Elsevier

Critical Care Clinics

Volume 29, Issue 1, January 2013, Pages 19-32
Critical Care Clinics

Preventing Catheter-Associated Urinary Tract Infections in the Intensive Care Unit

https://doi.org/10.1016/j.ccc.2012.10.005Get rights and content

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Key points

  • Catheter-associated urinary tract infection (CAUTI) is common and costly and causes substantial patient morbidity, especially in the ICU setting.

  • CAUTI is often caused by hospital-based pathogens with a propensity toward antimicrobial resistance.

  • Duration of urinary catheterization is the predominant risk for CAUTI; preventive measures directed at limiting placement and early removal of urinary catheters significantly improve CAUTI rates.

  • Intervention bundles, collaboratives, and hospital

Introduction: magnitude of the problem

Healthcare-associated urinary tract infections (UTIs) account for up to 40% of infections in hospitals and 23% of infections in the intensive care unit (ICU).1, 2, 3 The vast majority of UTIs are related to indwelling urinary catheters; approximately 70% of UTIs (and 95% of UTIs occurring in ICUs) develop in patients with urinary catheters.4 The Centers for Disease Control and Prevention (CDC) estimated that in 2007, 139,000 CAUTIs occurred in US hospitals.

CAUTI has significant clinical and

Pathogenesis

Urinary catheters interfere with the normal innate defense mechanisms that prevent attachment and migration of pathogens into the bladder; these mechanisms include length of the urethra and micturition.1, 3 Biofilms, composed of clusters of microorganisms and extracellular matrix (primarily polysaccharide materials), form on both the internal lumen and external surfaces of urinary catheters.8, 9 Typically, the biofilm is composed of one type of microorganism, although polymicrobial biofilms are

Epidemiology of catheter-associated urinary tract infections

CAUTIs make up approximately 40% of all hospital-acquired infections, but they account for a smaller proportion of healthcare-associated infections in the ICU setting. With interventions occurring across the country, rates of CAUTI in ICUs declined significantly between 1990 and 2007.4 Rates of CAUTIs reported through the National Healthcare Safety Network (NHSN) in 2010 ranged from 4.7 infections per 1000 catheter-days in burn ICUs to 1.3 infections per 1000 catheter-days in medical/surgical

Surveillance for catheter-associated urinary tract infections

Clinical diagnosis of CAUTI remains challenging, as neither pyuria nor bacteriuria is a reliable indicator of symptomatic UTI in the setting of catheterization.17, 18 Bacteriuria in a catheterized patient is usually defined as growth of 102 or more colony forming units per milliliter of a predominant microorganism.1, 19 The term, bacteriuria, is often used interchangeably with UTI in the published literature, as many early studies used bacteriuria to define catheter-associated infection.

Prevention of catheter-associated urinary tract infections

Several guidelines exist regarding prevention of CAUTI.23, 24, 25 General strategies are formulated for prevention of all healthcare-associated infections, whereas targeted strategies are focused at risk factors specific for CAUTI (Box 2).

Implementation: the role of bundles and collaboratives

Recently, “bundles” of interventions have been used with resounding success for prevention of several types of healthcare-associated infections. An example of a bundle applied to CAUTI prevention is the memory aide “ABCDE” outlined in Box 4.37 This bundle for preventing CAUTI was successfully adopted by the Michigan Hospital Association Keystone initiative.30 Finally, the important role of local hospital leadership and followership for ensuring effective implementation of preventive initiatives

Summary

CAUTIs are common, costly, and cause significant patient morbidity, especially in the ICU setting. CAUTIs are associated with hospital pathogens with a high propensity toward antimicrobial resistance. Despite studies showing benefit of interventions for prevention on CAUTI, many US healthcare facilities have not adopted these practices. Duration of urinary catheterization is the predominant risk for CAUTI; preventive measures directed at limiting placement and early removal of urinary catheters

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    Disclosures: C.E.C.—none and S.S.—honoraria and speaking fees from academic medical centers, hospitals, specialty societies, state-based hospital associations, and nonprofit foundations (eg, Michigan Health and Hospital Association, Institute for Healthcare Improvement) for lectures about catheter-associated urinary tract infection.

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