VIII. Evidence Review

Q1. Who should receive urinary catheters?

Q1A. When is urinary catheterization necessary?

The available data examined five main populations. In all populations, we considered CAUTI outcomes as well as other outcomes we deemed critical to weighing the risks and benefits of catheterization. The evidence for this question consists of 1 systematic review,³⁷ 9 RCTs,^38-46 and 12 observational studies.^47-58 The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 1A.

For operative patients, low-quality evidence suggested a benefit of avoiding urinary catheterization.^37-44,47-49 This was based on a decreased risk of bacteriuria/unspecified UTI, no effect on bladder injury, and increased risk of urinary retention in patients without catheters. Urinary retention in patients without catheters was specifically seen following urogenital surgeries. The most common surgeries studied were urogenital, gynecological, laparoscopic, and orthopedic surgeries. Our search did not reveal data on the impact of catheterization on peri-operative hemodynamic management.

For incontinent patients, low-quality evidence suggested a benefit of avoiding urinary catheterization.^45,50-52 This was based on a decreased risk of both SUTI and bacteriuria/unspecified UTI in male nursing home residents without urinary catheters compared to those with continuous condom catheters. We found no difference in the risk of UTI between having a condom catheter only at night and having no catheter. Our search did not reveal data on the impact of catheterization on skin breakdown.

For patients with bladder outlet obstruction, very low-quality evidence suggested a benefit of a urethral stent over an indwelling catheter.⁵³ This was based on a reduced risk of bacteriuria in those receiving a urethral stent. Our search did not reveal data on the impact of catheterization versus stent placement on urinary complications.

For patients with spinal cord injury, very low-quality evidence suggested a benefit of avoiding indwelling urinary catheters.^54,56 This was based on a decreased risk of SUTI and bacteriuria in those without indwelling catheters (including patients managed with spontaneous voiding, clean intermittent catheterization [CIC], and external striated sphincterotomy with condom catheter drainage), as well as a lower risk of urinary complications, including hematuria, stones, and urethral injury (fistula, erosion, stricture).

For children with myelomeningocele and neurogenic bladder, very low-quality evidence suggested a benefit of CIC compared to urinary diversion or self voiding.^46,57,58 This was based on a decreased risk of bacteriuria/unspecified UTI in patients receiving CIC compared to urinary diversion, and a lower risk of urinary tract deterioration (defined by febrile urinary tract infection, vesicoureteral reflux, hydronephrosis, or increases in BUN or serum creatinine) compared to self-voiding and in those receiving CIC early (< 1 year of age) versus late (> 3 years of age).

Evidence Review Table 1A. When is urinary catheterization necessary?

1A.1. Use urinary catheters in operative patients only as necessary, rather than routinely. (Category IB)

1A.2. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. (Category IB)

1A.2.a. Further research is needed on periodic (e.g., nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown. (No recommendation/unresolved issue)

1A.3. Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction. (No recommendation/unresolved issue)

1A.4. Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. (Category II)

1A.5. Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration. (Category II)

Q1B. What are the risk factors for CAUTI?

To answer this question, we reviewed the quality of evidence for those risk factors examined in more than one study. We considered the critical outcomes for decision-making to be SUTI and bacteriuria. The evidence for this question consists of 11 RCTs^59-69 and 37 observational studies.^{9,50,54,70-103} The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 1B.

For SUTI, ^{50,54,61,62,74,75,79,83,102,103} low-quality evidence suggested that female sex, older age, prolonged catheterization, impaired immunity, and lack of antimicrobial exposure are risk factors. Very low quality evidence suggested that catheter blockage and low albumin level are also risk factors. For bacteriuria, ^{9,59-61,63-68,72,73,76-78,82,84-86,89-94,96-100} multiple risk factors were identified; there was high quality evidence for prolonged catheterization and moderate quality evidence for female sex, positive meatal cultures, and lack of antimicrobial exposure. Low-quality evidence also implicated the following risk factors for bacteriuria: older age, disconnection of the drainage system, diabetes, renal dysfunction, higher severity of illness, impaired immunity, placement of the catheter outside of the operating room, lower professional training of the person inserting the catheter, incontinence, and being on an orthopaedic or neurology service. Our search did not reveal data on adverse events and antimicrobial resistance associated with antimicrobial use, although one observational study found that the protective effect of antimicrobials lasted only for the first four days of catheterization, and that antimicrobial exposure led to changes in the epidemiology of bacterial flora in the urine.

