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"Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America"

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Published: Clinical Infectious Diseases ; 2010 ; 50 : 625 -663

Abstract

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities. 

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was last reviewed and deemed current as of 07/2013.

Recommendations

Method of Diagnosing CA-ASB and CA-UTI

  1. CA-UTI in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined by the presence of symptoms or signs compatible with UTI with no other identified source of infection along with ⩾103 colony-forming units (cfu)/mL of ⩾1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 h (A-III).
    • Data are insufficient to recommend a specific quantitative count for defining CA-UTI in symptomatic men when specimens are collected by condom catheter.
  2. CA-ASB should not be screened for except in research studies evaluating interventions designed to reduce the incidence of CA-ASB or CA-UTI (A-III) and in selected clinical situations, such as in pregnant women (A-III).
    • CA-ASB in patients with indwelling urethral, indwelling suprapubic, or intermittent catheterization is defined by the presence of ⩾105 cfu/mL of ⩾1 bacterial species in a single catheter urine specimen in a patient without symptoms compatible with UTI (A-III).
    • CA-ASB in a man with a condom catheter is defined by the presence of ⩾105 cfu/mL of ⩾1 bacterial species in a single urine specimen from a freshly applied condom catheter in a patient without symptoms compatible with UTI (A-II).
  3. Signs and symptoms compatible with CA-UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in those whose catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness (A-III).
    • In patients with spinal cord injury, increased spasticity, autonomic dysreflexia, or sense of unease are also compatible with CA-UTI (A-III).
  4. In the catheterized patient, pyuria is not diagnostic of CA-bacteriuria or CA-UTI (AII).
    • The presence, absence, or degree of pyuria should not be used to differentiate CA-ASB from CA-UTI (A-II).
    • Pyuria accompanying CA-ASB should not be interpreted as an indication for antimicrobial treatment (A-II).
    • The absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI (A-III).
  5. In the catheterized patient, the presence or absence of odorous or cloudy urine alone should not be used to differentiate CA-ASB from CA-UTI or as an indication for urine culture or antimicrobial therapy (A-III).


Reduction of Inappropriate Urinary Catheter Insertion and Duration

Limiting Unnecessary Catheterization

  1. Indwelling catheters should be placed only when they are indicated (A-III).
    • Indwelling urinary catheters should not be used for the management of urinary incontinence (A-III). In exceptional cases, when all other approaches to management of incontinence have not been effective, it may be considered at patient request.
  2. Institutions should develop a list of appropriate indications for inserting indwelling urinary catheters, educate staff about such indications, and periodically assess adherence to the institution-specific guidelines (A-III).
  3. Institutions should require a physician's order in the chart before an indwelling catheter is placed (A-III).
  4. Institutions should consider use of portable bladder scanners to determine whether catheterization is necessary for postoperative patients (B-II).


Discontinuation of Catheter

  1. Indwelling catheters should be removed as soon as they are no longer required to reduce the risk of CA-bacteriuria (A-I) and CA-UTI (A-II).
  2. Institutions should consider nurse-based or electronic physician reminder systems to reduce inappropriate urinary catheterization (A-II) and CA-UTI (A-II).
  3. Institutions should consider automatic stop-orders to reduce inappropriate urinary catheterization (B-I).


Strategies to Consider Prior to Catheter Insertion

Infection Prevention

  1. Hospitals and LTCFs should develop, maintain, and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies, and replacement indications (A-III).
    • Strategies should include education and training of staff relevant to these policies and procedures (A-III).
  2. Institutions may consider feedback of CA-bacteriuria rates to nurses and physicians on a regular basis to reduce the risk of CA-bacteriuria (C-II).
    • Data are insufficient to make a recommendation as to whether such an intervention might reduce the risk of CA-UTI.
  3. Data are insufficient to make a recommendation as to whether institutions should place patients with indwelling urinary catheters in different rooms from other patients who have indwelling urinary catheters or other invasive devices to reduce the risk of CA-bacteriuria or CA-UTI.
  4. In men for whom a urinary catheter is indicated and who have minimal postvoid residual urine, condom catheterization should be considered as an alternative to short-term (A-II) and long-term (B-II) indwelling catheterization to reduce CA-bacteriuria in those who are not cognitively impaired.
    • Data are insufficient to make a recommendation as to whether condom catheterization is preferable to short-term or long-term indwelling urethral catheterization for reduction of CA-UTI.
    • Data are insufficient to make a recommendation as to whether condom catheterization is preferable to short-term or long-term indwelling urethral catheterization for reduction of CA-bacteriuria in those who are cognitively impaired.
  5. Intermittent catheterization should be considered as an alternative to short-term (C-I) or long-term (A-III) indwelling urethral catheterization to reduce CA-bacteriuria and an alternative to short-term (C-III) or long-term (A-III) indwelling urethral catheterization to reduce CA-UTI.
  6. Suprapubic catheterization may be considered as an alternative to short-term indwelling urethral catheterization to reduce CA-bacteriuria (B-I) and CA-UTI (C-III).
    • Data are insufficient to make a recommendation as to whether suprapubic catheterization is preferable to long-term indwelling urethral catheterization for reduction of CA-bacteriuria or CA-UTI.
    • Data are insufficient to make a recommendation as to whether intermittent catheterization is preferable to suprapubic catheterization for reduction of CA-bacteriuria or CA-UTI.


