A skeleton key to the new UTI guidelines

Cutting through the thicket of recommendations

The Centers for Disease Control and Prevention has completed a massive update and revision of its 1981 guidelines to prevent catheter-associated urinary tract infections (CA-UTIs).1 A painstaking review of reams of evidence — even the appendix is 268 pages long — boils down to some of the common-sense measures that many infection preventionists on the front lines are already practicing.

"When you look at the guidelines in general, the primary strategy is trying to minimize urinary catheter use — that's definitely where we have focused our efforts. And once they are in there — get them out as quick as possible," says Titus Daniels, MD, MPH, associate hospital epidemiologist at Vanderbilt University Medical Center in Nashville, TN. "One of the things we have found successful is to make this a nursing directed initiative so they can remove them whenever the patient no longer needs them rather than waiting for the physician to actually write an order. It gives the nurses a lot of ownership."

Indeed, the new CDC guidelines specifically recommend establishing "protocols for nurse-directed removal of unnecessary urinary catheters" as one of the quality improvement projects recommended for reducing CA-UTIs.

Sanjay Saint"It would be a good idea to initiate quality improvement projects for hospitals focusing on CA-UTIs for a couple of reasons," says Sanjay Saint, MD, MPH, a health care epidemiologist at the University of Michigan Health System in Ann Arbor. "The first reason is that now we actually have some evidence about what we should be doing based on these HICPAC guidelines and other [guidelines and articles.] Not only to prevent CA-UTIs, but noninfectious complications associated with indwelling catheters."

This does not have to approach rocket science to be successful. For example, IPs at one hospital reduced the mean duration of catheterization from 4.5 days to 2.8 days after adding a bright yellow sticker to the patient's chart that requested a few pieces of information: Does the patient have an indwelling urinary catheter? If so, when was it inserted and how long has it been in place? A statement to "Please consider if the IUC is still necessary" was the sticker's concluding reminder.

"The nurses took ownership of it and they were very involved in it," says Judy Ptak, RN, MSN, infection preventionist at Dartmouth-Hitchcock Medical Center in Lebanon, NH. "It was coming from them. That was one of the keys."

The nurses still need to confer with the doctors on removing the catheter but the prompt moves the process forward at the hospital, which is now considering incorporating the approach as part of its switch to an electronic charting system, she notes.

In any case, hospitals will take particular note of the CDC UTI guidelines because there is, to put it bluntly, money at stake. The Centers for Medicare & Medicaid Services (CMS) has reduced reimbursements for additional costs generated by CA-UTIs in 2008.

"Hospitals now have more of a financial stake in the prevention of CA-UTIs," Saint says. "Given the long time lag between the previous CDC CA-UTI recommendations, people are now looking to operationalize these guidelines. This guideline, like most guidelines, primarily gives an assessment of the evidence, which is very important because that is the starting point. With so much data, it's impractical to expect IPs and hospital epidemiologists to do their own literature searches and evidence review. The CDC has done that, given a grade to evidence, and done it in a fairly transparent way."

Between 15% and 25% of hospitalized patients may receive short-term indwelling urinary catheters, the CDC notes in the guidelines. In many cases, catheters are placed for inappropriate indications, and health care providers are often unaware that their patients have catheters, leading to prolonged, unnecessary use. In particular, the prevalence of urinary catheter use in residents in long-term care facilities in the United States is on the order of 5%, representing approximately 50,000 residents with catheters at any given time. The high prevalence of urinary catheters in patients transferred to skilled nursing facilities suggests that acute care hospitals should focus more efforts on removing unnecessary catheters prior to transfer, the CDC advises.

Although morbidity and mortality from CA-UTI is considered to be relatively low compared to other HAIs, the high prevalence of urinary catheter use leads to a large cumulative burden of infections with resulting infectious complications and deaths. An estimate of annual incidence of HAIs and mortality in 2002, based on a broad survey of U.S. hospitals, found that urinary tract infections made up the highest number of infections (> 560,000) compared to other HAIs, and attributable deaths from UTI were estimated to be over 13,000 (mortality rate 2.3%). And while fewer than 5% of bacteriuric cases develop bacteremia, CA-UTI is the leading cause of secondary nosocomial bloodstream infections; about 17% of hospital-acquired bacteremias are from a urinary source, with an associated mortality of approximately 10%.

The source of microorganisms causing CA-UTI can be endogenous, typically via meatal, rectal, or vaginal colonization, or exogenous, such as via contaminated hands of health care personnel or equipment. Microbial pathogens can enter the urinary tract either by the extraluminal route, via migration along the outside of the catheter in the periurethral mucous sheath, or by the intraluminal route, via movement along the internal lumen of the catheter from a contaminated collection bag or catheter-drainage tube junction. Again, the key appears to be avoiding unnecessary catheterization in the first place and then removing those appropriately placed catheters as quickly as possible after they are no longer needed.

Cutting through the thicket of recommendations and references, Saint says IPs can best implement the CDC guidelines by taking an elementary "ABCDE" approach. That's the way I distill it down," says Saint, an expert on CA-UTI prevention who has reviewed the CDC guidelines and similar recommendations by other medical groups. Here are Saint's alphabetic essentials:

  • A is for Adherence: "Adherence to generally accepted infection control principles — hand hygiene, education, feedback, aseptic insertion technique, surveillance. Those types of activities."
  • B is for Bladder ultrasound to avoid placing an unnecessary indwelling catheter.
  • C is for Condom catheter or some other type of intermittent catheterization in appropriate patients.
  • D is for Do not use a catheter unless you must. "That's means avoiding indwelling catheterization especially in the emergency department."
  • E is for Early catheter removal using nursing protocols, written or computerized reminders or stop orders.

"For me, those are the five key features of the evidence," Saint says. "Unfortunately, I think there is only one that has a 1A [CDC grade of evidence]. "Everything is 1B or less, and that highlights the need for more research."

Indeed, the CDC guidelines inadvertently reinforce the perception that surefire approaches to UTI prevention are few and far between. In that regard, the CDC reminds in the guidelines that "it is important to note that Category I recommendations are all considered strong recommendations and should be equally implemented; it is only the quality of the evidence underlying the recommendation that distinguishes between levels A and B."

Reference

  1. Gould CV, Unscheid CA, Agarwal RK, et al. Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections 2009. Available at: http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html.