Evidence Review Table 1B. What are the risk factors for CAUTI?

1B.1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Category IB) More data are available under Question 2B.

1B.2. Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB) More data are available under Question 2C.

1B.3. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI such as women, the elderly, and patients with impaired immunity. (Category IB)

1B.4. Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB)

1B.5. Maintain unobstructed urine flow. (Category IB) More data are available under Question 2D.

Q1C. What populations are at highest risk of mortality from urinary catheters?

To answer this question, we reviewed the quality of evidence for those risk factors examined in more than one study. The evidence for this question consists of 2 observational studies.^7,74 The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 1C.

Low-quality evidence suggested that older age, higher severity of illness, and being on an internal medicine service compared to a surgical service were independent risk factors for mortality in patients with indwelling urinary catheters. Both studies evaluating these risk factors found the highest risk of mortality in patients over 70 years of age. Low-quality evidence also suggested that CAUTI was a risk factor for mortality in patients with catheters.

Evidence Review Table 1C. What populations are at highest risk of mortality from catheters?

1C.1. Minimize urinary catheter use and duration in all patients, particularly those who may be at higher risk for mortality due to catheterization, such as the elderly and patients with severe illness. (Category IB)

Q2. For those who may require urinary catheters, what are the best practices?

Q2A. What are the risks and benefits associated with different approaches to catheterization?

The available data examined the following comparisons of different catheterization approaches:

1. External versus indwelling urethral
2. Intermittent versus indwelling urethral
3. Intermittent versus suprapubic
4. Suprapubic versus indwelling urethral
5. Clean intermittent versus sterile intermittent

For all comparisons, we considered SUTI, bacteriuria/unspecified UTI, or combinations of these outcomes depending on availability, as well as other outcomes critical to weighing the risks and benefits of different catheterization approaches. The evidence for this question consists of 6 systematic reviews,^37,104-108 16 RCTs,^{62,63,109-122} and 18 observational studies.^{54,73,81,84,123-136} The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 2A.

Q2A.1. External versus indwelling urethral

Low-quality evidence suggested a benefit of using external catheters over indwelling urethral catheters in male patients who require a urinary collection device but do not have an indication for an indwelling catheter such as urinary retention or bladder outlet obstruction.^81,109,123 This was based on a decreased risk of a composite outcome of SUTI, bacteriuria, or death as well as increased patient satisfaction with condom catheters. Differences were most pronounced in men without dementia. Statistically significant differences were not found or reported for the individual CAUTI outcomes or death. Our search did not reveal data on differences in local complications such as skin maceration or phimosis.

Q2A.2. Intermittent versus indwelling urethral

Low-quality evidence suggested a benefit of using intermittent catheterization over indwelling urethral catheters in selected populations.^{84,104-106,110-114,124-126,135,136} This was based on a decreased risk of SUTI and bacteriuria/unspecified UTI but an increased risk of urinary retention in postoperative patients with intermittent catheterization. In one study, urinary retention and bladder distension were avoided by performing catheterization at regular intervals (every 6-8 hrs) until return of voiding. Studies of patients with neurogenic bladder most consistently found a decreased risk of CAUTI with intermittent catheterization. Studies in operative patients whose catheters were removed within 24 hrs of surgery found no differences in bacteriuria with intermittent vs. indwelling catheterization, while studies where catheters were left in for longer durations had mixed results. Our search did not reveal data on differences in patient satisfaction.

Q2A.3. Intermittent versus suprapubic

Very low-quality evidence suggested a benefit of intermittent over suprapubic catheterization in selected populations^{115,116,134-136} based on increased patient acceptability and decreased risk of urinary complications (bladder calculi, vesicoureteral reflux, and upper tract abnormalities). Although we found a decreased risk of bacteriuria/unspecified UTI with suprapubic catheterization, there were no differences in SUTI. The populations studied included women undergoing urogynecologic surgery and spinal cord injury patients.

