Application of Catheter-Associated

Urinary Tract Infections Bundles

Essay
Submitted for Partial Fulfillment of Infection Control Diploma
 
 Under Supervision of
Dr. Rania Abdel Halim
Professor of Clinical Pathology
Faculty of medicine
Ain Shams University
 
Project Team Members
Dr. Omneya Kamel
MD Clinical Pathology at Electricity Hospital
Dr. Manal Farouk
MSc Clinical Pathology at El-Helal Hospital
Dr. Fatma EL-Zahraa Kassem
MSc Clinical Pathology at TBRI
Dr. Heba Matar
MSc Clinical Pathology at El-Tahrir hospital
Miss Margret Said
IC member at Italian hospital

Faculty of Medicine Ain Shams University

2020
 Acknowledgement

First of all, all gratitude is due to Allah almighty for blessing this work, until it
has reached its end, as a part of his generous help, throughout our lives.

We wish to express our deepest thanks, gratitude and profound respect to our
honored Professor Dr. Rania Abdel Halim, professor of chemical & clinical
pathology. We consider ourselves fortunate to work under her supervision. Her
constant encouragement and constructive guidance were of paramount importance
for initiation, progress and completion of this work.

We would like to express our sincere thanks to Professor Dr. Shereen El Masry,
professor of chemical and clinical pathology & Professor Dr. Sally Saber, professor
of chemical and clinical pathology for their support, facilities, careful supervision,
continuous advice and guidance which were the cornerstone for this work.

We are also deeply grateful and would like to express our sincere thanks and
gratitude to all Infection Control Department Professors and specially for Professor
Dr. Samia Abdo, head of infection control department, faculty of medicine, Ain
Shams university for dedicating her precious time and kind help to complete this
work.
Introduction
•Healthcare-associated infections (HCAIs) are common complications for hospitalized
patients globally.

• Indwelling devices, such as urinary catheters, increase the risk of infection in critically ill
patients and have been associated with increased mortality, morbidity, length of stay and cost.
Catheter-associated urinary tract infection (CAUTI) is one of the most common device-
related HAIs, accounting for more than 30% of all acute care hospital infections (Snyderet et al.,
2020).

•Urinary tract infections (UTIs) are the fifth most common type of health care associated
infection, Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract.
It has been estimated that each year, more than 13,000 deaths are associated with UTIs as estimated
by Magill et al. (2018).

•Approximately 12%-16% of adult hospitalized patients will have an indwelling urinary catheter
(IUC) at some time during their hospitalization and each day the indwelling urinary catheter
remains a patient has a 3%-7% increased risk of acquiring a catheter-associated urinary tract
infection (CAUTI) (Lo et al., 2014).
•CAUTI can lead to such complications as prostatitis, epididymitis, and orchids in males and
cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic
arthritis, endophthalmitis, meningitis and causing antimicrobial overuse and antimicrobial
resistance (Cortese et al., 2018).
 Aim of Work
 

Objectives:
• explain the problem of CAUTI.
• explain catheter use, occurrence of CAUTI and related risk
factors.
• recognize CAUTI and understand management principles.
• explain evidence-based (multimodal) implementation strategies
for CAUTI
• prevention including appropriate catheter insertion, maintenance
and removal to present the importance of bundle compliance and
ensuring appropriate urethral catheterization to reduce the
incidence of catheter-associated urinary tract infections.
Review of Literature
 
 In developed countries, 5-15% of hospitalized patients and more than 50% of patients in
intensive care units (ICUs) develop healthcare-associated infections (Khan et al., 2015).

 In resource-limited countries, the magnitude of HCAIs is underestimated or unknown due to the

absence of well-established surveillance system. The burden of HCAIs is assumed to be high in
less developed countries because of health-care system deficiencies such as overcrowding in
healthcare settings, understaffing, inadequate infection control practices, and lack of
infection control policies (Chernet et al., 2020).

 Urinary tract infections (UTI) are the commonest healthcare-associated infections (HAI),
accounting for up to 40% of all HAIs.

 Most involve urinary drainage devices, such as bladder catheters.

 The risk of a catheterised patient acquiring bacteriuria increases with the duration of
catheterisation, the daily rate is about 5% so that by 4 weeks almost 100% of patients are
bacteriuria.

 1-4% of patients with bacteriuria will ultimately develop clinically significant infection, e.g.,
cystitis, pyelonephritis, and septicaemia (CDC/HICPAC Guideline, 2010).

