, VLF, & Fernandes, FAV (2016). Prevention of catheter-associated urinary tract infection: implementation strategies of international guidelines. Latin-American magazine of enfermagem , 24 .
Connor, B. (2018). Best Practices: CAUTI Prevention. American Nurses Association.
Cortese, Y. J., Wagner, V. E., Tierney, M., Devine, D., & Fogarty, A. (2018). Review of catheter-associated urinary tract infections and in vitro urinary tract models. Journal of healthcare engineering, 2018.
Fisher, J. (2015). Preventing catheter associated urinary tract infections: implementation of a nurse driven catheter removal protocol and education program (Doctoral dissertation).
Flores-Mireles, A., Hreha, T. N., & Hunstad, D. A. (2019). Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection. Topics in spinal cord injury rehabilitation, 25(3), 228-240.
Henry, M. (2018). Evaluation of evidence-based practice of catheter associated urinary tract infections prevention in a critical care setting: An integrative review. Journal of Nursing Education and Practice, 8(7).
Menegueti, M. G., Ciol, M. A., Bellissimo-Rodrigues, F., Auxiliadora-Martins, M., Gaspar, G. G., da Silva Canini, S. R. M.,& Laus, A. M. (2019). Long-term prevention of catheter- associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study. Medicine, 98(8).
Mitchell, B. G., Fasugba, O., Gardner, A., Koerner, J., Collignon, P., Cheng, A. C., & Gregory, V. (2017). Reducing catheter-associated urinary tract infections in hospitals: study protocol for a multi-site randomised controlled study. BMJ open, 7(11), e018871.
Parker, V., Giles, M., Graham, L., Suthers, B., Watts, W., O’Brien, T., & Searles, A. (2017). Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): a pre-post control intervention study. BMC health services research, 17(1), 314.
Wang, L., Zhang, S., Keatch, R., Corner, G., Nabi, G., Murdoch, S., & Zhao, Q. (2019). In- vitro antibacterial and anti-encrustation performance of silver-polytetrafluoroethylene nanocomposite coated urinary catheters. Journal of Hospital Infection, 103(1), 55-63.