Q2A.4. Suprapubic versus indwelling urethral

Low-quality evidence suggested a benefit of suprapubic catheters over indwelling urethral catheters in selected populations.^{37,62,104,107,108,128-133,135,136} This was based on a decreased risk of bacteriuria/unspecified UTI, recatheterization, and urethral stricture, and increased patient comfort and satisfaction. However, there were no differences in SUTI and an increased risk of longer duration of catheterization with suprapubic catheters. Studies involved primarily postoperative and spinal cord injury patients. Our search did not reveal data on differences in complications related to catheter insertion or the catheter site.

Q2A.5. Clean intermittent versus sterile intermittent

Moderate-quality evidence suggested no benefit of using sterile over clean technique for intermittent catheterization.^{63,73,105,117-122} No differences were found in the risk of SUTI or bacteriuria/unspecified UTI. Study populations included nursing home residents and adults and children with neurogenic bladder/spinal cord injury.

Evidence Review Table 2A. What are the risks and benefits associated with different approaches to catheterization?

2A.1. Consider using external catheters as an alternative to indwelling urethral catheters in cooperative male patients without urinary retention or bladder outlet obstruction. (Category II)

2A.2. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. (Category II)

2A.3. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. (Category IB)

2A.4. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB) More data are available under Question 2C.

2A.5. Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization, particularly with respect to complications related to catheter insertion or the catheter site. (No recommendation/unresolved issue)

2A.6. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. (Category IA)

Q2B. What are the risks and benefits associated with different catheters or collecting systems?

For all comparisons, we considered CAUTI outcomes as well as other outcomes critical to weighing the risks and benefits of different types of catheters or collecting systems. The evidence for this question consists of 5 systematic reviews,^37,137-140 17 RCTs,^64,143-158 23 observational studies,^{82,86,89,97,159-163, 165-178} and 3 economic analyses.^179180,181 The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 2B.

Q2B.1.a. Silver-coated catheters vs. standard catheters

Low-quality evidence suggested a benefit of silver-coated catheters over standard latex catheters.^{37,82,86,137-139,143,159-163, 165,166} This was based on a decreased risk of bacteriuria/unspecified UTI with silver-coated catheters and no evidence of increased urethral irritation or antimicrobial resistance in studies that reported data on microbiological outcomes. Differences were significant for silver alloy-coated catheters but not silver oxide-coated catheters. In a meta-analysis of randomized controlled trials (see Appendix), silver alloy-coated catheters reduced the risk of asymptomatic bacteriuria compared to standard latex catheters (control latex catheters were either uncoated or coated with hydrogel, Teflon®, or silicone), whereas there were no differences when compared to standard, all silicone catheters. The effect of silver alloy catheters compared to latex catheters was more pronounced when used in patients catheterized <1 week. The results were robust to inclusion or exclusion of non peer-reviewed studies. Only one observational study found a decrease in SUTI with silver alloy-coated catheters.¹⁶⁶ The setting was a burn referral center, where the control catheters were latex, and patients in the intervention group had new catheters placed on admission, whereas the control group did not. Recent observational studies in hospitalized patients found mixed results for bacteriuria/unspecified UTI.

Q2B.1.b. Nitrofurazone-impregnated catheters vs. standard catheters

Low-quality evidence suggested a benefit of nitrofurazone-impregnated catheters in patients catheterized for short periods of time.^137,138 This was based on a decreased risk of bacteriuria and no evidence of increased antimicrobial resistance in studies that reported microbiological outcomes. Differences were significant in a meta-analysis of three studies examining nitrofurazone-impregnated catheters (only one individual study significant) when duration of catheterization was <1 week. No differences were seen when duration of catheterization was >1 week, although the meta-analysis was borderline significant.

Q2B.2. Hydrophilic catheters vs. standard catheters

Very low-quality evidence suggested a benefit of hydrophilic catheters over standard non-hydrophilic catheters in specific populations undergoing clean intermittent catheterization.^{137,144-148,169} This was based on a decreased risk of SUTI, bacteriuria, hematuria, and pain during insertion, and increased patient satisfaction. Differences in CAUTI outcomes were limited to one study of spinal cord injury patients and one study of patients receiving intravesical immunochemoprophylaxis for bladder cancer, while multiple other studies found no significant differences.