Intermittent Catheterization Technique

  1. Clean (nonsterile) rather than sterile technique may be considered in outpatient (A-III) and institutional (B-I) settings with no difference in risk of CA-bacteriuria or CA-UTI.
  2. Multiple-use catheters may be considered instead of sterile single-use catheters in outpatient (B-III) and institutional (C-I) settings with no difference in risk of CA-bacteriuria or CA-UTI.
  3. Data are insufficient to make a recommendation as to whether one method of cleaning multiple-use catheters is superior to another.
  4. Hydrophilic catheters are not recommended for routine use to reduce the risk of CA-bacteriuria (B-II) or CA-UTI (B-II).
  5. Data are insufficient to make recommendations on whether use of portable bladder scanners or "no-touch" technique reduces the risk of CA-UTI, compared with standard care.


Insertion Technique for Indwelling Urethral Catheter

  1. Indwelling urethral catheters should be inserted using aseptic technique and sterile equipment (B-III).


Prevention Strategies to Consider after Catheter Insertion

Closed Catheter System

  1. A closed catheter drainage system, with ports in the distal catheter for needle aspiration of urine, should be used to reduce CA-bacteriuria (A-II) and CA-UTI (A-III) in patients with short-term indwelling urethral or suprapubic catheters and to reduce CA-bacteriuria (A-III) and CA-UTI (A-III) in patients with long-term indwelling urethral or suprapubic catheters.
    • Institution-specific strategies should be developed to ensure that disconnection of the catheter junction is minimized (A-III) and that the drainage bag and connecting tube are always kept below the level of the bladder (A-III).
  2. Use of a preconnected system (catheter preattached to the tubing of a closed drainage bag) may be considered to reduce CA-bacteriuria (C-II).
    • Data are insufficient to make a recommendation as to whether such a system reduces CA-UTI.
  3. Use of a complex closed drainage system or application of tape at the catheter-drainage tubing junction after catheter insertion is not recommended to reduce CA-bacteriuria (A-I) or CA-UTI (A-III).


Antimicrobial Coated Catheters

 

  1. In patients with short-term indwelling urethral catheterization, antimicrobial (silver alloy or antibiotic)-coated urinary catheters may be considered to reduce or delay the onset of CA-bacteriuria (B-II).
    • Data are insufficient to make a recommendation about whether use of such catheters reduces CA-UTI in patients with short-term indwelling urethral catheterization.
    • Data are insufficient to make a recommendation as to whether use of such catheters reduces CA-bacteriuria or CA-UTI in patients with long-term catheterization.


Prophylaxis with Systemic Antimicrobials

  1. Systemic antimicrobial prophylaxis should not be routinely used in patients with short-term (A-III) or long-term (A-II) catheterization, including patients who undergo surgical procedures, to reduce CA-bacteriuria or CA-UTI because of concern about selection of antimicrobial resistance.


Prophylaxis with Methenamine Salts

  1. Methenamine salts should not be used routinely to reduce CA-bacteriuria or CA-UTI in patients with long-term intermittent (A-II) or long-term indwelling urethral or suprapubic (A-III) catheterization.
    • Data are insufficient to make a recommendation about the use of methenamine salts to reduce CA-UTI in patients with condom catheterization.
  2. Methenamine salts may be considered for the reduction of CA-bacteriuria and CA-UTI in patients after gynecologic surgery who are catheterized for no more than 1 week (C-I). It is reasonable to assume that a similar effect would be seen after other types of surgical procedures.
    • Data are insufficient to make recommendations about whether one methenamine salt is superior to another.
  3. When using a methenamine salt to reduce CA-UTI, the urinary pH should be maintained below 6.0 (B-III).
    • Data are insufficient to recommend how best to achieve a low urinary pH.