 Therefore, urinary catheters must only be inserted when there are clear medical indications as
shown in the following Table.
.Indications for the use of indwelling urinary catheters
Pathogenesis of CAUTI
The bladder is usually sterile because under normal circumstances urethral flora, which tends to
migrate into the bladder, is constantly flushed out during urination. However, when a foreign
body such as a urinary catheter is in place, bacteria (i.e. uropathogens) can enter the bladder
resulting in infection (Cortese et al., 2018).
A urinary catheter can result in the following risks
• Disruption of protective mechanisms against infection e.g. urine flow.
• Damage during insertion exposing the tract to colonization and infection.
• Damage to uroepithelial mucosa exposing binding sites to bacterial adhesions.
• Incomplete voiding of urine from the bladder because of retention of residual urine due to
catheter balloon providing a media for bacterial growth.
• Reflux of contaminated urine from collecting bag.

The source of microorganisms causing CAUTI can be (WHO, 2018):

endogenous—typically via meatal, rectal, or vaginal colonization—
exogenous__ such as via equipment or contaminated hands
of healthcare personnel.
Bacteria may ascend into the tract via the external or internal
surface of the catheter.
External (extraluminal) bacterial ascension:
• Microorganisms colonize the external catheter surface, most
often creating a biofilm
Internal (intraluminal) bacterial ascension:
• Bacteria tend to be introduced when opening the otherwise
closed urinary drainage system.
• Microbes ascend from the urine collection bag into the bladder via reflux.
Multiple factors contribute to CAUTI
The CDC reports that the most frequent pathogens associated with CAUTI in
hospitals reporting to National Healthcare Safety Network were :
• E. coli (21.4%)
• Candida spp. (21.0%)
• Enterococcus spp. (14.9%)
• P. aeruginosa (10.0%)
• K. pneumonia (7.7%)
• Enterobacter spp. (4.1%)
• Acinetobacter baumannii (1,2%).
• A smaller proportion was caused by other gram-negative bacteria and
Staphylococcus spp.(Köves et al 2017).

However, there is increase in CAUTIs caused by more resistant Gram-negative

species, including Klebsiella and Pseudomonas, as well as resistant E.coli.
Similarly, ampicillin-resistant Enterococcus and vancomycin-resistant (VRE) are
becoming common. With additional antibiotic exposure, infections occur with drug
resistant bacteria (e.g., ESBL, CRE, VRE) (WHO, 2018).
.Factors contributing to CAUTI (Köves et al 2017)
The Role of Biofilm:
The introduction of bacteria with urinary catheter use is often associated with catheter-related
biofilms (Cortese et al., 2018).
Biofilms are complex structures : Bacteria , host cells , cellular by-products.

Steps of biofilm formation (Vasdev et al., 2018).

Bacteria living in a biofilm significantly differ from free-floating bacteria, as the dense
extracellular matrix of biofilm and the outer layer of cells may protect the bacteria from
antibiotics and normal host defense mechanisms of the white blood cells, such as
phagocytosis.
Types of catheterization and catheters
1. Indwelling (Foley) catheters.
 urethral (most common) .
 suprapubic (e.g. abdominal stab wound).
2. External catheters (condom catheters/Paul’s tubing) .
3. Short-term (intermittent) catheters .
 
Urinary catheters come in different sizes to accommodate adults and paediatrics and the
anatomical differences between males and females.
Urinary catheters are also available in different materials including latex, silicone (to minimize
biofilm formation; good for latex allergies) (Bhatia et al., 2010).

Definition of CAUTI
The CDC define CAUTI in the National Healthcare Safety Network (NHSN) Manual in 2020 as a
UTI where an indwelling urinary catheter was in place for more than two consecutive days in an
inpatient location on the date of event, with day of device placement being day one, and an
indwelling urinary catheter was in place on the date of event or the day before.
If an indwelling urinary catheter was in place for more than two consecutive days in an inpatient
location and then removed, the date of event for the UTI must be the day of device discontinuation.
 Diagnostic criteria for CAUTI

The Infectious Disease Society of America (IDSA) definition of CAUTI requires all of the following

components (Hooton et al., 2010) :

1. Culture growth of at least 1,000 colony-forming units per ml of a uropathological bacteria

(positive urinary culture by itself does not indicate CAUTI and most often such patients won't

have a CAUTI).

2. Symptoms or signs of a urinary tract infection (e.g., fever, costovertebral angle tenderness,

hypotension).

