Prevention of Nosocomial Urinary Tract Infections

Urinary tract infection (UTI) accounts for more than 40% of all nosocomial infections in acute care hospitals. Majority of UTIs occur after the placement of an indwelling urinary catheter, other urinary instrumentation procedures, such as cystoscopy and urological surgery, also play a role. The Centers for Disease Control and Prevention (CDC) released the Guidelines Prevention & Control of Catheter-Associated Urinary Tract Infections in 2009. We present here the executive summary of the guideline and its recommendation. The complete version of the guideline can be accessed at the following link: http://www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html

Recommendations:

1. Personnel
a. Only persons (e.g., hospital personnel, family members, or patients themselves) aware of
correct technique of aseptic insertion and maintenance of the catheter should handle catheters
b. Hospital personnel and others who take care of catheters should be given periodic in-service
training

2. Catheter Use
a. Urinary catheters should be inserted only when necessary and left in place only for as long as necessary. They should not be used solely for the convenience of patient-care personnel.
b. For selected patients, other methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, and intermittent urethral catheterization can be useful alternatives

3. Handwashing
Handwashing should be done immediately before and after any manipulation of the catheter site or apparatus

4. Catheter Insertion
a. Catheters should be inserted using aseptic technique and sterile equipment
b. Gloves, drape, sponges, an appropriate antiseptic solution for periurethral cleaning, and a single-use packet of lubricant jelly should be used for insertion.
c. As small a catheter as possible, consistent with good drainage, should be used to minimize urethral trauma
d. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction

5. Closed Sterile Drainage
a. A sterile, continuously closed drainage system should be maintained
b. The catheter and drainage tube should not be disconnected unless the catheter must be irrigated.
c. If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using aseptic technique after disinfecting the catheter-tubing junction.

6. Irrigation
a. Irrigation should be avoided unless obstruction is anticipated; closed continuous irrigation may be used to prevent obstruction. To relieve obstruction due to clots, mucus, or other causes, an intermittent method of irrigation may be used. Continuous irrigation of the bladder with antimicrobials has not proven to be useful and should not be performed as a routine infection prevention measure.
b. The catheter-tubing junction should be disinfected before disconnection.
c. A large-volume sterile syringe and sterile irrigant should be used and then discarded. The person performing irrigation should use aseptic technique.
d. If the catheter becomes obstructed and can be kept open only by frequent irrigation, the catheter should be changed if it is likely that the catheter itself is contributing to the obstruction.

7. Specimen Collection
a. If small volumes of fresh urine are needed for examination, the distal end of the catheter, or preferably the sampling port if present, should be cleansed with a disinfectant, and urine then aspirated with a sterile needle and syringe
b. Larger volumes of urine for special analyses should be obtained aseptically from the drainage bag.

8. Urinary Flow
a. Unobstructed flow should be maintained.
b. To achieve free flow of urine

1) the catheter and collecting tube should be kept from kinking;
2) the collecting bag should be emptied regularly using a separate collecting container for each patient (the draining spigot and nonsterile collecting container should never come in contact)
3 ) poorly functioning or obstructed catheters should be irrigated or if necessary, replaced
4) collecting bags should always be kept below the level of the bladder.

9. Meatal Care
Twice daily cleansing with povidone-iodine solution and daily cleansing with soap and water have been shown in 2 recent studies not to reduce catheter-associated urinary tract infection. Thus, at this time, daily meatal care with either of these 2 regimens cannot be endorsed

10. Catheter Change Interval
Indwelling catheters should not be changed at arbitrary fixed intervals

11. Spatial Separation of Catheterized Patients
To minimize the chances of cross-infection, infected and uninfected patients with indwelling catheters should not share the same room or adjacent beds

12. Bacteriologic Monitoring
The value of regular bacteriologic monitoring of catheterized patients as an infection control measure has not been established and is not recommended

Summary of Major Recommendations

Category I. Strongly Recommended for Adoption

• Educate personnel in correct techniques of catheter insertion and care.
• Catheterize only when necessary.
• Emphasize handwashing.
• Insert catheter using aseptic technique and sterile equipment.
• Secure catheter properly.
• Maintain closed sterile drainage.
• Obtain urine samples aseptically.
• Maintain unobstructed urine flow.

Category II. Moderately Recommended for Adoption

• Periodically re-educate personnel in catheter care.
• Use smallest suitable bore catheter.
• Avoid irrigation unless needed to prevent or relieve obstruction.
• Refrain from daily meatal care with either of the regimens discussed in text.
• Do not change catheters at arbitrary fixed intervals.

Category III. Weakly Recommended for Adoption

• Consider alternative techniques of urinary drainage before using an indwelling urethral catheter.
• Replace the collecting system when sterile closed drainage has been violated.
• Spatially separate infected and uninfected patients with indwelling catheters.
• Avoid routine bacteriologic monitoring.

Dr Summiya Nizamuddin
Consultant Medical Microbiologist
Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC)
MBBS, FCPS