Q2B.3. Closed vs. open drainage systems

Very low-quality evidence suggested a benefit of using a closed rather than open urinary drainage system.^89,171 This was based on a decreased risk of bacteriuria with a closed drainage system. One study also found a suggestion of a decreased risk of SUTI, bacteremia, and UTI-related mortality associated with closed drainage systems, but differences were not statistically significant. Sterile, continuously closed drainage systems became the standard of care based on an uncontrolled study published in 1966 demonstrating a dramatic reduction in the risk of infection in short-term catheterized patients with the use of a closed system.²³ Recent data also include the finding that disconnection of the drainage system is a risk factor for bacteriuria (Q1B).

Q2B.4. Complex vs. simple drainage systems

Low-quality evidence suggested no benefit of complex closed urinary drainage systems over simple closed urinary drainage systems.^{150-152,154,172,176,177} Although there was a decreased risk of bacteriuria with the complex systems, differences were found only in studies published before 1990, and not in more recent studies. The complex drainage systems studied included various mechanisms for reducing bacterial entry, such as antiseptic-releasing cartridges at the drain port of the urine collection bag; see evidence table for systems evaluated.

Q2B.5. Preconnected/sealed junction catheters vs. standard catheters

Low-quality evidence suggested a benefit of using preconnected catheters with junction seals over catheters with unsealed junctions to reduce the risk of disconnections.^{64,153,156,175} This was based on a decreased risk of SUTI and bacteriuria with preconnected sealed catheters. Studies that found differences had higher rates of CAUTI in the control group than studies that did not find an effect.

Q2B.6. Catheter valves vs. drainage bags

Moderate-quality evidence suggested a benefit of catheter valves over drainage bags in selected patients with indwelling urinary catheters.¹⁴⁰ Catheter valves led to greater patient satisfaction but no differences in bacteriuria/unspecified UTI or pain/bladder spasms. Details regarding the setting for recruitment and follow-up of the patients in the studies were unclear, and the majority of subjects were men. Our search did not reveal data on the effect of catheter valves on bladder function, bladder/urethral trauma, or catheter blockage.

Evidence Review Table 2B. What are the risks and benefits associated with different catheters or collecting systems?

2B.1. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (see Section III. Implementation and Audit). (Category IB)

2B.1.a. Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters. (No recommendation/unresolved issue)

2B.2. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization. (Category II)

2B.3. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Category IB)

2B.4. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use. (Category II)

2B.5. Urinary catheter systems with preconnected, sealed catheter-tubing junctions are suggested for use. (Category II)

2B.6. Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications. (No recommendation/unresolved issue)

Q2C. What are the risks and benefits associated with different catheter management techniques?

The available data examined the following catheter management techniques:

1. Antimicrobial prophylaxis
2. Urinary antiseptics (i.e., methanamine)
3. Bladder irrigation
4. Antiseptic instillation in the drainage bag
5. Periurethral care
6. Routine catheter or bag change
7. Catheter lubricants
8. Securing devices
9. Bacterial interference
10. Catheter cleansing
11. Catheter removal strategies (clamping vs. free drainage prior to removal, postoperative duration of catheterization)
12. Assessment of urine volumes

For all comparisons, we considered CAUTI outcomes as well as other outcomes critical to weighing the risks and benefits of different catheter management techniques. The evidence for this question consists of 6 systematic reviews,^{37,105,106,182-184} 56 RCTs,^{60,61,65-69,143,158,158,185-231} 34 observational studies,^{83,85,88,90,96,102,133,167,178,232-258} and 1 economic analysis.¹⁸⁰ The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 2C.

Q2C.1. Antimicrobial prophylaxis

Low-quality evidence suggested no benefit of antimicrobial prophylaxis in patients undergoing short-term catheterization.^{37,60,61,83,85,133,158,178,182,185,186,189-191,232-234} This was based on heterogeneous results for SUTI and bacteriuria/unspecified UTI and no adverse events related to antimicrobials. Lack of consistency in specific factors, such as patient population, antimicrobial agents, timing of administration, and duration of follow-up, did not allow for a summary of evidence of the effect of antimicrobial prophylaxis on CAUTI in patients undergoing short term catheterization. Only two studies evaluated adverse events related to antimicrobials. Our search did not reveal data on antimicrobial resistance or Clostridium difficile infection.

