CAUTI Prevention for Nurses

Catheter-associated urinary tract infections (CAUTI) are infections associated with the use of an indwelling urinary catheter. According to the Infectious Disease Society of America, in order for an infection to be identified as a CAUTI, specific criteria must be met. This includes the presence of an indwelling catheter for more than two days, one sign or symptom of infection, and a positive urine culture. Before covering CAUTI prevention, let’s go over a few eye-opening facts about CAUTIs.

Prevalence of CAUTIs

Catheter-associated urinary tract infections (CAUTI) are one of the most commonly reported hospital-acquired conditions, and have a big impact on length of stay, cost, and mortality. 

• Length of stay – According to the Agency for Healthcare Research and Quality, a CAUTI increases length of stay by 2 to 4 days.
• Cost – On average, the cost of treating a CAUTI can range from $900 to $14,000 per case which accounts for an estimated $340 to $450 million per year in the United States. Since most cases of CAUTI are preventable, Medicare and Medicaid do not reimburse hospitals for these costs. 
• Mortality – In critically ill patients, the mortality rate for CAUTI is 30%. It is estimated that more than 13,000 patients die each year due to CAUTI-related complications. 

Note that UTIs can occur without the use of a urinary catheter. However, in the hospital setting, approximately 65% of all UTIs that develop are associated with the use of a urinary catheter. 

How do CAUTIs occur?

The most significant determinant in the development of a CAUTI is duration of catheterization with the risk increasing by 3 to 7 percent for each day the indwelling catheter remains in place. Catheter insertion causes histological and immunological changes in the bladder leading to an inflammatory response and edema. Additionally, the presence of the catheter irritates the epithelium of the urinary tract leading to ongoing inflammation while also disrupting normal urination and weakening the urinary tract’s natural defense mechanisms. This allows microbes to create a biofilm on the catheter and easily find their way into the body. Further, catheters cause continual mechanical damage to the urinary tract which leads to the accumulation of fibrinogen in the bladder. The fibrinogen then spreads to the catheter and provides a ripe environment for pathogens such as staphylococcus aureus and candida albicans. The most common pathogen involved in CAUTI is is E. coli.

In summary, the presence of a catheter and the associated inflammation modify the urinary tract and bladder, disrupt the urinary tract’s natural defense mechanisms, and create opportunities for microbial colonization and infection. 

Note there are catheters available that are made with an antimicrobial coating to help delay the creation of biofilm and bacterial colonization. Even with these specialized catheters, CAUTI rates remain high.

Why do CAUTIs occur? 

A root cause analysis (RCA) conducted in 2019 showed that the most common factors that contributed to infection were patient comorbidities, substandard catheter care, the presence of fecal incontinence, and duration of catheter use. 

CAUTI complications

Unfortunately, a catheter-associated urinary tract infection is often more than just a UTI. Complications of CAUTI can be serious and even deadly. These include: 

• Sepsis and septic shock – an overwhelming inflammatory response that can lead to hemodynamic instability and death
• Pyelonephritis – inflammation of the kidney resulting from bacterial infection
• Bacteremia – bloodstream infection due to presence of bacteria
• Endocarditis – inflammation of the lining of the heart chambers and heart valves
• Septic arthritis – infection in the synovial fluid
• Meningitis – inflammation of the tissues that surround the brain and spinal cord
• Vertebral osteomyelitis – infection affecting the bones of the vertebrae
• Urolithiasis – kidney stones that have existed the renal pelvis and moved into the ureters, bladder and/or urethra
• Antibiotic resistance – some of the common pathogens responsible for CAUTI are resistant to antibiotics, which can make treatment challenging

Who is at risk for a CAUTI

Individuals at higher risk for CAUTI include: 

• Incontinent patients or those with poor perineal hygiene – Bacteria from stool can easily find its way onto the catheter, which provides a direct line into the urinary tract and bladder.
• Immobile patients – Studies show a correlation between immobilization and CAUTI. This is believed to be due to decreased urine flow from the renal pelvis into the bladder.
• Individuals with diabetes – Individuals with diabetes are at higher risk for CAUTI for a variety of reasons. For starters, diabetes can cause neuropathy, which can lead to inadequate bladder emptying and create an environment ripe for bacterial growth. Second, individuals with diabetes (especially poorly-controlled diabetes) have higher blood glucose levels in the urine, which inhibits leukocyte performance and also creates an environment favorable to bacterial growth.
• Females – Due to the shorter urethra, female patients are at higher risk for CAUTI than male patients.
• Age – Individuals over age 60 are at higher risk for CAUTI, possibly due to the presence of comorbidities.
• Neurological conditions – CAUTI rates have been shown to be higher in patients with stroke and paraplegia.
• Caregiver factors – Poor catheter maintenance can lead to CAUTI.
• Latex – Catheters made of latex carry a higher risk of infection.
• Length of catheterization – The biggest determinant in CAUTI risk is duration of catheter use.

CAUTI prevention

Since most cases of CAUTI are preventable, dedicated efforts have been underway since 2009 to reduce infection and are now widely adopted by healthcare systems throughout the United States.

