Physician's Weekly Article - Catheter-Related UTIs: A Disconnect in Preventive Strategies

       Catheter-related urinary tract infections, or UTIs, are increasingly common and can lead to dangerous complications. Proven strategies to prevent these problems are available, but few hospitals are using them.

      According to the CDC, the most common healthcare-associated infections are urinary tract infections (UTIs), accounting for nearly 40% of all nosocomial infections. “Urinary catheters are associated with the vast majority of nosocomial UTIs,” explains Sanjay Saint, MD, MPH. “In fact, between 12% and 25% of patients receive a urinary catheter at some point during their hospital stay. The incidence of bacteriuria in catheterized patients—which ranges from 3% to 10% each day—is directly and most powerfully related to the duration of catheterization. Among patients with bacteriuria, 10% to 20% will develop symptoms of local UTIs, including suprapubic or flank pain. Although bloodstream infections complicate catheter-related bacteriuria in only about 2% to 4% of all patients, these complications are serious and sometimes life-threatening.”

      There are important patient safety concerns associated with urinary catheterization, Dr. Saint says, including patient discomfort, activity restriction, and discharge delays. “In a study my colleagues and I performed several years ago, about 40% of catheterized patients reported that their indwelling catheters were uncomfortable. Almost 50% complained that they were painful, and over 60% noted that they restricted their activities of daily living. For some, urinary catheters operate as a physical restraint, binding them to the bed. They can substantially—and sometimes unnecessarily—limit patients’ ability to function freely and with dignity. Restricted activity also promotes other nosocomial complications, such as venous thromboembolism and pressure ulcers.”

      The Heavy Impact of UTIs

      UTIs are an important cause of increased healthcare costs in hospitals. “Each episode of symptomatic nosocomial UTI costs at least $600,” says Dr. Saint, “and each episode of urinary tract-related bloodstream infection leads to even greater costs. A recent conservative analysis estimates that each episode increases costs by at least $2,800.” He adds that Medicare’s recent decision to decline reimbursement for the extra cost of treating certain complications during hospitalization—notably, catheter-associated UTIs—will likely spur efforts by hospitals to reduce the incidence of these infections.

      “Compounding the problem,” Dr. Saint continues, “is that even though bacteriuria can be asymptomatic, many patients with an indwelling urinary catheter and asymptomatic bacteriuria will receive an antibiotic. In many instances, this use of antibiotics is inappropriate; it can enable organisms to become multi-drug resistant. Furthermore, several studies have found the need for catheters is unjustified and unnecessary for about a third of the days that patients are catheterized. It also appears that physicians are often unaware that catheters are in place; as a result, they’re not writing orders to have them removed.”

      Assessing Prevention Efforts

      Despite the frequency with which healthcare-associated UTIs occur, little is known about what U.S. hospitals are doing to prevent them. A national survey conducted by Dr. Saint and colleagues sought to better explain variations in prevention practices in more than 700 hospitals. Published in the January 2008 issue of Clinical Infectious Diseases, several noteworthy findings emerged (Table 1). “One key finding was that a minority of hospitals monitored their hospitalized patients with urinary catheters despite the strong link between catheters and subsequent UTI,” says Dr. Saint. “More than half of hospitals didn’t have a system that monitors which patients have urinary catheters, and nearly 75% failed to monitor catheter duration.”

      In addition, there was no single, widely-used strategy to prevent hospital-acquired UTIs in the investigation. “The most commonly used practices—bladder ultrasound and antimicrobial catheters—were each used in less than one-third of hospitals,” Dr. Saint says. “Also, despite evidence of benefit and high-face validity, urinary catheter reminders were used in fewer than 10% of hospitals.” Dr. Saint also notes that VA hospitals were more likely than non-VA hospitals to use portable bladder scanners, condom catheters, and suprapubic catheters. However, he says that VA hospitals were less likely to use antimicrobial urinary catheters.

      Avoid Catheters Whenever Possible

      According to Dr. Saint, the most effective strategy to prevent nosocomial UTIs is to avoid catheterization altogether (Table 2). “Greater attention is needed on behalf of clinicians to avoid inserting catheters in patients unnecessarily,” he says. “When catheters are already in place, the focus should change to getting them out as quickly as possible. It may also be helpful to educate clinicians about the non-infectious complications of urinary catheterization.”

      Use Systems-Based Approaches

      While avoiding catheters is ideal, some patients will truly require catheterization. In these situations, Dr. Saint says using proper insertion and maintenance techniques is paramount. “In fact, one of the most important advances in preventing urinary catheter-related infections was the introduction of the closed-catheter drainage system nearly 50 years ago. Proper aseptic techniques, which include aseptic insertion and maintenance of the catheter and drainage bag, remain essential in preventing catheter-related UTIs. Once placed, however, urinary catheters should be removed with alacrity. Rather than relying on busy physicians to remember which patients have urinary catheters, systems-based solutions and protocols are necessary to practically manage these problems.”

      Several systems-based solutions have been evaluated in recent clinical trials. Dr. Saint and colleagues have recently evaluated a novel urinary catheter reminder system in both a VA and non-VA hospital. “This simple intervention significantly decreased urinary catheter use,” he says. “Another study of ours utilized the VA’s computerized order entry system to remind physicians to remove catheters after 3 days of use. Other investigations have observed improved outcomes by using nurse-based reminder systems. These techniques and strategies are important for preventing catheter-related UTIs. Considering the unjustified use of many catheters and the frequent lack of physician awareness of catheter presence, methods that alert physicians to the catheter status of their patients might help reduce inappropriate catheterizations.”

      Consider Potential Alternatives

      In addition to developing systems solutions, Dr. Saint says that use of antimicrobial catheters has been explored as another option to prevent catheter-based UTIs. “However, there is some controversy surrounding their use because of conflicting data regarding the ability of these devices to prevent symptomatic UTIs, rather than asymptomatic bacteriuria,” says Dr. Saint. “Also, these catheters tend to cost more than non-coated catheters.”

      Alternatives to indwelling catheters should also be considered in appropriate patients, Dr. Saint says. “In a recent randomized trial comparing condom catheters with urethral catheters in male veterans requiring short-term urinary collection, my colleagues and I found that using condom catheters instead of indwelling catheters reduced infectious outcomes. Additionally, condom catheters were reportedly more comfortable and less painful than indwelling catheters. Portable bladder ultrasound scanners are another prevention option. They have been used to measure urinary retention and are advocated by some to reduce the need for catheterization. They may help reduce the number of intermittent catheterizations and perhaps even decrease the risk of UTI. The emergence of these scanners as well as various types of catheters highlight our need for better prevention. The hope is that the emerging data will increase physician awareness of this important issue so that they can be better equipped to decrease the burden of catheter-related UTIs.”

      Sanjay Saint, MD, MPH has indicated to Physician’s Weekly that he has received honoraria for speaking at a nosocomial infection conference sponsored by VHA (a group-purchasing organization).