Low-quality evidence suggested no benefit of antimicrobial prophylaxis in patients undergoing long-term catheterization (indwelling and clean intermittent catheterization).^{106,183,192,194,235,238} This was based on a decreased risk of bacteriuria, heterogeneous results for SUTI, and no differences reported for catheter encrustation or adverse events, although data were sparse. One systematic review suggested an increase in antimicrobial resistance with antimicrobial use.

Q2C.2. Urinary antiseptics

Low-quality evidence suggested a benefit of methenamine for short-term catheterized patients.^196,197 This was based on a reduced risk of SUTI and bacteriuria and no differences in adverse events. Evidence was limited to two studies of patients following gynecological surgery in Norway and Sweden.

Very low-quality evidence suggested a benefit of methanamine for long-term catheterized patients.^106,236-239 This was based on a reduced risk of encrustation but no differences in risk of SUTI or bacteriuria. Data on encrustation was limited to one study. Studies involved primarily elderly and spinal cord injury patients with chronic indwelling catheters

Q2C.3. Bladder irrigation

Low-quality evidence suggested no benefit of bladder irrigation in patients with indwelling or intermittent catheters.^{66,69,199-206,240-242} This was based on no differences in SUTI and heterogeneous findings for bacteriuria.

Q2C.4. Antiseptic instillation in the drainage bag

Low-quality evidence suggested no benefit of antiseptic instillation in urinary drainage bags.^{90,207-211,243-245} This was based on no differences in SUTI and heterogeneous results for bacteriuria.

Q2C.5. Periurethral care

Low-quality evidence suggested no benefit of antiseptic meatal cleaning regimens before or during catheterization to prevent CAUTI.^{65,67,68,88,158,212-216,246,247} This was based on no difference in the risk of bacteriuria in patients receiving periurethral care regimens compared to those not receiving them. One study found a higher risk of bacteriuria with cleaning of the urethral meatus-catheter junction (either twice daily application of povidine-iodine or once daily cleaning with a non-antiseptic solution of green soap and water) in a subgroup of women with positive meatal cultures and in patients not receiving antimicrobials. Periurethral cleaning with chlorhexidine before catheter insertion did not have an effect in two studies.

Q2C.6. Routine catheter or bag change

Low-quality evidence suggested no benefit of routine catheter or drainage bag changes to prevent CAUTI.^{102,217-219,248,249} This was based on no difference or an increased risk of SUTI and no difference in bacteriuria with routine compared to as-needed changes or with more frequent changing intervals. One study in nursing home residents found no differences in SUTI with routine monthly catheter changes compared to changing only for obstruction or infection, but the study was underpowered to detect a difference. Another study in home care patients found an increased risk of SUTI when catheters were changed more frequently than monthly.

Q2C.7. Catheter lubricants

Very low-quality evidence suggested a benefit of using lubricants for catheter insertion.^{167,220-223,250-254} This was based on a decreased risk of SUTI and bacteriuria with the use of a pre-lubricated catheter compared to a catheter lubricated by the patient and a decreased risk of bacteriuria with use of a lubricant versus no lubricant. Studies were heterogeneous both in the interventions and outcomes studied. Several studies comparing antiseptic lubricants to non-antiseptic lubricants found no significant differences.

Q2C.8. Securing devices

Low-quality evidence suggested no benefit of using catheter securing devices to prevent CAUTI.²²⁴ This was based on no significant difference in the risk of SUTI or meatal erosion. The only study in this category looked at one particular product.

Q2C.9. Bacterial interference

Moderate-quality evidence suggested a benefit of using bacterial interference in catheterized patients.²²⁵ In the one study evaluating this intervention, urinary colonization with a non-pathogenic Escherichia coli was associated with a decreased risk of SUTI in adults with spinal cord injury and a history of frequent CAUTI.