Prophylaxis with Cranberry Products

  1. Cranberry products should not be used routinely to reduce CA-bacteriuria or CA-UTI in patients with neurogenic bladders managed with intermittent or indwelling catheterization (A-II).
    • Data are insufficient to make a recommendation on the use of cranberry products to reduce CA-bacteriuria or CA-UTI in other groups of catheterized patients, including those using condom catheters.


Enhanced Meatal Care

  1. Daily meatal cleansing with povidone-iodine solution, silver sulfadiazine, polyantibiotic ointment or cream, or green soap and water is not recommended for routine use in men or women with indwelling urethral catheters to reduce CA-bacteriuria (A-I).
    • Data are insufficient to make a recommendation as to whether meatal cleansing reduces the risk of CA-UTI.


Catheter Irrigation

  1. Catheter irrigation with antimicrobials should not be used routinely to reduce or eradicate CA-bacteriuria (A-I) or CA-UTI (A-II) in patients with indwelling catheters.
  2. Catheter irrigation with antimicrobials may be considered in selected patients who undergo surgical procedures and short-term catheterization to reduce CA-bacteriuria (C-I).
    • Data are insufficient to make a recommendation about whether bladder irrigation in such patients reduces CA-UTI.
  3. Catheter irrigation with normal saline should not be used routinely to reduce CA-bacteriuria, CA-UTI, or obstruction in patients with long-term indwelling catheterization (B-II).


Antimicrobials in the Drainage Bag

  1. Routine addition of antimicrobials or antiseptics to the drainage bag of catheterized patients should not be used to reduce CA-bacteriuria (A-I) or CA-UTI (A-I).


Routine Catheter Change

  1. Data are insufficient to make a recommendation as to whether routine catheter change (eg, every 2-4 weeks) in patients with functional long-term indwelling urethral or suprapubic catheters reduces the risk of CA-ASB or CA-UTI, even in patients who experience repeated early catheter blockage from encrustation.


Prophylactic Antimicrobials at Time of Catheter Removal or Replacement

  1. Prophylactic antimicrobials, given systemically or by bladder irrigation, should not be administered routinely to patients at the time of catheter placement to reduce CA-UTI (A-I) or at the time of catheter removal (B-I) or replacement (A-III) to reduce CA-bacteriuria.
    • Data are insufficient to make a recommendation as to whether administration of prophylactic antimicrobials to such patients reduces bacteremia.


Screening for and Treatment of CA-ASB in Catheterized Patients to Reduce CA-UTI

  1. Screening for and treatment of CA-ASB are not recommended to reduce subsequent CA-bacteriuria or CA-UTI in patients with short-term (A-II) or long-term (A-I) indwelling urethral catheters.
  2. Screening for and treatment of CA-ASB are not recommended to reduce subsequent CA-bacteriuria or CA-UTI in patients with neurogenic bladders managed with intermittent catheterization (A-II).
  3. Screening for and treatment of CA-ASB are not recommended to reduce subsequent CA-bacteriuria or CA-UTI in other catheterized patients (A-III), except in pregnant women (A-III) and patients who undergo urologic procedures for which visible mucosal bleeding is anticipated (A-III).

Screening for and Treatment of CA-ASB at Catheter Removal to Reduce CA-UTI

  1. Antimicrobial treatment of CA-ASB that persists 48 h after short-term indwelling catheter removal in women may be considered to reduce the risk of subsequent CA-UTI (C-I).
    • Data are insufficient, however, to make a recommendation as to whether all women should be uniformly screened for CA-ASB at catheter removal.
    • Data are insufficient to make a recommendation about screening for or treatment of persistent CA-ASB in men.


Urine Culture and Catheter Replacement before Treatment

  1. A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed CA-UTI because of the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance (A-III).
  2. If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA-bacteriuria and CA-UTI (A-I).
    • The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy to help guide treatment (A-II).
    • If use of the catheter can be discontinued, a culture of a voided midstream urine specimen should be obtained prior to the initiation of antimicrobial therapy to help guide treatment (A-III).

Duration of Treatment

  1. Seven days is the recommended duration of antimicrobial treatment for patients with CA-UTI who have prompt resolution of symptoms (A-III), and 10-14 days of treatment is recommended for those with a delayed response (A-III), regardless of whether the patient remains catheterized or not.
    • A 5-day regimen of levofloxacin may be considered in patients with CA-UTI who are not severely ill (B-III). Data are insufficient to make such a recommendation about other fluoroquinolones.
    • A 3-day antimicrobial regimen may be considered for women aged ⩽65 years who develop CA -UTI without upper urinary tract symptoms after an indwelling catheter has been removed (B-II).

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