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1 A PRINTED copy of this guideline may not be the most recent version. The OFFICIAL version is located on IHNET at the Policies & Procedures Home Page IX0200: Prevention & Control of Catheter Associated Urinary Tract Infections (CAUTI) EFFECTIVE DATE: September 2006 REVISED DATE: November 2010 February 2015 REVIEWED DATE: 1.0 PURPOSE To provide evidence-based practice guidance for the prevention of Urinary Tract Infection and Catheter-Associated Urinary Tract Infection (CAUTI) in hospital, residential and community settings. 2.0 GUIDING PRINCIPLES 2.1 UTIs are the most common healthcare associated infection (HAI) in acute and residential care and contributes to increased mortality and costs (diagnostic tests, antibiotics, and increased length of stay). Asymptomatic bacteriuria is common especially in the elderly and almost 100% in catheterized individuals. The presence of a urinary catheter provides a direct entry for microorganisms into the urinary tract, either along the outside of the catheter, from the inside of the catheter itself, from a contaminated collection bag or from a break in the urinary drainage system. The chance of infection increases 5-7% for every day a catheter is left in. 3.0 SIGNS AND SYMPTOMS of UTI/CAUTI Typical Symptoms (No Indwelling Catheter) Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate OR two of the following: Fever or leukocytosis Acute costovertebral angle pain Suprapubic pain Gross hematuria New or increase in incontinence New or increase in urgency New or increase in frequency time Typical Symptoms (Indwelling Catheter) Fever, rigors OR new onset hypotension, with no alternate site of infection Acute change in mental status or acute functional decline with no alternate diagnosis AND leukocytosis (WBC > 14,000) New onset suprapubic pain or costovertebral angle pain or tenderness Purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis, or prostate UTI Assessment Tool Infection Prevention & Control-IX0200 Page 1

2 4.0 OBTAINING A URINE SPECIMEN FOR CULTURE A physician order is required Obtain urine samples aseptically The specimen of choice is a clean catch or midstream urine specimen If a voided specimen cannot be obtained, a specimen collected from a freshly applied condom catheter is suitable for men and in and out catheterization is suitable for women. For patients with an indwelling catheter (>=14 days) who are suspected of having a UTI, remove existing catheter and insert a new catheter and collect specimen. For patients with an indwelling catheter (<14 days) take specimen from sampling port on drainage tubing - clean port with alcohol swab and use sterile needle to obtain urine sample; do not obtain specimen from drainage bag. Note: Collect the urine sample prior to administration of antibiotics. Repeat testing after completion of antibiotic therapy is NOT indicated unless signs and symptoms of a UTI persist or recur. Do not collect urine samples in the absence of UTI symptoms. Dipstick is not recommended to diagnose UTIs. A negative dipstick test indicates the absence of a UTI. Re-assess patient for other causes of symptoms. A positive dipstick contact physician regarding symptoms and need for C&S. 5.0 PREVENTION OF NON CATHETER RELATED URINARY TRACT INFECTIONS 5.1 Ensure proper hydration and nutrition Educate residents, healthcare providers, and families on the importance of hydration and urinary health Offer a variety of fluids throughout the day and during social activities 5.2 Provide good perineal hygiene Perineal hygiene with mild soap and water should be done daily, and after episodes of bowel incontinence Assist or remind patients with good personal hygiene including handwashing 5.3 Promote healthy voiding habits Ensure that any issues with constipation or fecal impaction are addressed Completely emptying the bladder is best accomplished by providing a relaxed voiding environment Consider regular prompting to encourage voiding for adults with urinary incontinence 6.0 PREVENTION OF CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTIs) 6.1 Appropriate Reasons for Indwelling Catheter Infection Prevention & Control-IX0200 Page 2

3 6.2 Alternatives to indwelling catheters Alternative nursing measures to avoid urinary catheterization Regular toileting schedule Bedside commode, urinal, or continence garments: to manage incontinence Bladder Scanner: to assess and confirm urinary retention, prior to placing catheter In-Out Catheter: for one-time, intermittent, or chronic voiding needs. 4 in-out caths = same infection risk as 1 indwelling catheter External condom catheter: appropriate for cooperative men without urinary retention or obstruction 6.3 Catheter Care Best Practice to Prevent CautIs Catheterization should only be done for specific, appropriate medical reasons Consider alternatives Remove catheter as soon as possible assess daily Hand hygiene immediately before and after insertion or any manipulation of the catheter Aseptic technique for catheter insertions Ensure properly trained persons, including family members or patients themselves, know the correct technique of aseptic catheter insertion and maintenance Secure catheters to prevent movement and urethral traction Use smallest bore catheter possible to minimize urethral trauma Maintain a closed system Change catheters based on clinical indications such as infection, obstruction or when the closed system is compromised ** Note: catheters should not be left in longer than 12 weeks due to breakdown of the catheter material. Refer to manufacture s recommendation. Infection Prevention & Control-IX0200 Page 3