Q2C.10. Catheter cleansing

Very low-quality evidence suggested a benefit of wet versus dry storage procedures for catheters used in clean intermittent catheterization.²⁵⁵ This was based on a decreased risk of SUTI with a wet storage procedure in one study of spinal cord injury patients undergoing clean intermittent catheterization compared to a dry storage procedure where the catheter was left to air dry after washing. In the wet procedure, the catheter was stored in a dilute povidone-iodine solution after washing with soap and water.

Q2C.11. Catheter removal strategies

Q2C.12. Assessment of urine volumes

Low-quality evidence suggested a benefit of using portable ultrasound to assess urine volume in patients undergoing intermittent catheterization.^229,230 This was based on fewer catheterizations but no reported differences in risk of unspecified UTI. Patients studied were adults with neurogenic bladder in inpatient rehabilitation centers. Our search did not reveal data on the use of ultrasound in catheterized patients in other settings.

Evidence Review Table 2C. What are the risks and benefits associated with different catheter management techniques?

2C.1. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely as prophylaxis for UTI in patients requiring either short or long-term catheterization. (Category IB)

2C.2.a. Further research is needed on the use of urinary antiseptics (e.g., methanamine) to prevent UTI in patients requiring short-term catheterization. (No recommendation/unresolved issue)

2C.2.b. Further research is needed on the use of methanamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. (No recommendation/unresolved issue)

2C.3.a. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery), bladder irrigation is not recommended. (Category II)

2C.3.b. Routine irrigation of the bladder with antimicrobials is not recommended. (Category II)

2C.4. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Category II)

2C.5.a. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing) is appropriate. (Category IB)

2C.5.b. Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue)

2C.6. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II)

2C.7.a. Use a sterile, single-use packet of lubricant jelly for catheter insertion. (Category IB)

2C.7.b. Routine use of antiseptic lubricants is not necessary. (Category II)

2C.8. Further research is needed on the use of bacterial interference to prevent UTI in patients requiring chronic urinary catheterization. (No recommendation/unresolved issue)

2C.9. Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization. (No recommendation/unresolved issue)

2C.10.a. Clamping indwelling catheters prior to removal is not necessary. (Category II)

2C.10.b. Insert catheters only for appropriate indications, and leave in place only as long as needed. (Category IB)

2C.10.c. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. (Category IB)

2C.11.a. Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II)

2C.11.b. Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output. (No recommendation/unresolved issue)

Q2D. What are the risks and benefits associated with different systems interventions?

The available data examined the following systems interventions:

1. Infection control/quality improvement programs (multifaceted)
2. Catheter reminders
3. Bacteriologic monitoring
4. Hand hygiene
5. Patient placement
6. Catheter team versus self-catheterization
7. Feedback
8. Nurse-directed catheter removal

We considered CAUTI outcomes, duration of catheterization, recatheterization, and transmission of pathogens when weighing the risks and benefits of different systems interventions. The evidence for this question consists of 1 RCT²⁵⁹ and 19 observational studies.^3,25,260-276 The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 2D.

Q2D.1. Multifaceted infection control/quality improvement programs

Low-quality evidence suggested a benefit of multifaceted infection control/quality improvement programs to reduce the risk of CAUTI.^3,260-267 This was based on a decreased risk of SUTI, bacteriuria/unspecified UTI, and duration of catheter use with implementation of such programs. Studies evaluated various multifaceted interventions. The studies with significant findings included:

1. education and performance feedback regarding compliance with catheter care, emphasizing hand hygiene, and maintaining unobstructed urine flow;
2. computerized alerts to physicians, nurse-driven protocols to remove catheters, and use of handheld bladder scanners to assess for urinary retention;
3. guidelines and education focusing on perioperative catheter management; and
4. a multifaceted infection control program including guidelines for catheter insertion and maintenance.

A program using a checklist and algorithm for appropriate catheter use also suggested a decrease in unspecified UTI and catheter duration, but statistical differences were not reported.

Q2D.2. Reminders

Very low-quality evidence suggested a benefit of using urinary catheter reminders to prevent CAUTI.^268-270 This was based on a decreased risk of bacteriuria and duration of catheterization and no differences in recatheterization or SUTI when reminders were used. Reminders to physicians included both computerized and non-computerized alerts about the presence of urinary catheters and the need to remove unnecessary catheters.

