New Guidelines Issued for Management of Catheter-Associated Urinary Tract Infection

Fran Lowry

February 12, 2010

February 12, 2010 — An Expert Panel of the Infectious Diseases Society of America has issued new guidelines to diagnose, prevent, and manage catheter-associated urinary tract infection (UTI) in adults 18 years and older. They are aimed at physicians in all medical specialties who perform direct patient care, especially of patients in hospital or long-term care facilities. The guidelines are published in the March 1 issue of Clinical Infectious Diseases.

"Catheter-associated bacteriuria is the most common health care-associated infection worldwide and is a result of the widespread use of urinary catheterization, much of which is inappropriate," write Thomas M. Hooton, MD, from the University of Miami, Miami, Florida, and members of the Expert Panel. The most effective way to lower its incidence "is to reduce the use of urinary catheterization by restricting its use to patients who have clear indications and by removing the catheter as soon as it is no longer needed."

One way to accomplish this is through nurse-based or electronic physician reminder systems or automatic stop-orders. Institutions should also develop a list of appropriate indications and educate their staff, so that at least 90% of catheters are placed according to the indications. At least 95% of catheter placements should be by a physician's order, the Expert Panel recommends.

The panel reached consensus on its recommendations by weighing the strength and quality of evidence from studies identified through a PubMed search.

Indications for Urinary Catheter Use

Acceptable indications for indwelling urinary catheter use include the following:

  • Clinically significant urinary retention if medical therapy is not effective and surgical correction is not indicated.

  • Urinary incontinence for comfort in a terminally ill patient if less invasive measures fail and collecting devices are not an acceptable alternative.

  • Need for accurate urine output monitoring in critically ill patients.

  • When the patient is unable or unwilling to collect urine (ie, during prolonged surgical procedures with general or spinal anesthesia; selected urologic and gynecologic procedures in the perioperative period).

Indwelling urinary catheters should not be used for the management of urinary incontinence in general, unless all other approaches have failed, in which case their use may be considered at patient request.

The above recommendations are all designated A-III, meaning they are supported by good evidence from more than 1 properly randomized controlled trial.

Hospitals and long-term care facilities should have policies and procedures in place for catheter insertion, maintenance, discontinuation, and replacement to minimize or prevent infection. These institutions should ensure that staff are appropriately educated and trained (A-III).

Additional A-III recommendations to reduce infection include minimizing disconnection of the catheter junction and keeping the drainage bag and connecting tube below the level of the bladder at all times.

The panel writes that there are many gaps in the knowledge about catheter-associated infections, which are partly because of the poor quality of many clinical studies.

"Continued development of intraurethral alternatives to indwelling catheterization in men and women and external urine collection alternatives to indwelling catheterization in women, as well as evaluations of whether these devices reduce the risk of CA-UTI [catheter-associated urinary tract infection], are needed," the panel writes.

Major advances to prevent these infections will require development of biomaterials that can prevent or limit biofilm formation, they add. Right now, infection and encrustation remain associated with the use of biomaterials in the urinary tract, which limits their long-term indwelling time. "But research is promising in this area," the panel concludes.

Support for the guidelines was provided by the Infectious Diseases Society of America.

Dr. Hooton has disclosed financial relationships with Alita Pharmaceuticals. Other members of the Expert Panel have disclosed financial relationships with Coloplast A/S, Coloplast A/C, AstraTech, Alita Pharmaceuticals, Pfizer, Novabay Pharmaceuticals, Exoxemis, American Medical Systems, Monitor Company Group, Propagate Pharma, Hagen/Sinclair Research Recruiting, Advanstar Communications, Haymarket Media, CombinatoRx, the Scientific Consulting Group, the Multidisciplinary Alliance Against Device-Related Infections, the American Society of Microbiology, the American Urological Association, Merck, GlaxoSmithKline, Bristol-Myers Squibb, AstraZeneca, Baxter, Merlion Pharma, Interimmune, Johnson & Johnson, and Leo Pharmaceuticals.

Clin Infect Dis. 2010;50:625-663.