4 Daily cleaning of periurethral area with soap and water (antiseptics are not necessary) Avoid obstruction to urinary flow: o Keep drainage bag below bladder level at all times o Ensure no kinks in tubing o Empty drainage bag regularly and/or when 2/3 full Keep catheter bag off of the floor Urinary catheter irrigation is not recommended as it can push debris farther up the urinary tract. (Continuous irrigation maybe necessary for tissue/clots obstructing drainage after prostatic or bladder surgery as per physician s order). 6.4 Procedure See Clinical Practice Standard and Procedure on Urinary Catheters in Adults: Insertion, Care/Maintenance and Removal, May REFERENCES 7.1 Association for Professionals in Infection Control and Epidemiology. (2014). Guide to Preventing Catheter-Associated Urinary Tract Infections Gould et al. Healthcare Infection Control Practices Advisory Committee (HICPAC): Healthcare Infection Control Practices Advisory Committee. (2009) Guideline for Prevention of Catheter-Associated Urinary Tract Infections. 7.3 Stone et al. Society for Healthcare Epidemiology Long-Term Care Special Interest Group: SHEA/CDC Position Paper. (2012). Surveillance Definition of Infections in Long Term Care Facilities: Revisiting the McGeer Criteria. 7.4 Smith et al. SHEA/APIC Guideline (2008). Infection prevention and control in the long-term care facility. American Journal of Infection Control, 36: Saskatchewan Infection Prevention and Control Program (2013). Guidelines for the Prevention and Treatment of Urinary Tract Infections (UTIs) in Continuing Care Settings. 7.6 Toward Optimized Practice Program and Do Bugs Need Drugs (2010). Guideline for the Diagnosis and Management of Urinary Tract Infections in Long Term Care. Infection Prevention & Control-IX0200 Page 4

5 Appendix A Urinary Tract Infections Infection Prevention & Control-IX0200 Page 5

6 Appendix B Glossary Aseptic Technique use of sterile equipment, e.g. gloves, drapes, sponges and catheter, a sterile or antiseptic solution and sterile lubricant for insertion Asymptomatic Bacteruia the presence of bacteria in the urine of persons who do not have dysuria, frequency, urgency, fever, flank pain, or other symptoms related to infection of the urethra, bladder or kidney Bacteruria presence of bacteria in the urine; patients are often asymptomatic and do not require antibiotic treatment or prophylaxis. Catheter-Associated Urinary Tract Infection (CAUTI) includes those infections in which a patient has/had an indwelling urinary catheter in place. A urinary catheter provides a portal of entry into the urinary tract. Bacteria may ascend into the tract via either the external or internal surface of the catheter. Condom Catheter a soft flexible sheath that fits over the penis and is attached to a urinary drainage bag; used for bladder management instead of an indwelling foley catheter. Indwelling Urinary Catheter a drainage tube that is inserted into the bladder through the urethra, is left in place, and is connected to a closed drainage system. Intermittent ( in-and-out ) Catheterization involves brief insertion of a catheter into the bladder through the urethra to drain urine at intervals; used for bladder management with para and quadriplegic patients. Suprapubic Catheter a catheter that is surgically inserted into the bladder through an incision above the pubis. Urinary Tract Infection (UTI) a symptomatic bladder infection characterized by frequency, urgency, dysuria, or suprapubic pain and/or hematuria AND >=10⁵ CFU/ml of any organism. Definition for CAUTI must have one of the following: Fever, rigors or new onset hypotension with no alternate site of infection Acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis New onset suprapubic pain or costovertebral angle pain or tenderness Purulent discharge from around the catheter or acute pain, swelling or tenderness of the testes, epididymis, or prostate AND Urine culture>10⁵ CFU/ml of any organism(s)-specimen obtained after catheter replaced if in >14 days OR Positive blood and urine culture with the same organism without an alternate source Infection Prevention & Control-IX0200 Page 6

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