3. No alternative explanation of these symptoms, despite adequate evaluation.

4. Patient is catheterized for> 48 hours or has had a urinary catheter removed within <48 hours.
.CAUTI diagnostic pathway (Hooton et al., 2010)
Bladder Ultrasonography
• This might be the single most important investigation to perform in a patient with
possible CAUTI.
• The finding of a distended bladder indicates dysfunction of the Foley catheter. This
indicates a real risk of cystitis, pyelonephritis, septic shock, and obstructive renal failure.
• Urinary obstruction is an emergent problem which requires immediate attention (e.g.,
flushing or replacement of the Foley catheter).
• A non-distended bladder indicates normal function of the Foley catheter.
Urinalysis
Bacterial culture
• Over time, most urinary catheters will become colonized with bacteria (asymptomatic
bacteriuria).
• The presence of bacteria doesn't necessarily indicate CAUTI.
• >1,000 bacteria/ml is recommended as a level that may be considered positive by IDSA
guideline. However, most patients with CAUTI will have >100,000 bacteria/ml
Pyuria (>10 WBC/uL) (Shuman and Chenoweth, 2018).
Procalcitonin
• It does appear that procalcitonin>0.5 is sensitive for the detection of UTI with bacteremia
(Yan et al., 2017).
 
 Treatment of CAUTI
• The routine administration of systemic prophylactic antibiotics at the time of catheter
insertion/removal is not recommended as this does not prevent CAUTI, it leads to resistant
bacteria.
• The antibiotic treatment of CAUTIs in the presence of long-term indwelling catheters may not
be successful because the causative bacteria are often embedded in biofilm on the surface of
the catheter and protected from the action of antibiotics (WHO, 2018).

When to start antibiotics?

• For patients with clinical signs of septic shock or neutropenic fever, antibiotic initiation
should not be delayed.
• For patients with an isolated fever, antibiotics should generally be withheld pending
additional investigation (Cunha, 2013).

Selection of antibiotics (Potential empiric regimens):

• Piperacillin-tazobactam is a reasonable initial agent for sicker patients, given
coverage of Pseudomonas and Enterococcus.
• Ceftazidime with a goal of covering pseudomonas, while accepting some gram-
positive coverage.
• Aztreonam good gram-negative coverage, without affecting gram-positive flora.
• Culture and sensitivity information should almost always be available within 48-72
hours. This should allow for narrowing and focusing of antibiotic therapy(Cunha, 2013).
 Prevention of CAUTI
The following four principles and practices are critical for CAUTI prevention WHO (2018):
•  Avoid unnecessary urinary catheters.
• Insert urinary catheters using aseptic technique with hand hygiene must be observed at the right moments as
shown below.
• Maintain urinary catheters based on recommended guidelines.
• Review urinary catheter necessity daily and remove promptly.

Current strategies to prevent CAUTIs are based on the

implementation of a ‘care bundle’.

The 5 Moments for hand hygiene focus on caring

for a patient with a urinary catheter (WHO,2018).
Poster of indwelling urinary catheterization using aseptic Non TouchTechnique (ANTT)
.(WHO, 2018)
Posters showing indications for catheterisation and catheter maintenance
(NHSI, 2020)
Prevention of bacterial colonisation/infection of the bladder in patients with indwelling
urethral catheter
Staff training

Catheter size

Catheter insertion

Meatal cleansing

Drainage bag

Emptying the drainage bag

Bladder irrigation

Condom catheters

Multimodal strategy
.trigger questions
 Conclusion
and
Recommendations
• Make sure that there is an appropriate indication for the indwelling urinary
catheter and Avoid urinary catheterization if possible.
• When feasible, use a two-person team to perform insertion.
• Use sterile equipment and aseptic technique during insertion and
aftercare/maintenance.
• Review the need for the catheter daily and remove as soon as possible when no
longer needed.
• Hand hygiene is critical.
• Don’t change the catheter routinely if it is functioning properly.
• Maintain closed drainage.
• Bladder irrigation/washout and use of antiseptics/antimicrobial agents does not
prevent CAUTI: do not use.
• Empty drainage bag regularly into a clean receptacle used only on one patient.
• The clean receptacle should be changed daily.
• Insert the catheter aseptically using sterile gloves.
• Patients with indwelling urinary catheters do not need antibiotics (including
for asymptomatic bacteriuria), unless they have a documented infection.
 
 References
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https://doi.org/10.4103/0974-777X.62870
• CDC/HICPAC (2009): Guideline for prevenion of catheter-associated urinary tract infecions 2009. CDC, Atlanta: 2010.
htp://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009inal.pdf [Accessed 29 September 2020]
• Chernet, A. Z., Dasta, K., Belachew, F., Zewdu, B., Melese, M., & Ali, M. M. (2020): Burden of Healthcare-Associated Infections and Associated Risk Factors at Adama
Hospital Medical College, Adama, Oromia, Ethiopia. Drug, healthcare and patient safety, 12, 177–185.
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