Q2D.3. Bacteriologic monitoring

Very low-quality evidence suggested no benefit of bacteriologic monitoring to prevent CAUTI.^25,271 Although one study found a decreased risk of bacteriuria during a period of bacteriologic monitoring and feedback, only 2% of SUTI episodes were considered potentially preventable with the use of bacteriologic monitoring.

Q2D.4. Hand hygiene

Very low-quality evidence suggested a benefit of using alcohol hand sanitizer in reducing CAUTI. This was based on one study in a rehabilitation facility that found a decrease in unspecified UTI, although no statistical differences were reported.²⁷² A separate multifaceted study that included education and performance feedback on compliance with catheter care and hand hygiene showed a decrease in risk of SUTI.²⁶⁵

Q2D.5. Patient placement

Very low-quality evidence suggested a benefit of spatially separating patients to prevent transmission of urinary pathogens.²⁷³ This was based on a decreased risk of transmission of urinary bacterial pathogens in nursing home residents in separate rooms compared to residents in the same rooms.

Q2D.6. Catheter team versus self-catheterization

Very low-quality evidence suggested no benefit of a catheter team to prevent CAUTI among patients requiring intermittent catheterization.²⁷⁴ This was based on one study showing no difference in unspecified UTI between use of a catheter care team and self-catheterization for intermittent catheterization in paraplegic patients.

Q2D.7. Feedback

Very low-quality evidence suggested a benefit of using nursing feedback to prevent CAUTI.²⁷⁵ This was based on a decreased risk of unspecified UTI during an intervention where nursing staff were provided with regular reports of unit-specific rates of CAUTI.

Q2D.8. Nurse-directed catheter removal

Very low-quality evidence suggested a benefit of a nurse-directed catheter removal program to prevent CAUTI.²⁷⁶ This was based on a decreased risk of unspecified UTI during an intervention where criteria were developed that allowed a registered nurse to remove a catheter without a physician's order when no longer medically necessary. Of the three intensive care units where the intervention was implemented, differences were significant only in the coronary intensive care unit.

Evidence Review Table 2D. What are the risks and benefits associated with different systems interventions?

2D.1.a. Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training stressing the correct techniques and procedures for urinary catheter insertion, maintenance, and removal. (Category IB)

2D.1.b. Implement quality improvement (QI) programs or strategies to enhance appropriate use of indwelling catheters and to reduce the risk of CAUTI based on a facility risk assessment. (Category IB)

2D.2. Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended. (Category II)

2D.3. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter site or device. (Category IB)

2D.5. Maintain unobstructed urine flow. (Category IB)

2D.6. Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems. (No recommendation/unresolved issue)

2D.7. When performing surveillance for CAUTI, consider providing regular (e.g., quarterly) feedback of unit-specific CAUTI rates to nursing staff and other appropriate clinical care staff. (Category II)

Q3: What are the best practices for preventing UTI associated with obstructed urinary catheters?

The available data examined the following practices:

1. Methods to prevent/reduce encrustations or blockage
2. Catheter materials preventing blockage

For this question, available relevant outcomes included blockage/encrustation. We did not find data on the outcomes of CAUTI. The evidence for this question consists of 1 systematic review,²⁷⁷ 2 RCTs,^278,279 and 2 observational studies.^280,281 The findings of the evidence review and the grades for all important outcomes are shown in Evidence Review Table 3.

Q3.1. Methods to prevent/reduce encrustations or blockage

Low-quality evidence suggested a benefit of acidifying solutions or oral acetohydroxamic acid in preventing or reducing catheter encrustations and blockage in long-term catheterized patients.^{277,278,280,281} No differences were seen with daily catheter irrigation with normal saline.

Q3.2. Catheter materials preventing blockage

Low-quality evidence suggested a benefit of silicone over latex or Teflon-coated catheters in prevention or reducing catheter encrustations in long-term catheterized patients who were prone to blockage. No differences were seen with different materials in patients considered "non-blockers."²⁷⁹

Evidence Review Table 3. What are the best practices for preventing UTI associated with obstructed urinary catheters?

3.1.a. Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. (No recommendation/unresolved issue)

3.2.a. Silicone might be preferable to other materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (Category II)