In the clinical setting, you will likely see CAUTI prevention tactics referred to as a “bundle.” The concept of bundles was developed by the Institute for Healthcare Improvement to help healthcare practitioners provide more effective care for their patients. A bundle is a set of interventions that, when completed in their entirety, reduces complications. The American Nurses Association has developed a CAUTI Prevention Tool to help guide evidence-based practice. Let’s go through this tool step-by-step.

Step 1: Determine if the patient meets the criteria for an indwelling urinary catheter. CDC criteria for catheter insertion includes: 

• Acute urinary retention
• Need for strict I&O monitoring in critically ill patients
• Specific surgical procedures such as colorectal surgery and those involving the genitourinary tract
• The presence of a sacral or perineal wound in an incontinent patient
• Patients who are unable to mobilize due to injury such as pelvic fractures or unstable spinal injury
• To provide comfort at end-of-life

If the patient does not meet criteria (and incontinence is never a criteria all on its own), then the nurse should develop a toileting plan and consider the use of alternative collection devices such as external catheters and urinals where indicated.

Step 2: Go through the catheter insertion checklist to ensure proper technique. This involves:

• Selecting the smallest size catheter appropriate for the patient. In most cases, a 14 Fr catheter is adequate in adults. 
• Getting assistance as needed. This could be utilizing another nurse or a mechanical aid (such as a lift device) to ensure clear visualization of the perineal area and proper insertion technique. 
• Performing hand hygiene.
• Cleaning the perineal area and performing hand hygiene again.
• Maintaining strict aseptic (sterile) technique throughout the catheter insertion process. It is no longer evidence-based practice to pre-inflate the balloon, though be aware some schools and institutions may still teach this.
• Ensure the catheter is inserted to the appropriate length. In females this is generally 1 inch beyond the point where you see urine flow. In males, insert all the way to the “Y” connection. Lubrication of the catheter reduces patient discomfort and urethral irritation. Note that if you have too much lubricant on the tip of the catheter, this can impede urine flow.
• Do not inflate the balloon until urine flow has been confirmed. Ensure you are inflating the balloon to the correct volume (it will be labeled 10 ml or 5 ml).

Step 3: Once the catheter has been inserted, perform these three components to help prevent CAUTI.

• Use a catheter securement device to prevent the catheter from excess movement and urethral irritation.
• Ensure the drainage bag is below the level of the bladder and not resting on the floor. Most, if not all, hospital beds have a spot toward the foot of the bed for hanging catheter drainage bags.
• Maintain catheter patency by ensuring there are no obstructions or kinks in the catheter.

Step 4: Reassess daily to ensure the patient still meets criteria for an indwelling catheter. In many facilities, protocols are utilized to allow the nurse to determine if the catheter can be removed. Once an order is received to remove a catheter, remove it promptly!

Step 5: Maintain the catheter system throughout the duration of use. This involves:

• Ensure the catheter securement device remains in use. The type that wrap around the leg tend to move around quite a bit while the adhesive securement devices are much more stable.
• Ensure the drainage bag remains below the level of the bladder at all times. If the patient needs to be moved from one bed to another, you may see a nurse or tech lifting the bag and placing it on the bed. This allows pathogens to easily enter the bladder. Instead, either hold the drainage bag throughout the transer, or clamp it prior to lifting it onto the bed. Just be sure to unclamp it once you have it back in position!
• Don’t let the bag get too full and empty it regularly with a clean collection device specific to that patient. While emptying, do not let the drainage spout touch the collection device. In some facilities, it is protocol to wipe the drainage spout with an alcohol swab after emptying. Make it a habit to check to ensure the bag is not touching the floor. This can easily happen when placing patients into reverse Trendelenburg or lowering a bed all the way to its lowest position.
• Maintain catheter patency by ensuring there are no kinks in the tubing or obstructions. For example, a patient who has had renal or bladder surgery could have blood clots in the urine. Keep an eye out for these so you can flush them through before they cause urinary retention. To flush a urinary catheter, obtain sterile normal saline, perform hand hygiene, don gloves, vigorously scrub the infusion port, clamp the catheter so the saline goes the direction you want it to, and inject the saline toward the occlusion. And don’t forget to include the amount infused in your I&O.
• Always maintain a closed drainage system and only open the drainage spout for periodic collection bag drainage.
• If the catheter tubing becomes dislodged or the tubing is cracked, replace the catheter.
• Perform perineal hygiene or “catheter care” per facility protocol. In most cases this is at least daily and after any episodes of fecal incontinence.

In closing, I will leave you with this acronym to help you remember the key components of CAUTI prevention: 

C	Catheter removal	Get that catheter out ASAP!
A	Aseptic insertion	Ensure you have the proper training and skill for catheter insertion. If you’re not sure, ask a friend to help!
U	Use regular assessments	Remember to reassess your patient’s need for a catheter daily.
T	Training for catheter care	Ensure you have the proper training for catheter care. If the patient is going home with a catheter, ensure they understand how to care for it as well.
I	Incontinence care planning	Consider alternatives to catheters with your incontinent patients. External catheters and timed toileting are great options!

Review CAUTI prevention again on-the-go in episode 366 of the Straight A Nursing podcast wherever you get your podcasts, or listen from your browser here.

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Last Updated on September 27, 2024 by Maureen Osuna, MSN, RN