COMMENTARY

CDC Commentary: Reducing Healthcare-Associated Urinary Tract Infections

Sanjay Saint, MD, MPH

Disclosures

April 27, 2010

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Hello, I'm Dr. Sanjay Saint. I'm the associate chief of medicine at the Ann Arbor VA Medical Center, a professor of medicine at the University of Michigan Medical School, and a liaison to CDC's Healthcare Infection Control Practices Advisory Committee. The topic I want to discuss with you today is urinary tract infections (or UTIs).

UTIs, a type of healthcare-associated infection, account for more than 30% of infections reported by acute care hospitals in the United States. Virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract (mainly catheters). Catheter-associated UTIs can result in increased mobidity, mortality, hospital cost, and length of stay. Bacteriuria can lead to unnecessary antimicrobial use, and urinary drainage systems are often reservoirs for multidrug-resistant bacteria and a source of transmission to other patients. The good news, however, is that many catheter-associated UTIs can be prevented with recommended infection control measures.

CDC's Healthcare Infection Control Practices Advisory Committee has recently released updated recommendations for the prevention of catheter-associated UTIs, which provides valuable prevention information for healthcare providers. Clinicians in any healthcare facility, either acute care settings or non-acute settings (such as long-term care facilities), will want to be aware of these updated recommendations so you can protect your patients.

First, let's start at the beginning. Catheters should be used only when necessary and for the shortest amount of time possible. Up to 25% of hospitalized patients receive urinary catheters, and some of those are unnecessary. Healthcare providers are sometimes even unaware that their patients have catheters, leading to prolonged use. It's important that patients with catheters be assessed at least daily so that the catheter can be removed as soon as possible.

Patients who may need a urinary catheter include critically ill patients, surgical patients undergoing urologic or prolonged surgery, those who have received large-volume infusions or diuretics during surgery, and those patients whose urinary output needs to be closely monitored. Additionally, patients who have bladder obstruction, prolonged immobilization, or patients needing additional comfort in end-of-life care have appropriate indications for the use of indwelling catheters. Catheters should not be used as a substitute for nursing care of patients with incontinence, as a means for obtaining urine for culture or other diagnostic tests, or for an extended period of time after surgery.

Second, for patients who require a urinary catheter, ensure only properly trained individuals who know aseptic technique are responsible for insertion of catheters and their maintenance (this includes all healthcare personnel and caregivers). Hand hygiene should be performed immediately before and after insertion or manipulation of the catheter. Maintain unobstructed urine flow by keeping the catheter and collection tube free from kinking, the collection bag below the level of the bladder at all times, and empty the collection bag regularly using a separate clean container for each patient.

Third, there are several quality improvement programs that can ensure appropriate urinary catheter utilization. These include installing system alerts or reminders to remove unnecessary catheters, implementing guidelines or protocols for nurse-initiated removal of unnecessary urinary catheters, and ensuring education and performance feedback of staff regarding appropriate use of urinary catheters, hand hygiene, and catheter care. Facilities should also consider surveillance for catheter-associated UTIs when indicated by a facility-based risk assessment.

As a clinician myself, I have seen how implementation of these simple techniques can have a profound impact on the well-being patients. For more information about how you can prevent UTIs in your patients and your facility, please review the resources on this page or visit www.cdc.gov/hicpac. Together we can prevent infections and save more lives, faster. Thank you.

Web Resources

Guideline for prevention of catheter-associated urinary tract infections, 2009. Page last updated: December 29, 2009. Available at: http://www.cdc.gov/hicpac/cauti/001_cauti.html Accessed April 26, 2010.

Healthcare Infection Control Practices Advisory Committee (HICPAC). Page last updated: March 31, 2010. Available at: http://www.cdc.gov/hicpac/ Accessed April 26, 2010.

Sanjay Saint, MD, MPH, a Professor of Internal Medicine at the Ann Arbor VA Medical Center and the University of Michigan, is the Director of the VA/University of Michigan Patient Safety Enhancement Program. His research focuses on: enhancing patient safety by preventing healthcare-associated infection; translating research findings into practice; and medical decision-making (including cognitive errors). He has authored approximately 170 peer-reviewed papers with over 50 appearing in the New England Journal of Medicine, JAMA, or the Annals of Internal Medicine. His research is currently funded through extramural grants from the National Institutes of Health and the Department of Veterans Affairs. Dr. Saint has also authored or edited several books, including the Saint-Frances Guide to Inpatient Medicine (published by Lippincott Williams & Wilkins) and Clinical Problem-Solving (published by McGraw-Hill), and is a Special Correspondent to the New England Journal of Medicine. He is an elected member of the American Society for Clinical Investigation (ASCI) and has received several major teaching awards at UCSF and the University of Michigan, including the Kaiser Award for Excellence in Teaching.

He received his Medical Doctorate from UCLA, completed a medical residency and chief residency at the University of California at San Francisco (UCSF), and obtained a Masters in Public Health (as a Robert Wood Johnson Clinical Scholar) from the University of Washington in Seattle. He was a visiting scholar at the University of Florence during the 2007-2008 academic year and has been a visiting professor at over 30 universities and hospitals in the United States, Europe, and Japan.

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